National Partnership for Women & Families

Monthly Women's Health Research Review

Researchers analyze women's experience obtaining abortion care in Alabama

Summary of "Experience accessing abortion care in Alabama among women traveling for services," White et al., Women's Health Issues, Jan. 8, 2016.

Research shows that "89% of U.S. counties lack a clinic that provides abortion, and 38% of reproductive-aged women live in these counties," according to Kari White of the University of Alabama at Birmingham and colleagues. The researchers noted that as of 2008, a woman seeking abortion care in the United States had to travel an average of 30 miles each way to access care, while at least 27 percent of women had to travel a minimum of 50 miles. According to the researchers, nearly half of reproductive-aged women in Southern states live in a county without an abortion clinic, and these women "travel greater distances for services."

Moreover, "many states have established or extended mandatory [delays] of at least 24 hours after an initial consultation, along with passing other abortion regulations," the researchers wrote. Noting that requirements such as these can compel women to make two in-person visits to receive abortion care, the researchers wrote that mandatory delays "are likely to increase women's overall travel burden."

In an effort to "examin[e] the experiences of women who must travel long distances for services in settings with few providers and extensive restrictions on abortion care," the researchers interviewed women who sought abortion care in Alabama. They explained that the state requires a woman to wait 48 hours after an initial consultation with an abortion provider before she can receive an abortion, adding that while Alabama allows the counseling information to be provided by certified mail rather than in person, "not all clinics offer to mail the materials because it is administratively burdensome." According to the researchers, the study's findings "highlight the types of challenges women encounter in their process of obtaining abortion care in this setting and have implications for identifying approaches that may reduce barriers to access where abortion services are limited."

Methods

For the study, researchers interviewed women seeking abortion care at one of two abortion clinics in Alabama between July and September 2014. At the time of the study, two of the state's five clinics had temporarily stopped providing abortion care and one of the remaining three provided abortion care only one day per week. The researchers recruited women from the two clinics, Clinic A and Clinic B, that had the highest patient volume. Clinic A provided abortion care through 16 weeks after a woman's last menstrual period (LMP), while Clinic B offered abortion care up to 20 weeks after LMP.

The researchers recruited participants who were at the clinic for abortion care, at least 19 years old and English-speaking. According to the researchers, the sample also was limited to women "who traveled more than 30 miles one way," as confirmed by distance or time spent travelling.

Overall, the researchers conducted phone interviews with 25 participants about their abortion experiences. The study "focuse[d] on women's processes [for] obtaining abortion care and themes related to the ways in which distance intersects with the service and policy environment to shape their experiences."

Findings

Participant characteristics

The researchers found that most participants were black, younger than 30 years old and had children. According to the researchers, most participants had their abortion at 12 weeks or less since LMP. Nine of the 25 women had medication abortion. While "many women had insurance, almost all of them paid out-of-pocket for their procedure," the researchers noted. "More than two-thirds of participants traveled more than 50 miles one way to the clinic where they obtained services," the researchers wrote, adding that seven women came from out of state, "primarily Mississippi."

The study found that while the women said they usually did not have difficulty accessing gynecological services from their local providers, "they often experienced multiple difficulties accessing abortion [care]."

Locating a clinic providing abortion care

Nearly all of the participants confirmed their pregnancy status with a home pregnancy test. To find an abortion clinic, about half used the Internet, while some "talked to women in their social networks who previously had abortions," the researchers found. About half of participants "who used these strategies commented that finding a clinic was easy because 'the place just popped up'" in an online search "or they were referred through an organizational website."

The researchers noted that seven women found multiple clinics when they searched online. Of those women, three "did not identify the nearest facility" and six "stated that finding a clinic was difficult and confusing," according to the researchers. When women searched online for a clinic, they "did not always retrieve accurate information" and the information available "was not always up to date," the researchers wrote, noting that one woman was "'shocked' to learn there was a clinic" in Mississippi.

According to the researchers, of the six women who learned of their pregnancy status during a health care visit, "only one ... received a referral after telling her family practice doctor that she did not want to continue her pregnancy." One woman "said her regular doctor 'was totally against the idea'" of her having an abortion and "dismissed her request for information," the researchers wrote. All six women "eventually searched for a clinic online."

Attending the consultation visit

The researchers found that all of the women received the state-mandated consultation in-person. About two-thirds said they "believed an in-person visit was unnecessary." Participants "commented that the information they felt was important to know about what to expect from the procedure could have been provided on the same day as their abortion or over the phone or by email." Another woman, the only one who learned the information could be mailed, opted for an in-person visit when she learned how burdensome the certified mail process would be.

The researchers noted that while six women said "they liked the in-person aspect of the visit because it felt supportive," all of the women who returned for abortion care said "the requirement to make a second visit after receiving information ... did not change their mind."

Moreover, according to the researchers, "For most women, the in-person consultation visit ... was burdensome because of the extra time and travel required." Due to the high volume of women seeking services at the clinics, women reported "spend[ing] between 2 and 6 hours at the clinic for their visit." Further, the additional travel also "added to women's overall costs of getting an abortion." For example, one 34-year-old woman who traveled more than 150 miles each way said she "'paid about $150 in gas back and forth.'"

Arranging for first trimester abortion visits

The researchers noted that only five of the 17 women who received abortion care during the first trimester "were able to return to the clinic for their procedure 48 hours after the consultation visit." According to the researchers, several other women had the procedure "more than 48 hours but less than 1 week after" their consultation, and seven waited one to two weeks after the consultation for the procedure, "in part for work-related reasons."

The researchers found that "[w]omen also were unable to return within 48 hours because they had to make multiple arrangements to accommodate the extended time needed for travel." While most of the "women were able to make the necessary arrangements by relying on those who already knew about their decision to have an abortion," two women had to "reluctantly" disclose their decision to people they would not have otherwise informed because "they needed additional coverage at work or for childcare" to make two visits. The researchers quoted one woman, who had to travel more than 100 miles to the clinic and ask her ex-husband to watch their children, who said, "'If there were something closer, I am sure it would not have been as difficult.'"

According to the researchers, women who had a medication abortion also had to return to the clinic for a third visit to confirm they were no longer pregnant. The researchers found that while "women did not have to pay for the follow-up appointment, they did incur additional expenses for gas and lost wages." In fact, the researchers noted that the need for a third visit led one "woman to choose aspiration abortion at 6 weeks from LMP because she lived more than 100 miles away" from the clinic and because "it 'did not seem practical ... to spend more money to go that far, and take the time off.'"

Accessing care in the second trimester

The researchers found that, compared with women who had an abortion in the first trimester, the eight women who had the procedure during the second trimester "were more often delayed in scheduling the consultation visit because they did not initially recognize their pregnancy or needed additional time to save money or reach a decision." However, according to the researchers, "the service and policy environment further delayed care for almost all of these women, four of whom initially sought services during their first trimester."

For example, the researchers noted that one woman who learned she was pregnant at the end of the first trimester was unable to locate and schedule a consultation visit at "the nearest clinic 80 miles away" until she was 13 weeks pregnant. She said she was not able to schedule the abortion for another week and a half, primarily because the clinic had a backlog of patients.

Moreover, the researchers wrote that along with "delays locating a clinic and arranging the procedure, women obtaining abortions at 15 or more weeks from LMP had extended time away from home to accommodate their need for cervical preparation before the abortion" and "also reported extra out-of-pocket expenses, unrelated to the procedure." For example, two women who obtained abortion care at 16 weeks LMP reported paying for hotels to accommodate the two-day procedure.

Discussion

The study's results "indicate that it is often difficult for [women living in the South] to access [abortion care] given the limited number of clinics in Alabama and neighboring states," the researchers wrote.

Further, the study found that while women most frequently relied on friends or the Internet to find a clinic, neither process was "necessarily straightforward for women," the researchers wrote. The researchers added, "The difficulties women face locating services in this way is concerning since this study and others have found that women are unlikely to turn to their regular health care provider for an abortion referral or are unable to obtain a referral when requested, and because some websites about abortion, such as those for crisis pregnancy centers, may be particularly misleading."

The researchers wrote that the findings "support and expand on those of other studies regarding the added time and cost associated with mandated consultation visits and [mandatory delays] for women traveling long distances." The researchers explained that women in the study "relied extensively on their social networks for logistical and financial support needed to arrange time off work, transportation, and childcare." These logistical challenges were exacerbated by long wait times at clinics, "which are not standard for other routine office-based health care visits," the researchers wrote.

The researchers added, "Because of the extra time and expense associated with the consultation visit in particular, women in our study often said they would prefer other ways of obtaining the information." Although "there was not a consensus" as to a preferred alternative, the researchers noted that "the option to receive the ... materials by certified mail was not seen as a practical alternative because it would have delayed care." Moreover, according to the researchers, "None of the participants ... were dissuaded by the state-mandated information they received," which "calls into question the extent to which this requirement is achieving the objective of discouraging women from having abortions."

The interviews "also highlight the fact that few women living far from clinics are able to return to the facility immediately after the mandated waiting period has passed," requiring some women to delay care until the second trimester and incur additional costs, the researchers wrote.

Policy implications

The researchers noted that while mandatory delays and other abortion restrictions will likely not be "repealed without judicial intervention," stakeholders in the meantime can "striv[e] to prevent further restrictions on services" and take steps "to make abortion care easier to access in the current service and policy environment." For instance, they noted, "it may be possible to increase health and social service providers' comfort and skills making a referral for women faced with an unintended pregnancy" and to "improv[e] Internet clinic locator services."

The researchers continued, "It also is important to minimize burdens on women once they have contacted a clinic." For example, according to the study, "women might obtain care in a more timely manner if information could be sent by regular mail, provided over the phone, or if the mandatory [delay] was waived for those living more than a certain distance from a clinic." In addition, clinics "could increase the availability of appointments ... by modifying" medication abortion protocols. The researchers explained that instead of having women come to the office for a third visit, "providers could give women choosing [medication abortion] the option of confirming abortion completion by obtaining a blood test ... closer to home." They concluded, "Such changes in service delivery should be considered in order to reduce burdens for the many women who live in communities without an abortion provider."