Dissertations and Theses
Date of Degree
6-2-2026
Document Type
Dissertation
Degree Name
Doctor of Philosophy (Ph.D.)
Department
Community Health and Social Sciences
Advisor(s)
Dr. Diana Romero
Committee Members
Dr. Emma Tsui
Dr. Chloe Teasdale
Dr. Wendy Chavkin
Subject Categories
Public Health
Keywords
reproductive justice, reproductive autonomy, abortion care, contraceptive autonomy, mixed-methods, New York City, Alabama, Idaho, Oklahoma, Tennessee
Abstract
Background: Reproductive health decision-making is applicable to a wide range of reproductive choices, and the extent to which a person can make autonomous decisions may be infringed by interpersonal, institutional, or structural factors. The current conditions of reproductive autonomy in the United States (US) vary significantly, in large part because state and local policies dictate the availability and affordability of potential options across the continuum of reproductive care. Reproductive healthcare decisions are often jointly made by clinicians and patients; however, most research about reproductive health decisions focuses on the decision-making experience of the patient. Through three specific aims, this work explores the influence of structural factors (e.g., state-level policy, neighborhood-level racialized segregation of income, and individual-level income) on the self-perceived autonomy of physicians and patients in making reproductive health decisions related to pregnancy termination and contraceptive use.
Methods: Mixed-methods approaches were intentionally selected to effectively explore the three specific aims below.
- Aim 1: Describe the ways in which constrained options for reproductive healthcare affects clinicians’ decision-making and subsequent patient care, using a thematic analysis approach with grounded theory methodology to analyze in-depth interviews with clinicians practicing in four states where strict abortion bans are in place.
- Aim 2: Explore how practicing in an environment with constrained reproductive care options has influenced clinicians’ psychological experiences of practicing medicine, including their relationship to their work and their sense of self professionally and personally, using narrative analysis of in-depth interviews with clinicians practicing in four states where strict abortion bans are in place.
- Aim 3: Measure the association between individual socioeconomic status and two constructs of reproductive autonomy (contraceptive autonomy and abortion self-efficacy) in an environment with high availability of reproductive care, and the extent to which this relationship is modified by area-based racialized economic deprivation, using multilevel regression models.
The first two aims used transcripts from in-depth interviews collected in the Medical Integrity Initiative, a study of 32 in-depth interviews with physicians currently or recently practicing in four states with strict abortion bans (Alabama, Idaho, Oklahoma, Tennessee). Participants were practicing in emergency medicine, maternal fetal medicine including some with training in genetics, obstetrics, oncology, or reproductive endocrinology. Between July and October 2024, interviews were conducted via Zoom and then transcribed. In Aim 1, thematic analyses based on grounded theory methodology uncovered nuances related to physicians’ decision-making practices and subsequent effects on patient care. Analysts coded data in Dedoose using open followed by axial coding, and in-depth interpretive analysis. In Aim 2, a narrative analysis approach informed by Carol Gilligan’s Listening Guide was used to explore a subset (n=11) of these physicians’ psychological experiences providing reproductive and other health care. Aim 3 used cross-sectional survey data from the Abortion and Reproductive Autonomy in New York City Survey, which captured information in July-August 2023 from NYC residents who were assigned female at birth and were between 18-54 years. The final analytic sample included 1,651 respondents. Regression models were used to examine the associations between individual-level socioeconomic status and two reproductive autonomy outcomes—contraceptive autonomy and abortion self-efficacy—and to evaluate how area-level racialized economic deprivation influences these relationships. Quantitative analyses were conducted in SAS-callable SUDAAN (descriptive statistics) and SAS 9.4 (inferential statistics). All aspects of this dissertation included intentional reflexivity practices to mitigate potential biases, capitalize on unique insights and possibilities, and increase the overall trustworthiness of the study findings.
Results: In Aim 1, we identified three themes related to clinical decision-making: (1) physicians have lost capacity and security in making independent treatment decisions; (2) physicians are forced to compromise care quality when all medical options are not permitted; and (3) some participants engaged in acts of resistance to uphold their integrity as physicians. In Aim 2, we found that physicians’ experiences trying to uphold their personal and professional integrity under severe constraints on their work are emotionally charged and often painful experiences. These experiences were encapsulated in five voices: (1) the voice of measured professionals; (2) the voice of guarded isolationists; (3) the voice of strategized solidarity; (4) the voice of defiant opposition; and (5) the voice of traumatized healers. Results indicate that physicians are suffering from moral injury because they perceive that the harm caused to their patients is, in part, due to their own actions and inactions. In Aim 3, we found that women of reproductive age in NYC who are living in poverty are at greater risk of experiencing compromised contraceptive autonomy and abortion self-efficacy compared to those with higher household incomes, even when accounting for other social and demographic characteristics. These associations are not modified by the relative degree of racialized income segregation in their residential neighborhood.
Conclusion: This dissertation explored specific structural constraints on autonomous decision-making related to contraceptives, abortion care, and medical treatments that are constrained by rendering pregnancy termination illegal. We found evidence that abortion bans are changing decision-making processes for physicians practicing medicine across various specialty areas, including through changes to their ability/comfort in making treatment decisions independently and changes to the quality of care they can provide. Further, we found that these physicians are experiencing distress, despair, and moral injury as they navigate the ethical complexities of complying with – or defying – laws that contradict standard-of-care guidelines. Lastly, this research showed that the constraints of living in poverty are associated with compromised contraceptive autonomy and abortion self-efficacy, even in a setting with high accessibility to reproductive care like NYC. This dissertation identifies opportunities for future research, has implications for public policy related to reproductive access and anti-poverty efforts, and contributes to the evolving public discourse related to sexual and reproductive rights.
Recommended Citation
Shiman, Lauren J., "Reproductive decision-making under constraint: A mixed-methods assessment of structural barriers to reproductive freedom in the post-Dobbs United States" (2026). CUNY Academic Works.
https://academicworks.cuny.edu/sph_etds/130
