In the wake of the Supreme Court’s June 2022 Dobbs v. Jackson decision that allowed states to severely restrict abortion or ban it outright, social and occupational epidemiologist Erika Sabbath has been working with colleagues at the University of North Carolina at Chapel Hill to study how the decision is affecting OB-GYNs both personally and professionally. The collaboration, called SOPRA (the Study of OB-GYNs in Post-Roe America), has produced 10 papers, including one published July 30. Here, Sabbath—adjunct associate professor of social and behavioral sciences, director of Harvard T.H. Chan School of Public Health’s Center for Work, Health, and Well-being, and associate professor at Boston College School of Social Work—describes what her research has found.
Q: What led you to study the impact of the Dobbs decision on OB-GYNs?
Erika Sabbath
A: When the Dobbs decision was leaked in April 2022, there were a lot of news articles about how this would affect patients and access to care. But because I’m an occupational epidemiologist who studies work as a social determinant of health, I immediately started thinking about potential worker health impacts. It occurred to me that OB-GYNs, who provide the majority of pregnancy care in the nation, were potentially going to be put in a position where they’d have to decide between providing care to their patients and protecting themselves legally. The penalties they could face for providing the standard of care to a critically ill pregnant patient—which in some cases is abortion care—were not just fines. They were prison sentences of up to 99 years, loss of medical license, civil and criminal penalties, and felony convictions. These work-related hazards facing OB-GYNs were not really part of the conversation at the time. I wanted to conduct research to learn how they were faring. My colleagues and I submitted a grant proposal to the Greenwall Foundation a few days after Dobbswas decided, and we were funded and collecting data less than nine months after the decision.
Q: What did your initial research involve, and what did you find?
A: Starting in March 2023, my colleague Mara Buchbinder (at UNC-Chapel Hill) and I recruited 54 OB-GYNs in 13 out of 14 states that instituted abortion bans in the wake of Dobbs for a qualitative study. Our research questions were: How have abortion bans impacted OB-GYNs’ clinical practice, moral distress, and work-related well-being? And how can institutions support OB-GYNs to provide high-quality care in restrictive policy environments?
We specifically asked about clinical scenarios that led to moral distress—defined as when a clinician knows the right thing to do clinically but is barred from doing it because of some external constraint.
The OB-GYNs we interviewed described a range of impacts of the laws—clinical, professional, and personal. We heard consistent reports about restrictions on counseling patients, and delays in care until a patient became sick enough to qualify for a medical exception to the ban. And we commonly heard feelings of distress, burnout, and other mental health impacts. One OB-GYN told us about caring for a patient who was hemorrhaging with an intrauterine pregnancy with a heartbeat, and the interviewee could not reach the legal department for clearance to proceed with the termination. I’ll never forget how the OB-GYN described how that felt. She said, “There’s only so many times you can transfuse somebody and they’re begging for their life before you say, ‘This is unconscionable.’”
While obstetric emergencies like these had a deep impact on participants, they were relatively rare. But there was another, more frequent, and we felt more insidious form of what we termed chronic moral distress—everyday encounters in clinic that chipped away at their sense of professional integrity. One quote from an interview continues to stand out to me. The OB-GYN talked about “having patients sobbing and crying and begging and just being like, ‘I cannot carry this pregnancy,’ and knowing that you have the skills, you’ve got the procedure rooms just down the hallway, you’ve got medications right next door, you could fix this person’s problem, and you’re not able to do it.”
Q: It sounds like conducting this research was quite emotional.
A: Yes, and at the same time, we all felt enormously privileged to be able to give voice to professionals who were largely suffering in silence, many of whom feared speaking out publicly due to concerns about retribution. Our confidential interview setting and strict human subjects protocols gave people a space to be able to share both what was really happening and how they felt about it. During our interviews, several people cried, and many of them thanked us for doing this research.
Q: Did your research uncover anything about how policymakers’ efforts to limit access to mifepristone, one of two drugs typically used in medication abortions, is impacting OB-GYNs?
A: While we didn’t focus on mifepristone specifically, OB-GYNs frequently spoke about how the threat of the loss of tools like mifepristone has been so stressful, and how having to come up with a clinical workaround is just very disorienting.
And in general, we heard how stressful it is for providers when legality changes day to day—when a new policy is enacted either at the state or federal level, and a patient walks into the clinic the next day who needs care that is potentially affected by that policy and there has not yet been time to interpret it.
We found that when a healthcare institution provides timely legislative updates—if it proactively communicates what these changes mean for providing care, rather than letting people figure it out for themselves—it helps people feel like they are on safer legal ground.
Q: You just published a new paper on how OB-GYNs are faring several years after the Dobbs ruling. What did you find?
A: This is the first publication from the second phase of SOPRA, a national mixed-methods study—which combines both qualitative and quantitative data—of OB-GYN mental health and work-related well-being, funded by an R01 grant from the National Institute for Occupational Safety and Health. We had an article published July 30 in JAMA Network Open that uses data from a national survey that we conducted of 864 OB-GYNs in 49 states plus the District of Columbia. The paper focuses on the extent to which OB-GYNs are experiencing abortion-related clinical constraints, and the link between these constraints and moral distress.
We found that, in abortion-restrictive states, OB-GYNs reported higher levels of specific clinical constraints: on counseling their patients, providing overall care, and providing care for patients with potentially life-threatening pregnancy complications.
We also found a strong relationship between experiencing these constraints and the level of overall moral distress OB-GYNs experience. What was interesting is that this relationship transcended the abortion policy environment, whereas we’d hypothesized that this relationship would be stronger in abortion-restrictive states. We have also collected qualitative data through 81 additional interviews with OB-GYNs nationally that could help us understand the reasons that we observed this. We are still analyzing that data, but some initial analyses suggest that OB-GYNs in protective states may still be unable to provide certain types of care in spite of relatively liberal abortion laws. Or perhaps these OB-GYNs are receiving patients from out of state or are anticipating future abortion restrictions.
Q: You’ve documented the challenges facing OB-GYNs in the current environment. What do you hope will change as a result of this research?
A: A major goal of our research has been identifying actions that institutions can take to protect both OB-GYN well-being and patient care quality, even in very restrictive states. In a 2024 Viewpoint paper in JAMA, we offered a “playbook” with recommendations for several concrete institutional practices, grounded in our research. For example, one recommendation is to provide standardized, legally vetted electronic medical record documentation for care in legal gray areas. Clinicians don’t want documentation to be used against them, so it’s helpful to have resources for documenting medically necessary abortion care.
Overall, our work has aimed to highlight the public health importance of supporting the OB-GYN workforce, both for its instrumental role in providing maternal and reproductive healthcare, and also because it’s a uniquely at-risk occupational group due to the impacts of these state laws.
About The Author
Karen Feldscher
Associate Director for News in the Office of Communications
