Physicians have observed significant impacts on workforce sustainability, physician health, and patient outcomes from state laws banning abortion, according to a recent study published in JAMA Network Open.
Takeaways
- State laws banning abortion have significant impacts on workforce sustainability and physician health. The study highlights the challenges faced by obstetrician-gynecologists practicing under such bans, including concerns about legal repercussions, loss of medical license, and incarceration.
- Functional bans on abortions have led to decreased patient health and worsened disparities in pregnancy outcomes, particularly based on racial, ethnic, and socioeconomic factors. The restrictions also hinder clinicians in delivering reproductive health care, affecting both patients and providers.
- Many physicians reported the need to delay care, with interventions only possible in cases of imminent risk to the patient or fetal well-being. Delays caused by legal restrictions and emergencies led to painful labors, impacting both patients and providers.
- Clinicians practicing under abortion bans experienced moral distress, describing it as a "moral injury." They expressed conflict between knowing what is right for their patients and facing legal worries, including fears of criminal prosecution, loss of income, and incarceration.
- The study revealed that 70% of clinicians reported symptoms of anxiety or depression. Concerns about practicing in an uncertain legal climate, potential criminal prosecution, and restrictive institutional policies contributed to increased stress levels. Only 30% did not feel an increase in stress, mainly because of pre-existing institutional policies.
The US Supreme Court overturned the federal right for abortion in the Dobbs v Jackson Women’s Health Organization (Dobbs v Jackson) in June 2022. Between this time and December 2023, functional bans on abortions have been placed in 16 states, with similar legislation pending in 5 states.
Data has indicated these bans have decreased patient health and worsened disparities in pregnancy outcomes based on racial, ethnic, and socioeconomic factors. These bans also impact clinicians delivering reproductive health care, including obstetrician-gynecologists, as illegal pregnancy termination may lead to a loss of medical license and a prison sentence.
While state bans on abortion following Dobbs v Jackson may impact all ob-gyns, most data is about the 14% who provide abortion care. To evaluate experiences of ob-gyns practicing under state abortion bans, investigators conducted a qualitative study.
Participants included physicians practicing obstetrics and gynecology in one of the 14 states with abortion bans placed between June 2022 and March 2023. Physicians who worked in one of these states post-Dobbs v Jackson but had since relocated were categorized based on their previous state.
Announcements on ob-gyn listservs and social media groups, direct email recruitment, snowball sampling, and professional networks were used to recruit eligible participants. Participants completed a 60-to-75-minute interview over Zoom, with audio recordings professionally transcribed and identified.
There were 5 domains evaluated during the interviews, including professional background, perspective on bans, impact of bans on clinical practice and experiences of moral distress, impacts on personal health and well-being, and institutional practices and policies.
Questions about leadership experience were also asked when relevant. Age, race, ethnicity, gender, and professional characteristics were determined through a verbal questionnaire.
There were 54 ob-gyns included in the final analysis, aged a mean 42 years. Of clinicians, 61% were female, 6%, non-Hispanic Black, 83% White, 72% practicing in general obstetrics and gynecology, 13% maternal-fetal medicine, 15% complex family planning subspecialists, 17% in private practice, 74% employed by a hospital, and 5% in federally qualified health centers.
A need to delay care was reported by many participants, with care only possible when a patient was at risk of death or permanent impairment, or if the fetal heart stopped suddenly. Middle-of-the-night emergencies also led to delays because of unanswered calls to legal teams for clearance. This has caused painful labors that impacted patients and providers.
Some participants were also unable to provide referrals for abortions or discuss the option with their patients. According to study authors, clinicians described these restrictions as, “an affront to their medical expertise and autonomy.” Even clinicians who counselled patients without documenting their discussions felt as though they were taking a risk.
In states without counseling restrictions, providers were able to discuss care options with their patients, but their patients were unable to receive this care. Being unable to access care was especially common for low-income patients and those with Medicaid insurance who could not travel out of state.
Being unable to provide care led to frustrations for providers. These individuals would often spend hours arranging hospital or inter-state transfer and continue to feel worried about poor outcomes after the transfer.
Moral distress was also common among clinicians. One said, “That word moral injury is getting thrown around a lot now, but that’s really what this is…I know what the right thing is to do for my patients, but I am carrying this legal worry and worried about what could happen to my family at the same time. And that’s a terrible thing to feel.”
Fears about practicing in an uncertain legal climate were reported by 87% of participants, and included potential for criminal prosecution, loss of medical license, loss of income, and incarceration. Eleven percent of participants relocated to a state with stronger abortion practices, with those remaining experiencing additional burdens of clinical care.
Anxiety or depression symptoms were reported in 70% of patients. Only 30% felt their state’s ban had not increased stress level. This lack of increased stress was mainly because of restrictive institutional policies in place before Dobbs v Jackson.
These results indicated significant impacts of abortion bans on providers and patients. Investigators concluded ob-gyns should receive significant support to foster effective reproductive health care in the United States.
Reference
Sabbath EL, McKetchnie SM, Arora KS, Buchbinder M. US obstetrician-gynecologists’ perceived impacts of post-Dobbs v Jackson state abortion bans. JAMA Netw Open. 2023. doi:10.1001/jamanetworkopen.2023.52109
