National Partnership for Women & Families

Monthly Women's Health Research Review

Study explores how 72-hour mandatory delay influences women's experiences seeking abortion care in Utah

Summary of "Utah's 72-hour waiting period for abortion: Experiences among a clinic-based sample of women," Roberts et al., Perspectives on Sexual and Reproductive Health, March 24, 2016.

"To contribute to the literature on … new, more severe [abortion] restrictions, this study seeks to understand women's experiences with Utah's 72-hour [mandatory delay]," according to Sarah Roberts of Advancing New Standards in Reproductive Health, University of California-San Francisco, and colleagues.

The researchers explained that mandatory delays "are often accompanied by a requirement that women receive state-mandated abortion information in person … thereby necessitating two visits." According to the researchers, as of November 2015, 27 states had mandatory delay laws, 13 of which required two visits.

In May 2012, Utah was the first state to enact a 72-hour mandatory delay. Because Utah also requires a woman to attend a face-to-face biased counseling session at the start of the mandatory delay period, a woman must make two visits, the researchers explained. According to the researchers, the study aimed "to examine women's reasons for not having an abortion under the 72-hour waiting period and two-visit requirement"; the costs related to each visit; the actual delay between the information visit and the abortion; and what women listed as "the hardest part of waiting and of making two visits."

Methods

For the study, researchers recruited eligible participants from four family planning facilities in Utah "who presented for an information visit between October 2013 and April 2014." The study included a baseline self-administered survey distributed to women prior to the information visit and a follow-up phone call conducted three weeks later.

The survey asked women about their socioeconomic status and decisional conflict regarding abortion. The survey also included questions about women's demographic and reproductive health characteristics, mental health history, substance use, experience with domestic violence and overall knowledge of abortion care. In addition, women were asked about the financial burden of completing the information visit and whether they had to disclose their consideration of abortion to someone otherwise unaware of the pregnancy to attend the information visit.

In the follow-up interviews, the researchers asked questions "to assess whether women had had an abortion and, if not, their reasons." The researchers also asked several questions about "women's experiences with the abortion visit," such as the financial cost, formal and informal financial assistance, disclosure to people otherwise uninformed about the pregnancy and the overall delay between the first and second visit. The researchers noted that they asked women who were delayed more than 72 hours for the reasons behind the extended delay. In addition, they asked all women who obtained an abortion about "the hardest part of making two visits."

Results

According to the researchers, 309 (63 percent) of the 500 women who agreed to participate in the study completed the follow-up interview.

At baseline, the researchers found that 95 percent said they preferred an abortion, 4 percent said they would prefer to deliver and raise the child and fewer than 1 percent said they would prefer to deliver and place the child for adoption. Overall, the mean decisional conflict score was 15 on a scale from 0-69, "indicating low conflict," the researchers wrote. According to the researchers, "Seventy-one percent of women had scores indicating low conflict, and 8% had scores indicating high conflict."

The researchers found that among women who completed the follow-up interviews, "86% had had an abortion, 8% were no longer seeking abortion, 3% had had a miscarriage or discovered they had not been pregnant, and 2% were still seeking abortion." They noted, "One woman was still deciding, and one had not had an abortion because of the 72-hour [mandatory delay]."

Predictors of and reasons for not having abortion

Of the 27 women who at the follow-up interview said they were no longer seeking abortion, still undecided or were past the gestational limit, the researchers found:

  • Eleven (4 percent of those completing follow-up) at baseline had indicated they preferred to carry to term;
  • Nine (3 percent of those completing follow-up) at baseline "had preferred abortion and had been somewhat or highly conflicted"; and
  • Seven (2 percent of those completing follow-up) at baseline "had preferred abortion and had low conflict."

According to the researchers, women who had an abortion had a mean conflict score of 13.9, while women who did not have an abortion had a mean conflict score of 28.5.

The researchers found that the most common response to open-ended questions about why a woman decided not to terminate a pregnancy "was that the woman 'just couldn't do it.'" The researchers noted that while the response "could be read as indicating a change of mind, the nuance tended toward having been conflicted to begin with and then deciding not to have the abortion."

According to the researchers, "The next most common reason was financial" and the third most common reason was women reporting "other people had come through for them."

In addition, three participants said they were "'too far along' in pregnancy to have an abortion," which the researchers wrote sometimes "meant that women felt too far along for their own comfort." For instance, one woman noted, "'Had I not had to do the first appointment, I would have been able to have the abortion earlier. But because I had to wait so long to schedule the first appointment, by the time I was able to gather funds, get child care and find a way to get to the second appointment, I was 13 weeks, and I wasn't comfortable with getting the abortion anymore.'" Another woman "discovered at her abortion appointment that she was 20 weeks pregnant ... and was beyond the gestational limit at her facility," while a third woman "was pushed beyond her facility's gestational limit because of the 72-hour [mandatory delay]."

According to the researchers, two women said the information visit "was part of exploring options," two others said they "want[ed] more time to think," and one woman "reported logistical challenges scheduling the abortion appointment."

In response to close-ended questions, the researchers found that "the top two reasons women gave for not having had an abortion were a change of mind (cited by 71% of women who were still pregnant, or 8% of women overall) and the cost of the procedure (47% and 5%, respectively)." The researchers also found that while "women's open-ended responses referred to other people's having come through for them, the closed-ended responses had a different nuance: Others had not wanted them to have an abortion, they had needed to keep the abortion secret…, and they had needed help with logistics."

Costs

Regarding costs, the researchers found that participants had to spend an average of $44 for costs associated with the initial visit. One-quarter of women said they paid over five percent of their monthly household income on such costs, while 10 percent of women said they paid over 17 percent. Overall, the researchers wrote that women "who had an abortion spent a mean of $103 ... on costs related to the abortion visit and paid a mean of $387 ... for the abortion." According to the researchers, "The costs for the information visit represent 11% of the cost of the abortion and 9% of the costs of the abortion plus the abortion visit."

The researchers noted that among participants who obtained an abortion, "20% received financial help from a formal source, mostly abortion funds or clinic discounts (19%); 42% received help from another person, mostly the man involved in the pregnancy, a boyfriend or a partner (32%)." However, the researchers found that "[e]ven when women used their own money, 26% had had to tell someone else they were spending it." They noted, "Of these, 77% had had to tell the man involved in the pregnancy, a boyfriend or a partner."

According to the researchers, six percent of women had to disclose their decision to seek abortion care to someone otherwise unaware of the pregnancy to make the information visit. Overall, study participants "who had an abortion waited about eight days between the information visit and the abortion," the researchers wrote. They noted that the four most commonly cited reasons for delaying care for more than 72 hours "were appointment availability (48%), the woman's own logistics (19%), the need to make financial arrangements (9%) and the need for more time to think (6%)."

Hardest part

The researchers found that the "most common difficulty women had with waiting was wanting the abortion to be over with," cited by 22 percent of women who completed follow up. According to the researchers, women who cited this difficulty "expressed knowing what they wanted to do, but feeling that they could not move on until they had the abortion."

In addition, the researchers found that "[t]hree of the 10 most difficult aspects of waiting focused on the abortion decision: feeling sure about it (reported by 10% of women); questioning it (8%); and dwelling on it, without necessarily expressing certainty or uncertainty (6%)." The study also found that nine percent of women expressed nervousness about the procedure, with some such women "fear[ing] being too far along for a medication abortion" and others fearing they would be delayed "beyond their comfort zone for having an abortion and that costs would increase."

According to the researchers, between six and seven percent of respondents reported other difficulties, including pregnancy symptoms and logistical challenges. They added that nearly all of the hardest parts of the two-visit requirement pertained to logistics and associated costs. They found that the most common logistical challenge "(reported by 22% of women) was having to miss work, but women also mentioned difficulties with travel (logistics, cost, distance and the need to arrange for other people to travel with them), with scheduling the appointment and arranging child care, and with the time required."

Discussion

The researchers found that while "Utah's 72-hour [mandatory delay] and two-visit requirement did not prevent women who presented for information visits at the study facilities from having abortions," the two-visit requirement did "creat[e] logistical and financial difficulties, including increasing the cost of having an abortion by about 10%." The study also "confirmed findings from other studies indicating that women had difficulty finding money for their abortions." The researchers noted that although they "do not know for sure, the increased costs associated with having to make two visits may have exacerbated existing challenges women face in paying for abortion in a state where Medicaid coverage for abortion is available in only limited circumstances, as is the case in Utah and 32 other states."

In addition, the researchers found that the delay, "though mandated at 72 hours, actually turned into more than a week." This extended delay "led to prolonged nervousness about the procedure and forced attention to a decision they had already made and were ready to implement" among women early in their pregnancy and without pregnancy symptoms. Moreover, "[f]or women who preferred medication abortion and women further along in their pregnancies," the mandatory delay "potentially contributed to their not being able to have their preferred type of abortion and incurring extra costs."

The researchers also found that while eight percent of study participants "reported changing their mind," the phrase "'change of mind' may best describe only those who indicated at the information visit that they preferred having an abortion and were not conflicted about their decision, and who then decided to continue their pregnancies." According to the researchers, "Our estimate of 2% changing their minds" in "this narrower sense" is "in the range of the proportions found changing their minds (1-3%) in settings with no or minimal [mandatory delays]." As a result, the researchers suggested that "requiring women to wait 72 hours may not affect the proportion changing their minds." They added, "[O]ur data confirm findings from other studies indicating that the vast majority of women have made a decision when they present for abortion and that most who present have an abortion."

Regarding the "small minority of women (8%) [who] had levels of decisional conflict that correspond to a clinical level of concern," the researchers concluded, "If further research continues to confirm that only a minority are conflicted, it would seem more appropriate to use individualized patient education and counseling to assist those who are conflicted" rather than "a blunt policy instrument like a law that requires all women seeking abortion care to face additional logistical hassles and costs."