Restrictive Abortion Policies Research Articles

Race and Ethnicity of Reproductive-Age Females Affected by US State Abortion Bans

This study compares the race and ethnicity of reproductive-age females between states that implemented restrictive abortion policies after the Dobbs v Jackson Women’s Health Organization decision and states that did not.

The impact of hostile abortion legislation on the United States maternal mortality crisis: a call for increased abortion education.

The growing restrictive abortion policies nationwide and the Supreme Court decision on Dobbs v. Jackson Women's Health Organization place increasing barriers to abortion access in the United States. These restrictions disproportionately affect low-income people of color, immigrants, and non-English speakers, and have the potential to exacerbate already existing racial inequities in maternal and neonatal outcomes. The United States is facing a Black maternal health crisis where Black birthing people are more than twice as likely to experience maternal mortality and severe maternal morbidity compared to White birthing people. Restrictions creating geographic, transportation, and financial barriers to obtaining an abortion can result in increased rates of maternal death and adverse outcomes across all groups but especially among Black birthing people. Restrictive abortion laws in certain states will decrease already limited training opportunities in abortion care for medical professionals, despite the existing abortion provider shortage. There is an immediate need for federal legislation codifying broad abortion care access into law and expanding access to abortion training across medical education. This commentary explores the impact of restrictive abortion laws on the Black maternal health crisis through multiple pathways in a logic model. By identifying current barriers to abortion education in medical school and residency, we created a list of action items to expand abortion education and access.

Mental health and abortions among young women: time-varying unobserved heterogeneity, health behaviors, and risky decisions

In this paper, we provide causal evidence on abortions and risky health behaviors as determinants of mental health development among young women. Using administrative in- and outpatient records from Sweden, we apply a novel grouped fixed-effects estimator proposed by Bonhomme and Manresa (2015) to allow for time-varying unobserved heterogeneity. We show that the positive association obtained from standard estimators shrinks to zero once we control for grouped unobserved heterogeneity that varies across ages. We estimate the group profiles of unobserved heterogeneity, which reflect differences in unobserved risk to be diagnosed with a mental health condition. In addition, we analyze mental health development and risky health behaviors other than unintended pregnancies across groups. Our results suggest that these are determined by the same type of unobserved heterogeneity, which we attribute to the same unobserved process of decision-making. We develop and estimate a theoretical model of risky choices and mental health that is consistent with our empirical results. In the model, mental health disparity across groups is generated by different degrees of self-control problems. Our findings imply that mental health concerns cannot be used to justify restrictive abortion policies.

State-Level Abortion Policy Hostility and Unplanned Births in the Pre-Dobbs Era.

An increasingly hostile policy climate has reshaped abortion access in the United States. Recent literature has studied the effects of restrictive abortion policies on reproductive health outcomes. This study is the first to investigate the association between state-level abortion policy hostility and the pregnancy intentions of women with a pregnancy resulting in live birth. Data are from the Pregnancy Risk Assessment Monitoring System survey, merged with a state-level legislative database from 2012-2018 and other state-level controls. Cross-sectional results reveal that a one-unit increase in abortion policy hostility is associated with a relative risk (odds) of having a live birth resulting from an unintended versus intended pregnancy that is 1.02 times as high (RRR = 1.02, 95% confidence interval = 1.01, 1.03). This result corresponds to a 13% increase in the predicted probability of having a live birth resulting from an unintended pregnancy between a zero-hostility and a maximum-hostility state. Models stratified by demographic and socioeconomic characteristics reveal that the association between abortion policy hostility and live birth resulting from an unintended pregnancy is particularly robust among women in younger, less educated, Medicaid, uninsured, and rural populations.

Improving Access and Equity in a Post-Dobbs World

Improving Access and Equity in a Post-Dobbs World

The association between reproductive rights and access to abortion services and mental health among US women

BackgroundThis study examines whether living in US states with (1) restrictive reproductive rights and (2) restrictive abortion laws is associated with frequent mental health distress among women. MethodsWe operationalize reproductive rights using an overall state-level measure of reproductive rights as well as a state-level measure of restrictive abortion laws. We merged data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) with these state-level exposure variables and other state-level information. We used multilevel logistic regression to assess the relationship between these two measures and the likelihood of reporting 14 or more days of frequent mental health distress. We also tested whether associations differed across race, household income, education, and marital status. ResultsIn the adjusted models, a standard deviation-unit increase in the reproductive rights score was significantly associated with decreased odds of reporting frequent mental health distress (OR = 0.95, 95% CI = 0.91, 0.99). Women in states with very hostile abortion restrictions had higher odds of frequent mental health distress. Associations between state-level abortion restrictions were larger among women 25–34 years old and women with a high school degree. For example, women aged 25–34 years residing in moderate (OR = 1.54, 95% CI = 1.14, 2.04), hostile (OR = 1.59, 95% CI = 1.15, 2.18), and very hostile (OR = 1.29, 95% CI = 1.02, 1.64) states were more likely to report frequent mental health distress than women living in states with less restrictive abortion policies. ConclusionWe found the association between state-level restrictions on reproductive rights and abortion access and frequent mental health distress differed by age and socioeconomic status. These results suggest abortion rights restrictions may contribute to mental health inequities among women.

Abortion Access and Medically Complex Pregnancies Before and After Texas Senate Bill 8.

To evaluate how Texas health care professionals who care for patients experiencing medically complex pregnancies navigate abortion restrictions. We conducted qualitative in-depth interviews with health care professionals across Texas who cared for patients with life-limiting fetal diagnoses or who had existing or developed health conditions that adversely affected pregnancy. We conducted the first round of interviews March-June 2021 and the second round of interviews January-May 2022 after the implementation of Texas Senate Bill 8 (SB8), which prohibited most abortions after detection of embryonic cardiac activity. We used inductive and deductive qualitative analysis to identify themes and changes in practice after the implementation of SB8. We conducted a total of 50 interviews: 25 before implementation of SB8 and 25 after the law's implementation. We interviewed 21 maternal-fetal medicine specialists, 19 obstetrician-gynecologists, eight physicians whose primary practice is the provision of abortion care, and two genetic counselors. Participants reported presenting their patients with information about health risks and outcomes of continued pregnancy in each policy period; however, counseling on these options was curtailed after implementation of SB8. Even in cases in which a patient's health and, in some cases, life would be compromised, narrow criteria for abortions at hospitals limited care before implementation of SB8, and criteria often became more stringent after implementation of SB8. Administrative approval processes and referrals for abortion delayed care and endangered patients' health, which worsened after in-state options were eliminated after implementation of SB8. Participants noted that patients with more limited resources who were unable to travel out of state often had to continue pregnancies, further increasing their risk of morbidity. Texas health care professionals' abilities to provide evidence-based abortion care to patients with medically complex pregnancies were constrained by institutional policies, and care options narrowed further after implementation of SB8. Abortion restrictions limit shared decision making, compromise patient care, and put pregnant people's health at risk.

All abortions are medically necessary

When restrictive abortion policies are presented there are often two questions posed: will there be an exception to save the life of the ‘mother’ and will there be an exception in the case of rape or incest. This article will demonstrate that there are no distinctive elements to the first ‘exception’, that do not also apply to all abortions on demand. Through consideration of the potentially lethal impacts of pregnancy on physical and mental health, the case will be made that all requested abortions fit the criteria of ‘medically necessary’.

Abortion Policy in the United States: The New Legal Landscape and Its Threats to Health and Socioeconomic Well-Being.

Policy Points The historic 2022 Supreme Court Dobbs v Jackson Women's Health Organization decision has created a new public policy landscape in the United States that will restrict access to legal and safe abortion for a significant proportion of the population. Policies restricting access to abortion bring with them significant threats and harms to health by delaying or denying essential evidence-based medical care and increasing the risks for adverse maternal and infant outcomes, including death. Restrictive abortion policies will increase the number of children born into and living in poverty, increase the number of families experiencing serious financial instability and hardship, increase racial inequities in socioeconomic security, and put significant additional pressure on under-resourced social welfare systems.

Comparison of Early Pregnancy Loss Management Between States With Restrictive and Supportive Abortion Policies.

Mifepristone-misoprostol and office uterine aspiration used for abortion care are also evidence-based, cost-effective strategies for early pregnancy loss management. We aimed to compare the provision of mifepristone-misoprostol and office uterine aspiration for early pregnancy loss between states with restrictive and supportive abortion policies. We conducted a cross-sectional, internet-based survey regarding early pregnancy loss management among obstetrician-gynecologists (OBGYNs) at academic medical centers. We assessed management offered along with facilitators and barriers to implementation of mifepristone-misoprostol and office uterine aspiration. We used χ2 and multivariable logistic regression to compare practice patterns. We analyzed responses from 350 physicians, 56% from states with restrictive abortion policies. OBGYNs in states with restrictive abortion policies were less likely than those in states with supportive abortion policies to offer both mifepristone-misoprostol and office uterine aspiration (33.2% vs. 51.3%; p=.001), to report having received induced abortion training (67.3% vs. 89.6%; p<.001), and to report perceived institutional support for abortion care (49.0% vs. 85.0%; p<.001). After adjusting for confounders, restrictive state policy was no longer associated with providing both mifepristone-misoprostol and office uterine aspiration for early pregnancy loss (adjusted odds ratio, 1.19; 95% confidence interval [CI], 0.58-2.45). However both prior induced abortion training and institutional support for abortion care remained significantly associated (adjusted odds ratio, 2.06; 95% CI, 1.07-3.97 and adjusted odds ratio, 3.91; 95% CI, 2.08-7.38, respectively). OBGYNs practicing in states with restrictive abortion policies are less likely than those in states with supportive abortion policies to have received abortion training or perceive institutional support for abortion care, and they are less likely to offer mifepristone-misoprostol and office uterine aspiration for early pregnancy loss.

Assessing the Effect of Abortion Restrictions: Improving Methodology and Expanding Outcomes.

Assessing the Effect of Abortion Restrictions: Improving Methodology and Expanding Outcomes.

P065Long acting reversible contraceptive (larc) insertions in 2019 in the states with most restrictive and trigger abortion policies

<h3>Objectives</h3> As of May 2022, 26 states have been identified as certain or almost certain to ban abortion should the 1973 Roe decision recognizing women's constitutional right to choose to terminate be overturned. The purpose of this analysis was to describe the rate of insertions of long-acting reversible contraceptives (LARCs), the most effective forms of contraception, in those 26 states. <h3>Methods</h3> Data was from a HealthVerity Marketplace claims data source representing 130 million patients, representing 58% of the US census population. Women aged 15–44 were included in the analysis. For each healthcare encounter, the following data were gathered: three-digit zip code, age, implant insertion (y/n), intrauterine device (IUD) insertion (y/n), provider specialty, and payer type (Medicaid or commercial). LARC insertion rates by three-digit zip code geographic areas in the 26 states with pending abortion bans were described. <h3>Results</h3> In four states with pending abortion bans, LARC insertion rates were consistently low: <2.6% in either all or nearly all three-digit zip code areas. Four states had consistently top quartile LARC insertion rates (>4.1%). The remaining states had wide variation in LARC insertion rates; some three-digit zip code areas fell in the lowest quartile of insertions (<2.6%) and other areas showing highest percentiles of LARC insertions (>4.1%) <h3>Conclusions</h3> Use of LARCs vary among the geographic areas within the states with certain or near-certain abortion trigger bans. These variations in LARC insertion rates may indicate significant additional reproductive health burdens for women who may already be facing significant restrictions on their reproductive health choices.

The Adolescent's Right to Confidential Care When Considering Abortion.

The American Academy of Pediatrics reaffirms its position that the rights of adolescents under 18 years of age to confidential care when considering legal medical and surgical abortion therapies should be protected. Most adolescents voluntarily involve parents and other trusted adults in decisions regarding pregnancy termination and should be encouraged to do so when safe and appropriate. The legal climate surrounding abortion law is rapidly becoming more restrictive and threatens to adversely impact adolescents. Mandatory parental involvement, the judicial bypass procedure, and general restrictive abortion policies pose risks to adolescents' health by causing delays in accessing medical care, increasing volatility within a family, and limiting their pregnancy options. These harms underscore the importance of adolescents' access to confidential abortion care. This statement presents a summary of pertinent current information related to the impact of legislation requiring mandatory parental involvement in an adolescent's decision to obtain abortion services.

The ethical indefensibility of heartbeat bills.

Recently, several states in the United States have sought to adopt more restrictive abortion policies. Most have tried to enact "heartbeat bills" that prohibit most abortions once a fetal heartbeat becomes detectable. This article explores this question: Are heartbeat bills ethically defensible? I argue that they are not. There are at least four problems with them. First, heartbeat bills rely on a problematic understanding of human death. Second, they contradict and even undermine the leading arguments in ethics against abortion. Third, they are ambiguous not just in terms of when they judge fetal heartbeats to be detectable but also in what they deem to be heartbeats. Finally, there is a case to be made that heartbeat bills are disingenuous, both in their intentions and in their underlying motives.

Association of Provider Specialty With Abortion-Related Morbidity and Adverse Events Among Patients Having Procedural and Medication Abortions

Since abortion was legalized throughout the United States in 1973, states have passed restrictive abortion policies, including permitting only obstetrician-gynecologist physicians (OBGYNs) to provide abortions. We are unaware of any research that directly compares patient safety-related outcomes by physician specialty. In this study, we compared major and any abortion-related morbidity and adverse events in abortion care provided by physicians of other specialties versus OBGYNs. Using the IBM Watson Health MarketScan claims database, we identified privately insured individuals who had an induced abortion between January 1, 2011, and December 31, 2014. The primary outcome was major abortion-related morbidity or adverse events, and the secondary outcome was any abortion-related morbidity or adverse events occurring within 6weeks of the abortion. The study cohort included 34,764 patients who had 35,407 abortions-4,843 (13.7%) abortions provided by physicians of other specialties and 30,564 (86.3%) abortions provided by OBGYNs. Major and any abortion-related morbidity or adverse event occurred in 115 (0.3%) and 1,271 (3.6%) of 35,407 of abortions, respectively. In adjusted analyses, there was no statistically significant difference in major abortion-related morbidity or adverse events comparing physicians of other specialties versus OBGYNs (adjusted odds ratio, 1.02; 95% confidence interval, 0.59-1.75), and no statistically significant difference in any abortion-related morbidity or adverse events comparing physicians of other specialties versus OBGYNs (adjusted odds ratio, 0.91; 95% confidence interval, 0.77-1.09). There were no differences in abortion-related morbidity or adverse events by physician specialty. Our findings do not support state laws limiting abortion care to OBGYN physicians.

Variation in Restrictive Abortion Policies and Adverse Birth Outcomes in the United States from 2005 to 2015.

Since 2011, U.S. states have enacted more than 400 policies restricting abortion access. As structural determinants, abortion policies have the potential to influence maternal and child health access, outcomes, and equity through multiple mechanisms. Limited research has examined their implications for birth outcomes. We created a state-level abortion restrictiveness index composed of 18 restrictive abortion policies and evaluated the association between this index and individual-level probabilities of preterm birth (PTB) and low birthweight (LBW) within the United States and by Census Region, using data from the 2005-2015 National Center for Health Statistics Period Linked Live Birth-Infant Death Files. We used logistic multivariable regression modeling, adjusting for individual- and state-level factors and state and year fixed effects. Among 2,500,000 live births, 269,253 (12.0%) were PTBs and 182,960 (8.1%) were LBW. On average from 2005 to 2015, states had approximately seven restrictive abortion policies enacted, with more policies enacted in the Midwest and South. Nationally, relationships between state restrictiveness indices and adverse birth outcomes were insignificant. Regional analyses revealed that a 1 standard deviation increase in a state's restrictiveness index was associated with a 2% increase in PTB in the Midwest (marginal effect [ME], 0.25; 95% confidence interval [CI], 0.04-0.45; p<.01), a 15% increase in LBW in the Northeast (ME, 1.24; 95% CI, 0.12-2.35; p<.05), and a 2% increase in LBW in the West (ME, 0.12; 95% CI, 0.01-0.25; p<.05). Variation in restrictive abortion policy environments may have downstream implications for birth outcomes, and increases in abortion restrictions were associated with adverse birth outcomes in three out of four Census Regions.

Racial/ethnic and educational inequities in restrictive abortion policy variation and adverse birth outcomes in the United States

BackgroundTo examine racial/ethnic and educational inequities in the relationship between state-level restrictive abortion policies and adverse birth outcomes from 2005 to 2015 in the United States.MethodsUsing a state-level abortion restrictiveness index comprised of 18 restrictive abortion policies, we conducted a retrospective longitudinal analysis examining whether race/ethnicity and education level moderated the relationship between the restrictiveness index and individual-level probabilities of preterm birth (PTB) and low birthweight (LBW). Data were obtained from the 2005–2015 National Center for Health Statistics Period Linked Live Birth-Infant Death Files and analyzed with linear probability models adjusted for individual- and state-level characteristics and state and year fixed-effects.ResultsAmong 2,250,000 live births, 269,253 (12.0%) were PTBs and 182,960 (8.1%) were LBW. On average, states had approximately seven restrictive abortion policies enacted from 2005 to 2015. Black individuals experienced increased probability of PTB with additional exposure to restrictive abortion policies compared to non-Black individuals. Similarly, those with less than a college degree experienced increased probability of LBW with additional exposure to restrictive abortion policies compared to college graduates. For all analyses, inequities worsened as state environments grew increasingly restrictive.ConclusionFindings demonstrate that Black individuals at all educational levels and those with fewer years of education disproportionately experienced adverse birth outcomes associated with restrictive abortion policies. Restrictive abortion policies may compound existing racial/ethnic, socioeconomic, and intersecting racial/ethnic and socioeconomic perinatal and infant health inequities.

Abortion as obtainable: Insights into how pregnant people in the United States who considered abortion understand abortion availability,

ObjectiveIn the United States, restrictive abortion policies are concentrated in a subset of states. Little research has examined how people who consider abortion make sense of abortion obtainability and the extent of regulation of abortion care in their state. Study designWe conducted in-depth interviews with 30 pregnant women in Maryland, a state with high abortion service availability and few policies restricting abortion, and 28 pregnant women in Louisiana, a state with low service availability and numerous restrictions, who had considered but not obtained an abortion for their pregnancy. We analyzed findings using inductive qualitative analytic techniques. ResultsAll participants were financially struggling. Most participants in Maryland considered abortion easy to get, while a plurality of participants in Louisiana considered abortion difficult to get. Yet, despite their measurable differences in access, participants in both states considered abortion generally obtainable. Participants in Louisiana who thought abortion difficult to get, but nonetheless obtainable, cited strategies that they already employed for other challenges in their lives as options for overcoming abortion barriers. ConclusionsPregnant women who consider abortion and are subject to restrictions do not necessarily perceive restrictions as barriers. Their accounts illustrate how those impacted by restrictions adapt to constraints on their reproductive autonomy just as they manage many other challenges that restrict their freedom to live self-determined lives. ImplicationsFinancially struggling pregnant people who considered abortion in Louisiana did not perceive restrictions as barriers to abortion, illustrating the broader adoption of strategies to deal with constraints among women living on low incomes.

POSTER ABSTRACTS: P30 ASSOCIATION OF PROVIDER SPECIALTY WITH ABORTION-RELATED MORBIDITY AND ADVERSE EVENTS AMONG PATIENTS HAVING PROCEDURAL AND MEDICATION ABORTIONS

Objectives: Since abortion was legalized throughout the US in 1973, states have passed many restrictive abortion policies, including, in some cases, only permitting obstetrician-gynecologist physicians (Ob-Gyn) to provide abortions. There is no data directly comparing patient safety-related outcomes by physician specialty. To understand if patient safety differs by physician specialty, we compared major and any abortion-related morbidity and adverse events in abortion care provided by physicians of other specialties versus Ob-Gyns.

Greasing the wheels: The impact of COVID-19 on US physician attitudes and practices regarding medication abortion

ObjectiveTo explore US provider perspectives about self-sourced medication abortion and how their attitudes and clinic practices changed in the context of the COVID-19 pandemic. Study DesignWe conducted a multi-method study of survey and interview data. We performed 40 baseline interviews and surveys in spring 2019 and 36 follow-up surveys and ten interviews one year later. We compared pre- and post-Likert scale responses of provider views on the importance of different aspects of standard medication abortion assessment and evaluation (e.g., related to ultrasounds and blood-typing). We performed content analysis of the follow-up interviews using deductive-inductive analysis. ResultsSurvey results revealed that clinics substantially changed their medication abortion protocols in response to COVID-19, with more than half increasing their gestational age limits and introducing telemedicine for follow-up of a medication abortion. Interview analysis suggested that physicians were more supportive of self-sourced medication abortion in response to changing clinic protocols that decreased in-clinic assessment and evaluation for medication abortion, and as a result of physicians' altered assessments of risk in the context of COVID-19. Having evidence already in place that supported these practice changes made the implementation of new protocols more efficient, while working in a state with restrictive abortion policies thwarted the flexibility of clinics to adapt to changes in standards of care. ConclusionThis exploratory study reveals that the COVID-19 pandemic has altered clinical assessment of risk and has shifted practice towards a less medicalized model. Further work to facilitate person-centered abortion information and care can build on initial modifications in response to the pandemic. ImplicationsCOVID-19 has shifted clinician perception of risk and has catalyzed a change in clinical protocols for medication abortion. However, state laws and policies that regulate medication abortion limit physician ability to respond to changes in risk assessment.