OB/GYNs Experiencing High Levels of Moral Distress
May 1, 2024 6 minutes read
An OB/GYN was asked by researchers how it felt to work in an abortion-ban state after the U.S. Supreme Court overturned Roe v. Wade — the physician’s response was shocking.
“When I was in the Army, I deployed to Iraq … I left a 15-month-old baby at home with my husband. I practiced medicine in a war zone … but it’s never felt like this,” one OB/GYN told researchers who asked about symptoms of anxiety and depression.1
The OB/GYN said working in a war zone with actual risk to one’s life was not as distressing as working with patients in an abortion-ban state where the physician continually feared arrest or patient death. The physician never had to seek mental health care services until the Dobbs v. Jackson Women’s Health Organization decision happened.1
“We found that 93% of participants reported situations where they or their colleagues could not follow clinical standards due to legal constraints,” says Erika L. Sabbath, ScD, lead study author and co-director of the Center for Work, Health, and Well-Being at Harvard T.H. Chan School of Public Health. “I didn’t expect it to be that high. They could not counsel someone, or they just knew that they had the skills to help someone in the way the person needed, and they weren’t able to help them.”
Eleven percent of the OB/GYNs interviewed said they had moved their practices to states with stronger abortion protections. “I think that there’s a real risk as doctors continue to leave because they can no longer pit their own livelihood against patients’ well-being,” Sabbath says. “There [could be] whole pockets of the United States that don’t have OB/GYNs, and the states with the abortion bans are the states with the highest rates of maternal mortality before Dobbs. This has the potential to exacerbate that by creating a provider shortage.”
Sabbath and colleagues interviewed OB/GYNs from 14 states that enacted total or partial abortion bans when they started collecting data in March 2023. The physicians described many instances of delayed care for their patients. “They needed to wait until a patient was at risk of death or permanent impairment before they were able to intervene,” Sabbath says. “They talked about how difficult it was to watch someone get sicker and to not be able to use their skills to help them.”
Often, the chief obstacle was how their institution interpreted the state law. “An example is Texas and Oklahoma, which have aiding and abetting clauses. If you help someone obtain an abortion, you can be held liable,” Sabbath explains. “Some institutions have interpreted that by saying you cannot talk about abortion at all with your patient.”
Physicians told researchers their institution banned them from providing counseling on abortion, which was one of the most damaging parts of the laws. Other institutions had different policies that were just as effective at blocking counseling. “Someone explained that for her, the institution told her she could counsel, but if she was charged with aiding and abetting, they would not defend her,” Sabbath says.
The New Yorker published a story about Yeniifer Alvarez-Estrada Glick, a young married woman with a history of hypertension, diabetes, obesity, and pulmonary edema. Glick was pregnant for the first time and experienced difficulty breathing seven weeks into her pregnancy. She continued to have difficulty throughout the pregnancy and saw physicians at various hospitals, including Catholic hospitals. None of Glick’s medical records show that someone discussed ending the pregnancy because of her health problems and the risk of the pregnancy killing her. Glick was en route to a hospital when she died at about 23 weeks of pregnancy after a diagnosis of pulmonary edema. Outside experts asked by The New Yorker to review Glick’s medical file, which the woman’s mother had obtained, said her death was preventable and that a therapeutic abortion probably would have saved her life.2
This story highlights the lack of abortion counseling even as the young woman’s health deteriorated and her pregnancy grew increasingly dangerous. But the lack of documentation of abortion counseling may not prove definitively that no providers told her of the dangers of continuing her pregnancy, Sabbath notes. In cases like the Texas woman’s pregnancy, some providers are willing to discuss the dangers and options, including abortion, in closed-door meetings that are not documented, she explains.
“It’s a problem, in this case, that the medical record doesn’t accurately reflect the medical encounter. It’s bad for patients, bad for doctors, and bad for others treating the patient,” Sabbath says. Some of the providers interviewed for the study said they did counsel some patients, but they found that patients wanted the pregnancy under all circumstances, she adds.
Glick’s case highlights the moral distress that many of the physicians who treated her might have experienced. “We documented a lot of moral distress, which is when you know the right thing to do but you are blocked for some reason — either institutional policy or public policy — from doing it,” Sabbath says. “A lot of [OB/GYNs] reported being depressed and anxious all the time.”
More than half of the people interviewed said they had entertained the idea of leaving their state. Some said they were looking for jobs in another state, and others said they wondered how much longer they could do their jobs there.
“One person [who left her state] said that pitting her livelihood against her patients was not something she was willing to do anymore, and she was not willing to keep sending people across state lines for care she could have provided herself,” Sabbath says. “She felt that for her, the right decision was to move.”
Among the OB/GYNs who said they would stay in their abortion-ban state, some discussed their motivation to stay stemmed from the knowledge that only a few people in their state could treat someone dying from a pregnancy.
“They talked about their colleagues moving away and how the burden of clinical care increased for them and that they were having a hard time recruiting new doctors to come practice in that legal environment,” Sabbath explains. “Their workload increased, plus there was a higher volume of high-risk pregnancies that previously wouldn’t have been carried to term.”
Another cause of OB/GYNs’ increased workload was that patients with critical conditions returned to their office each day for evaluation and monitoring because the physicians could not act until the patients’ conditions had worsened. “They described it as being extraordinarily stressful,” she says. “Some talked about a constant feeling of unease and background worry.”
Healthcare institutions often increased physicians’ stress. Their responses ranged from offering help for stress to worsening it by telling providers they could not act until a person had more than a 50% risk of dying.
Sabbath and colleagues heard these stories: “One said, ‘The way our legal teams interpreted it, until they became septic or started hemorrhaging, we couldn’t proceed … [it] puts women in a very challenging, risky position. Is a 5% risk of death enough? Does it take 20%? Does it take 50%? What is enough legally? And the legal people seem to have a different definition that also just feels horrible, to say until you’re at a greater-than-likely chance of dying, you can’t make a decision.”1
While this study only focused on OB/GYNs working in abortion-ban states, the next step is to study physicians nationwide, Sabbath says.
“We want to know the impact of the policies on OB/GYNs who are receiving patients from out of state, those in states like Colorado that get many patients coming in from states with bans,” she says. “That’s something we [need] to understand.”
REFERENCES
- Sabbath EL, McKetchnie SM, Arora KS, Buchbinder M. US obstetrician-gynecologists’ perceived impacts of post-Dobbs v. Jackson state abortion bans. JAMA Netw Open 2024;7:e2352109.
- Taladrid S. Did an abortion ban cost a young Texas woman her life? The New Yorker. Jan. 8, 2024. https://www.newyorker.com/maga...
An OB/GYN was asked by researchers how it felt to work in an abortion-ban state after the U.S. Supreme Court overturned Roe v. Wade — the physician’s response was shocking. The OB/GYN said working in a war zone with actual risk to one’s life was not as distressing as working with patients in an abortion-ban state where the physician continually feared arrest or patient death.
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