TRAP laws and the invisible labor of US abortion providers

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.

Intimacy, Anonymity, and "Care with Nothing in the Way" on an Abortion Hotline

This essay is an ethnographic account of a volunteer, anonymous hotline of physicians and advanced practice providers who offer medical advice and guidance to those who are taking medications on their own to end their pregnancies. Attending to the phenomenology of caring on the Hotline reveals a new form of medical expertise at play, which we call "care with nothing in the way." By operating outside the State's scrutiny of abortion provision, the Hotline offers its volunteers a way to practice abortion care that aligns with their professional and political commitments and that distances them from the direct harm they see caused by the political, financial, and bureaucratic constraints of their clinical work. By delineating the structure of this new regime of care, these providers call into question the notion of the "good doctor." They radically re-frame widely shared assumptions about the tenets of the ideal patient-doctor relationship and engender a new form of intimacy-one based, ironically, out of anonymity and not the familiarity that is often idealized in the caregiving relationship. We suggest the implications of "care with nothing in the way" are urgent, not only in the context of increasing hostility to abortion rights, but also for a culture of medicine plagued by physician burnout.

When law and ethics come apart: Constraints versus guidance

The generally agreed upon principle that legality and ethics can come apart is frequently overlooked in our professional ethics education and decision-making procedures. The crux of the issue is that we teach in our philosophy classes that the law can sometimes be unethical, but then clearly state in nursing codes of ethics that students should always follow the law. The law could no doubt give us some reason to choose action A over action B, but in professional contexts we frequently treat the law as a side-constraint that limits the logical space of choices to exclude even consideration of action B. If B is the mandatory action, this in effect forces professionals to do something unethical by preventing them from ever seeing the ethical action as an option. This is a problem. Ultimately we concede that there might be an irresolvable tension in competing normative interests in ethics and the law, though we suggest that a more nuanced approach to ethical code formation could help alleviate the issue somewhat.

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.

"No One Does This for the Money or Lifestyle": Abortion Providers' Perspectives on Factors Affecting Workforce Recruitment and Retention in the Southern United States

Objectives

Movements to stem abortion accessibility and provision are underway across the southern United States. Preserving access to safe abortion requires a steady maternal health workforce. Targeted laws and limiting environments have contributed to a regional dearth of abortion providers. This study evaluates the consequences of restrictive environments for the abortion workforce to inform strategies to reduce the provider shortage in the South.

Methods

We recruited twelve physicians using purposive sampling and interviewed them on their motivations and experiences practicing in the South. We employed grounded theory analysis to translate their perspectives into recommendations for provider recruitment and retention.

Results

Abortion providers identified challenges relating to restrictive legislation, institutional separation of abortion from other medical services, training unavailability, safety concerns, identity struggles, and marginalization within their profession. This contributed to providers widely experiencing stigma and isolation within their work and life environments. Their motivations for practicing in the South despite these challenges included wanting to be impactful in areas of high need, combating health access disparites, and having personal ties to the region. Providers’ suggested increasing regional networking and training opportunities, creating an information clearinghouse, and offering additional compensation to better support their work. We conceptualized these findings into a framework detailing the challenges, impacts and opportunities for abortion provision in the southern United States.

Conclusions for Practice

Our recommendations for provider recruitment and retention include cooperation between professional organizations, training programs, and healthcare institutions to create opportunities for training and networking and encourage abortion-supportive organizational and policy environments.

The Critical Role of Midwives in Safe Self-Managed Abortion

As access to legal abortion in the United States becomes more complex, there is increasing interest in self-managed abortion. Choosing to seek abortion care outside the clinical setting can also help people marginalized or harmed by existing health care systems to access needed care in a way that feels safe and empowering. However, patients and midwives alike often have a lack of information about expected outcomes and potential complications that may arise, as well as how to manage these in a health care system that may make appropriate follow-up difficult to access if needed. This article discusses patient education as a harm-reduction approach, and reviews ways that midwives may strategically and ethically participate in this patient education need. As trusted health care providers who are expert in pregnancy and reproductive health, midwives are ideally positioned to meet patient knowledge needs around self-managed abortion.

COVID-19 and Independent Abortion Providers: Findings from a Rapid-Response Survey

CONTEXT

The ways in which the COVID-19 pandemic has affected abortion providers and abortion care, and the strategies clinics are adopting to navigate the pandemic, have not been well documented.

METHODS

In April-May 2020, representatives from 103 independent abortion clinics (i.e., those not affiliated with Planned Parenthood) completed a survey that included close-ended questions about how the pandemic, the public health response, and designations of abortion as a nonessential service had affected their clinic, as well as open-ended questions about the pandemic's impact. Analyses were primarily descriptive but included an exploration of regional variation.

RESULTS

All U.S. regions were represented in the sample. At 51% of clinics, clinicians or staff had been unable to work because of the pandemic or public health responses. Temporary closures were more common among clinics in the South (35%) and Midwest (21%) than in the Northeast and West (5% each). More than half of clinics had canceled or postponed nonabortion services (e.g., general gynecologic care); cancelation or postponement of abortion services was less common (25-38%, depending on type) and again especially prevalent in the South and Midwest. Respondents reported the pandemic had had numerous effects on their clinics, including disrupting their workforce, clinic flow and work practices; increasing expenses; and reducing revenues. State laws (including designations of abortion as nonessential) had exacerbated these difficulties.

CONCLUSIONS

Although independent abortion clinics have faced considerable challenges from the pandemic, most continued to provide abortion care. Despite this resiliency, additional support may be needed to ensure sustainability of these clinics.

The mesoeconomics of abortion: A scoping review and analysis of the economic effects of abortion on health systems

BACKGROUND

Despite the high incidence of abortion around the globe, we lack synthesis of the known economic consequences of abortion care and abortion policies at the mesoeconomic level (i.e. health systems and communities). This scoping review examines the mesoeconomic costs, benefits, impacts, and values of abortion care and policies.

METHODS AND FINDINGS

Searches were conducted in eight electronic databases. We conducted the searches and application of inclusion/exclusion criteria using the PRISMA extension for Scoping Reviews. For inclusion, studies must have examined at least one of the following outcomes: costs, benefits, impacts, and value of abortion care or abortion policies. Quantitative and qualitative data were extracted for descriptive statistics and thematic analysis. Of the 150 included mesoeconomic studies, costs to health systems are the most frequently reported mesoeconomic outcome (n = 116), followed by impacts (n = 40), benefits (n = 17), and values (n = 11). Within health facilities and health systems, the costs of providing abortion services vary greatly, particularly given the range with which researchers identify and cost services. Financial savings can be realized while maintaining or even improving quality of abortion services. Adapting to changing laws and policies is costly for health facilities. American policies on abortion economically impact health systems and facilities both domestically and abroad. Providing post-abortion care requires a disproportionate amount of health facility resources.

CONCLUSIONS

The evidence base has consolidated around abortion costs to health systems and health facilities in high-income countries more than in low- or middle-income countries. Little is known about the economic impacts of abortion on communities or the mesoeconomics of abortion in the Middle East and North Africa. Methodologically, review papers are the most frequent study type, indicating that researchers rely on evidence from a core set of costing papers. Studies generating new primary data on mesoeconomic outcomes are needed to strengthen the evidence base.

Abortion service delivery in clinics by state policy climate in 2017

Objective

The objective was to examine service delivery in clinics that provided abortions in 2017, including differences by abortion policy climate.

Study design

Using data from the Guttmacher Institute's 2017 Abortion Provider Census, we examine amount charged for abortion care, pregnancy gestation at which abortions were offered, number of days per week that clinics provided abortions and types of nonabortion services offered. Our analysis focuses on the 808 clinic facilities that provided 95% of abortions that year. Measures were calculated nationally and according to whether the clinic was in a state we categorized as hostile, middle ground or supportive of abortion rights.

Results

In 2017, 64% of clinics offered abortion at 11 weeks pregnancy gestation, and 22% did so at 20 weeks gestation. Supportive states had a higher density of clinics that provide abortion for every measured gestation than hostile states. Clinics charged an average of $549 for a surgical abortion at 10 weeks and $551 for medication abortion. Some 46% of clinics in supportive states offered abortion care 5 or more days per week compared to 29% in hostile states. Most clinics offered standalone contraception and family planning (87%) and gynecological care (85%), but the proportion of clinics that provided these services was higher in supportive states (93% and 90%) than in hostile states (75% and 73%).

Conclusions

A substantial proportion of abortion facilities provide a range of other health care services. Aspects of service delivery, such as number of days abortions are provided, may vary according to abortion policy climate.

Implications statement

Onerous policies in states hostile to abortion rights may inhibit some facilities from providing abortion more days per week, and if so, could further burden patients obtaining abortion care in these states.

Real Men Love Babies: Protest Speech and Masculinity at Abortion Clinics in the Southern United States

This article examines the politicized space outside the abortion clinic as a site where gender ideologies about male roles and responsibilities in abortion are contested, using anti-abortion protest rhetoric that targets men accompanying women. Protesters attempt to elicit reactions from men using gendered stereotypes, in hopes that men will change their minds about or prevent an abortion. Anti-abortion protest speech uses mixed messages about masculinity, strength, and fatherhood to shame male companions for their support of abortion. Protesters' rhetoric constructs men as inherently responsible for preventing abortion, where only by leaving the clinic space can these men gain power, controlling their reproductive futures by controlling their female companion's. However, men reacted in different ways to the words shouted by protesters: by ignoring them, agreeing with them, or occasionally by initiating physical or verbal altercations. I find that male companions often employ tropes of patriarchal masculinity within attempts to perform supportive masculinity in response to protest speech, while protesters simultaneously use patriarchal masculinity and contemporary gender ideologies on responsible fatherhood in attempts to prevent abortion. These conflicting rhetorical themes and diverse reactions are indicative of larger struggles in the U.S. pro-choice and pro-life movements about the role of men in abortion.

Differences in Abortion Service Delivery in Hostile, Middle-ground, and Supportive States in 2014

OBJECTIVES

In 2013, the majority of women lived in states considered hostile to abortion rights, or states with numerous abortion restrictions. By comparison, 31% lived in supportive states. This study examined differences in abortion service delivery according to the policy climate in which clinics must operate.

METHODS

Data come from the 2014 Abortion Provider Census, which contains information about all known abortion-providing facilities in the United States. In addition to number and type of facility, we examine several aspects of abortion care: provision of only early medication abortion (EMA-only), whether an advanced practice clinician provided abortions, gestational parameters, and average charge for procedure. All indicators were examined nationally and according to whether the clinic was in a state that was hostile, middle ground, or supportive of abortion rights.

RESULTS

In 2014, hostile and supportive states accounted for the same proportion of all U.S. abortions-44% (each)-although 57% of women age 15 to 44 lived in hostile states. Hostile states had one-half as many abortion-providing facilities as supportive ones. EMA-only facilities accounted for 37% of clinics in supportive states compared with 8% in hostile states. Sixty-five percent of clinics in supportive states reported that advanced practice clinicians provided abortion care, compared with 3% in hostile states. After cost of living adjustments, a first-trimester surgical abortion was most expensive in middle-ground states ($470) and least expensive in supportive states ($402).

CONCLUSIONS

The distribution of abortion services, the type of facility in which they are provided, and the amount a facility charges all vary according to the abortion policy climate.

Unintended pregnancy: a framework for prevention and options for midlife women in the US

Recently unintended pregnancies have been described as "a new kind of mid-life crisis." Given the high prevalence of unwanted or mistimed pregnancy in the US, we examined the sexual and reproductive health patterns of sexually active midlife women. An examination of the prevalence of unintended pregnancy among midlife women revealed a gap in data indicating unmet sexual and reproductive health needs of midlife women. The application of a framework for primary, secondary and tertiary prevention for unintended pregnancy may assist with guiding care for women and identifying implications for reproductive health policy and potential political interference as they relate to sexual and reproductive health in midlife women.