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Original research article
Change in abortion services after implementation of a restrictive law in Texas
⁎, Sarah Baum
, Liza Fuentes
, Kari White
, Kristine Hopkins
, 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 2012–April 2013 to November 2013–April 2014, there was
a 13% decrease in the abortion rate (from 12.9 to 11.2 abortions/1000 women age 15–44). 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
Recent years have seen a surge in state laws restricting
abortion services . Initially these laws focused on the
“demand”side of abortion and aimed to discourage women
from seeking abortion by mandating parental involvement
for minors, biased counseling or waiting periods . Other
than laws requiring an extra visit to the clinic, demand-side
restrictions appear to have minimal effect on the overall
abortion rate . More recently, states have passed laws
focused on the “supply”side of abortion that makes it more
difficult for facilities to provide services .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) .
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: DGrossman@ibisreproductivehealth.org (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 .
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 24–48 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 .
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 15–44 residing in each of Texas's
254 counties on July 1, 2012 . 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
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) 496–501
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 .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 15–44 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.
During Period 1 (November 1, 2012–April 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
El Paso San Angelo Killeen
Fig. 1. Geographic distribution of abortion facilities in Texas, November 2012–April 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, 2012–April 30, 2013 October 31, 2013 November 1, 2013 April 30,
498 D. Grossman et al. / Contraception 90 (2014) 496–501
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
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 Dallas–Ft. 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.
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
Abortions performed in Texas during three periods, November 2012–April 2014
(Nov 1, 2012–
Apr 30, 2013)
(May 1, 2013–
Oct 31, 2013)
(Nov 1, 2013–
Apr 30, 2014)
Period 1 to 3
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 15–44)
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%)
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%)
Number of women living in LRGV
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 15–44 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 15–44 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) 496–501
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 .
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 . In 2011, about one
quarter of Texas abortions were to women living outside the
four largest metropolitan areas , 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 .
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 . 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 ,
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 ,
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
abortions”were 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 .
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.
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