Abortion clinicians report high moral distress, particularly those in restrictive states

Key takeaways:

• Most survey respondents reported more moral distress after Dobbs.
• Clinicians practicing in states with vs. without abortion restrictions reported higher moral distress.

In the U.S., moral distress was high for all abortion-providing clinicians but was twice as high for clinicians practicing in states with vs. without strict abortion laws, according to survey results published in JAMA Network Open.

“The concept of moral distress in health care originates from discussions with nurses over care that they are expected to provide but they ethically oppose. While early definitions of moral distress focused on negative claims of conscience, the definition has since broadened to include positive claims of conscience, or the inability to provide the care that one feels morally compelled to provide,” Katherine Rivlin, MD, MSc, associate professor in the department of obstetrics and gynecology at the University of Chicago Medicine, and colleagues wrote. “In this context, moral distress has direct applications to abortion-providing clinicians facing abortion bans. Prolonged exposure to moral distress without resolution can lead to moral injury. Both moral distress and moral injury have been associated with clinician burnout, psychological distress and low self-reported well-being.”

Rivlin and colleagues conducted a national survey study of 310 abortion-providing clinicians (mean age, 41.4 years; 87.7% women) in the U.S. from May to December 2023. An electronic survey was distributed nationally through professional listservs and snowball sampling to assess self-reported moral distress, as measured by the Moral Distress Thermometer, with higher scores indicating worse distress, after the Dobbs decision overall and by state-level abortion policy.

The survey study did not distinguish between negative and positive claims of conscience.

Overall, 58.5% of responses were from clinicians practicing in states with abortion protections, and 41.5% were from clinicians practicing in states with abortion restrictions. After Dobbs, 78.1% of respondents reported more moral distress.

Reported moral distress scores ranged from 0 to 10 and were more than doubled for clinicians practicing in states with abortion restrictions compared with clinicians practicing in states with abortion protections (8 vs. 3; P < .001). Clinicians practicing in states with abortion restrictions reported higher moral distress vs. those practicing in states with abortion protections, even when adjusting for health care role, abortion-providing status and practice setting (adjusted incidence rate ratio [aIRR] = 2.03; 95% CI, 1.81-2.83).

Researchers also observed higher moral distress scores among physicians vs. advanced practice clinicians (6 vs. 4; P = .005), clinicians practicing in free-standing abortion clinics vs. hospitals (6 vs. 4; P < .001) and clinicians no longer providing abortion care vs. those continuing abortion care (8 vs. 5; P = .004).

In addition, clinicians practicing in states with the greatest vs. smallest abortion volume declines since Dobbs (aIRR = 1.59; 95% CI, 1.4-1.79) and clinicians practicing in states with the greatest vs. smallest increases in abortion volume since Dobbs (aIRR = 1.24; 95% CI, 1.09-1.41) also had higher moral distress scores.

Limitations to this study include the risk for selection bias, the inability to compare results since no pre-Dobbs assessment of moral distress among abortion-providing clinicians exists, the inability to calculate response rates due to recruitment and definition challenges and the possibility of not capturing nuances and changing nature of moral distress through the Moral Distress Thermometer.

“These findings suggest that structural change that addresses bans on necessary health care is needed at institutional, state and federal policy levels, including minimizing institutional barriers, bolstering state protections through abortion shield laws and codifying federal protections for abortion,” the researchers wrote.