Question:
You are given the full text of a scientific research paper.

    Identify and summarize the **policy problem** that this research addresses. Your response should:
    - Clearly state the societal, environmental, or strategic issue motivating the study
    - Be written in accessible, policy-brief style sentences
    - Focus on the core challenge the research aims to solve
    - Avoid excessive detail or technical jargon unless necessary for clarity

    Write a short paragraph suitable for inclusion under the “Policy Problem” section of a policy brief.

    Scientific Research Paper:
    https://doi.org/10.1177/00221465231172177
Journal of Health and Social Behavior
2023, Vol. 64(4) 470–485
© American Sociological Association 2023
DOI: 10.1177/00221465231172177
journals.sagepub.com/home/hsb
Original Article
Medical uncertainty has interested sociologists for
decades (Fox 1957, 1980; Gerrity, DeVellis, and
Light 1992; Mackintosh and Armstrong 2020).
Uncertainty refers to the unknown in medical prac-
tice and is significant due to its role in medical
knowledge, diagnosis, and decision-making (Fox
2000;
Jenkins,
Jessen,
and
Steffen
2005).
Uncertainty has various sources, such as the inher-
ent limits of what is knowable in medicine (Atkinson
1984). Clinical experience, standardization, guide-
lines, and technology can alleviate some aspects of
uncertainty but introduces others (e.g., Rapp 2004;
Rothman 1993). Sociological research has primar-
ily focused on the sources of medical uncertainty
and how professionals and patients experience and
manage it (Dumit 2006; Jutel 2009; Littlejohn and
Kimport 2017).
We build on prior work by exploring an unex-
amined source of medical uncertainty: the political
context of care. We use the case of abortion in Ohio,
a state with one of the most restrictive legislative
contexts in the United States prior to the
1172177 HSBXXX10.1177/00221465231172177Journal of Health and Social BehaviorCzarnecki et al.
research-article2023
1Case Western Reserve University, Cleveland, OH,
USA
2University of Cincinnati, Cincinnati, OH, USA
3Ohio State University, Columbus, OH, USA
4Mayo Clinic, Rochester, MN, USA
Corresponding Author:
Danielle Czarnecki, Department of Sociology, Case
Western Reserve University, 226 Mather Memorial
Building, 10900 Euclid Avenue, Cleveland, OH 44106-
7124, USA.
Email: dxc735@case.edu
State of Confusion: Ohio’s
Restrictive Abortion
Landscape and the Production
of Uncertainty in Reproductive
Health Care
Danielle Czarnecki1
, Danielle Bessett2, Hillary J. Gyuras2,
Alison H. Norris3, and Michelle L. McGowan2,4
Abstract
This study examines an underexplored source of medical uncertainty: the political context of care. Since
2011, Ohio has passed over 16 abortion-restrictive laws. We know little about how this legislation affects
reproductive health care outside of abortion clinics. Drawing on focus groups and interviews with genetic
counselors and obstetrician-gynecologists, we examine how abortion legislation impacts their work. We
find that interpretation and implementation of legislation is not straightforward and varies by institution
and region of the state. An ever-changing legislative landscape combined with uneven implementation
of restrictions into policy produces uncertainty in reproductive health care. We also found uncertainty
about the legal consequences of abortion in restrictive contexts, with obstetrician-gynecologists reporting
greater concerns given their proximity to care provision. We argue that uncertainty can result in stricter
interpretations of regulations than necessitated by the law, thereby amplifying the impacts of an already
restrictive context for abortion care.
Keywords
abortion, genetic counseling, ob-gyns, reproduction, uncertainty

Czarnecki et al.
471
overturning of Roe (Guttmacher Institute 2018), to
show how the political context of care produces
uncertainty. The political context of care includes
(1) cultural politicization, such as stigma; (2) the
legal, regulatory, and policy contexts; and (3) the
economic organization of health care. We focus on
how an influx of laws and regulations that are often
unclear and incongruent with evidence-based medi-
cine necessitate and complicate the interpretive
work of institutions and providers. Frequent policy
changes disrupt standards and practices, economic
and legal penalties stigmatize abortion care, and
variation in policies across institutions and states
limits information seeking to address uncertainty.
This politicized climate as a source of uncertainty is
what we seek to understand.
This form of uncertainty matters because
patients’ lives and providers’ professional integrity
and livelihoods are at stake. Health care providers
face the threat of criminalization, experience dis-
tress when unable to provide necessary care, and
are burdened with increased labor when navigating
complicated restrictions and institutional con-
straints (Field et al. 2022; Heuerman et al. 2022).
Medical exceptions to abortion restrictions, such as
life-threatening circumstances, leave clinicians
uncertain about whether their clinical interpretation
will be viewed as legally defensible (Arey et al.
2022). These laws ultimately challenge the grounds
on which care decisions should be made, from med-
ical evidence to other metrics, thereby eroding
patient and provider autonomy in decision-making.
As the politicization of care expands to other areas
of health care, medical uncertainty may increase.
We interviewed genetic counselors and obstetrician-
gynecologists (ob-gyns) working in hospital set-
tings to explore how abortion legislation affects
their work. We find that the interpretation and
implementation of legislation is not straightforward
and varies by institution. An ever-changing legisla-
tive landscape combined with different institutional
interpretations of legal restrictions produces uncer-
tainty for those working in reproductive health care
settings. This uncertainty occurs within a climate of
fear and stigma surrounding abortion care provision
in restrictive contexts, impacting health care profes-
sions differently depending on their professional
status and proximity to abortion care. We argue that
a political context that produces uncertainty can
result in more limiting interpretations and imple-
mentation of legal restrictions than necessitated by
the law, thereby amplifying the impacts of an
already restrictive context. This chilling effect cap-
tures how the political context of care can constrain
care beyond what law and policy dictate because
clinicians and institutions err on the side of cau-
tion when uncertain whether providing clinically
appropriate care is legal. With Roe overturned, the
legislative context remains in flux such that repro-
ductive rights depend on one’s state of residence
(McCann 2022). Practicing in a state of uncer-
tainty is more relevant than ever for many health
care providers.
Our contribution to the medical sociology litera-
ture is threefold. First, we expand the sources of
medical uncertainty to include the political context
of care. Second, we demonstrate how health care
providers experience uncertainty and how it limits
access to care to a greater degree than the law.
Third, we discuss the impact and implications of
uncertainty for abortion care and beyond.
Background
Sources of Medical Uncertainty
Medical sociologists have explored the sources of
medical uncertainty and how clinicians manage
them (Atkinson 1984; Gerrity et al. 1992; Light
1979; Mackintosh and Armstrong 2020). Fox (1957,
1980, 2000) identified three sources of uncertainty
that arise during medical training: an insufficient
grasp of medical knowledge, the limits of medical
knowledge, and an inability to distinguish between
the two. Clinicians routinely grapple with decision-
making amid uncertainty, such as identifying a med-
ical problem (Barker 2008) and determining how
best to treat it (Light 1979). Although uncertainty is
part of medicine, it can also lead to physician burn-
out and decreased engagement, with consequences
for patient care (Begin et al. 2022).
Cultural and technological change can also gen-
erate new sources of uncertainty (Alderson 2009;
Jenkins et al. 2005; Mesman 2008). In genetic
counseling, uncertainty about screening results is
common
(Brookes-Howell
2006).
Diagnostic
uncertainty following newborn screening can leave
newborns and parents in a liminal state as “patients-
in-waiting” (Timmermans and Buchbinder 2010).
Cultural shifts may also contribute to uncertainty.
For instance, childhood becoming a domain of sci-
entific study factored in the diagnostic category of
attention-deficit/hyperactivity disorder (ADHD;
Rafalovich 2013). Some clinicians experience
uncertainty and ambivalence about prescribing
stimulants for ADHD that potentially cause patient
harm. While cultural and technological change con-
tributing to uncertainty has been documented, less

472
Journal of Health and Social Behavior 64(4)
explored are changes from the politicization of
medical care that may also result in uncertainty.
Physicians manage uncertainty in different
ways, such as by acquiring more knowledge and
skills, adopting a treatment model, or by “muting”
the voice of uncertainty (Fox 2000; Light 1979). In
a study of pediatric residents’ use of evidence-based
medicine (EBM), Timmermans and Angell (2001)
found that EBM provided guidelines to navigate
uncertainty but also produced new “research-
based” uncertainties. In the context of transgender
medicine, some clinicians navigate uncertainty and
their lack of knowledge about transgender identity
by relying on EBM even though affirming gender
identity is not an illness (shuster 2016). Uncertainty
about transgender care can also result in stigmatiza-
tion and discrimination (Poteat, German, and
Kerrigan 2013). Another study found that internal
medicine residents experiencing uncertainty faced
barriers to obtaining attending physicians’ input,
such as professional hierarchy and admitting
knowledge gaps, which compromised patient care
(Farnan et al. 2008).
Uncertainty characterizes various aspects of
reproduction. Prenatal screening may entail diag-
nostic uncertainty regarding the implications for the
pregnant person and fetus (Markens, Browner, and
Preloran 2003; Rapp 2004; Rothman 1993). For
those who want to avoid pregnancy, there is consid-
eration of contraceptive method, risk, and side
effects (Geampana 2019). A study of contraceptive
counseling found that how clinicians communicate
uncertain side effects impacts patient decision-
making and autonomy and has health consequences
(Littlejohn and Kimport 2017). Changes in the
organization of medicine also contribute to uncer-
tainty. Following the corporatization of hospitals,
Morris (2014) found that greater economic pres-
sures combined with fear of obstetric malpractice
suits fueled the rise in caesarian sections in the
United States, limiting organizational and profes-
sional risk at the expense of patients’ well-being.
While uncertainty characterizes all of medicine,
abortion is medically relatively straightforward.
Uncertainty about abortion care often originates
from outside rather than within the medical context.
For example, those seeking care in restrictive con-
texts may be uncertain about whether care is legally
available and contend with social myths about
abortion that influence decision-making (Heymann
et al. 2022; Kimport 2021). Therefore, it appears
that a critical unexplored source of uncertainty is
the political context of care.
The Politicization of Abortion Care in
the United States
Abortion in the United States has a history of politi-
cization that shapes contemporary care provision
(e.g., Cohen and Joffe 2021; Ginsburg 1998; Luker
1985). Despite abortion being a safe and common
procedure, it has been marginalized such that the
majority of abortions are performed in dedicated
abortion clinics (Freedman 2010). Anti-abortion
violence and legislative battles further constrain
abortion access and increase stigma (Harris et al.
2013). Since 2010, a surge in state-level abortion
restrictions has further politicized abortion care,
with close to half of all restrictions being enacted
during this period (Guttmacher Institute 2019). In
2022, the Supreme Court of the United States over-
turned Roe v. Wade, which eliminated the federal
right to abortion and resulted in immediate legal
restrictions—including complete bans—throughout
parts of the country (Guttmacher Institute 2022).
The legislative context continues to rapidly change
in many states (McCann 2022).
Prior studies on abortion restrictions focus on
their impact on the provision of care and decreased
access to abortion. Restrictions result in increased
costs and travel distances, delays in obtaining care,
and medical practices that raise rather than reduce
medical risk (Fuentes et al. 2016; Grossman and
White 2018). Others show that restrictions increase
clinic closures and service fluctuations (McGowan,
Norris, and Bessett 2020). Recent research exam-
ines abortion seekers’ and the public’s knowledge
of abortion legality and barriers to accurate infor-
mation (Bessett et al. 2015; White et al. 2016). For
example, uncertainty about the legality of abortion
in Ohio and believing that it was illegal increased
during periods of legislative activity to propose a
six-week abortion ban (Gallo et al. 2021).
A growing body of literature explores providers’
experiences of recent abortion regulations. For exam-
ple, abortion providers in North Carolina challenged
regulations by creatively scripting state-mandated
abortion counseling (Buchbinder 2016). Restrictions
and separating abortion care from mainstream medi-
cine also contribute to challenges in training abortion
providers, limiting the number of providers (Gyuras
et al. 2023). Only 64% of U.S. obstetrics and gynecol-
ogy residency programs offer routine abortion train-
ing (Steinauer et al. 2018), which will likely decrease
in a post-Dobbs context. Even trained providers find
themselves unable to provide care for various rea-
sons, such as work policies (Freedman 2010).

Czarnecki et al.
473
Also important, yet underexplored, is how
reproductive health care providers working outside
of abortion clinics experience abortion restrictions
and whether restrictions contribute to uncertainty.
These providers also interact with patients who
need and desire abortion care, which is offered—
although less frequently—in some hospitals
(Czarnecki et al. 2019; McLemore, Kools, and Levi
2015). A recent study of genetic counselors work-
ing in Ohio showed that legislation negatively
impacted the provider–patient relationship by com-
pressing the timeline for decision-making, inhibit-
ing capacity for patient advocacy, and increasing
emotional burnout (Heuerman et al. 2022). Prior
research on regulations in religious hospitals offers
insights into constraints on reproductive health care
(Stulberg, Jackson, and Freedman 2016). Across
the United States, Catholic hospital policies restrict
care—including for miscarriage management
(Freedman and Stulberg 2013). Abortion clinic clo-
sures further decrease referral options (Zurek and
O’Donnell 2019). A mixed-methods study assess-
ing abortion policies in U.S. teaching hospitals
found that over half limited abortion beyond what
is mandated by state law, particularly in the
Midwest and South (Zeldovich et al. 2020). This
research shows that the political context of care
shapes medical practice and training.
The Political Context of Abortion
Care in Ohio
Since 2011, Ohio has passed numerous abortion-
restrictive laws. Prior to the recent Dobbs decision,
Ohio was one of the most abortion-restrictive states
(Norris et al. 2020). The day that Roe was over-
turned, a federal judge granted the state of Ohio’s
request to allow a bill that had been suspended by a
legal challenge under Roe to take effect immedi-
ately (SB23). Doing so made providing abortion
illegal in almost all circumstances upon detection of
embryonic cardiac activity, typically around six
weeks’ gestation. The embryonic cardiac activity
ban remained in effect until mid-September 2022,
when a state court judge blocked the bill for the
duration of a new legal challenge to the ban. As of
this writing, the embryonic cardiac activity ban
remains blocked. The dynamic status of Ohio’s
abortion restrictions demonstrates the evolving leg-
islative climate in the post-Dobbs era.
Numerous Ohio restrictions remain in effect,
including mandatory waiting periods, counseling
requirements, restrictions constraining minors seek-
ing abortion care, prohibitions on public insurance
coverage for abortion and on facilities performing
them, viability and gestational restrictions, transfer
agreement requirements, a Down syndrome abor-
tion ban, and abortion method bans (Heuerman et al.
2022). Providers may face considerable civil and
criminal penalties, such as felony charges, prison
sentences, fines amounting to several thousands of
dollars, and loss of medical licensure, should they
be found to be in violation of certain laws, including
restrictions on dilation and evacuation1 (D&E) pro-
cedures, a ban on abortions sought due to fetal
Down syndrome, and a 22-week gestational limit.
Our study examines how the distinct character
of recent legislative restrictions—their number,
scope, and frequency—contributes to uncertainty
that may impact patient care. Uncertainty is likely
even more common and challenging in a post-
Dobbs context where the legal context in many
states is in greater flux (McCann 2022).
Data and Methods
We conducted focus groups with prenatal genetic
counselors and ob-gyns employed in a variety of
Ohio hospital settings (e.g., private, public, aca-
demic, religious). Focus groups are a useful method
for exploratory research that enables respondents
with similar characteristics, such as profession, to
engage in conversation. Participants who were
unable to attend focus groups shared their experi-
ences in individual, semistructured interviews. The
University of Cincinnati’s Institutional Review
Board approved this study.
Participants were recruited through professional
society memberships and listservs, advocacy
groups, university-affiliated hospitals, and snow-
ball sampling. Participants were eligible if they
were ob-gyns or genetic counselors who worked in
Ohio for at least six months between 2010 and
2020. We excluded providers working in dedicated
abortion clinics because the impact of abortion reg-
ulations on those who work in abortion clinics has
been well documented. Less understood are the
implications of these laws for general obstetric-
gynecological practice and for abortion-adjacent
health care providers—such as genetic counselors—
who work in the same state regulatory context.
Genetic counselors counsel patients on their repro-
ductive options, including abortion, prior to prena-
tal testing and following prenatal diagnosis.
Ob-gyns interact with patients who need a range of
reproductive health care, such as abortion, contra-
ception, and management of miscarriage and ecto-
pic pregnancy.

474
Journal of Health and Social Behavior 64(4)
We conducted four ob-gyn focus groups, ranging
from 2 to 19 participants per group, and five individ-
ual interviews with ob-gyns (n = 35). We conducted
five genetic counselor focus groups, ranging from 2
to 6 participants per group, and two individual inter-
views with genetic counselors (n = 19). The total
number of participants in the study was 54.
Participants provided verbal consent and received an
Ohio legislative timeline of abortion restrictions
between 2010 and 2019 (Heuerman et al. 2022).
Participants were asked to review the timeline and
discuss how regulations impacted their work. A
semistructured interview guide ensured comprehen-
sive coverage of the topic. Although some partici-
pants reported the type of hospital at which they
were employed (e.g., private, public), some
expressed uncertainty about their institution type,
thus we were unable to definitively collect that infor-
mation from all respondents. When a respondent’s
hospital type was provided, we note it in the results.
Interviews and focus groups were audio-
recorded. Focus groups were 90 minutes; individual
interviews lasted 45 to 60 minutes. The recordings
were transcribed and deidentified, including provi-
sion of pseudonyms for participants. At least two
members of the research team thematically coded
each transcript using ATLAS.ti, a qualitative analy-
sis software. Coders met regularly to discuss
themes and resolve discrepancies. Analysis con-
sisted of an iterative process of thematic categoriza-
tion,
consultation
with
relevant
literature,
discussion of themes, and revisiting the data and
refining codes (Emerson, Fretz, and Shaw 2011).
Major themes emerged: uncertainty and confusion,
negative impacts of restrictions on patients and pro-
viders, ethical dilemmas, varied interpretations,
regional variation, and inequalities in access.
Results
We found that Ohio’s rapidly shifting legislative
landscape of abortion regulation produced uncer-
tainty for ob-gyns and genetic counselors working
in hospitals. Hospitals’ interpretation and imple-
mentation of abortion legislation—some of which
was not in effect at the time of the study—deepened
uncertainty about what is permissible. We show that
uncertainty can result in more stringent restrictions
than necessitated by the law, further limiting access
to care. We also found uncertainty about the legal,
professional, and personal consequences of provid-
ing or facilitating access to abortion care in a restric-
tive context, with ob-gyns’ closer proximity to
abortion care increasing their perception of threats
to their professional and personal integrity and live-
lihood. Importantly, all respondents understood
abortion as health care and were frustrated when
they were unable to provide appropriate patient care.
“It Was Always Hard to Keep Up with”:
Uncertainty about Legal Restrictions
Although respondents voiced familiarity with abor-
tion legislation, there was widespread uncertainty and
frustration regarding the legal status and content of
several bills, such as abortion method restrictions, rea-
son bans, and prohibitions on the use of public funds.
This uncertainty was partly due to the challenges of
keeping up with a changing legislative context that
includes numerous bills with varied legal statuses
(proposed, passed, enacted, enjoined,2 partially
enjoined). Anna, an ob-gyn, explained, “It’s always so
confusing what went up for votes, what went through,
and what got blocked by a judge and what was enacted
. . . it was always hard to keep up with.”
The swift pace of legislative changes left pro-
viders in a chronic state of uncertainty in the work-
place, with patients’ options being subject to change
from one day to the next. For instance, genetic
counselors described how routine referrals became
a process marked by uncertainty, which is exacer-
bated by abortion clinic closures in the state, limit-
ing referral options. Genetic counselors managed
uncertainty by regularly calling abortion clinics for
the most current legal information about patient
options. Bridget, a genetic counselor working in an
academic setting, explained:
Every week I had to call [the clinic] that we
typically refer to and say, “What is the status this
week? . . . What is my time limit now?” I found
it frustrating that I would have to make that call
every single week to know how to guide
[patients].
To navigate uncertainty, some respondents adapted
their care approaches. For example, prenatal genetic
counselors typically see patients as they are nearing the
state’s 21 weeks and 6 days gestational limit on abor-
tion because imaging technology used to detect fetal
abnormalities is effective at 18-weeks’ gestation and
later. Aware of the compressed timeline for decision-
making, some genetic counselors counseled patients
considering termination to start fulfilling the numerous
legal requirements for abortion care because “every
day counts.” Other providers encouraged earlier pre-
natal testing, but technological limits and uneven utili-
zation of prenatal care limit this strategy.

Czarnecki et al.
475
Ob-gyns also described how uncertainty about
changing laws affected their practices. In 2018, the
Ohio legislature restricted D&E procedures, the
most common second trimester abortion method
and the only method available after 15 weeks in
Ohio. Ob-gyns described how the dynamic political
context affects patient care:
Sandy: After the D&E ban was officially passed . . .
[the courts] were figuring out injunctions and
stuff. We had a patient come in for a miscar-
riage, which regardless of the method would
have been okay at that point. But it was around
14 weeks, we were going to do a D&C and
ended up doing kind of like a modified D&E,
and right before we started doing that part, my
chief resident turns to me and goes, “Wait, we’re
allowed to do this right?” Because literally just
in terms of that information, it’s just not widely
available or widespread.
The focus group conversation continued at length
about whether a D&E would be legal in a variety of
patient circumstances that ob-gyns encounter in
their work, showing the extent of uncertainty on
their practice.
Professional organizations, advocacy groups,
and their employers were rarely cited as useful
sources of information about abortion legislation.
Respondents described that hospitals typically
refrained from formally discussing legislation.
Anna, aforementioned ob-gyn, could not recall her
employers ever addressing these laws with clini-
cians, “The institutions that I worked at . . . never
directly addressed these laws or their regulations on
abortion to the med students or the fellows or any-
body.” Respondents often learned what was permis-
sible through social media, the news, and on an ad
hoc basis when a patient presented for care.
Legal stipulations that are not medically legible
were another source of uncertainty. Tamara, an ob-
gyn resident at a public hospital, discussed her frus-
tration with a proposed bill that would, if in effect,
require that clinicians reimplant an ectopic preg-
nancy into the uterus or face murder charges:
It doesn’t even make sense. It’s not a thing we
are capable of doing. So, it’s crazy to me that
there’s a lot of made-up medicine . . . that’s not
safe to patients, ectopics are dangerous. People
can bleed out very quickly.
Tamara was puzzled by a bill that would require doc-
tors to perform something that was not medically
appropriate or technically possible, thereby under-
mining EBM and professional autonomy.
An ob-gyn resident, Tracy, who worked in a
religious hospital, summed up what we often heard
from respondents: an awareness of the laws without
a full understanding of their status or what it meant
for their work:
It’s hard to know [the laws], you have attendings
that kind of know, or the hospital policies, I kind
of have a sense of what the trajectory has been,
but I don’t know what the current thing is, I
would have to look it up or ask someone. That’s
hard to keep up with.
Tracy’s comment points to multiple actors, such as
senior clinicians and hospital administrators,
involved in translating laws into hospital policy.
Implicit in her comment is that while policies
informed by legislation exist in her workplace, they
may not fully reflect or reference the law.
“Legal versus What’s Available Is
Not the Same Thing”: Institutional
Interpretations of Abortion Legislation
and Regional Variation
Another factor contributing to uncertainty was that
interpretations of legislation could vary by institu-
tion and region of the state. Although the most obvi-
ous reason for institutional variation is due to
restrictions based on funding or institution type, we
found that this does not fully explain the variation.
Respondents also perceived that institutional cul-
tures, personal beliefs, fear and stigma, or a combi-
nation thereof accounted for some variation. We
heard from respondents that Ohio’s hospitals—both
religious and nonreligious—tend to have abortion
restrictions that are more conservative than the law,
impacting patients’ access to abortion care more
than legislation alone would suggest. In fact, laws
not in effect during the study period still informed
institutional policies and practices.
In 2011, Ohio imposed a public facilities ban for
“non-therapeutic abortions,” which remains in
effect. We found that some respondents—including
those working at the same institution—were uncer-
tain about their institution type, such as whether it
was public, private, or nonprofit. This uncertainty is
unsurprising given that hospital mergers and
diverse hospital funding sources can make “institu-
tion type” unclear in practice, making the applica-
bility of an institution-based law potentially unclear

476
Journal of Health and Social Behavior 64(4)
(Creswell and Abelson 2013). Institution-based
restrictions and uncertainty or inaccuracies about
them matter because they decrease access and
because health care providers communicate
patients’ care options. Relaying inaccurate informa-
tion to patients may further decrease access to
services that remain legal. Moreover, hospital net-
works may include different kinds of institutions
with distinct regulations. Susan, a genetic counselor
working in a public hospital, noted:
In our perinatology practice, one of the off sites,
[perinatologists] go to visit a Catholic hospital
where they cannot even address [abortion] at all.
And so, if we want to talk more about [patient]
options, let’s have you come to the main hospital.
Requiring patients to visit a different building in the
same hospital network to discuss options thoroughly
complicates a routine aspect of patient care and
undermines provider autonomy and authority in
relaying options. Respondents explained that these
cumbersome processes burdened patients with
abortion stigma. The added layer of uncertainty
about institution type makes it challenging to know
not only what the restrictions are but also the reason for
them (laws, institutional type, Catholic directives).
Ob-gyns also had different understandings of
what legislation was in effect and what it meant for
their work, even at the same institution. For exam-
ple, a 2017 bill prohibits abortion for reasons
related to fetal Down syndrome. The bill was
enjoined and not in effect at the time of the study.
Carla and Pamela had different understandings of
the bill’s status:
Carla: I don’t think it’s [the Down syndrome ban] in
effect that I know of.
Pamela: I thought it was in effect . . . so we say that
[patients] may have to cross state lines. For
patients that don’t bring it up, I feel I still need
to bring it up and explain that this may be a rea-
son they may or may not be able to have a termi-
nation. It’s part of my standard genetic
counseling for OB patients.
Although at the time a doctor in Ohio could legally
perform an abortion for a Down syndrome diagno-
sis, Pamela thought the bill was in effect and coun-
seled all of her patients that they would need to
travel out of state if they opted to terminate for that
reason. While this is not uncertainty, it points to
confusion and misunderstanding stemming from the
political context, where abortion legislation is
frequently proposed, passed, partially implemented,
or not in effect. Moreover, Ohio’s attorney general
has communicated inaccurate information about
legislation to the media (Bischoff 2022).
Legal and institutional definitions of terms such
as “lethal” and “life-threatening” can be ambiguous
in practice and may not correspond to clinical real-
ties. We often heard that institutions and providers
erred toward more conservative interpretations.
Karen, an ob-gyn at a private hospital, described
how when a patient presented hemorrhaging, the
hospital and providers disagreed on when the case
became “emergent.” Although the medical evi-
dence left little doubt as to the outcome, the legal
uncertainty required providers to stand by and let
the patient’s condition worsen before intervening:
It was a very heated situation. We had to wait ’til
her blood count was low enough to call it
emergent. So, we waited ’til her hemoglobin was
below seven . . . even at that point, there was a lot
of back and forth, but that was legally through
the hospital. We had to wait until that point. So,
there’s definitely a lot of frustration . . . because
[providers] knew what they wanted to do, but
they couldn’t legally do that.
Karen described this as a case of medical but not
legal certainty. Although clinicians had clarity about
the likely course of the condition, the hospital
required more extreme evidence of the life-threatening
circumstances to show they had met the law’s
requirements.
Similarly, Carol, a genetic counselor, told us that
after legislature passed the Down syndrome bill,
her hospital changed their policies to ban not only
terminations for Down syndrome—even though the
regulation was not actually in effect—but for any
“non-lethal” diagnoses. She described the sudden
shift in her hospital’s policy and the subsequent
day-to-day challenges of determining what consti-
tutes a “lethal” diagnosis:
It was really unfortunate because we literally
had the surgery [to terminate a pregnancy with a
Down syndrome diagnosis] planned for this
particular patient, and we had to call her the day
before her surgery and say, “Oh sorry, we can’t
do this for you anymore.” . . . It makes it more
difficult for me to figure out, is this considered—
well, for any genetic condition—is this
considered lethal enough? . . . Is my institution
likely to consider this lethal or not?

Czarnecki et al.
477
Carol’s hospital, which she characterized as “pretty
liberal,” shifted their policy to be more conservative
than the law. When asked why she thought the pol-
icy shifted to such an extreme, Carol explained:
Well, the publicity generated from the enactment
of that law prompted our department head to
question why we were doing this, and then that
led to legal getting involved, and I think with the
political environment that’s when things
changed and they [hospital leadership] started
cracking down on us.
Carol cited the political climate as shifting her hos-
pital’s policy toward greater restriction than the law
would require, demonstrating the chilling effect of
the political context.
Similarly, institutions had different definitions
of clinical and legal terms. Judy, an ob-gyn, had
experience working in two different public hospi-
tals in two regions of the state. She described how
the 2011 public facilities ban for “non-therapeutic
abortions” applied to both institutions but “legal
higher ups” at each had different interpretations of
what “non-therapeutic” meant:
It’s whether or not we can provide terminations
in a government-supported hospital, basically.
Some have chosen to interpret the law that if
it’s not immediately potentially lethal to the
mom, we can’t do a termination in the hospital
whereas other hospitals say, “If we can say that
this anomaly will not result in a live born baby
than any risk—any pregnancy carries a risk—
there’s a risk to the mom then with no benefit to
the fetus, we can justify performing the
procedures.”
The hospital legal departments’ different interpreta-
tions of “non-therapeutic” resulted in differences in
abortion provision, with one being more restrictive
than the other.
However, we also heard from respondents who
drew on traditional notions of medical uncertainty
to challenge their institutions’ interpretations. Erin
described how clinicians challenged her hospital’s
legal team’s interpretation of “life-threatening,”
which hinged on a degree of certainty of predicting
death that was not possible:
We’ve been back in front of our legal team and
saying these circumstances, you can never
guarantee if anyone dies. . . I can’t guarantee she
is going to die. And so, we’ve had a little bit
stronger push the other way, with a legal team
and they seem to then go that way.
Erin’s experience of her hospital’s shift points to
internal pressures from clinicians, hospital adminis-
trators, and ethics and legal teams that can shape
institutional policy.
Referral practices were also marked by uncer-
tainty. In 2017, a gestational limit bill went into
effect that bans abortion at 20-weeks postfertiliza-
tion, which is 22 weeks since the person’s last men-
strual period. The bill, often referred to as the
“20-week ban,” itself suggests a stricter interpreta-
tion of two fewer weeks than the law actually per-
mits. Although the law is confusing, other factors
may impact an institution’s gestational limit, such
as fear of legal liability, lack of providers, staff, and
institutional pressures. Genetic counselors debated
the gestational limit up to which their local abortion
clinic provided care:
Martha: I think it’s 17 and 6 and there’s a consistent
three-week waiting period and they require one
week in between the first and second appoint-
ment . . .
Sarah: [Patients] have to know by like 13 and 6 to
meet all of those requirements. . .
I asked [the clinic] why they changed that from
19 and 6 to less, and the person I spoke to on
the phone honestly couldn't give me an
answer. . . I haven’t been able to get an actual
answer. I assumed it was because of legisla-
tion, but it’s the same physicians who do it at
[hospital] and there's a different time limit
there.
This exchange shows uncertainty about the clinic’s
gestational limit, confusion about the legally
required wait time between abortion counseling and
provision appointments (24 hours in Ohio), and
whether the clinic’s gestational limit changed due to
legislation or institutional factors. There is not only
uncertainty about one’s own institution but also
where patients are referred for care.
Respondents noted that local political climate
shaped hospital policy across the state. Mary, an ob-
gyn working in southwest Ohio, explained that her
hospital’s interpretation of the law is more conser-
vative than other regions of the state:
Talking to other providers at other locations,
[they don’t seem] to be as restrictive. . . I think
the law is restrictive, but our institution’s

478
Journal of Health and Social Behavior 64(4)
interpretation is so severely conservative
[compared to] other parts of the state.
Patients present at hospitals with complicated
pregnancies. Ob-gyns discussed variation in the
treatment of one such complication, premature
membrane rupture, which can lead to sepsis. Andrea,
an ob-gyn, grimly stated, “I’ve had one recently that
was 16 weeks, no fluid on ultrasound, and I had to
look at the patient and say, ‘I’m afraid that you’re
going to get septic and die,’ but I can’t do anything
about it.” Others shared varied institutional interpre-
tations for such cases that spanned from permitting
care, waiting until a patient becomes septic, waiting
until patients are near death (although still uncertain
about whether they could provide care), sending
patients out of state when a “heartbeat” is detected,
and requiring thorough documentation.
Even hospitals considered to be less conserva-
tive imposed hurdles to providing care. A group of
ob-gyn residents, who described their institution as
less conservative, elaborated:
We don’t do elective abortion, so there needs to
be an agreement between a couple clinicians that
it’s indicated, then the ethics department has to
be called, and it is frequently more of a formality.
. . . It’s not a barrier, but it’s a check in the system.
. . . They’ll ask for discussion between usually
two different providers, oftentimes two different
maternal fetal medicine [MFM] physicians, or
an ob-gyn and a MFM, and then the Department
Chair, and an ethicist . . . we have to do a lot of
documentation. . . If it’s in that gray zone, then
getting other physicians to also approve their
decision . . . sometimes it’s consulting other
providers from other specialties like cardiology
or rheumatology to weigh in on how this
pregnancy would impact this patient.
The hospital sought to mitigate uncertainty through
a convoluted process of approvals and documenta-
tion about how pregnancy would affect a patient
physically. In doing so, they undermined profes-
sional autonomy and judgment and contributed to
abortion stigma.
As we have shown, a source of uncertainty in
clinical settings is that institutions across the state
have variable policies, with many being more limit-
ing than the law. Ad hoc institutional guidance that
conflicts with medical expertise constrained care
and endangered patients.
“I Don’t Want to Go to Jail”: Uncertain
Consequences for Providing Care
Uncertainty in reproductive health care settings out-
side of abortion clinics includes the potential legal,
personal, and professional consequences for
involvement in abortion care. Uncertainty about
legal restrictions occurs within a climate of fear and
stigma surrounding abortion care in restrictive con-
texts that impact ob-gyns and genetic counselors
differently. Genetic counselors and ob-gyns are dif-
ferently positioned in their proximity to abortion
care. Ob-gyns may find themselves directly
involved with the provision of abortion care. If they
violate the law, they are subject to civil and criminal
prosecution, along with other risks such as loss of
livelihood and exposing themselves and their fami-
lies to risk of violence. At the time of this research,
this played out differently for genetic counselors,
who voiced their profession’s concerns with profes-
sional legitimacy and public distancing from abor-
tion. All respondents tried to adhere to the law
without exception.
Uncertainty about consequences surfaced when
clinicians were legally or institutionally obligated
to provide or withhold forms of care that might
result in increasing medical risk. For instance, ob-
gyns expressed concern that the D&E ban would
“require us to perform procedures [to cause fetal
demise] that have no medical benefit to the woman
and potentially have a risk.” The law requires that
physicians induce fetal demise prior to a D&E
unless maternal life or health are at risk. This
requirement introduces invasive procedures to
cause fetal demise despite no evidence of a benefit
for this approach as standard practice (Guttmacher
Institute 2017). At the time of the study, providers
found to be in violation of the law could face a
fourth-degree felony charge. Charlotte, an ob-gyn,
shared her fear:
What worries me about . . . the felony [charge] is
that we might allow a woman to hemorrhage to
death, right? Because we’re so afraid . . . I’m
scared to do a D&E on someone coming in
hemorrhaging with her second trimester loss.
And I am going to want to be self-serving, and
say, “Oh well, I am scared . . . I don’t want to go
to jail. What are my kids going to do when I’m in
jail?” and that is horrible. I have been trained to
serve society, and I should do that. To save this
woman’s life because I have the skills to.

Czarnecki et al.
479
Fulfilling a medical obligation to a patient could
place a clinician’s professional and personal well-
being in jeopardy. Conversely, not providing essen-
tial care could put a patient’s life in danger.
Similarly, another ob-gyn, Emily, explained the
role of fear and uncertainty about the consequences
of abortion provision in an ever-changing policy
context:
If you know that overnight that there could be a
new law in place that you could be inadvertently
breaking, I think that is a deterrent for lots of
providers who . . . “I’m not aware of the laws, I
don’t feel comfortable, and because of that I’m
not going to do this” . . . we all take an oath that
we are going to take care of people and we all do,
and I think none of us would sit there and
necessarily let someone hemorrhage to death,
but at the same time, if your livelihood, your
[medical] license, your family, and potentially
your freedom is all on the line, you’re not going
to provide for a patient, unless they’re actively
dying in front of you, a procedure that you’re not
sure is legal . . . because we do see these laws
pop up out of nowhere.
The chilling effect of the political context of care
includes the cumulative toll of restrictions, uncer-
tainty, and constraints on the ability to provide care
that leads some to avoid abortion provision alto-
gether, even for those who support abortion. For
example, Anna shifted her earlier conservative
views on abortion during her medical training and
considered herself to be one of the most well-trained
abortion providers in Ohio. She had worked at a
hospital that was particularly restrictive. Despite her
support of abortion, she explained that it was easier
to work there because she did not have to closely
follow the changing legislation:
In honesty, I’m probably (pause) not proud to
say that there’s a sense of, just acceptance of this
kind of environment . . . [restrictions are]
changing all the time, it’s so hard to know what’s
going on with the laws, it can be really hard to
know even what battles to fight if you wanted to.
So, I think . . . it’s easier to just work at a place
that doesn't allow any abortions and kind of stay
out of the fray.
Anna and others were candid about feeling worn
down and fearful from the onslaught of restrictions
and wanting to avoid uncertainty. For some, more
restrictive institutional interpretations were viewed
as providing “black and white” rules that could
lessen the moral and ethical ambiguities uncertainty
caused and the potential legal and professional
repercussions. But the cost of this was reinforcing
institutional restrictions on patients’ access to abor-
tion and institutional buck-passing (Freedman
2010). A few ob-gyns challenged their institutions
and were able to shift policy. But there is consider-
able risk that leads others to “stay out of the fray.”
Genetic counselors are not directly involved
with abortion provision, which they perceived as
providing a degree of protection from prosecution.
Yet they still experienced uncertainty about being
implicated. Susan explained:
I feel there is some protection from me being a
genetic counselor who currently doesn't bill
under my name because . . . I’m not doing the
procedure. So, I can be an advocate for my
patient and tell them this is what we know, this is
what we don’t know . . . I do feel some protection
at the end of the day that should there ever be
some sort of scenario in which a law was broken
. . . I would hope that I would not be liable for
anything, but I don’t know. . . My name is not on
the letter, so I hope . . . I don’t know; this is scary.
It’s a scary, scary thing to be in.
Susan illustrates how uncertainty and a climate of
fear also pervade professions adjacent to abortion
care. Several laws are written so that who can be
prosecuted remains vague, furthering uncertainty,
fear, and the reach of restrictive legislation. Genetic
counselors could not distance themselves com-
pletely from abortion care and the impact of restric-
tive legislation and uncertainty.
We have shown that politically produced uncer-
tainty is burdensome for health care providers.
Those hoping to evade such uncertainty have few
options that would not further limit abortion access.
Ultimately, we have shown that the political context
produces uncertainty and fear that are far-reaching
and together create a chilling effect that restricts
abortion beyond the law.
Discussion
Abortion is one of the most common and politicized
medical procedures. Although prior scholars have
identified sources of uncertainty that arise from
within medical contexts (Atkinson 1984; Fox 2000;
Gerrity et al. 1992; Light 1979), abortion is

480
Journal of Health and Social Behavior 64(4)
illustrative of how the politicization of care can also
create uncertainty. Our study shows how an influx
of abortion legislation produced uncertainty for ob-
gyns and genetic counselors in hospital settings.
Abortion—a relatively uncomplicated procedure or
medication protocol—was not the source of uncer-
tainty. Rather, respondents reported uncertainty
about legality, institutional policy, and the conse-
quences of providing care in an abortion-restrictive
state. Research on abortion restrictions has illumi-
nated the detrimental impact on access, costs, and
stigma (Fuentes et al. 2016; Grossman and White
2018; White et al. 2019). We show that uncertainty
can also function to restrict abortion beyond what
the law dictates. Our findings describe an additional
source of medical uncertainty and contribute to
understanding the politics of abortion by showing
that the political context of care is a source of medi-
cal uncertainty.
Prior research establishes that cultural and tech-
nological change may contribute to medical uncer-
tainty; we show that the politicization of care may
also contribute to uncertainty. We identify at least
three ways that the politicization of abortion con-
tributed to uncertainty. First, a stark increase in
abortion-restrictive legislation and litigation over
the past decade left our respondents unsure about
the status of bills and laws. We also found that
pending and enjoined legislation nevertheless
shaped hospital policies. Second, despite profes-
sional enthusiasm for standardized, evidence-based
medicine, hospitals across the state have different
interpretations of legislation. Some clinicians prac-
tice at multiple institutions, and policies can differ
between institutions and regionally. Among respon-
dents who reported their institution type, we found
that policy differences were not reducible to institu-
tion type. Because funding sources and the compo-
sition of hospital organizations are complex, some
respondents were unsure of their institution type or
the rationale for some institutional policies. Such
lack of understanding is important because certain
laws apply to specific kinds of institutions.
Variation in policy across institutions and regions
can contribute to uncertainty in referral practices as
well. A recent study found that half of physicians
across different specialties did not know how to
refer patients for abortion (Anderson et al. 2022).
Turning to others to mitigate uncertainty is limited
in this context because policies vary and colleagues
may have inaccurate understandings of them.
Attempts to resolve uncertainty may also bring
unwanted attention that constrains practice. Third,
there is uncertainty about the legal, personal, and
professional consequences for abortion care provi-
sion, where criminal and civil penalties may apply.
This parallels Morris’s (2014) study on caesarian
sections showing that practice changes resulted
from hospitals’ concern about liability. The political
context of care may derail the broader trend toward
evidence-based medicine when laws and policies
are not grounded in medicine (Timmermans and
Berg 2010).
Uncertainty from the political context of care is
significant because it profoundly impacts patients
and health care providers. Although uncertainty is
inherent to medicine, clinicians do not typically
wonder whether providing evidence-based medi-
cine will result in a felony charge or loss of medical
licensure. Politically produced uncertainty prevents
health care professionals from providing medically
appropriate care, compromising their professional
obligations (Field et al. 2022). Relatively straight-
forward protocols, such as managing ectopic preg-
nancies and miscarriages, become fraught with
uncertainty. Medical exceptions to abortion laws
confuse more than clarify when criteria are not
defined in medical terms and are unlikely to capture
the full range of medical circumstances (Arey et al.
2022). Uncertainty from politicizing abortion care
impinges on both patient and provider autonomy
because law and politics dictate medical practice
rather than medical expertise. Strict abortion bans
may also contribute to uncertainty about what con-
stitutes an abortion and clinical hesitation to inter-
vene (Zernike 2022).
Uncertainty has worsened in a post-Dobbs con-
text, as the legality of abortion in many states has
been in flux (McCann 2022). On June 24, 2022, the
day that Roe was overturned, Ohio banned abortion
provision after detection of embryonic cardiac activ-
ity, with a very narrow and poorly understood excep-
tion for patients with serious medical conditions.
Shortly after, a 10-year-old rape survivor in Ohio
was forced to travel to Indiana for abortion care.
Ohio’s attorney general then incorrectly stated that it
would have been legal to have the abortion in Ohio at
the time (Bischoff 2022). The embryonic cardiac
activity ban does not include a rape exception (Ohio
Revised Code 2019). The state’s leading legal
authority providing misinformation about state law
underscores the challenges that politicizing health
care presents for those providing and seeking care.
Prior studies show that uncertainty can reinforce
physician authority (e.g., Littlejohn and Kimport
2017). We found that uncertainty can also under-
mine authority by shifting the litmus for decision-
making
from
medical
evidence
to
legal

Czarnecki et al.
481
interpretations. The political context of care can
erode physicians’ autonomy as they face criminal,
professional, and personal threats to their lives
when regulatory policies conflict with medical
expertise (Field et al. 2022). Fear about the poten-
tial consequences of providing care in an ever-
changing policy context could result in ob-gyn
reluctance to provide abortion care at all, demon-
strating the chilling effect of politicized health care.
Respondents were frustrated that laws not grounded
in medicine interfere with their obligation to patients.
In contrast to studies showing that vague abortion
policies may allow for greater physician discretion
(Zeldovich et al. 2020), we found that vagueness
often intensified uncertainty in a context where the
threat of criminalization looms. Overinterpretation
of the law was the norm in Ohio, further demon-
strating the myriad ways in which a state’s political
climate can impede reproductive health promotion
(Blake and McGowan 2020).
Although genetic counselors voiced less fear
about repercussions because they are not perform-
ing abortions, they nevertheless expressed uncer-
tainty about liability for facilitating care. With the
passage of abortion bans for reasons related to fetal
characteristics, genetic counselors will be further
involved in navigating legislation (Heuerman et al.
2022). Moreover, anti-abortion bills inspired by
Texas’s SB8 empower ordinary citizens to sue any-
one facilitating abortion, potentially implicating an
array of health care professionals and exacerbating
uncertainty. Future research should consider the
conditions under which uncertainty erodes or
expands medical authority.
The political context of care may produce uncer-
tainty
wherever
medical
care
is
contested.
Transgender health care, an area already marked by
uncertain expertise, has parallels with the politiciza-
tion of abortion (shuster 2016). A Texas hospital
recently halted gender-affirming therapies out of fear
of potential ramifications after a politician equated
gender-affirming care to “child abuse” (Goodman
2022). Targeting clinicians providing gender-
affirming care echoes the anti-abortion movement’s
targeting of abortion providers, fueling a climate of
fear. Infertility clinicians have also expressed con-
cern that post-Roe personhood bills may extend to
IVF embryos, generating uncertainty in fertility
medicine (Hoffman 2022). Although our study
focuses on a shifting legislative and policy context,
political context encompasses more than legislation
and policy. For example, the politicization of the
COVID-19 pandemic contributed to uncertainty
about prevention, treatments, and vaccines (Abbas
2022; Kreps and Kriner 2020). Uncertainty arising
from the political context may have negative impli-
cations for patient trust in medicine as expertise and
evidence is undermined or criminalized.
Conclusion
Because the landscape of abortion care in the United
States is expected to continue to change, future
research should examine how restrictive policies
contribute to uncertainty in various clinical settings.
People unable to access timely abortion care may
present at hospital settings later in pregnancy with
more complicated care needs (Arey et al. 2022).
Because the use of self-managed abortion will likely
increase and may be further criminalized, emer-
gency medicine is poised to become a setting
marked by uncertainty related to abortion care and
legality (Harris and Grossman 2020). The relation-
ship between medicine and the law in different care
contexts will be important to examine. A recent
study on drug testing during pregnancy identified
how medical practice became a form of criminaliza-
tion and mode of governance (McCabe 2022). In
our study, criminalization of health care providers
was a greater concern given current state legislation.
How reproductive health care providers navigate
the shifting legislative context and how patients will
be impacted will be important to examine.
Our findings have implications for advocacy
and policymaking. Lack of clear information about
legislation and how it applies to patient care was a
prominent theme from our focus groups. Professional
societies and institutions should ensure that health
care providers are equipped with information about
how legislation impacts care provision, including
referral practices (Heuerman et al. 2022). Health
care providers may also require knowledge about
the policies and nuances of out-of-state referrals
(Goyal et al. 2022). Providers will be better able to
care for their patients if they have guidance about
how to navigate legislation that may not be medi-
cally legible in clinical practice. Professional soci-
eties
and
advocacy
organizations
preparing
recommendations for providers should also con-
sider that institutional policies can vary and contrib-
ute to uncertainty. The factors discussed here are
not inherent complications of abortion care—they
are politically produced complexities that impact
health care providers and patients. By identifying
the political context of care as a source of uncer-
tainty in medical practice, we expand our under-
standing of both medical uncertainty and barriers to
abortion access.

482
Journal of Health and Social Behavior 64(4)
Acknowledgments
The authors thank Jessie Hill, JD, for providing guidance
on understanding and discussing Ohio legal regulations.
We also thank Dr. Meredith Pensak for her insights on
abortion provision in Ohio; and Cynthia Beavin, Dyanna
Burnham, and Colleen Kavanagh for their research assis-
tance. We are grateful to the editors and three reviewers
for their insightful feedback.
Funding
The authors disclosed receipt of the following financial
support for the research, authorship, and/or publication of
this article: Data collection was supported by a grant from
an anonymous foundation.
ORCID iD
Danielle Czarnecki
 https://orcid.org/0000-0002-7299-9074
Notes
  1.	 Dilation and evacuation (D&E) involves dilating
the cervix and removing pregnancy tissue from the
uterus. It is used for terminations and miscarriage
management after 15 weeks’ gestation.
  2.	 “Enjoined” refers to laws that were passed but are
not currently in effect due to a court order. “Partially
enjoined” means some aspects of the law are in effect.
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Author Biographies
Danielle Czarnecki is a visiting assistant professor in the
Department of Sociology at Case Western Reserve
University. Her research explores contested medical tech-
nologies and practices, with a focus on reproduction. Her
new research examines women’s experiences with multi-
fetal pregnancy reduction.

Czarnecki et al.
485
Danielle Bessett (she/her) is a professor of sociology and
faculty affiliate of both Women’s, Gender, and Sexuality
Studies and the Medical Scientist Training Program at the
University of Cincinnati, Ohio. Her research centers on the
sociology of reproduction. Bessett directs UC’s Kunz
Center for Social Research and co-leads OPEN, which
conducts rigorous, interdisciplinary research to assess the
reproductive health and well-being of Ohioans in the con-
text of federal and state policies.
Hillary J. Gyuras is a senior research associate at the
University of Cincinnati with the Ohio Policy Evaluation
Network. Her research focuses on the politicization of
sexual and reproductive health care and seeks to center the
voices of those impacted by abortion restrictions.
Alison H. Norris is an associate professor in Ohio State
University’s College of Public Health and College of
Medicine. Dr. Norris is the co-principal investigator of
OPEN, an interdisciplinary research program that studies
the impacts of reproductive-health-related policies and
laws on the health and well-being of Ohioans. Dr. Norris
also leads a longitudinal epidemiologic cohort study inves-
tigating sexual and reproductive health decision-making
among rural Malawians, access to contraception and abor-
tion, prevention of unwanted pregnancy and sexually
transmitted diseases, and knowledge and stigma about
sexual and reproductive health.
Michelle L. McGowan is a senior associate consultant II
in the Biomedical Ethics Research Program and the
Department of Quantitative Health Sciences at Mayo
Clinic and a visiting scholar in Women’s, Gender, and
Sexuality Studies at University of Cincinnati. She is an
empirical bioethicist whose research focuses on the ethical
and social implications of reproductive health policies.
She leads a study on the impact of clinic closures and
changes in service delivery on abortion clinics, health care
providers, and abortion seekers.

    Policy Problem:

Answer: Since 2011 Ohio has enacted more than 16 abortion-restrictive statutes, and their rapid turnover, vague language and uneven institutional implementation have turned a relatively straightforward medical service into a source of pervasive clinical uncertainty far beyond dedicated abortion clinics.1 Obstetrician-gynecologists and prenatal genetic counsellors working in hospitals now face conflicting or incomplete guidance, region- and hospital-specific interpretations of the same laws, and the constant threat of felony prosecution or loss of licence if they misjudge whether a procedure is legal.2 To protect themselves, institutions routinely adopt policies that are even more conservative than state law, forcing providers to delay or deny evidence-based care such as miscarriage management or termination for lethal fetal anomalies, and compelling patients—especially those with low resources or complex pregnancies—to travel out of state or forgo timely treatment altogether.3 The chilling effect generated by politicised regulation therefore compromises patient safety, widens geographic and socioeconomic disparities in reproductive health, erodes professional autonomy, and burdens an already strained hospital workforce—demonstrating an urgent need for clear, clinically grounded policy that insulates medical decision-making from partisan flux.