State abortion policies and Medicaid coverage of abortion are associated with pregnancy outcomes among individuals seeking abortion recruited using Google Ads: A national cohort study

Waiting to start abortion: A qualitative exploration of narratives of waiting shared in a Reddit community for abortion post-Dobbs leak in 2022

With the Dobbs leak introducing uncertainty about access and the Dobbs v. Jackson Women's Health Organization decision in June of 2022 overturning the US constitutional right to abortion, delays in accessing desired abortion care are likely growing longer and more common. Timely research on people's experiences waiting to access abortion care is needed. Using data from an abortion subreddit (r/abortion), we analyzed posts that described waiting after having decided to terminate the pregnancy, either by having an in-clinic appointment or ordering medication(s) online for self-managed abortion. Our analysis explored described 1) wait time length, 2) factors contributing to waiting, and 3) impacts of waiting. We used a hybrid inductive and deductive thematic qualitative coding approach to analyze a month-stratified 10% random sample of posts to the r/abortion community in 2022 surrounding the Dobbs leak and decision (May-December, n = 523 posts). Among posts to r/abortion that described waiting to start an abortion (n = 80), wait times ranged from one day to more than a month. Lack of appointment availability and waiting for mailed medications were commonly described as causing delays in accessing in-clinic abortion care and self-managed abortion, respectively. People shared challenges with pregnancy symptoms and feelings of anxiety, fear, isolation, and uncertainty. Posters also commonly described needing additional support while waiting. Overall, waiting to start an abortion was extremely stressful and isolating., with people often waiting weeks between ordering medication or scheduling an appointment and initiating the abortion process. Experiences of waiting to start an abortion and their impacts are of increasing concern as abortion access is further restricted. Additional targeted information and support are needed to mitigate these challenges. Providing timely access is imperative to quality care and overall abortion experiences.

Patient experiences using public and private insurance coverage for abortion in Illinois: Implementation successes and remaining gaps

CONTEXT

Insurance coverage for abortion in states where care remains legal can alleviate financial burdens for patients and increase access. Recent policy changes in Illinois required Medicaid and some private insurance plans to cover abortion care. This study explores policy implementation from the perspectives of patients using their insurance to obtain early abortion care.

METHODOLOGY

Between July 2021 and February 2022, we interviewed Illinois residents who recently sought abortion care at ≤11 weeks of pregnancy. We also interviewed nine key informants with experience providing or billing for abortion or supporting insurance policy implementation in Illinois. We coded interview transcripts in Dedoose and developed code summaries to identify salient themes across interviews.

RESULTS

Most participants insured by Illinois Medicaid or eligible for enrollment received full coverage for their abortions; most with private insurance did not and faced challenges learning about coverage status. Some opted not to use insurance, often citing privacy concerns. Participants who benefited from abortion coverage expressed relief, gave examples of other financial challenges they could prioritize, and described feeling in control of their abortion experience. Those without coverage described feeling stressed, uncertain, and constrained in their decision-making.

CONCLUSION

When abortion was fully covered by insurance, it reduced financial burdens and enhanced reproductive autonomy. Illinois Medicaid policy-with seamless enrollment options and appropriate reimbursement rates-offers a model for improving abortion access in other states. Further investigation is needed to determine compliance among private insurance companies and increase transparency.

Sampling strategies among studies of barriers to abortion in the United States: A scoping review of abortion access research

OBJECTIVES

Understanding barriers to abortion care is particularly important post-Dobbs. However, many abortion access studies recruit from abortion-providing facilities, which overlook individuals who do not present for clinic-based care. To our knowledge, no studies have reviewed research recruitment strategies in the literature or considered how they might affect our knowledge of abortion barriers. We aimed to identify populations included and sampling methods used in studies of abortion barriers in the United States.

STUDY DESIGN

We used a scoping review protocol to search five databases for articles examining US-based individuals' experiences accessing abortion. We included English-language articles published between January 2011 and February 2022. For included studies, we identified the sampling strategy and population recruited.

RESULTS

Our search produced 2763 articles, of which 71 met inclusion criteria. Half of the included papers recruited participants at abortion-providing facilities (n = 35), while the remainder recruited from online sources (n = 14), other health clinics (n = 10), professional organizations (n = 8), abortion funds (n = 2), community organizations (n = 2), key informants (n = 2), and an abortion storytelling project (n = 1). Most articles (n = 61) reported information from people discussing their own abortions; the rest asked nonabortion seekers (e.g., physicians, genetic counselors, attorneys) about barriers to care.

CONCLUSIONS

Studies of abortion barriers enroll participants from a range of venues, but the majority recruit people who obtained abortions, and half recruit from abortion clinics.

IMPLICATIONS

As abortion access becomes constrained and criminalized in the post-Roe context, our findings indicate how investigators might recruit study participants from a variety of settings to fully understand the abortion seeking experience.

Self-managed medication abortion trajectories: results from a prospective observational study in Argentina, Nigeria and Southeast Asia

OBJECTIVES

Time is a crucial factor in abortion-seeking because options for care change with pregnancy duration, and most people prefer to access abortion care early in pregnancy. We aimed to collect data on the timing of steps in accompanied self-managed abortion-seeking experiences in legally restrictive settings.

METHODS

In this prospective, observational, cohort study we recruited callers from three abortion accompaniment groups in Argentina, Nigeria and a country in Southeast Asia. Participants completed a baseline survey before starting a self-managed medication abortion (SMA) and two follow-up surveys (approximately 1 and 3 weeks after taking medication). Primary outcomes of interest included: (1) time from abortion decision to contacting the hotline, (2) time from contacting the hotline to obtaining pills and (3) time from obtaining pills to taking the first dose. We explored relationships between participant characteristics and each of these outcomes and evaluated differences in overall abortion time using survival analyses.

RESULTS

Between July 31, 2019 and October 01, 2020 we enrolled 1352 eligible callers; 1148 provided data for this analysis. After deciding to have an abortion, participants took 12.2 days on average (95% CI: 11.6, 12.9) to start medications for abortion. On average, participants at later pregnancy durations progressed through the SMA process more quickly (<4 weeks: 20.9 days, 4 weeks: 11 days, 5-6 weeks: 10.1 days, 7-9 weeks, 10.4 days, 10+ weeks: 9.1 days; p<0.001).

CONCLUSIONS

Overall, participants accessed accompaniment group support and started abortion regimens quickly and at relatively early pregnancy durations. SMA with accompaniment provided a time-efficient route for obtaining abortions.

Characteristics of abortion patients in protected and restricted states accessing clinic-based care 12 months prior to the elimination of the federal constitutional right to abortion in the United States

BACKGROUND

As a result of the June 2022 decision of the United States (US) Supreme Court, as many as 24 states have, or are expected to, ban or severely restrict abortion. We provide baseline information about abortion patients living in different state environments prior to this decision.

METHODS

We obtained surveys from 6674 women, transgender men, and other pregnancy capable individuals accessing abortion care at 56 facilities across the US between June 2021 and July 2022. The final analytic sample uses information from 5930 abortion patients to compare the demographic and situational profiles of those living in the 24 states likely to ban abortion (restricted) to those living in states where it is likely to remain legal (protected).

RESULTS

Compared to respondents who lived in protected states, abortion patients in restricted states were more likely to be Black (39% vs. 30%) or white (35% vs. 28%) and less likely to be Latinx (18% vs. 32%). Respondents in restricted states were more likely to be paying out-of-pocket for care (87% vs. 42%), be relying on financial assistance (22% vs. 11%), and indicate that it was difficult to pay for the abortion (54% vs. 28%). Twelve percent of respondents who lived in a restricted state crossed state lines for care and the majority (59%) was going to another restricted state.

DISCUSSION

Prior to June 2022, abortion patients in restricted states encountered more situational and financial barriers compared to those in protected states. These barriers have undoubtedly been exacerbated by abortion bans.

Unwanted abortion disclosure and social support in the abortion decision and mental health symptoms: A cross-sectional survey

OBJECTIVES

To assess the extent of unwanted abortion disclosure and levels of social support in the abortion decision and their association with depression, anxiety, and stress.

STUDY DESIGN

From January to June 2019, we surveyed people presenting for abortion at four clinics in California, New Mexico, and Illinois regarding their experiences accessing abortion. We used multivariable regression to examine associations between unwanted abortion disclosure and social support in the abortion decision, and symptoms of depression, anxiety and stress.

RESULTS

Among 1092 people approached, 784 (72% response rate) eligible individuals initiated the survey, and 746 responded to the unwanted abortion disclosure item and were included in analyses. Over one-quarter (27%) told someone they would have preferred not to tell about their decision, mostly due to obstacles getting to the appointment-time to appointment (46%), travel distance (33%), and costs (32%). Three-quarters (74%, n=546) had at least one person in their life who supported the abortion decision "very much"; 20% had someone who supported the decision "not at all." In adjusted analyses, unwanted abortion disclosure was associated with more symptoms of depression (B = 0.62, 95% confidence interval: 0.28, 0.95), anxiety (B = 1.79; 95% CI: 0.76, 2.82) and stress (B = 1.80, 95% CI: 0.64, 1.72). People also had more symptoms of depression and stress when one or more person (B = 0.64; 95% CI: 0.27, 1.02 and B = 0.75, 95% CI: 0.15, 1.35, respectively) or the man involved in the pregnancy (B = 0.67, 95% CI: 0.16, 1.18 and B = 0.96, 95% CI: 0.13, 1.78, respectively) supported their decision "not at all" (vs "very much" support).

CONCLUSION

Being forced to disclose the abortion decision due to logistical and cost constraints may be harmful to people's mental health.

IMPLICATIONS

Logistical burdens such as travel, time to access care, and costs needed to access abortion may force people seeking abortion to involve others who are unsupportive in the abortion decision having negative implications for their mental health.

The Interest in Permanent Contraception Peaked Following the Leaked Supreme Court Majority Opinion of Roe vs. Wade: A Cross-Sectional Google Trends Analysis

Introduction With the leaked Supreme Court draft regarding Roe vs. Wade, substantial public reactions followed as the horizon of abortion laws within the United States of America have been changing. We sought to compare internet searches for vasectomy and tubal ligation seven days following the leaked draft on May 2, 2022. Methods We used public data provided by Google Trends to investigate the interest and geographic distribution of searches for the two forms of permanent contraception: Vasectomy and tubal ligation. We calculated the mean Search Volume Index (SVI) of these terms. Data analysis was performed with Microsoft Excel Version 16.60 (Redmond, USA), and comparisons between groups were performed using paired t-tests. Results The term 'vasectomy' saw a 121% increase (p=0.0063), and 'tubal ligation' had a 70% (p=0.029) increase compared to the week prior. 49/50 states had increased search inquiries for each term. However, the North and Southwestern regions of the U.S. had increased relative surge for vasectomy and the Midwest region for tubal ligation procedures, respectively. South Dakota and Idaho, with trigger laws that banned abortion immediately following the overturn of Roe vs. Wade, had the greatest surge in SVI for tubal ligation and vasectomy, respectively. Conclusion Our study indicates that with the potential overturn of Roe vs. Wade, there was a significantly increased interest in these two forms of permanent contraception. Future studies should investigate specific concerns and questions patients may have when it comes to the different options of contraception.

Association of Availability of State Medicaid Coverage for Abortion With Abortion Access in the United States

OBJECTIVE

To evaluate the association between state Medicaid coverage for abortion and abortion access measures among U.S. patients.

METHODS

We analyzed data from the Guttmacher Institute's 2014 Abortion Patient Survey. Respondents were included if they reported being enrolled in Medicaid, regardless of whether Medicaid covered the abortion. The exposure was self-report of residence in a state where Medicaid can be used to pay for abortion. Access outcomes included more than 14 days' wait time between decision for abortion and abortion appointment, presentation at more than 10 weeks of gestation when in the first trimester, and travel time more than 60 minutes to the clinic. Multivariable regression was performed to test the association between state Medicaid abortion coverage and dichotomous access outcomes, controlling for patient demographics.

RESULTS

Of 2,579 respondents enrolled in Medicaid who reported state of residence, 1,694 resided in states with Medicaid coverage for abortion and 884 resided in states without Medicaid coverage for abortion. Patients residing in states with Medicaid coverage for abortion had lower odds and rates of waiting more than 14 days between deciding to have an abortion and the appointment (adjusted odds ratio [aOR] 0.70; 95% CI 0.57-0.85, 66.8% vs 74.1%, P <.001), having abortions at more than 10 weeks of gestation when in the first trimester (aOR 0.62; 95% CI 0.49-0.80, 13.6% vs 20.1%, P <.001), and traveling more than 60 minutes to the abortion clinic (aOR 0.63; 95% CI 0.51-0.78, 18.7% vs 27.6%, P <.001) when compared with patients residing in states without Medicaid coverage for abortion.

CONCLUSION

Availability of state Medicaid coverage for abortion is associated with increased abortion access. Our findings support repealing the Hyde Amendment to promote equitable access to reproductive health care, particularly in the post-Roe era.

Association Between Distance to an Abortion Facility and Abortion or Pregnancy Outcome Among a Prospective Cohort of People Seeking Abortion Online

IMPORTANCE

Many people face barriers to abortion care, including long distances to an abortion facility.

OBJECTIVES

To investigate the association of distance to the nearest abortion facility with abortion or pregnancy outcome.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted using data from the Google Ads Abortion Access study, a prospective cohort study of individuals considering abortion recruited between August 2017 and May 2018. Individuals from 50 states and Washington, District of Columbia, who were pregnant and considering abortion based on self-report were recruited online using a stratified sampling technique. Participants completed online baseline and 4-week follow-up surveys. Data were analyzed between May and August 2021.

EXPOSURES

Driving distance to an abortion facility calculated from participant zip code and grouped into 4 categories (<5 miles, 5-24 miles, 25-49 miles, and ≥50 miles).

MAIN OUTCOMES AND MEASURES

Abortion or pregnancy outcome reported at 4-week follow-up, categorized as had an abortion, still seeking an abortion, or planning to continue pregnancy. Other measures included reported experience of 8 distance-related barriers to abortion, such as having to gather money for travel expenses and having to keep the abortion a secret.

RESULTS

Among 1485 pregnant individuals considering abortion who completed the baseline survey and provided contact information, 1005 individuals completed follow-up (follow-up rate, 67.7%) and 856 participants were included in the analytic sample (443 individuals ages 25-34 years [51.8%]; 208 Black individuals [24.3%]; 101 Hispanic or Latinx individuals [11.8%], and 468 White individuals [54.8%]). Most participants had at least some college education (474 individuals [55.5%]). Distance to an abortion facility was less than 5 miles for 233 individuals (27.2%), 5 to 24 miles for 373 individuals (43.6%), 25 to 49 miles for 85 individuals (9.9%), and 50 or more miles for 165 individuals (19.3%) (mean [SD] distance = 28.3 [43.8] miles). Most participants reported at least 1 distance-related barrier (763 individuals [89.1%]), with a mean of 3.3 barriers (95% CI, 3.2-3.5 barriers) reported. For 7 of 8 distance-related barriers, an increased percentage of participants living farther from an abortion facility reported the barrier compared with participants living less than 5 miles from a facility; for example, 61.8% (95% CI, 53.5%-69.4%) of individuals living less than 5 miles reported having to gather money for travel expenses, while 81.2% (95% CI, 70.8%-88.5%; P = .002) of those living 25 to 49 miles and 75.8% (95% CI, 69.9%-81.0%; P = .02) of those living 50 or more miles from a facility reported this barrier. At follow-up, participants living 50 or more miles from a facility had higher odds of still being pregnant and seeking abortion (adjusted odds ratio [aOR] = 2.07; 95% CI, 1.35-3.17; P = .001) or planning to continue pregnancy (aOR = 1.96; 95% CI, 1.06-3.63; P = .03) compared with participants living within 5 miles.

CONCLUSIONS AND RELEVANCE

This study found that greater distance from an abortion facility was associated with delays in obtaining abortion care and inability to receive abortion care. These findings suggest that innovative approaches to abortion provision may be needed to mitigate outcomes associated with long distances to abortion facilities.

Outcomes and Safety of History-Based Screening for Medication Abortion: A Retrospective Multicenter Cohort Study

IMPORTANCE

Screening for medication abortion eligibility typically includes ultrasonography or pelvic examination. To reduce physical contact during the COVID-19 pandemic, many clinicians stopped requiring tests before medication abortion and instead screened patients for pregnancy duration and ectopic pregnancy risk by history alone. However, few US-based studies have been conducted on the outcomes and safety of this novel model of care.

OBJECTIVE

To evaluate the outcomes and safety of a history-based screening, no-test approach to medication abortion care.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included patients obtaining a medication abortion without preabortion ultrasonography or pelvic examination between February 1, 2020, and January 31, 2021, at 14 independent, Planned Parenthood, academic-affiliated, and online-only clinics throughout the US.

EXPOSURES

Medications for abortion provided without preabortion ultrasonography or pelvic examination and dispensed to patients in person or by mail.

MAIN OUTCOMES AND MEASURES

Effectiveness, defined as complete abortion after 200 μg of mifepristone and up to 1600 μg of misoprostol without additional intervention, and major abortion-related adverse events, defined as hospital admission, major surgery, or blood transfusion.

RESULTS

The study included data on 3779 patients with eligible abortions. The study participants were racially and ethnically diverse and included 870 (23.0%) Black patients, 533 (14.1%) Latinx/Hispanic patients, 1623 (42.9%) White patients, and 327 (8.7%) who identified as multiracial or with other racial or ethnic groups. For most (2626 [69.5%]), it was their first medication abortion. Patients lived in 34 states, and 2785 (73.7%) lived in urban areas. In 2511 (66.4%) abortions, the medications were dispensed in person; in the other 1268 (33.6%), they were mailed to the patient. Follow-up data were obtained for 2825 abortions (74.8%), and multiple imputation was used to account for missing data. Across the sample, 12 abortions (0.54%; 95% CI, 0.18%-0.90%) were followed by major abortion-related adverse events, and 4 patients (0.22%; 95% CI, 0.00%-0.45%) were treated for ectopic pregnancies. Follow-up identified 9 (0.40%; 95% CI, 0.00%-0.84%) patients who had pregnancy durations of greater than 70 days on the date the mifepristone was dispensed that were not identified at screening. The adjusted effectiveness rate was 94.8% (95% CI, 93.6%-95.9%). Effectiveness was similar when medications were dispensed in person (95.4%; 95% CI, 94.1%-96.7%) or mailed (93.3%; 95% CI, 90.7%-95.9%).

CONCLUSIONS AND RELEVANCE

In this cohort study, screening for medication abortion eligibility by history alone was effective and safe with either in-person dispensing or mailing of medications, resulting in outcomes similar to published rates of models involving ultrasonography or pelvic examination. This approach may facilitate more equitable access to this essential service by increasing the types of clinicians and locations offering abortion care.

"It just seemed like a perfect storm": A multi-methods feasibility study on the use of Facebook, Google Ads, and Reddit to collect data on abortion-seeking experiences from people who considered but did not obtain abortion care in the United States

Most studies of abortion access have recruited participants from abortion clinics, thereby missing people for whom barriers to care were insurmountable. Consequently, research may underestimate the nature and scope of barriers that exist. We aimed to recruit participants who had considered, but failed to obtain, an abortion using three online platforms, and to evaluate the feasibility of collecting data on their abortion-seeking experiences in a multi-modal online study. In 2018, we recruited participants for this feasibility study from Facebook, Google Ads, and Reddit for an online survey about experiences seeking abortion care in the United States; we additionally conducted in-depth interviews among a subset of survey participants. We completed descriptive analyses of survey data, and thematic analyses of interview data. Recruitment results have been previously published. For the primary outcomes of this analysis, over one month, we succeeded in capturing data on abortion-seeking experiences from 66 individuals who were not currently pregnant and reported not having obtained an abortion, nor visited an abortion facility, despite feeling that abortion could have been the best option for a recent pregnancy. A subset of survey respondents (n = 14) completed in-depth interviews. Results highlighted multiple, reinforcing barriers to abortion care, including legal restrictions such as gestational limits and waiting periods that exacerbated financial and other burdens, logistical and informational barriers, as well as barriers to abortion care less frequently reported in the literature, such as a preference for medication abortion. These findings support the use of online recruitment to identify and survey an understudied population about their abortion-seeking experiences. Further, findings contribute to a more complete understanding of the full range of barriers to abortion care that people experience in the United States, and how these barriers intersect to not just delay, but to prevent people from obtaining abortion.

Trends In Self-Pay Charges And Insurance Acceptance For Abortion In The United States, 2017-20

The Hyde Amendment prevents federal funds, including Medicaid, from covering abortion care, and many states have legal restrictions that prevent private insurance plans from covering abortion. As a result, most people pay for abortion out of pocket. We examined patient self-pay charges for three abortion types (medication abortion, first-trimester procedural abortion, and second-trimester abortion), as well as facilities' acceptance of health insurance, during the period 2017-20. We found that during this time, median patient charges increased for medication abortion (from $495 to $560) and first-trimester procedural abortion (from $475 to $575) but not second-trimester abortion (from $935 to $895). The proportion of facilities that accept insurance decreased over time (from 89 percent to 80 percent). We noted substantial regional variation, with the South having lower costs and lower insurance acceptance. Charges for first-trimester procedural abortions are increasing, and acceptance of health insurance is declining. According to the Federal Reserve, one-quarter of Americans could not pay for a $400 emergency expense solely with the money in their bank accounts-an amount lower than any abortion cost in 2020. Lifting Hyde restrictions and requiring public and private health insurance to cover this essential, time-sensitive health service without copays or deductibles would greatly reduce the financial burden of abortion.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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-SD 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).

CONCLUSION

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

BACKGROUND

To 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.

METHODS

Using 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.

RESULTS

Among 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.

CONCLUSION

Findings 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.

Barriers to abortion care and incidence of attempted self-managed abortion among individuals searching Google for abortion care: A national prospective study

OBJECTIVE

Studies on self-managed abortion conducted at abortion clinics may exclude those facing the greatest barriers to care. We aimed to assess association of attempted self-managed abortion with reported barriers to abortion care.

STUDY DESIGN

We used data from the Google Ads Abortion Access Study, a prospective cohort study that recruited people searching for abortion care on Google between August 2017 and April 2018. We used a stratified sampling design recruiting by state to ensure representation from all 50 states. Participants completed an online baseline survey and follow-up 4 weeks later. We modeled the adjusted odds of attempting self-managed abortion using multivariable logistic regression, with random effects for state of residence. We assessed attempted self-managed abortion at follow-up by asking: "Did you take or try to do any of the following to try to end this pregnancy?" with a closed-ended list of methods.

RESULTS

Among 856 participants with follow-up data, 28% (95% confidence interval [95% CI]: 25%-31%) reported attempting self-managed abortion. Most common methods used were: herbs, supplements, or vitamins (52%); emergency contraception or many contraceptive pills (19%); mifepristone and/or misoprostol (18%); and abdominal or other physical trauma (18%). Participants still seeking abortion at 4 weeks were more likely to attempt self-management (33%) than those planning to carry to term (20%, p < 0.001). Reporting having to keep the abortion a secret, fearing for one's safety/well-being, needing to gather money for travel or the abortion, or living further from an abortion facility as barriers were associated with higher odds of attempts.

CONCLUSIONS

Attempted self-managed abortion is higher among people facing barriers to abortion care.

IMPLICATIONS

Reducing financial and distance barriers, such as by removing legal restrictions on abortion, could help reduce attempted self-managed abortion. Additionally, removing restrictions on telehealth for abortion could reduce attempted self-managed abortion. Efforts are needed to permanently remove United States Food and Drug Administration (FDA) regulations and state policies prohibiting telehealth for medication abortion, thereby allowing individuals to end their pregnancies without a clinic visit.

State Abortion Policies and Maternal Death in the United States, 2015‒2018

Objectives. To examine associations between state-level variation in abortion-restricting policies in 2015 and total maternal mortality (TMM), maternal mortality (MM), and late maternal mortality (LMM) from 2015 to 2018 in the United States. Methods. We derived an abortion policy composite index for each state based on 8 state-level abortion-restricting policies. We fit ecological state-level generalized linear Poisson regression models with robust standard errors to estimate 4-year TMM, MM, and LMM rate ratios and 95% confidence intervals (CIs) associated with a 1-unit increase in the abortion index, adjusting for state-level covariates. Results. States with the higher score of abortion policy composite index had a 7% increase in TMM (adjusted rate ratio [ARR] = 1.07; 95% CI = 1.02, 1.12) compared with states with lower abortion policy composite index, after we adjusted for state-level covariates. Among individual abortion policies, states with a licensed physician requirement had a 51% higher TMM (ARR = 1.51; 95% CI = 1.15, 1.99) and a 35% higher MM (ARR = 1.35; 95% CI = 1.09, 1.67), and states with restrictions on Medicaid coverage of abortion care had a 29% higher TMM (ARR = 1.29; 95% CI = 1.03, 1.61). Conclusions. Restricting access to abortion care at the state level may increase the risk for TMM.

Real-Time Effects of Payer Restrictions on Reproductive Healthcare: A Qualitative Analysis of Cost-Related Barriers and Their Consequences among U.S. Abortion Seekers on Reddit

Objective: The Hyde Amendment and related policies limit or prohibit Medicaid coverage of abortion services in the United States. Most research on cost-related abortion barriers relies on clinic-based samples, but people who desire abortions may never make it to a healthcare center. To examine a novel, pre-abortion population, we analyzed a unique qualitative dataset of posts from Reddit, a widely used social media platform increasingly leveraged by researchers, to assess financial obstacles among anonymous posters considering abortion. Methods: In February 2020, we used Python to web-scrape the 250 most recent posts that mentioned abortion, removing all identifying information and usernames. After transferring all posts into NVivo, a qualitative software package, the team identified all datapoints related to cost. Three qualitatively trained evaluators established and applied codes, reaching saturation after 194 posts. The research team used a descriptive qualitative approach, using both inductive and deductive elements, to identify and analyze themes related to financial barriers. Results: We documented multiple cost-related deterrents, including lack of funds for both the procedure and attendant travel costs, inability to afford desired abortion modality (i.e., medication or surgical), and for some, consideration of self-managed abortion options due to cost barriers. Conclusions: Findings from this study underscore the centrality of cost barriers and third-party payer restrictions to stymying reproductive health access in the United States. Results may contribute to the growing evidence base and building political momentum focused on repealing the Hyde Amendment.

Abortion service availability during the COVID-19 pandemic: Results from a national census of abortion facilities in the U.S

Objective

This study assessed the impact of COVID-19 on abortion services in all 50 United States states and the District of Columbia.

Study design

ANSIRH's Abortion Facility Database is a systematic collection of data on all publicly-advertising abortion facilities in the United States, updated annually through online searches and mystery shopper phone calls. Research staff updated the database in May-August 2020, assessing the number of facilities that closed, limited or stopped providing abortions, and provided telehealth options in summer 2020 due to COVID-19.  We describe these changes using frequencies and highlighting themes and examples from coded qualitative data.

Results

Located primarily in the South and Midwest, 24 of 751 facilities that were open in 2019 temporarily closed due to the pandemic, with 9 still closed by August 2020. Other facilities described suspending abortions, referring abortion patients to other facilities, or limiting services to medication abortion. While most facilities required in-person visits for reasons like state abortion restrictions, 22% (n = 150) offered phone or telehealth consultations, no-test visits, or medication abortion by mail to reduce or eliminate patient time in the clinic. Some facilities used creative strategies to reduce COVID-19 risk like allowing patients to wait for visits in their cars or offering drive-through medication pick-up.

Conclusions

The COVID-19 pandemic caused several disruptions to abortion service availability, including closures. To reduce in-person visit time, some clinics shifted to offering medication abortion (versus procedural) or telehealth. While the pandemic and abortion restrictions increased barriers to abortion provision, facilities were resilient and adapted to provide safe care for their patients.

Implications

Barriers to abortion access were exacerbated during the COVID-19 pandemic, particularly in areas of the country with more restrictive policies toward abortion. Telehealth care protocols offered by many abortion facilities provide an option to reduce or eliminate in-person visits.

Association of Travel Distance to Nearest Abortion Facility With Rates of Abortion

IMPORTANCE

Travel distance to abortion services varies widely in the US. Some evidence shows travel distance affects use of abortion care, but there is no national analysis of how abortion rate changes with travel distance.

OBJECTIVE

To examine the association between travel distance to the nearest abortion care facility and the abortion rate and to model the effect of reduced travel distance.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional geographic analysis used 2015 data on abortions by county of residence from 1948 counties in 27 states. Abortion rates were modeled using a spatial Poisson model adjusted for age, race/ethnicity, marital status, educational attainment, household poverty, nativity, and state abortion policies. Abortion rates for 3107 counties in the 48 contiguous states that were home to 62.5 million female residents of reproductive age (15-44 years) and changes under travel distance scenarios, including integration into primary care (<30 miles) and availability of telemedicine care (<5 miles), were estimated. Data were collected from April 2018 to October 2019 and analyzed from December 2019 to July 2020.

EXPOSURES

Median travel distance by car to the nearest abortion facility.

MAIN OUTCOMES AND MEASURES

US county abortion rate per 1000 female residents of reproductive age.

RESULTS

Among the 1948 counties included in the analysis, greater travel distances were associated with lower abortion rates in a dose-response manner. Compared with a median travel distance of less than 5 miles (median rate, 21.1 [range, 1.2-63.6] per 1000 female residents of reproductive age), distances of 5 to 15 miles (median rate, 12.2 [range, 0.5-23.4] per 1000 female residents of reproductive age; adjusted coefficient, -0.05 [95% CI, -0.07 to -0.03]) and 120 miles or more (median rate, 3.9 [range, 0-12.9] per 1000 female residents of reproductive age; coefficient, -0.73 [95% CI, -0.80 to -0.65]) were associated with lower rates. In a model of 3107 counties with 62.5 million female residents of reproductive age, 696 760 abortions were estimated (mean rate, 11.1 [range, 1.0-45.5] per 1000 female residents of reproductive age). If abortion were integrated into primary care, an additional 18 190 abortions (mean rate, 11.4 [range, 1.1-45.5] per 1000 female residents of reproductive age) were estimated. If telemedicine were widely available, an additional 70 920 abortions were estimated (mean rate, 12.3 [range, 1.4-45.5] per 1000 female residents of reproductive age).

CONCLUSIONS AND RELEVANCE

These findings suggest that greater travel distances to abortion services are associated with lower abortion rates. The results indicate which geographic areas have insufficient access to abortion care. Modeling suggests that integrating abortion into primary care or making medication abortion care available by telemedicine may decrease unmet need.

Changes needed in Medicaid coverage and reimbursement to meet an evolving abortion care landscape

Medicaid is the largest publicly funded health insurance program in the United States, covering 76 million individuals as of August 2020. Research shows that Medicaid improves health and healthcare access on a variety of indicators. Abortion is a common reproductive health service in the United States. However, Medicaid coverage of abortion varies by state; with 34 states and the District of Columbia limiting themselves to a federal policy that only permits coverage under cases of incest, rape, or life endangerment. With 75% of abortion patients earning low incomes, Medicaid coverage of this service is particularly salient to abortion access. In this commentary, we describe the complexities of Medicaid coverage and reimbursement of abortion in the United States and the implications of this complexity. Further, we consider the potential impact of changes in abortion provision, including increasing provision of medication abortion and the use of healthcare delivery models such as telemedicine for medication abortion, on Medicaid coverage and reimbursement. Finally, we provide a few policy and practice recommendations for abortion coverage now and in the future.