Nurses, physicians, and others who work in reproductive healthcare are under increasing stress and pressure since states began to enforce abortion laws that range from total bans to restrictions on most abortion care.
Just as the COVID-19 pandemic created a large amount of anxiety and moral distress among frontline healthcare providers, the Dobbs era is compounding the stress for providers who work with pregnant patients.
Reproductive health clinicians in states with legal access to abortion care can suffer from stress as they work longer hours and see patients who have traveled hundreds of miles and spent thousands of dollars to receive the care they need.
The authors of a recent study found that abortion providers are burdened and affected emotionally when they help people who are turned away from abortion care in their own communities or state,1 says Sophie A. Hartwig, MPH, lead study author and co-administrative director and research project director of the Center for Reproductive Health Research in the Southeast (RISE) at Emory University.
“Those with greater resources are more likely to access care, and patients unable to access care may face consequences, such as unsafe practices and self-management of care,” Hartwig says. “One piece that was the hardest for providers in this study and the providers we talked to was the impact on patients.”
When a provider told a patient that abortion was not available in that state, the patient asked, “If I drank bleach, would that terminate the pregnancy?”1
“Self-management of abortion care is a valid and often very safe method of abortion care, but those restrictions push patients into situations that might not lend themselves to pursuing safe, comfortable, and desired self-managed abortion,” Hartwig laments.
Another stressor for clinicians is they are blamed for the repercussions of the abortion bans, such as women in later pregnancies who experience crises where immediate abortion care could preserve their health and lives, but the laws make this impossible.
“The providers in the study we conducted wanted to provide the care, but their hands are tied legally by the bans in place,” Hartwig says. “They can’t go against the law without repercussions of potential incarceration or risks to the provision of care they are allowed to do.” Clinicians receive criticism from the lawmakers who enacted the bans, and they may face emotional reactions and anger from patients who are turned away, she adds.
The internal turmoil also created provider distress. One clinician told researchers that caring for patients under the legal changes and challenges took an emotional toll on them, especially when they had to turn away women who often were facing heartbreaking circumstances.
Moral distress can occur when a provider sees a patient who may not survive after being denied evidence-based care due to state anti-abortion laws, says Kari White, PhD, MPH, the lead investigator at the Texas Policy Evaluation Project and an associate professor at the University of Texas at Austin.
“What we’re seeing is the physicians who are working in these banned states are really trying other ways to get patients in their care to a place that can provide the medical care they need,” White says. “They are working with physicians and their professional networks in other states to help with patient navigation and make sure the receiving clinician has the information they need to care for this patient.”2
These workarounds take time and can affect stress and burnout because the same doctors know that they could have easily scheduled the same patients for a necessary procedure only a couple of years earlier. “We’ve heard [from doctors] that this is taking time away from caring for other folks because there’s so much work that needs to be done to do this referral and warm handoff,” White says.
The overturn of Roe also is a personal stressor. Women — including OB/GYNs — who work in abortion-ban states may not be able to plan their families in a way that works best for their career plans. They might feel muzzled in discussing any of these issues with patients who have the same concerns.
From one state to another, from one hour to the next, they do not know if what they say and do is entirely legal in the places where abortion care is restricted or banned. “When things are difficult in a workplace, and there are challenges when a person does not have the resources to meet the challenge, it can lead to burnout,” says Mindy Bergman, PhD, an interim department head and professor in the department of psychological and brain sciences at Texas A&M University.
Uncertainty and fear of litigation, losing their license, or even arrest also can lead to mental health problems. “It can look like depression,” Bergman explains. “It leads to turnover when people either retire early or leave the state or do something else.”
There also is anxiety and potential moral distress in states where reproductive health professionals are trying to meet the increased need with influxes of out-of-state patients. Not every patient who needs an abortion can be seen when there are far fewer clinics and clinicians than demand.
“The emotional labor is increasing dramatically, as well. There’s already a lot of emotional labor in reproductive healthcare,” Bergman says.
For OB/GYNs delivering bad news to pregnant patients, the emotional effect can be particularly negative. “When a person has to give [bad] news and also says, ‘Here are your choices, but we can’t do the ones that are best practice,’ managing your emotions around that is very challenging,” Bergman says. “It’s also stressful and leads to burnout and turnover.”
Research shows that state policies can result in clinicians deviating from best practices when treating high-risk obstetric patients.3
“We’re already in a crisis of pregnancy,” says Alice Abernathy, MD, MSHP, an assistant professor in the department of obstetrics and gynecology at the University of Pennsylvania Perelman School of Medicine. “People need case-by-case discussions with specialists to figure out the best care for them. It’s frightening that patients wouldn’t be able to access that type of healthcare that all physicians strive to provide their patients.”
State policy should not dictate decisions that affect people’s lives and well-being. “I’m an OB/GYN and provide the full spectrum of care,” Abernathy notes. “I’m a mom, and I’m acutely aware of the risks that one experiences in pregnancy and what it would mean if you were denied options based on where you live and not based on any medical indication.”
Healthcare work is challenging regardless of political and legal context. Forcing providers to choose between making evidence-based medical decisions and risking arrest and losing their medical license can lead to moral distress.
“This is the place where people have the most positive and most devastating experiences of their lives,” Bergman says. “It’s not just the intellectual and physical challenges of reproductive healthcare — there’s also the emotional challenges and, in some places, the moral challenges, as well.”
For healthcare workers who are morally opposed to abortion, this may be a good result. “They may be delighted that this is out of their hands,” Abernathy says. “But I don’t think that’s true of most healthcare workers.”
Most reproductive health providers understand the moral and ethical nuances related to this medical procedure. “Sometimes an abortion is just what a person wants; sometimes, it’s what a person needs medically,” Bergman says. “The law doesn’t have those shades of gray.”
For many healthcare providers, this is a reproductive justice issue since abortion restrictions do not stop all women from seeking the procedure but make it difficult for women who live in remote areas and for those who have less money to access an out-of-state procedure. Abortion access is an issue of social power, Rose L. Siuta, PhD candidate at Texas A&M University, noted in a recently published paper.3
“In the wake of the Dobbs decision, some organizations were swift to offer a variety of abortion care type of assistance to their employees (e.g., expanding benefits coverage, offering travel fund assistance), but occupational health psychologists should be aware of the potential impediments to accessing this care,” Siuta wrote. “Importantly, the Dobbs decision elucidates a persistent hierarchy based in sex of who is afforded power, choice, autonomy, and care for basic health needs.”
The COVID-19 pandemic exacerbated healthcare provider burnout and stress, partly due to labor shortages and taking on additional work responsibilities. These problems are continuing and may worsen because of the Dobbs decision.3
The pandemic was a major shock that spurred many employees to leave their jobs. The Dobbs decision is an additional shock — especially for people who can become pregnant.2
The results of a recent survey revealed that half of nurses said they may leave their position in the next six months due to concerns about their own health, insufficient staffing, and a lack of support from their employer. Nurses younger than age 35 years were the most likely to say they intended to leave their jobs.3,4 Investigators also found that one-third of nurses said they were not emotionally healthy, and self-reported burnout increased by 350% since June 2020.4
Health systems and other organizations can mitigate workplace burnout by offering support to employees.
REFERENCES
- Hartwig SA, Youm A, Contreras A, et al. “The right thing to do would be to provide care… and we can’t:” Provider experiences with Georgia’s 22-week abortion ban. Contraception 2023 May 7;110059. doi: 10.1016/j.contraception.2023.110059. [Online ahead of print].
- Grossman D, Joffe C, Kaller S, et al. Care post-Roe: Documenting cases of poor-quality care since the Dobbs decision; Preliminary findings. Advancing New Standards in Reproductive Health/TxPEP. May 15, 2023.
- Bergman ME, Gaskins VA, Allen T, et al. The Dobbs decision and the future of occupational health in the US. Occup Health Sci 2023;7:1-37.
- American Nurses Foundation. Pulse of the Nation’s Nurses Survey Series: Mental Health and Wellness. Oct. 13, 2021.
Nurses, physicians, and others who work in reproductive healthcare are under increasing stress and pressure since states began to enforce abortion laws that range from total bans to restrictions on most abortion care. The authors of a recent study found that abortion providers are burdened and affected emotionally when they help people who are turned away from abortion care in their own communities or state.
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