There is an association between practicing in states with abortion restrictions and moral distress among clinicians, according to a recent study published in JAMA Network Open.1
Takeaways
- Clinicians in states with strict abortion restrictions reported significantly higher moral distress scores compared to those in states with protective abortion policies.
- Following the Dobbs vs Jackson Women's Health Organization decision, the removal of federal protections for abortion has led to severe restrictions or near-total bans in many states, exacerbating moral distress among abortion providers.
- The Dobbs decision influenced obstetric and gynecologic residency applications, with a majority of applicants preferring programs in states with fewer abortion restrictions.
- The survey included 310 respondents, with a notable increase in moral distress among clinicians practicing in restrictive states, showing a median score of 8 compared to 3 in protective states.
- The study's investigators recommend structural changes to address the heightened moral distress and challenges faced by clinicians because of restrictive abortion laws.
Following the Supreme Court’s Dobbs vs Jackson Women’s Health Organization decision, federal protections for abortion have been removed, leading to nearly full bans in 14 states and severe restrictions in 11 states. This increases the risks of felony charges and loss of medical license among clinicians providing abortion.
Exceptions to abortion bans remain unclear, leading to difficult decisions among clinicians that may increase moral distress or emotional harm. Moral distress is described as occurring when clinical guidelines lead clinicians to provide certain care, but external constraints such as state policies prevent them from doing so.
Data has also indicated an association between state abortion access and obstetric and gynecologic residency applications.2 Of survey respondents, 72.7% indicated Dobbs impacted which residency programs they applied to, with 96.9% applying to programs in states with fewer abortion restrictions at the time.
Investigators conducted a survey study to evaluate moral distress among clinicians providing abortion post-Dobbs based on state-level abortion policy.1 Clinicians with abortion care included in their practice completed a 30-item online survey about demographics, practice characteristics, and moral distress from May to December 2023.
Alongside clinicians providing abortion care during the survey period, those not currently providing but who had provided care between May 2021 and June 2022 were included in the study. Clinicians who did not provide abortion care during either of these periods and nonclinicians were excluded.1
When measuring the number of abortion-providing clinicians, states were divided into low clinic number and high clinic number using the 2020 Abortion Provider Census. Approximately 80% of included clinics were in states with high clinic numbers.
Moral distress was measured using the Moral Distress Thermometer (MDT). Scores ranged from 0 to 10, with higher scores indicating increased moral distress. Clinicians were also asked if they experienced more, less, or the same levels of moral distress after the Dobbs decision compared to before.1
Independent variables included whether abortion care practice was restrictive or protective and whether the clinician’s state of practice had a significant change in abortion volume after the Dobbs decision. The first variable was assessed based on classification from Guttmacher Institute, with moral distress responses allowed for up to 3 states. Changes in abortion volume included surge, loss, and stable.
There were 310 respondents included in the final analysis, 8.1% of whom were men, 87.7% were women, and 4.2% were nonbinary, genderfluid, or agender. The mean age of participants was 41.4 years, and 2% were Black, 6.8% Asian, 84.5% White, and 4.8% multiple races. For ethnicity, 8.1% were Hispanic while 91.9% were non-Hispanic.1
Participants completed 352 MDTs total, with 37 completing MDTs for 2 states and 5 for 3 states. Of MDTs, 33% were from states with a low abortion clinic number, 58.5% from states with abortion protections, and 41.5% from states with abortion restrictions.
The median MDT score was 5 among the overall study population. However, respondents practicing in states with abortion restrictions had more than 2-fold increased score, at 8 vs 3 in those practicing in states with protections. Additionally, median scores were higher among respondents in surge states vs stable states, at 7 vs 5, respectively.1
Physicians had a higher median MDT score vs practice clinicians, at 6 vs 4, respectively. Additionally, practicing at a free-standing clinic increased the median score vs other practice settings such as hospitals, at 6 vs 4, respectively.
Of respondents, 78.1% reported experiencing moral distress since the Dobbs decision while only 4.3% experienced less distress. Overall, residing in a state with restrictions was linked to increased moral distress vs residing in a state with protections, with an incidence rate ratio (IRR) of 2.14. For living in a loss state vs a stable state, the IRR was 1.72.
These results indicated an increased moral distress among clinicians providing abortion in restrictive states vs protective states following the Dobbs decision. Investigators recommended structural change to address bans on necessary health care.1
Reference
- Rivlin K, Bornstein M, Wascher J, Norris Turner A, Norris AH, Howard D. State Abortion Policy and Moral Distress Among Clinicians Providing Abortion After the Dobbs Decision. JAMA Netw Open. 2024;7(8):e2426248. doi:10.1001/jamanetworkopen.2024.26248.
- Kunzmann K. Survey: State abortion access impacted OB/GYN residency applications. Contemporary OB/GYN. May 19, 2024. Accessed August 5, 2024. https://www.contemporaryobgyn.net/view/survey-state-abortion-access-impacted-obgyn-residency-applications
