Project description:Moral distress occurs when individuals feel powerless to do what they think is right, including when clinicians are prevented from providing health care they deem necessary. The loss of federal protections for abortion following the Dobbs v Jackson Women's Health Organization Supreme Court decision may place clinicians providing abortion at risk of experiencing moral distress, as many could face new legal and civil penalties for providing care in line with professional standards and that they perceive as necessary. To assess self-reported moral distress scores among abortion-providing clinicians following the Dobbs decision overall and by state-level abortion policy. This survey study, conducted from May to December 2023, included US abortion-providing clinicians (physicians, advanced practice clinicians, and nurses). A purposive electronic survey was disseminated nationally through professional listservs and snowball sampling. Abortion policy in each respondent's state of practice (restrictive vs protective using classifications from the Guttmacher Institute). Using descriptive statistics and unadjusted and adjusted negative binomial regression models, the association between self-reported moral distress on the Moral Distress Thermometer (MDT), a validated psychometric tool that scores moral distress from 0 (none) to 10 (worst possible), and state abortion policy was examined. Overall, 310 clinicians (271 [87.7%] women; mean [SD] age, 41.4 [9.7] years) completed 352 MDTs, with 206 responses (58.5%) from protective states and 146 (41.5%) from restrictive states. Reported moral distress scores ranged from 0 to 10 (median, 5) and were more than double for clinicians in restrictive compared with protective states (median, 8 [IQR, 6-9] vs 3 [IQR, 1-6]; P < .001). Respondents with higher moral distress scores included physicians compared with advanced practice clinicians (median, 6 [IQR, 3-8] vs 4 [IQR, 2-7]; P = .005), those practicing in free-standing abortion clinics compared with those practicing in hospitals (median, 6 [IQR, 3-8] vs 4 [IQR, 2-7]; P < .001), those no longer providing abortion care compared with those still providing abortion care (median, 8 [IQR, 4-9] vs 5 [IQR, 2-8]; P = .004), those practicing in loss states (states with the greatest decline in abortion volume since the Dobbs decision) compared with those in stable states (unadjusted incidence rate [IRR], 1.72 [95% CI, 1.55-1.92]; P < .001; adjusted IRR, 1.59 [95% CI, 1.40-1.79]; P < .001), and those practicing in surge states (states with the greatest increase in abortion volume since the Dobbs decision) compared with those in stable states (unadjusted IRR, 1.27 [95% CI, 1.11-1.46]; P < .001; adjusted IRR, 1.24 [95% CI, 1.09-1.41]; P = .001). In this purposive national survey study of clinicians providing abortion, moral distress was elevated among all clinicians and more than twice as high among those practicing in states that restrict abortion compared with those in states that protect abortion. The findings suggest that structural changes addressing bans on necessary health care, such as federal protections for abortion, are needed at institutional, state, and federal policy levels to combat widespread moral distress.

Project description:ImportanceIn 2022, the US Supreme Court abolished the federal right to abortion in the Dobbs v Jackson Women's Health Organization decision. In 13 states, abortions were immediately banned via previously passed legislation, known as trigger laws.ObjectiveTo estimate changes in anxiety and depression symptoms following the Dobbs decision among people residing in states with trigger laws compared with those without them.Design, setting, and participantsUsing the nationally representative repeated cross-sectional Household Pulse Survey (December 2021-January 2023), difference-in-differences models were estimated to examine the change in symptoms of depression and anxiety after Dobbs (either the June 24, 2022, Dobbs decision, or its May 2, 2022, leaked draft benchmarked to the baseline period, prior to May 2, 2022) by comparing the 13 trigger states with the 37 nontrigger states. Models were estimated for the full population (N = 718 753), and separately for 153 108 females and 102 581 males aged 18 through 45 years.ExposureResiding in states with trigger laws following the Dobbs decision or its leaked draft.Main outcomes and measuresAnxiety and depression symptoms were measured via the Patient Health Questionnaire-4 ([PHQ-4]; range, 0-12; scores of more than 5 indicate elevated depression or anxiety symptoms; minimal important difference unknown).ResultsThe survey response rate was 6.04% overall, and 87% of respondents completed the PHQ-4. The population-weighted mean age was 48 years (SD, 17 years), and 51% were female. In trigger states, the mean PHQ-4 scores in the baseline period and after the Dobbs decision were 3.51 (95% CI, 3.44 to 3.59) and 3.81 (95% CI, 3.75 to 3.87), respectively, and in nontrigger states were 3.31 (95% CI, 3.27 to 3.34) and 3.49 (95% CI, 3.45 to 3.53), respectively. There was a significantly greater increase in the mean PHQ-4 score by 0.11 (95% CI, 0.06 to 0.16; P < .001) in trigger states vs nontrigger states. From baseline to after the draft was leaked, the change in PHQ-4 was not significantly different for those in trigger states vs nontrigger states (difference-in-differences estimate, 0.09; 95% CI, -0.03 to 0.21; P = .15). From baseline to after the Dobbs opinion, there was a significantly greater increase in mean PHQ-4 scores for those in trigger states vs nontrigger states among females aged 18 through 45 years (difference-in-differences estimate, 0.23; 95% CI, 0.08 to 0.37; P = .002). Among males aged 18 through 45 years, the difference-in-differences estimate was not statistically significant (0.14; 95% CI, -0.08 to 0.36; P = .23). Differences in estimates for males and females aged 18 through 45 were statistically significant (P = .02).Conclusions and relevanceIn this study of US survey data from December 2021 to January 2023, residence in states with abortion trigger laws compared with residence in states without such laws was associated with a small but significantly greater increase in anxiety and depression symptoms after the Dobbs decision.

Project description:ImportanceFollowing 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.ObjectiveTo 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 participantsThis 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.ExposureState abortion bans enacted between June 2022 and March 2023.Main outcomes and measuresOB-GYNs' perceptions of clinical and personal impacts of abortion bans.ResultsThis 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 relevanceIn 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.

Project description:BackgroundTelehealth abortion has taken on a vital role in maintaining abortion access since the Dobbs v. Jackson Women's Health Organization Supreme Court decision. However, little remains known about the landscape of new telehealth-only virtual clinic abortion providers that have expanded since telehealth abortion first became widely available in the United States in 2021.ObjectiveThis study aimed to (1) document the landscape of telehealth-only virtual clinic abortion care in the United States, (2) describe changes in the presence of virtual clinic abortion services between September 2022, following the Dobbs decision, and June 2023, and (3) identify structural factors that may perpetuate inequities in access to virtual clinic abortion care.MethodsWe conducted a repeated cross-sectional study by reviewing web search results and abortion directories to identify virtual abortion clinics in September 2022 and June 2023 and described changes in the presence of virtual clinics between these 2 periods. In June 2023, we also described each virtual clinic's policies, including states served, costs, patient age limits, insurance acceptance, financial assistance available, and gestational limits.ResultsWe documented 11 virtual clinics providing telehealth abortion care in 26 states and Washington DC in September 2022. By June 2023, 20 virtual clinics were providing services in 27 states and Washington DC. Most (n=16) offered care to minors, 8 provided care until 10 weeks of pregnancy, and median costs were US $259. In addition, 2 accepted private insurance and 1 accepted Medicaid, within a limited number of states. Most (n=16) had some form of financial assistance available.ConclusionsVirtual clinic abortion providers have proliferated since the Dobbs decision. We documented inequities in the availability of telehealth abortion care from virtual clinics, including age restrictions that exclude minors, gestational limits for care, and limited insurance and Medicaid acceptance. Notably, virtual clinic abortion care was not permitted in 11 states where in-person abortion is available.

Project description:ImportanceOnline pharmacies have emerged as stakeholders in abortion care since the US Food and Drug Administration (FDA) relaxed in-person dispensing requirements in 2020. The role of online pharmacies in dispensing abortion medications following the Dobbs v Jackson Women's Health Organization decision on June 24, 2022, is understudied.ObjectiveTo describe medication abortion prescription fulfillment patterns for 1 online pharmacy 1 year before and after the Dobbs v Jackson decision, considering patient, prescriber, and state policy characteristics.Design, setting, and participantsThis cross-sectional study assesses deidentified medication abortion prescription fulfilment data from 1 online pharmacy. Prescribers sent prescription requests to the online pharmacy, which dispensed abortion medications to patients by mail. The study sample included prescription requests fulfilled by the online pharmacy between June 20, 2021, and June 24, 2023, for patients aged at least 18 years who received the combined medication abortion regimen. Data were analyzed from July 2023 to July 2024.ExposuresThe US Supreme Court Dobbs v Jackson decision on June 24, 2022.Main outcomes and measuresPatient and prescriber characteristics are described, including patient age, state to which the prescription was sent, medications prescribed, and prescribing prescriber's clinic care modality (in-person only, hybrid [in-person and virtual], and virtual only). States were grouped according to the Guttmacher Institute classification of policy support for abortion (most or very supportive, somewhat supportive, and somewhat restrictive). Fulfillment trends were disaggregated by prescriber modality and state policy environment; 2 states with similar telehealth but differing coverage policies (Illinois and Colorado) were compared.ResultsThe dataset included 87 942 observations. Most prescriptions were sent to individuals younger than 30 years (57.1%), with a mean (SD) age of 28.7 (6.4) years. Throughout the study period, the greatest volume of prescription requests came from states with most or very supportive policies and from prescribers at virtual-only platforms. More prescriptions were sent in the year after Dobbs v Jackson (daily mean [SD], 88.5 [47.2] prescriptions in March 2022 vs 201.5 [97.5] prescriptions in March 2023) with fulfillment spikes following the Dobbs v Jackson leak on May 2, 2022, and decision on June 24, 2022. State policy contexts mirrored the overall trends, while prescriber modality trends were unique, with a big spike in fulfillment at 12 weeks after the Dobbs v Jackson decision for hybrid clinics compared with in-person-only clinics and telehealth-only platforms, which saw their largest spikes in mean daily prescription fulfillment the week immediately after Dobbs v Jackson. Illinois and Colorado had similar fulfillment trends, with spikes immediately following the Dobbs v Jackson decision and overall higher fulfillment after Dobbs v Jackson, with a daily mean (SD) of 10.5 (7.0) prescriptions in Illinois and 8.8 (5.7) prescriptions in Colorado in March 2022 versus 26.6 (13.6) prescriptions in Illinois and 16.7 (10.1) prescriptions in Colorado in March 2023.Conclusions and relevanceThese findings illustrate the increasingly critical role online pharmacies play in direct-to-patient abortion care provision in the US and the strong linkages between virtual-only prescribers and online pharmacies. These findings suggest that barriers to accessing online pharmacies for abortion care should be removed.

Project description:ImportanceThe Supreme Court decision in Dobbs v Jackson Women's Health Organization overturned the right to choose abortion in the US, with at least 16 states subsequently implementing abortion bans or 6-week gestational limits. Prior research indicates that in the 6 months following Dobbs, approximately 32 360 fewer abortions were provided within the US formal health care setting. However, trends in the provision of medications for self-managed abortion outside the formal health care setting have not been studied.ObjectiveTo determine whether the provision of medications for self-managed abortion outside the formal health care setting increased in the 6 months after Dobbs.Design, setting, and participantsCross-sectional study using data from sources that provided abortion medications outside the formal health care setting to people in the US between March 1 and December 31, 2022, including online telemedicine organizations, community networks, and online vendors. Using a hierarchical bayesian model, we imputed missing values from sources not providing data. We estimated the change in provision of medications for self-managed abortion after the Dobbs decision. We then estimated actual use of these medications by accounting for the possibility that not all provided medications are used by recipients.ExposureAbortion restrictions following the Dobbs decision.Main outcomes and measuresProvision and use of medications for a self-managed abortion.ResultsIn the 6-month post-Dobbs period (July 1 to December 31, 2022), the total number of provisions of medications for self-managed abortion increased by 27 838 (95% credible interval [CrI], 26 374-29 175) vs what would have been expected based on pre-Dobbs levels. Excluding imputed data changes the results only slightly (27 145; 95% CrI, 25 747-28 246). Accounting for nonuse of medications, actual self-managed medication abortions increased by an estimated 26 055 (95% CrI, 24 739-27 245) vs what would have been expected had the Dobbs decision not occurred.Conclusions and relevanceProvision of medications for self-managed abortions increased in the 6 months following the Dobbs decision. Results suggest that a substantial number of abortion seekers accessed services despite the implementation of state-level bans and restrictions.

Dataset Information

Use of Abortion Services in Massachusetts After the Dobbs Decision Among In-State vs Out-of-State Residents.

Publications

Use of Abortion Services in Massachusetts After the Dobbs Decision Among In-State vs Out-of-State Residents.

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