Relationship of job role and clinic type to perceived stigma and occupational stress among abortion workers

Providers' experiences with abortion care: A scoping review

BACKGROUND

Induced abortion is one of the most common gynecological procedures in the world, with as many as three in every ten pregnancies ending in abortion. It, however, remains controversial. The objective of this scoping review was to explore and map existing literature on the experiences of those who provide abortion care.

METHODS AND FINDINGS

This exploratory review followed the Levac et al. guidelines and was reported in accordance with the PRISMA-ScR checklist. CINAHL, Cochrane, EMBASE, PsycInfo, PubMed, and Web of Science were used to identify peer-reviewed, original research articles published on providers' experience of abortion. We identified 106 relevant studies, which include a total sample of 4,250 providers from 28 countries and six continents. Most of the studies were qualitative (n = 83), though quantitative (n = 15) and mixed methods (n = 8) studies were also included. We identified two overarching themes: (1) Providers' experiences with abortion stigma and (2) Providers' reflections on their abortion work. Our findings suggest that providers from around the world experience challenges within society and their communities and workplaces which reinforce the stigmatization and marginalization of abortion and pose questions about the morality of this work. Most, however, are proud of their work, believe abortion care to be socially important and necessary, and remain committed to the provision of care.

CONCLUSIONS

The findings of this review provide a comprehensive overview on the known experiences of providing abortion care. It is a key point of reference for international providers, researchers, and advocates to further this area of research or discussion in their own territories. The findings of this review will inform future work on how to support providers against stigmatization and will offer providers the chance to reflect on their own experiences.

US Obstetrician-Gynecologists' Perceived Impacts of Post-Dobbs v Jackson State Abortion Bans

Importance

Following the Dobbs v Jackson Women's Health Organization decision in June 2022, 17 US states have functionally banned abortion except in narrow circumstances, and physicians found in violation of these laws face felony charges, loss of their medical license, fines, and prison sentences. Patient impacts are being studied closely, but less research has focused on the consequences for obstetrician-gynecologists (OB-GYNs), for whom medically necessary care provision may now carry serious personal and professional consequences.

Objective

To characterize perceptions of the impact of abortion restrictions on clinical practice, moral distress, mental health, and turnover intention among US OB-GYNs practicing in states with functional bans on abortion.

Design, Setting, and Participants

This qualitative study included semistructured, remote interviews with OB-GYNs from 13 US states with abortion bans. Volunteer sample of 54 OB-GYNs practicing in states that had banned abortion as of March 2023.

Exposure

State abortion bans enacted between June 2022 and March 2023.

Main Outcomes and Measures

OB-GYNs' perceptions of clinical and personal impacts of abortion bans.

Results

This study included 54 OB-GYNs (mean [SD] age, 42 [7] years; 44 [81%] female participants; 3 [6%] non-Hispanic Black or African American participants; 45 [83%] White participants) who practiced in general obstetrics and gynecology (39 [72%]), maternal-fetal medicine (7 [13%]), and complex family planning (8 [15%]). Two major domains were identified in which the laws affected OB-GYNs: (1) clinical impacts (eg, delays in care until patients became more sick or legal sign-off on a medical exception to the ban was obtained; restrictions on counseling patients on pregnancy options; inability to provide appropriate care oneself or make referrals for such care); and (2) personal impacts (eg, moral distress; fears and perceived consequences of law violation; intention to leave the state; symptoms of depression and anxiety).

Conclusions and relevance

In this qualitative study of OB-GYNs practicing under abortion bans, participants reported deep and pervasive impacts of state laws, with implications for workforce sustainability, physician health, and patient outcomes. In the context of public policies that restrict physicians' clinical autonomy, organization-level supports for physicians are essential to maintain workforce sustainability, clinician health and well-being, and availability of timely and accessible health care throughout the US.

Experience of stigma and harassment among respondents to the 2019 Canadian abortion provider survey

OBJECTIVE

We conducted a national survey to assess the experiences of stigma and harassment among physicians and nurse practitioners providing abortions and abortion service administrators in Canada.

STUDY DESIGN

We conducted an exploratory, cross-sectional, national, anonymized, online survey between July and December 2020. Subsections of the survey explored stigma and harassment experienced by respondents, including the 35-item Revised Abortion Providers Stigma Scale and open-ended responses. We analyzed the quantitative data to generate descriptive statistics and employed a reflexive thematic analysis to interpret open-ended responses.

RESULTS

Three hundred fifty-four participants started the stigma and harassment section of the survey. Among low-volume clinicians (<30 abortions/year, 60%, n = 180) 8% reported harassment; 21% among higher volume clinicians (≥30 abortions/year, 40%, n = 119) and 47% among administrators (n = 39), most commonly picketing. The mean stigma score was 67.8 (standard deviation 17.2; maximum score 175). Our qualitative analysis identified five themes characterizing perceptions of stigma and harassment: concerns related to harassment from picketing, protestors, and the public; wanting protestor "bubble zones"; aiming to be anonymous to avoid being a target; not providing an abortion service; but also witnessing a safe and positive practice environment.

CONCLUSIONS

Being a low-volume clinician compared to higher volume clinician and administrator appears to be associated with less harassment. Clinicians providing abortion care in Canada reported mid-range abortion-related stigma scores, and expressed strong concerns that stigma interfered with their abortion provision. Our results indicate that further de-stigmatization and protection of abortion providers in Canada is needed through policy and practice interventions including bubble zones.

IMPLICATIONS

While Canadian abortion care clinicians and administrators reported relatively low incidence of harassment, our results indicate that they are concerned about stigma and harassment. However, as this was an exploratory survey, these data may not be representative of all Canadian abortion providers. Our data identify a need to support abortion clinicians and to bolster protections for dedicated abortion services.

Development of the Chinese Version of the Physician Internalized Occupational Stigma Scale (PIOSS)

Background/Objective

Internalized occupational stigma may develop in physicians as a result of their identification with the public negative labels and stereotypes about them, and then internalization of them as a part of their self-concept. This study aims to develop the Physician Internalized Occupational Stigma Scale (PIOSS) and to examine its reliability and validity.

Methods

In study 1, the initial scale was used to investigate 356 physicians. While in study 2, a total of 346 physicians were investigated with the survey tools named the PIOSS, the Career Commitment Scale (CCS), the Workplace Well-Being Scale (WWBS), the Scale for the Doctor with Patient-doctor Relationship (DDPRQ-10), the Intent to Leave Scale (ILS) and the Occupational Disidentification Scale (ODS).

Results

The PIOSS includes 19 items divided into 3 dimensions: label identification, status loss, and career denial. The results of confirmatory factor analysis (CFA) reveal that the three-factor model fitted well (χ 2/df=2.574, RMSEA= 0.068, CFI= 0.931, IFI= 0.931, TLI= 0.919, PNFI= 0.762, PCFI= 0.795). The PIOSS total and each dimension scores were significantly negatively correlated with the CCS and the WWBS scores and remarkably positively associated with the DDPRQ-10, the ILS, and the ODS scores. Cronbach's α coefficients for the PIOSS total scale and dimensions ranged from 0.775 to 0.914, and split-half reliability coefficients ranged from 0.801 to 0.931. In addition, the PIOSS exhibited cross-gender invariance.

Conclusion

Having good reliability and validity, the PIOSS can serve as a valid tool for the assessment of physician internalized occupational stigma.

Supporting Staff in Southern Family Planning Clinics: Challenges and Opportunities

Objectives

The aim of this study was to identify key challenges and opportunities to better support non-clinician clinic staff at family planning centers in Southern US states.

Methods

We conducted qualitative interviews with 15 individuals in clinic staff and leadership positions at family planning centers in seven Southern states.

Results

Turnover had negative impacts on both clinic functioning as well as patient care. Participants identified several challenges related to recruitment and retention in family planning health centers in the South, including the conservative contextual landscape, the perceived value of support staff, gaps in communication, and rural locations. In response to these challenges, staff also identified key strategies to better support and retain health center workers. These included prioritizing investment in management, creating career advancement opportunities, prioritizing staff retention, and creating space for self-care. Health center staff and leadership who used these strategies to support and retain staff noted improvements in the effectiveness of staff work as well as increases in patient volume.

Conclusions for Practice

Study findings provide key areas for intervention including providing development opportunities, commitment from leadership to recognize and invest in staff and supporting self-care. Focusing on ensuring internal organizational justice for staff may also facilitate resilience to external challenging environments. Better supporting clinic staff is likely also important for quality services and ensures the full workforce involved in providing family planning care can work at full capacity.

Exploring providers' experience of stigma following the introduction of more liberal abortion care in the Republic of Ireland

OBJECTIVE

To explore if abortion care providers in the Republic of Ireland experience abortion-related stigma.

STUDY DESIGN

The survey was distributed to abortion care providers working in community and hospital units nationwide. We measured stigma using the 35-item version of the Abortion Providers Stigma Scale (APSS). We also collected data on demography, professional involvement in providing abortion care, and risk of burnout (measured by the Maslach Burnout Inventory).

RESULTS

Of the 309 providers invited to take part, 156 (50.5%) completed the survey between January to May 2020. The sample reported a mean score of 70.9 on the total scale of the APSS. This was comparable with the scores of providers in a Massachusetts-based study but was lower than a sample of providers from across the USA. Linear regression analyses found that the Irish hospital-based obstetricians (b = 10.51, 95% CI 3.16-17.86) and midwives/nurses (b = 10.88, 95% CI 2.3-19.47) reported higher stigma than their colleagues working in general practice.

CONCLUSIONS

Comparing the scores of the current sample to published studies highlight the factors that may drive stigma in the Irish context. The Irish providers reported fewer issues in disclosing their abortion work than providers in the USA, which may be explained as they also reported fewer experiences of judgment and discrimination. They did, however, report higher levels of social isolation. Additionally, the findings suggest that providing surgical and/or later-gestation abortion care and providing within the hospital environment may present additional challenges for staff which increase level of stigma.

IMPLICATIONS

Despite widespread support for the expansion of the abortion care services, providers in Ireland still experience stigma related to this work. Our findings suggest that Irish providers, particularly those working in hospitals, may benefit from supports to reduce abortion-related isolation and challenges posed by collegial interactions or later-gestation care.

Attitudes of California Registered Nurses About Abortion

OBJECTIVE

To describe attitudes about abortion among registered nurses (RNs) licensed in California and to determine if demographic characteristics were associated with these attitudes.

DESIGN

Cross-sectional, one-time survey.

SETTING

Online between 2015 and 2017.

PARTICIPANTS

Nurses with active RN licenses in California (N = 2,500).

METHODS

An anonymous survey was sent to a random sample of 2,500 RNs with active California licenses between 2015 and 2017 to assess their personal and professional demographic characteristics and their attitudes toward abortion. Using scores on the Abortion Attitudes Scale, we dichotomized participants into proabortion and antiabortion categories. We used chi-square tests to determine differences based on demographic characteristics.

RESULTS

Data from 504 RNs licensed in California are included in this analysis. Most respondents identified as female (n = 462, 92%), older than 50 years of age (n = 379, 75%), married (n = 364, 72%), White (n = 354, 70%), and Christian (n = 322, 64%). They were more likely to have negative attitudes toward abortion care if they identified as Christian (p < .001) and more positive attitudes if they identified as White (p < .001) independent of identifying as Christian.

CONCLUSIONS

Respondents had a complex range of attitudes about abortion. In some cases, these attitudes aligned and/or conflicted with stated religious orientation. This study highlights the demographic characteristics that are associated with the attitudes and beliefs about abortion among RNs licensed in California.