State Abortion Laws and Moral Distress in a National Sample of Obstetrician-Gynecologists

Moral distress can occur when clinicians cannot provide clinically appropriate care due to external constraints. In the wake of Dobbs v Jackson Women's Health Organization, moral distress has been reported among subsets of obstetrician-gynecologists (OB-GYNs), yet little is known about how moral distress manifests among OB-GYNs nationally.

To evaluate the extent to which OB-GYNs in a nonprobability national sample experienced specific clinical constraints around abortion-related care and the extent to which these constraints were associated with moral distress overall and within policy environments.

This cross-sectional study used a national online survey of US OB-GYNs conducted in mid-2025. Attending OB-GYNs practicing in the US, providing care to pregnant patients, and either general OB-GYNs or subspecialists in maternal-fetal medicine or complex family planning were recruited by a physician market research firm.

Experience of clinical constraints associated with state abortion laws, including associations with patient counseling, ability to provide care, and ability to provide care for a patient with a potentially life-threatening pregnancy complication. State abortion policy climate was dichotomized into restrictive (29 states) and protective (21 states and the District of Columbia).

General moral distress (Moral Distress Appraisal scale; score range, 0-5; higher scores indicate greater moral distress).

Among 864 OB-GYNs surveyed (483 female [56.0%]; 623 aged ≥45 years [72.1%]; 113 Asian [13.1%], 35 Black [4.1%], and 625 White [72.3%]; 54 Hispanic [6.3%]), 795 respondents (92.0%) were nonsubspecialists. Self-reported endorsement of each clinical constraint was higher in abortion-restrictive than protective states (eg, counseling constraints: 405 of 566 participants [71.6%] vs 86 of 298 participants [28.9%]; P < .001). Associations were observed between all clinical constraints and moral distress scores (greater endorsement associated with increased overall moral distress). For example, when asked whether their state's abortion laws constrained their ability to provide care for patients with potentially life-threatening pregnancy complications, participants who endorsed this somewhat had an effect estimate (standard error [SE]) of 0.29 (0.07) for increased moral distress score (P < .001), while those who very much endorsed this had an effect estimate (SE) of 0.78 (0.10) for increased score (P < .001) compared with those who endorsed this not at all. Magnitude, direction, and significance of associations were similar in abortion-restrictive and abortion-protective states.

In this study, although self-reported experience of abortion-related clinical constraints was higher in abortion-restrictive vs abortion-protective states, experience of constraints was associated with moral distress across policy contexts. These findings suggest that institution-level programs and policies to reduce moral distress and its determinants among OB-GYNs may be indicated nationally.