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Change in Abortion Services after Implementation of a Restrictive Law in Texas

Original research article
Change in abortion services after implementation of a restrictive law in Texas
Daniel Grossman
, Sarah Baum
, Liza Fuentes
, Kari White
, Kristine Hopkins
Amanda Stevenson
, Joseph E. Potter
Texas Policy Evaluation Project, Austin, TX
Ibis Reproductive Health, Oakland, CA
Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA
Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
Population Research Center, University of Texas at Austin, Austin, TX
Received 12 July 2014; revised 15 July 2014; accepted 16 July 2014
Objectives: In 2013, Texas passed omnibus legislation restricting abortion services. Provisions restricting medical abortion, banning
most procedures after 20 weeks and requiring physicians to have hospital-admitting privileges were enforced in November 2013;
by September 2014, abortion facilities must meet the requirements of ambulatory surgical centers (ASCs). We aimed to rapidly assess the
change in abortion services after the first three provisions went into effect.
Study design: We requested information from all licensed Texas abortion facilities on abortions performed between November 2012 and
April 2014, including the abortion method and gestational age (b12 weeks vs. 12 weeks).
Results: In May 2013, there were 41 facilities providing abortion in Texas; this decreased to 22 in November 2013. Both clinics closed in the
Rio Grande Valley, and all but one closed in West Texas. Comparing November 2012April 2013 to November 2013April 2014, there was
a 13% decrease in the abortion rate (from 12.9 to 11.2 abortions/1000 women age 1544). Medical abortion decreased by 70%, from 28.1%
of all abortions in the earlier period to 9.7% after November 2013 (pb0.001). Second-trimester abortion increased from 13.5% to 13.9% of all
abortions (pb0.001). Only 22% of abortions were performed in the state's six ASCs.
Conclusions: The closure of clinics and restrictions on medical abortion in Texas appear to be associated with a decline in the in-state
abortion rate and a marked decrease in the number of medical abortions.
Implications: Supply-side restrictions on abortion especially restrictions on medical abortion can have a profound impact on access to
services. Access to abortion care will become even further restricted in Texas when the ASC requirement goes into effect in 2014.
© 2014 Elsevier Inc. All rights reserved.
Keywords: Abortion; Access; Restriction; Law; Texas
1. Introduction
Recent years have seen a surge in state laws restricting
abortion services [1]. Initially these laws focused on the
demandside of abortion and aimed to discourage women
from seeking abortion by mandating parental involvement
for minors, biased counseling or waiting periods [2]. Other
than laws requiring an extra visit to the clinic, demand-side
restrictions appear to have minimal effect on the overall
abortion rate [3]. More recently, states have passed laws
focused on the supplyside of abortion that makes it more
difficult for facilities to provide services [2].Oneofthefew
studies on supply-side restrictions found a substantial decline in
the number of abortions performed after 16 weeks to Texas
women following enactment of a law requiring later procedures
to be performed at ambulatory surgical centers (ASCs) [4].
In July 2013, the Texas legislature enacted House Bill 2
(HB2) that put into place four supply-side abortion restrictions:
abortions are banned after 20 weeks post-fertilization
excluding certain exceptions; physicians performing abortion
must have admitting privileges at a hospital within 30 miles
of the facility; the provision of medical abortion must follow
the labeling approved by the Food and Drug Administration
Contraception 90 (2014) 496 501
Corresponding author. Ibis Reproductive Health, 1330 Broadway,
Ste 1100,Oakland, CA 94612.Tel.: + 1-510-986-8941; fax: +1-510-986-8960.
E-mail address: (D. Grossman).
0010-7824/© 2014 Elsevier Inc. All rights reserved.
(with some allowances for drug dosages); and all abortion
facilities must meet the standards of an ASC. The first three
provisions went into effect on November 1, 2013, and the ASC
requirement is scheduled to go into effect September 1, 2014.
The American College of Obstetricians and Gynecologists
(ACOG) and the American Medical Association oppose these
restrictions, highlighting the safety of outpatient abortion in the
United States and concerns that HB2 would negatively affect
women's health [5].
The restrictions on medical abortion imposed several
important changes to practice. Prior to HB2, most facilities in
Texas provided medical abortion using the evidence-based
regimen of mifepristone 200 mg followed 2448 h later
by misoprostol 800 mcg administered buccally at home up
to 63 days' gestation. HB2 limited the gestational age to
49 days and required women to return to the facility for
misoprostol, as well as for a follow-up visit. These visit
requirements, in addition to the 2011 law requiring women
living less than 100 miles from an abortion facility to have an
ultrasound at least 24 h before the procedure, meant that
most women seeking medical abortion needed four clinic
visits after November 2013. Finally, under HB2 providers
could either use the regimen included in the Mifeprex®
labeling with 600 mg of mifepristone, which is considerably
more expensive than the evidence-based regimen, or they
could use the drug dosages in the 2005 ACOG Practice
Bulletin on medical abortion. This was interpreted as
allowing the use of mifepristone 200 mg followed 2 days
later by misoprostol 800 mcg orally, a regimen supported by
limited evidence [6].
Although a few states have implemented admitting
privilege requirements and one has enforced a similar
restriction on medical abortion, no state has implemented
both at the same time, and none has been evaluated. We
hypothesized that following HB2 there would be a
significant decrease in the abortion rate in Texas, as well
as in the proportion of medical abortions performed. The law
appeared likely to cause some clinics to close if physicians
could not obtain hospital privileges. The restrictions on
medical abortion also seemed likely to reduce use of this
method. In this paper, we aimed to rapidly assess the effect of
these provisions on abortion services in the first 6 months
after HB2 was implemented.
2. Material and methods
2.1. Tracking open licensed facilities
Since 2012, the Texas Policy Evaluation Project has
tracked the number of open facilities providing abortion care
in the state through interviews with clinic staff, reports in the
press and by intermittent requests to the Texas Department of
State Health Services (DSHS) concerning licensed abortion
providers. We focus on the number of facilities open in three
6-month periods relating to the passage and implementation
of HB2. Period 1 included the 6 months prior to the debate
on HB2: November 1, 2012 through April 30, 2013.
Period 2, May 1, 2013 through October 31, 2013, was
when HB2 was publicly debated and passed but before it was
enforced. Period 3 included November 1, 2013 through
April 30, 2014, after enforcement of all provisions of HB2
except the ASC requirement.
We also estimated the number of reproductive-aged
Texas women living in a county more than 50, 100 or 200
miles from a licensed Texas abortion provider in each of
these periods. For each county, we calculated the distance
that women would need to travel to an open facility as of
April 30, 2013; October 31, 2013; November 1, 2013; and
April 30, 2014. We also estimated travel distance as of
September 1, 2014 when we expect that there will be
only four metropolitan areas with facilities meeting the
ASC requirements: Austin, Dallas/Ft. Worth, Houston and
San Antonio. We used the US Census Bureau's American
FactFinder tool to generate county-level estimates of the
population of women aged 1544 residing in each of Texas's
254 counties on July 1, 2012 [7]. We computed the travel
distance from each of these counties to the nearest Texas
county in which there was at least one abortion provider
using Traveltime3 in Stata Version 13.0, which accesses the
Google Distance Matrix Application Programming Interface.
2.2. Collecting data from abortion providers
Evaluations of this kind usually use state vital statistics
on abortion. However, these data only become public
after approximately 2 years. In order to rapidly evaluate
the impact of HB2 to inform public policy debates in
Texas and elsewhere, we collected data directly from
abortion providers.
Between February and May 2014, we attempted to
contact by email or telephone every licensed abortion facility
that provided abortions in November 2012. We did not
include hospitals or physicians not licensed as abortion
facilities, since they performed only 0.3% of abortions in
Texas in 2012 (summary statistics on 2012 Texas occurrence
abortions obtained from the DSHS Center for Health
Statistics in response to a data request on June 3, 2014).
From providers we requested the total number of induced
abortions, early medical abortions (63 days gestation),
surgical abortions performed at b12 weeks gestation and
surgical abortions performed at 12 weeks for each month
between November 2012 and April 2014. We also requested
the monthly number of abortion patients who reported
residing in the Lower Rio Grande Valley (LRGV) in
South Texas, since both abortion facilities there had closed
by the start of Period 3. Women in the LRGV represent a
particularly vulnerable population since this area has higher
levels of poverty than the rest of the state, and women would
have to travel at least 150 miles to the nearest clinic;
undocumented immigrants in the LRGV faced particular
obstacles to access services further north since they would
need to pass border patrol stations.
497D. Grossman et al. / Contraception 90 (2014) 496501
Of the 41 licensed facilities open at some point during the
study periods, 36 (including all six ASCs) provided complete
data. One additional facility open in Period 3 provided data only
for Periods 1 and 2; data for Period 3 from another
nonresponding facility were reported in the media [8].For
most responding facilities, physicians or staff reviewed
electronic databases, logs or other records to determine the
number of monthly procedures and patients from the LRGV. If
these data were not available, the physician gave an estimate
based on her or his experience. In Period 1, 89% of estimated
abortions in Texas were reported by providers, 90% in Period 2
and 90% in Period 3, and almost all of these reports came from
clinic records. If we did not receive a response from a clinic, we
spoke with other providers in the same community to estimate
the total procedures performed by the nonresponding facility
and assumed that the distribution of the type of abortion
procedure was the same as the 2012 statewide total. We relied on
knowledgeable sources for 4% of procedures performed in
Period 1, 4% in Period 2 and 7% in Period 3. If these estimates
were not available, we made an internal estimate based on the
volume of other providers in the community or data available for
the facility for other periods. We relied on internal estimates for
7% of procedures performed in Period 1, 6% in Period 2 and 3%
in Period 3.
Using these data, we estimated the annualized abortion rate
per 1000 women aged 1544 for each period based on the
2012 population. We also compared the distribution of
abortions by procedure type and time period using chi-squared
tests. We also estimated the number of abortions among women
living in the LRGV in each period and the change in the number
of procedures performed in the four largest metropolitan areas.
This study was approved by the Institutional Review Board of
the University of Texas at Austin.
3. Results
During Period 1 (November 1, 2012April 30, 2013), 41
facilities provided abortion care, and none closed (Fig. 1).
Eight clinics closed or stopped providing abortions during
Period 2, leaving 33 facilities providing abortion care on
October 31, 2013. When HB2 was enforced on November 1,
2013, 11 clinics closed or stopped providing abortions, leaving
22 open facilities. During the remainder of Period 3, five
facilities reopened when physicians obtained admitting
privileges, and five facilities closed because physicians lost
temporary privileges or for other reasons. At the end of Period
3, there were 22 facilities providing abortion services.
Facilities outside the four largest metropolitan areas were
particularly affected, with 11 of 13 clinics closing between
Periods 1 and 3.
The number of reproductive aged women living more
than 50, 100 or 200 miles from a clinic providing abortions
in Texas increased as clinics closed (Fig. 2). While
approximately 10,000 women in Period 1 lived N200 miles
from a Texas clinic providing abortions, this increased to
Fort Worth
El Paso San Angelo Killeen
College Station
San Antonio
Corpus Christi
Fig. 1. Geographic distribution of abortion facilities in Texas, November 2012April 2014.For each city,dot charts present number of open (solid circle ) and closed
facilities (open circle ) on the Y axis at four key time points on X axis: November 1, 2012April 30, 2013 October 31, 2013 November 1, 2013 April 30,
498 D. Grossman et al. / Contraception 90 (2014) 496501
290,000 at the end of Period 3; more than twice that many
woman will live N200 miles from a Texas clinic when the ASC
requirement goes into effect.
Compared to Period 1, there was a 13% decline in
the state's abortion rate in Period 3 (the same 6-month period
1 year later), corresponding to about 9200 fewer abortions
annually (Table 1). The number of medical abortions
declined by 70% in Period 3 compared to Period 1,
and seven facilities stopped offering medical abortion in
Period 3. There was a small but significant increase in the
proportion of abortions performed in the second trimester in
Period 3 compared to Periods 1 and 2.
The number of abortions among women from the LRGV
declined from 1349 in Period 1 to approximately 1065 in
Period 3, a larger decrease than the state average. During
Period 3, 15% of the women from the LRGV obtained
abortions at a facility in San Antonio and 25% in Houston,
and about half went to the clinic in Corpus Christi, which has
since closed.
The percentage change in the number of abortions
performed between Periods 1 and 3 varied across the four
largest metropolitan areas, where the state's six ASCs are
located. The number of abortions performed in Austin and
Houston increased, while they decreased in DallasFt. Worth
and, to a lesser extent, in San Antonio. Although the proportion
of the state's abortions performed in these metropolitan areas
increased over time, only 22% of all abortions were performed
at ASCs in Period 3. This proportion is essentially unchanged
from 2012, when 21% of all abortions were performed at
ASCs, and is a decrease from Periods 1 and 2.
4. Discussion
This study was designed to rapidly assess the repercussions
of two abortion restrictions implemented in Texas in November
2013: the admitting privileges requirement and restrictions on
Table 1
Abortions performed in Texas during three periods, November 2012April 2014
Texas 2012
(12 months)
Period 1
(Nov 1, 2012
Apr 30, 2013)
Period 2
(May 1, 2013
Oct 31, 2013)
Period 3
(Nov 1, 2013
Apr 30, 2014)
Change from
Period 1 to 3
Change from
Period 2 to 3
Total number of abortions 68,298 35,415 32,611 30,800 13.0% 5.6%
Annualized abortion rate
(per 1000 women age 1544)
12.5 12.9 11.9 11.2 13.0% 5.6%
Number of early medical abortions
(% of all abortions)
18,960 (27.8%) 9948 (28.1%) 9079 (27.8%) 2991 (9.7%)
69.9% 67.1%
Number of first-trimester surgical abortions
(b12 weeks) (% of all abortions)
42,017 (61.5%) 20,698 (58.4%) 19,343 (59.3%) 23,531 (76.4%) 13.7% 21.7%
Number of second-trimester surgical abortions
(12 weeks) (% of all abortions)
7321 (10.7%) 4768 (13.5%) 4190 (12.8%) 4278 (13.9%)
10.3% 2.1%
Number of women living in LRGV
obtaining abortion
1349 1304 1065 21.1% 18.3%
Total number of abortions performed
in select metropolitan areas
Austin N/A 3444 3158 3744 8.7% 18.6%
Dallas/Ft. Worth N/A 11,468 11,111 8830 23.0% 20.5%
Houston N/A 10,349 10,156 11,254 8.7% 10.8%
San Antonio N/A 4321 3605 4034 6.6% 11.9%
Total (% of all abortions) 29,582 (83.5%) 28,030 (86.0%) 27,862 (90.5%)
Total number of abortions
performed at an ASC
14,361 (21.0%) 9378 (26.4%) 8867 (27.2%) 6786 (22.0%)
p value b0.001 for medical abortion compared to surgical abortion b12 weeks for both Period 1 versus Period 3 and Period 2 versus Period 3.
p value b0.001 for surgical abortion 12 weeks compared to surgical abortion b12 weeks for both Period 1 versus Period 3 and Period 2 versus Period 3.
Women reporting a residence in Starr, Hidalgo, Willacy or Cameron County.
Data not available for 2012. In 2011, 2634 women living in the LRGV obtained an abortion.
Number of women age 15-44
Fig. 2. Number of women age 1544 living in a county at various distances
from the nearest Texas abortion provider on various dates.The blue line
(diamonds) represents the number of women age 1544 in a county N50
miles from the nearest Texas abortion provider, the red line (squares)
represents those living in a county N100 miles from the nearest Texas
provider and the green line (triangles) represents those living in a county
N200 miles from the nearest Texas provider.
499D. Grossman et al. / Contraception 90 (2014) 496501
medical abortion. The admitting privileges requirement was
almost certainly the main driver of the large number of clinic
closures observed in the months preceding and following its
implementation. In just 1 year, the number of facilities
providing abortion in Texas declined by 46%, vast swaths of
the state were left without a provider and the number of women
required to travel great distances to reach a provider increased
dramatically. Over the same year, the state abortion rate
declined by 13%, a drop that is steeper than that reported for
both Texas and the nation in recent years [9].
Given the number of closures, and the size of the population
left without a nearby provider, it is surprising that the overall
decline in the abortion rate was not greater than the 13% change
we observed. One reason is that the admitting privileges
requirement disproportionately affected clinics in smaller cities,
where there may be fewer hospitals and where stigma may
discourage hospital-based physicians from publicly endorsing
the privileging of abortion providers [10]. In 2011, about one
quarter of Texas abortions were to women living outside the
four largest metropolitan areas [11], and these women have
been profoundly affected by the closures. For example, women
living in the LRGV now must travel 250 miles each way to
obtain an abortion in San Antonio, where the nearest open
facility is located. Our findings suggest that most women
desiring an abortion but not all overcame the barriers of
distance and additional cost to obtain the service they needed. In
addition, the public opposition to HB2 galvanized a coordinated
response among activists who provided financial and logistical
support to women seeking abortions [12].
The decrease in the abortion rate also may have been
muted by a potential increased demand for abortion
following the severe reduction in public funding for family
planning in Texas in 2011 [13]. Although the legislature
restored some funding in 2013, many organizations had not
yet received these funds by the end of 2013. Preliminary data
from the Centers for Disease Control and Prevention for
2013 indicate an increase in births to women in Texas since
2012 [14,15]. While representative survey data on pregnancy
intentions in Texas after 2011 are not yet available, we
expect that unintended pregnancy increased during the
period of observation.
The second restriction we assessed related to the use of
medical abortion. In contrast to the national trend toward an
increase in the proportion of abortions that are medical [9],
the 70% decline in medical abortion we observed in Texas is
dramatic evidence of the law's effect. Some facilities stopped
offering medical abortion because of the law, and fewer
women were eligible because of the gestational age limit.
The cost of the procedure increased at most facilities offering
the regimen with 600 mg of mifepristone, and the increased
number of visits also likely reduced its appeal. Many women
have a strong preference for medical abortion [16,17], and it
may be that some of these women either traveled out of state
to obtain the method or perhaps decided not to have an
abortion at all if they could not obtain it. Women with a
strong preference for a medical method of termination may
be more likely to attempt to self-induce their abortion [18],
and this should be explored in future research in Texas.
The final restriction included in HB2, the ASC requirement,
will go into effect in September 2014. While we can only
speculate about the likely impact of this provision, our study
showed virtually no increase in the proportion of abortions
performed in ASCs. Indeed, despite the increase in abortions
performed in some cities with ASCs, less than a quarter of all
abortions in the state are currently performed at ASCs, and it
seems highly unlikely that existing facilities could expand their
capacity fourfold to meet the demand for services. The ASC
requirement will further reduce the number of facilities
providing abortion to about six in the entire state, leaving
Texas women with very few options.
This analysis has several limitations. Since this is an
observational study, we cannot prove causality between
the state restrictions and falling abortion rate; the timing,
however, is suggestive of a link. In addition, where data
were not directly available, we used informants or made
internal estimates. However, our estimates for Period 1 are
similar to numbers reported by the state for 2012. We also
do not have data on women traveling out of state for
abortion services, so we do not know if the missing
abortionswere obtained elsewhere or not at all. Since
Louisiana and Oklahoma have recently enacted admitting
privilege requirements, the option to travel to a neighbor-
ing state soon will be very limited. While we successfully
collected statewide data very rapidly after HB2 was
enforced, more in-depth research will be needed in the
coming years to fully understand the law's impact. For
example, the eventual impact of the admitting privileges
requirement remains to be seen, since some hospitals
require a minimum number of admissions to maintain
privileges, a condition that abortion providers with a
limited practice are unlikely to meet. Strengths of the study
are that it includes the entire universe of licensed abortion
facilities in the state and that 90% of the abortion data was
obtained directly from providers.
As more restrictions on abortion care are imposed by state
legislatures, it is critical to assess the effect of these laws on
women. In Texas, we plan further research to explore
whether limited access to services pushes women to obtain
an abortion later in pregnancy, as suggested by our findings
here, when the procedure has a higher risk of complications
and is more expensive [19,20]. We also plan to study
whether abortion self-induction may become more prevalent
in Texas, where it already appears to be more common than
other parts of the country [21].
This study was supported by an anonymous foundation.
The funder had no role in study design; in the collection,
analysis and interpretation of data; in the writing of the
report; or in the decision to submit the article for publication.
500 D. Grossman et al. / Contraception 90 (2014) 496501
[1] Nash E, Gold RB, Rowan A, Rathbun G, Vierboom Y. Laws affecting
reproductive health and rights: 2013 state, policy review; 2014 [cited
June 15, 2014].
[2] Joyce T. The supply-side economics of abortion. N Engl J Med
[3] Joyce TJ, Henshaw SK, Dennis A, Finer LB, Blanchard K. The
impact of state mandatory counseling and waiting period laws on
abortion: a literature review. New York: Guttmacher Institute; 2009.
[4] Colman S, Joyce T. Regulating abortion: impact on patients and
providers in Texas. J Policy Anal Manage 2011;30:77597.
[5] Brief of amici curiae American College of Obstetricians and
Gynecologists and the American Medical Association in support of
plaintiffs-appellees andin support of affirmance. [cited June 20, 2014]
Available from:
[6] Raymond EG, Shannon C, Weaver MA, Winikoff B. First-trimester
medical abortion with mifepristone 200 mg and misoprostol: a systematic
review. Contraception 2013;87(1):2637.
[7] Census Bureau US. Population estimates. [cited May 15, 2014];
Available from:
[8] Ackerman T. Houston abortion clinic shut down by state. Houston:
Chronicle; 2014 [cited May 1, 2014]; Available from: http://www.
5237377.php 2014.
[9] Jones RK, Jerman J. Abortion incidence and service availability in
the United States, 2011. Perspect Sex Reprod Health 2014;46
[10] Freedman L, Landy U, Darney P, Steinauer J. Obstacles to the
integration of abortion into obstetrics and gynecology practice.
Perspect Sex Reprod Health 2010;42(3):14651.
[11] Texas Department of State Health Services. Induced terminations
of pregnancy by age and county of residence; Texas. [cited July 12,
2014]; Available from:
[12] Ura A. As abortion clinics close, student creates travel fund. Texas
Tri bune . [cited June 22, 2014]; Available from: http://www.texastribune.
[13] White K, Grossman D, Hopkins K, Potter JE. Cutting family planning
in Texas. N Engl J Med 2012;367(13):117981.
[14] Martin JA, Hamilton BE, Osterman JK, et al. Births: Final data for
2012. National vital statistics reports, vol 62 no 9. Hyattsville, MD:
National Center for Health Statistics; 2013.
[15] Hamilton BE, Martin JA, Osterman MJK, Curtin SC. Births:
Preliminar y data for 2013. National vital statistics reports web
release, vol 63 no 02. Hyattsville, MD: National Center for Health
Statistics; 2014.
[16] Harvey SM, Beckman LJ, Satre SJ. Choice of and satisfaction with
methods of medical and surgical abortion among U.S. clinic patients.
Fam Plann Perspect 2001;33(5):2126.
[17] Shochet T, Trussell J. Determinants of demand: method selection and
provider preference among US women seeking abortion services.
Contraception 2008;77(6):397404.
[18] Grossman D, Holt K, Peña M, Lara D, Veatch M, Córdova D, et al.
Self-induction of abortion among women in the United States. Reprod
Health Matters 2010;18(36):13646.
[19] Bartlett LA, Berg CJ, Shulman HB, Zane SB, Green CA, Whitehead S, et
al. Risk factors for legal induced abortion-related mortality in the
United States. Obstet Gynecol 2004;103(4):72937.
[20] Jones RK, Kooistra K. Abortion incidence and access to services in the
United States, 2008. Perspect Sex Reprod Health 2011;43(1):4150.
[21] Grossman D, White K, Hopkins K, Potter JE. The public health threat
of anti-abortion legislation. Contraception 2014;89:734.
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... Laws can also target the cost of providing a particular type of abortion. In Texas, House Bill 2 increased the cost of medical abortion in most facilities by requiring providers to choose between a drug regimen that was considerably more expensive than the evidence-based regimen or a drug regimen supported by limited evidence (Grossman, Baum et al. 2014). The Partial-Birth Abortion Ban Act (2003), upheld in 2007 by the Supreme Court of the United States, led to three facilities in Massachusetts increasing their charges for second trimester abortion services (Haddad, Yanow et al. 2009). ...
... Inefficiencies related to missed follow-up appointments may reduce providers' availability to perform abortions or other services and drive up the costs of care. (Grossman, Baum et al. 2014 ...
Full-text available
Objective: To systematically search for and synthesize the social science literature on the consequences of abortion-related care, abortion policies, and abortion stigma on economic costs, benefits, impacts, and values at the micro- (i.e., abortion seekers and their households), meso- (i.e., communities and health systems), and macro- (i.e., societies and nation states) levels. Methods: We conduct a scoping review using the PRISMA extension for Scoping Reviews (PRISMA-ScR) tool. Studies reporting on qualitative and/or quantitative data from any world region are considered. For inclusion, studies must examine one of the following economic outcomes at the micro, meso-, and/or macro-levels: costs, benefits, impacts, and/or value of abortion-related care or abortion policies. Results: Our searches yielded 19,653 unique items, of which 365 items were included in our synthesis. The economic levels are operationalized as follows: at the micro-level we examine individual decision making, at the meso-level we consider the impact on abortion services and medical systems in context, and at the macro the impact of access to abortion services on broader indicators (e.g., women’s educational attainment). At the micro-economic level, results indicate that economic costs and consequences play an important role in women’s trajectories to abortionrelated care. However, the types of costs that are studied are often unclear and tend to focus narrowly on costs to and at health facilities. Our evidence suggests that a much broader range of economic costs, impacts and values are likely to be important in a wide range of contexts. At the meso-economic level, we find that adapting to changes in laws and policies is costly for health facilities, and that financial savings can be realized while maintaining or even improving quality of abortion care services. At the macro-economic level, the evidence shows that post-abortion care services are expensive and can constitute a substantial portion of health budgets. Public sector coverage of abortion costs is sparse, and women bear most of the financial costs. Conclusions: This scoping review has uncovered a wealth of information about the economic costs, impacts, value, and benefits of abortion services and policies. The review also points to knowledge gaps, such as the ways in which women perceive the intersections between costs and quality of care, safety, and risk. Similarly, there is a dearth of methodological variation and innovation, with an abundance of studies using costing methods and regression analysis while other tools seen elsewhere in behavioral studies (such as discrete choice experiments and randomized control trials) are underexploited. This study provides a conceptual mapping of the economics of abortion in a new way, reinforcing some findings already well known while uncovering underexplored questions and methods.
... Bernie and Clavier poignantly note that "health promotion research is inherently political" and caution researchers against conceptualizing a fictitious world where health interventions and scientific research are politically neutral topics [21]. For example, recent policy changes in the USA demonstrate strong political influence, some to the detriment of public health and individual rights through restrictions in access to care [23][24][25]. Public health is also criticized for naïvely perceiving policymaking as a linear process with research serving as the strongest influence over decision-makers [20,21,26,27]. Policy D&I research has the potential to address these criticisms by examining how complex, nonlinear policymaking and implementation processes are shaped by a plurality of interests including evidence, politics, personal and societal values, finances, and other factors of variable transparency [14,[28][29][30]. ...
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Background Implementation science aims to accelerate the public health impact of evidence-based interventions. However, implementation science has had too little focus on the role of health policy — and its inseparable politics, polity structures, and policymakers — in the implementation and sustainment of evidence-based healthcare. Policies can serve as determinants, implementation strategies, the evidence-based “thing” to be implemented, or another variable in the causal pathway to healthcare access, quality, and patient outcomes. Research describing the roles of policy in dissemination and implementation (D&I) efforts is needed to resolve persistent knowledge gaps about policymakers’ evidence use, how evidence-based policies are implemented and sustained, and methods to de-implement policies that are ineffective or cause harm. Few D&I theories, models, or frameworks (TMF) explicitly guide researchers in conceptualizing where, how, and when policy should be empirically investigated. We conducted and reflected on the results of a scoping review to identify gaps of existing Exploration, Preparation, Implementation, and Sustainment (EPIS) framework-guided policy D&I studies. We argue that rather than creating new TMF, researchers should optimize existing TMF to examine policy’s role in D&I. We describe six recommendations to help researchers optimize existing D&I TMF. Recommendations are applied to EPIS, as one example for advancing TMF for policy D&I. Recommendations (1) Specify dimensions of a policy’s function (policy goals, type, contexts, capital exchanged). (2) Specify dimensions of a policy’s form (origin, structure, dynamism, outcomes). (3) Identify and define the nonlinear phases of policy D&I across outer and inner contexts. (4) Describe the temporal roles that stakeholders play in policy D&I over time. (5) Consider policy-relevant outer and inner context adaptations. (6) Identify and describe bridging factors necessary for policy D&I success. Conclusion Researchers should use TMF to meaningfully conceptualize policy’s role in D&I efforts to accelerate the public health impact of evidence-based policies or practices and de-implement ineffective and harmful policies. Applying these six recommendations to existing D&I TMF advances existing theoretical knowledge, especially EPIS application, rather than introducing new models. Using these recommendations will sensitize researchers to help them investigate the multifaceted roles policy can play within a causal pathway leading to D&I success.
... Using data from their national survey of abortion-providing facilities, the Guttmacher Institute estimated that approximately 21% of all pregnancies in the United States ended in induced abortion in 2020 (34). Multiple factors influence the incidence of abortion, including access to health care services and contraception (36)(37)(38); the availability of abortion providers and clinics (6,39,40); state regulations, such as mandatory waiting periods (41)(42)(43), parental involvement laws (44,45), and legal restrictions on abortion providers and clinics (46)(47)(48)(49)(50)(51)(52); and changes in the economy and the resulting impact on family planning decisions and contraceptive use (53). ...
Problem/condition: CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States. Period covered: 2020. Description of system: Each year, CDC requests abortion data from the central health agencies for the 50 states, the District of Columbia, and New York City. For 2020, a total of 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2011-2020. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2019 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS). Results: A total of 620,327 abortions for 2020 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2011-2020, in 2020, a total of 615,911 abortions were reported, the abortion rate was 11.2 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 198 abortions per 1,000 live births. From 2019 to 2020, the total number of abortions decreased 2% (from 625,346 total abortions), the abortion rate decreased 2% (from 11.4 abortions per 1,000 women aged 15-44 years), and the abortion ratio increased 2% (from 195 abortions per 1,000 live births). From 2011 to 2020, the total number of reported abortions decreased 15% (from 727,554), the abortion rate decreased 18% (from 13.7 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 9% (from 217 abortions per 1,000 live births).In 2020, women in their 20s accounted for more than half of abortions (57.2%). Women aged 20-24 and 25-29 years accounted for the highest percentages of abortions (27.9% and 29.3%, respectively) and had the highest abortion rates (19.2 and 19.0 abortions per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.7%, respectively) and had the lowest abortion rates (0.4 and 2.6 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios were highest among adolescents (aged ≤19 years) and lowest among women aged 25-39 years.Abortion rates decreased from 2011 to 2020 among all age groups. The decrease in abortion rate was highest among adolescents compared with any other age group. From 2019 to 2020, abortion rates decreased or did not change for all age groups. Abortion ratios decreased from 2011 to 2020 for all age groups, except adolescents aged 15-19 years and women aged 25-29 years for whom abortion ratios increased. The decrease in abortion ratio was highest among women aged ≥40 years compared with any other age group. From 2019 to 2020, abortion ratios decreased for adolescents aged <15 years and women aged ≥35 and increased for women 15-34 years.In 2020, 80.9% of abortions were performed at ≤9 weeks' gestation, and nearly all (93.1%) were performed at ≤13 weeks' gestation. During 2011-2020, the percentage of abortions performed at >13 weeks' gestation remained consistently low (≤9.2%). In 2020, the highest percentage of abortions were performed by early medical abortion at ≤9 weeks' gestation (51.0%), followed by surgical abortion at ≤13 weeks' gestation (40.0%), surgical abortion at >13 weeks' gestation (6.7%), and medical abortion at >9 weeks' gestation (2.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 63.9% of abortions were early medical abortions. In 2019, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, four women died as a result of complications from legal induced abortion. Interpretation: Among the 48 areas that reported data continuously during 2011-2020, overall decreases were observed during 2011-2020 in the total number, rate, and ratio of reported abortions. From 2019 to 2020, decreases also were observed in the total number and rate of reported abortions; however, a 2% increase was observed in the total abortion ratio. Public health action: Abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies.
... This reflects a decline in the abortion rate for adolescent girls ages 15-19 between 2008 and 2014, which can be attributed to the increased popularity of long-acting reversible contraception (LARC), like the intrauterine devices (IUDs) and implants (Jones & Jerman, 2017;Lindberg et al., 2016). After Texas's House Bill 2 restricting procedural and medication abortion in 2013, a noticeable reduction in abortion rates among Texas women were discovered, with increased travel times to clinics causing a severe hinderance in obtaining an abortion (Baum et al., 2016;Bhardwaj et al., 2020;Goyal et al., 2020aGoyal et al., , 2020bGrossman et al., 2014;Myers et al., 2019). It is imperative to measure the potential effects of these bills on adolescent pregnancy rates though rates have declined over time in this age group. ...
The recent overturning of Roe v. Wade has the potential to adversely impact reproductive health among adolescents experiencing unplanned pregnancies from dating violence. We examined the associations between contraceptive use and dating violence among Texas high schoolers in the years leading up to this new law. Youth Risk Behavior Surveillance System data from Texas 9th to 12th graders from 2011, 2013, 2017, and 2019 were analyzed. Multinomial logistic regression analyses examined the association between contraceptive use and key descriptive predictors (physical and/or sexual dating violence, survey year, age, sex, and race/ethnic group). Eleven percent of Texas adolescents surveyed reported experiencing either physical or sexual dating violence and 2% reported experiencing both types of violence. Those who experienced any dating violence were significantly more likely to report not using contraception versus those who did not experience violence (12.5% vs. 68.3%, p = 0.01). Adolescents who experienced any type
... Abortion can be difficult to access in the United States for many reasons, including state and federal regulations that restrict how a pregnant person can access abortion care (1)(2)(3); decreasing numbers of abortion providers (4,5); the need to travel long distances to reach an abortion-providing facility (6)(7)(8); and costs associated with the procedure and/or travel to the facility (9,10). Over the past decade, abortion providers have implemented site-to-site telehealth for medication abortion (referred to here as "site-to-site TeleMAB") services to allow health centers that do not have a clinician onsite to provide medication abortion services remotely. ...
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Background: In the site-to-site telehealth for medication abortion model, patients visit a health center to meet with a remote clinician using telehealth technology. This model is safe, effective, and acceptable to patients and providers. The objective of this study was to document the experiences of patients and providers using telehealth for medication abortion in Planned Parenthood health centers across different geographical contexts in the United States. Methods: We conducted in-depth interviews with Planned Parenthood medication abortion patients who either met with a clinician at the clinic via telehealth or in-person about their experiences receiving care. We also interviewed Planned Parenthood staff members about their experiences implementing telehealth for medication abortion at their health center. Results: We interviewed 29 patients who received care at Planned Parenthood health centers in five states. Both telehealth and in-person patients described positive interactions with health center staff and clinicians. The vast majority of telehealth patients said that they felt comfortable speaking with the clinician over telehealth and had no trouble using the telehealth technology. We interviewed 12 providers, including clinicians and administrative staff, who worked in seven states. Providers largely thought that telehealth for medication abortion expanded access to medication abortion. Conclusions: Across different locations, our findings indicate that patients found telehealth for medication abortion services to be highly acceptable and providers found that telehealth services may help improve medication abortion access. As the use of telehealth for medication abortion expands, future research should include additional measures of quality to ensure that services are acceptable across different identities and experiences, including age, race, gender, and income level.
Importance: Following the US Supreme Court ruling in Dobbs v Jackson Women's Health Organization, Georgia's law limiting abortion to early pregnancy, House Bill 481 (HB481), was allowed to go into effect in July 2022. Objectives: To estimate anticipated multiyear effects of HB481, which prohibits abortions after detection of embryonic cardiac activity, on abortion incidence in Georgia, and to examine inequities by race, age, and socioeconomic status. Design, setting, and participants: This repeated cross-sectional analysis used abortion surveillance data from January 1, 2007, to December 31, 2017, to estimate future effects of HB481 on abortion care in Georgia, with a focus on the 2 most recent years of data (2016 and 2017). Abortion surveillance data were obtained from the 2007-2017 Georgia Department of Public Health's Induced Termination of Pregnancy files. Linear regression was used to estimate trends in abortions provided at less than 6 weeks' gestation and at 6 weeks' gestation or later in Georgia, and χ2 analyses were used to compare group differences by race, age, and educational attainment. Data were analyzed from July 26 to September 22, 2022. Exposures: HB481, Georgia's law limiting abortion to early pregnancy. Main outcome and measures: Weeks' gestation at abortion (<6 vs ≥6 weeks). Results: From January 1, 2007, to December 31, 2017, there were 360 972 reported abortions in Georgia, with an annual mean (SD) of 32 816 (1812) abortions. Estimates from 2016 to 2017 suggest that 3854 abortions in Georgia (11.6%) would likely meet eligibility requirements for abortion care under HB481. Fewer abortions obtained by Black patients (1943 [9.6%] vs 1280 [16.2%] for White patients), patients younger than 20 years (261 [9.1%] vs 168 [15.0%] for those 40 years and older), and patients with fewer years of education (392 [9.2%] with less than a high school diploma and 1065 [9.6%] with a high school diploma vs 2395 [13.5%] for those with some college) would likely meet eligibility requirements under HB481. Conclusions and relevance: These findings suggest that Georgia's law limiting abortion to early pregnancy (HB481) would eliminate access to abortion for nearly 90% of patients in Georgia, and disproportionately harm patients who are Black, younger, and in lower socioeconomic status groups.
This paper evaluates the financial and economic consequences of being denied an abortion. We link credit report data to the Turnaway Study, which collected high-quality, longitudinal data on women receiving or being denied a wanted abortion in the United States. We compare financial outcomes over a ten-year period for women who had pregnancies just above and below a gestational age limit allowing for a wanted abortion. Outcomes evolved similarly for the two groups prior to the abortion encounter. Following the encounter, women who were denied an abortion experience a large increase in financial distress that remains for several years. (JEL G51, I18, J13, J16)
State laws have influenced access to abortion in the 50 years since Roe v. Wade. The 2022 Dobbs decision returned questions about the legality of abortion to the states, which increased the importance of state laws for abortion access. The objective of this study is to illustrate trends in abortion-restrictive and abortion-supportive state laws using a unique longitudinal database of reproductive health laws across the U.S. from 1994-2022. This study offers a descriptive analysis of historical trends in state-level pre-viability abortion bans, abortion method bans, efforts to dissuade abortion, TRAP laws (targeted regulation of abortion providers), other laws that restrict reproductive choice, and laws that expand abortion access and support reproductive health. Data sources included state statutes (from Nexis Uni) and secondary sources. The data reveal that pre-viability bans, including gestation-based and total bans, became significantly more prevalent over time. Other abortion-restrictive laws increased 1994-2022, but states also passed a growing number of laws that support reproductive health. Increasing polarization into abortion-restrictive and abortion-supportive states characterized the 1994-2022 period. These trends have implications for maternal and infant health and for racial-ethnic and income disparities.
Objectives Assess preferences for and use of medication abortion in Texas after implementation of two policy changes: a 2013 state law restricting medication abortion and the FDA label change for mifepristone in 2016 nullifying some of this restriction. Study design We analyzed surveys conducted in 2014 and 2018 with abortion patients at 10 Texas abortion facilities. We calculated the percentage of all respondents with an initial preference for medication abortion by survey year, and the type of abortion obtained or planned to obtain among those who were at <10 weeks of gestation. We used multivariable-adjusted mixed-effects Poisson regression models to assess factors associated with medication abortion preference and actual/planned use. Results Overall, 156 (41%) of 376 respondents in 2014 and 247 (55%) of 448 respondents in 2018 reported initial preference for medication abortion (Prevalence ratio [PR]: 1.28; 95% CI 1.03-1.59). Among those who were <10 weeks of gestation and initially preferred medication abortion, 39/124 (31%) obtained or were planning to obtain the method in 2014, compared with 188/223 (84%) in 2018 (PR: 2.65; 95% CI: 1.69-4.15). After multivariable adjustment, respondents who initially preferred medication abortion and were 7-9 weeks of gestation at the time of their ultrasonography (vs <7 weeks) were less likely to obtain or plan to obtain the method (PR: 0.69; 95% CI: 0.57-0.84). Conclusions Abortion patients were more likely to prefer and obtain or plan to obtain their preferred medication abortion after legal restrictions in Texas were nullified. Implications State policies can affect people's ability to obtain their preferred abortion method. Efforts to provide both abortion options whenever possible, and inform people where each can be obtained, remains an important component of person-centered care despite increasing state abortion restrictions and bans following the reversal of Roe v Wade.
Movement lawyering often results in litigation battles. Litigant lawyers in Supreme Court abortion cases, who are typically affiliated with, if not members of the reproductive-rights and antiabortion movements, for many years have engaged in a war of words as they dispute abortion laws and what constitutes an undue burden on abortion access. I use and build on social movement framing theory to examine the legal-framing contest unfolding across the undue-burden abortion cases, toward discerning the anatomy and causal sequence of this discursive legal battle. Using both qualitative and quantitative-computerized text analysis, I show that a broad discursive-opportunity structure shapes the legal-framing contest, and the contest itself is structured by framing innovations and persistence and by dialogic and monologic framing. This theoretical framework can aid our understanding of the sometimes fierce discursive battles in movement litigation, shedding light on how social movements influence legal policy development.
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Objectives: This report presents 2012 data on U.S. births according to a wide variety of characteristics. Data are presented for maternal age, live-birth order, race and Hispanic origin, marital status, attendant at birth, method of delivery, period of gestation, birthweight, and plurality. Birth and fertility rates are presented by age, live-birth order, race and Hispanic origin, and marital status. Selected data by mother's state of residence and birth rates by age and race of father also are shown. Trends in fertility patterns and maternal and infant characteristics are described and interpreted. Methods: Descriptive tabulations of data reported on the birth certificates of the 3.95 million births that occurred in 2012 are presented. Results: A total of 3,952,841 births were registered in the United States in 2012. The general fertility rate declined to 63.0 per 1,000 women aged 15-44. The teen birth rate fell 6%, to 29.4 per 1,000 women. Birth rates declined for women in their twenties and increased for women aged 30-44. The total fertility rate (estimated number of births over a woman's lifetime) declined 1% to 1,880.5 per 1,000 women. The rate of births to unmarried women declined; the percentage of births to unmarried women was essentially stable at 40.7%, but the number of births to unmarried women increased slightly. The cesarean delivery rate was unchanged at 32.8%. The preterm birth rate declined for the sixth straight year to 11.55%; the low birthweight rate declined slightly to 7.99%. The twin birth rate was stable at 33.1 per 1,000 births; the rate of triplet and higher-order multiple births dropped 9% to 124.4 per 100,000 total births.
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Context: National and state-level information about abortion incidence can help inform policies and programs intended to reduce levels of unintended pregnancy. Methods: In 2015-2016, all U.S. facilities known or expected to have provided abortion services in 2013 or 2014 were surveyed. Data on the number of abortions were combined with population data to estimate national and state-level abortion rates. The number of abortion-providing facilities and changes since a similar 2011 survey were also assessed. The number and type of new abortion restrictions were examined in the states that had experienced the largest proportionate changes in clinics providing abortion services. Results: In 2014, an estimated 926,200 abortions were performed in the United States, 12% fewer than in 2011; the 2014 abortion rate was 14.6 abortions per 1,000 women aged 15-44, representing a 14% decline over this period. The number of clinics providing abortions declined 6% between 2011 and 2014, and declines were steepest in the Midwest (22%) and the South (13%). Early medication abortions accounted for 31% of nonhospital abortions, up from 24% in 2011. Most states that experienced the largest proportionate declines in the number of clinics providing abortions had enacted one or more new restrictions during the study period, but reductions were not always associated with declines in abortion incidence. Conclusions: The relationship between abortion access, as measured by the number of clinics, and abortion rates is not straightforward. Further research is needed to understand the decline in abortion incidence.
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Objectives: This report presents 2011 data on U.S. births according to a wide variety of characteristics. Data are presented for maternal characteristics, including age, live-birth order, race and Hispanic origin, marital status, attendant at birth, method of delivery, and infant characteristics (e.g., period of gestation, birthweight, and plurality). Birth and fertility rates are presented by age, live-birth order, race and Hispanic origin, and marital status. Selected data by mother's state of residence and birth rates by age and race of father also are shown. Trends in fertility patterns and maternal and infant characteristics are described and interpreted. Methods: Descriptive tabulations of data reported on the birth certificates of the 3.95 million births that occurred in 2011 are presented. Denominators for population-based rates are postcensal estimates derived from the U.S. 2010 census. Birth and fertility rates for 2001-2009 are based on revised intercensal population estimates. Denominators for 2011 and 2010 rates for the specific Hispanic groups are derived from the American Community Survey; denominators for earlier years are derived from the Current Population Survey. Results: The number of births declined 1% in 2011 to 3,953,590. The general fertility rate also declined 1%, to 63.2 per 1,000 women aged 15-44. The teen birth rate fell 8%, to 31.3 per 1,000 women. Birth rates declined for women in their 20s, were unchanged for women aged 30-34, and rose for women aged 35-44. The total fertility rate (estimated number of births over a woman's lifetime) declined 2% to 1,894 per 1,000 women. The number and rate of births to unmarried women declined; the percentage of births to unmarried women was essentially stable at 40.7%. The cesarean delivery rate was unchanged from 2010 at 32.8%. The preterm birth rate declined for the fifth straight year to 11.73%; the low birthweight rate declined slightly to 8.10%. The twin birth rate was not significantly changed at 33.2 per 1,000 births; the rate of triplet and higher-order multiple births also was essentially stable at 137.0 per 100,000.
Recent media coverage and case reports have highlighted women's attempts to end their pregnancies by self-inducing abortions in the United States. This study explored women's motivations for attempting self-induction of abortion. We surveyed women in clinic waiting rooms in Boston, San Francisco, New York, and a city in Texas to identify women who had attempted self-induction. We conducted 30 in-depth interviews and inductively analyzed the data. Median age at time of self-induction attempt was 19 years. Between 1979 and 2008, the women used a variety of methods, including medications, malta beverage, herbs, physical manipulation and, increasingly, misoprostol. Reasons to self-induce included a desire to avoid abortion clinics, obstacles to accessing clinical services, especially due to young age and financial barriers, and a preference for self-induction. The methods used were generally readily accessible but mostly ineffective and occasionally unsafe. Of the 23 with confirmed pregnancies, three reported a successful abortion not requiring clinical care. Only one reported medical complications in the United States. Most would not self-induce again and recommended clinic-based services. Efforts should be made to inform women about and improve access to clinic-based abortion services, particularly for medical abortion, which may appeal to women who are drawn to self-induction because it is natural, non-invasive and private. Résumé Aux États-Unis, les tentatives de femmes d'interrompre elles-mêmes leur grossesse ont récemment fait l'objet d'une couverture médiatique et de rapports. Cette étude a exploré les raisons incitant les femmes à s'auto-avorter. Nous avons enquêté dans les salles d'attente de dispensaires à Boston, San Francisco, New York et une ville du Texas pour identifier les femmes qui avaient tenté d'auto-avorter. Nous avons mené 30 entretiens approfondis et analysé les données par induction. L'âge médian au moment de la tentative d'auto-avortement était de 19 ans. Entre 1979 et 2008, les femmes ont utilisé diverses méthodes, notamment des médications, des boissons maltées, des plantes, des manipulations physiques et, de plus en plus, du misoprostol. Parmi les raisons de l'auto-avortement figuraient le désir des femmes d'éviter les centres d'avortement, les difficultés d'accès aux services cliniques, particulièrement en raison de leur jeunesse et du manque de moyens financiers, et une préférence pour l'auto-avortement. Les méthodes utilisées étaient généralement aisément disponibles, mais pour la plupart inefficaces et occasionnellement dangereuses. Des 23 femmes avec une grossesse confirmée, trois ont fait état d'un avortement réussi n'ayant pas nécessité de soins cliniques. Une femme a rapporté des complications médicales aux États-Unis. La plupart d'entre elles ne recommenceraient pas à s'auto-avorter et recommandaient des services institutionnels. Il faut informer les femmes sur les services d'avortement dans des centres et en élargir l'accès, en particulier pour l'avortement médicamenteux qui peut convenir aux femmes attirées par l'auto-avortement parce que c'est une méthode naturelle, non invasive et qui respecte l'intimité. Resumen En recientes reportajes e informes de casos se han destacado los intentos de interrupción del embarazo mediante la autoinducción del aborto en Estados Unidos. Este estudio exploró las motivaciones de las mujeres para intentar la autoinducción del aborto. Encuestamos mujeres en las salas de espera de clínicas en Boston, San Francisco, Nueva York y una ciudad en Texas para identificar a las que habían intentado la autoinducción. Realizamos 30 entrevistas a profundidad y analizamos los datos de manera inductiva. La edad mediana en el momento del intento de autoinducción fue de 19 años. Entre 1979 y 2008, las mujeres utilizaron una variedad de métodos, como medicamentos, malta, hierbas, manipulación física y, cada vez más, misoprostol. Los motivos para autoinducirse un aborto eran: el deseo de evitar las clínicas de aborto, obstáculos al acceso a los servicios clínicos, especialmente debido a la temprana edad y a las barreras financieras, y la preferencia por la autoinducción. Los métodos utilizados generalmente eran fáciles de obtener pero la mayoría ineficaces y a veces inseguros. De las 23 con embarazos confirmados, tres dijeron que lograron abortar sin necesitar atención médica. Solo una relató haber presentado complicaciones médicas en Estados Unidos. La mayoría no volvería a autoinducirse un aborto y recomendó servicios clínicos. Se deberían realizar esfuerzos por informar a las mujeres acerca de los servicios de aborto en las clínicas y por mejorar el acceso a estos, particularmente al aborto con medicamentos, una opción que probablemente les interese a las mujeres que se inclinan hacia la autoinducción, por ser natural, no invasivo y privado.
Objectives-This report presents prelimina ry data for 2013 on births in the United States. U.S. data on births are shown by age, live-birth order, race, and Hispanic origin of mother. Data on marital status, cesarean delivery, preterm births, and low birthwe ight are also presented. Methods-Data in this report are based on 99.85% of 2013 births. Records for the few states with less than 100% of records received are weighted to independent control counts of all births received in state vital statistics offices in 2013. Comparisons are made with final 2012 data and earlier years. Results- The 2013 preliminary number of births for the United States was 3,957,577, slightly more births (4,736) than in 2012. The number of births increased or were unchanged for most race and Hispanic origin groups from 2012 to 2013; however, the number of births for Asian or Pacific Islander women declined 2% in 2013. • The general fertility rate was 62.9 births per 1,000 women age 15-44 years, down slightly from 2012 and a record low. • The birth rate for teens aged 15-19 declined 10% in 2013 to 26.6 births per 1,000 women, yet another historic low for the nation, with rates declining for both younger and older teenagers to record lows. • The birth rate for women in their early twenties also declined in 2013, to a record low of 81.2 births per 1,000 women. • Birth rates for women in their thirties and forties rose in 2013. • The nonmarita l birth rate was down 1% in 2013 to 44.8 births per 1,000 unmarried women aged 15-44; the number of births to unmarried women declined slightly, as did the percentage of births to unmarr ied women (40.6% in 2013). • A small decline was seen in the cesarean delivery rate (32.7%). • The preterm birth rate fell for the seventh year in a row to 11.38% in 2013. • The low birthweight rate was essentially unchanged at 8.02%.
Following a long-term decline, abortion incidence stabilized between 2005 and 2008. Given the proliferation of state-level abortion restrictions, it is critical to assess abortion incidence and access to services since that time. In 2012-2013, all facilities known or expected to have provided abortion services in 2010 and 2011 were surveyed. Data on the number of abortions were combined with population data to estimate national and state-level abortion rates. Incidence of abortions was assessed by provider type and caseload. Information on state abortion regulations implemented between 2008 and 2011 was collected, and possible relationships with abortion rates and provider numbers were considered. In 2011, an estimated 1.1 million abortions were performed in the United States; the abortion rate was 16.9 per 1,000 women aged 15-44, representing a drop of 13% since 2008. The number of abortion providers declined 4%; the number of clinics dropped 1%. In 2011, 89% of counties had no clinics, and 38% of women of reproductive age lived in those counties. Early medication abortions accounted for a greater proportion of nonhospital abortions in 2011 (23%) than in 2008 (17%). Of the 106 new abortion restrictions implemented during the study period, few or none appeared to be related to state-level patterns in abortion rates or number of providers. The national abortion rate has resumed its decline, and no evidence was found that the overall drop in abortion incidence was related to the decrease in providers or to restrictions implemented between 2008 and 2011.
The State of Texas began enforcement of the Woman's Right to Know (WRTK) Act on January 1, 2004. The law requires that all abortions at or after 16 weeks' gestation be performed in an ambulatory surgical center (ASC). In the month the law went into effect, not one of Texas's 54 nonhospital abortion providers met the requirements of a surgical center. The effect was immediate and dramatic. The number of abortions performed in Texas at or after 16 weeks' gestation dropped 88 percent, from 3,642 in 2003 to 446 in 2004, while the number of residents who left the state for a late abortion almost quadrupled. By 2006, abortions at or after 16 weeks' gestation in a nonhospital setting were available in four major cities in Texas (down from nine in 2003), and the abortion rate at or after 16 weeks' gestation remained 50 percent below its pre-Act level. Regulation of abortion providers that require new facilities or costly renovations could have profound effects on the market for second-trimester abortions.
In 2011, Texas slashed funding for family planning services and imposed new restrictions on abortion care, affecting the health care of many low-income women. For demographically similar states, Texas's experience may be a harbinger of public health effects to come.