National Partnership for Women & Families

Monthly Women's Health Research Review

Study Evaluates Patients' Perceptions of Mandatory Delay Requirement

Summary of "Abortion Patients' Experience and Perceptions of Waiting Periods: Survey Evidence Before Arizona's Two-Visit 24-Hour Mandatory Waiting Period Law," Karasek et al., Women's Health Issues, Nov. 25, 2015.

"The past decade has seen an unprecedented increase in the number and scope of state laws restricting provision of abortion care," including mandatory delay laws, according to Deborah Karasek of the University of California-San Francisco's Bixby Center for Global Reproductive Health and colleagues.

The researchers describe a mandatory delay law in Arizona that "requires women to visit an abortion facility to receive state-mandated information and informed consent materials and then wait for 24 hours ... before making a second visit to obtain an abortion." The law took full effect in 2011.

According to the researchers, the "period before enforcement of the law offered an opportunity to evaluate women's experiences accessing abortion care in the absence of the two-visit [mandatory delay] and their opinions about the impending change." The study "investigate[d] the experiences of women seeking abortion and their perceptions of a 24-hour [mandatory delay] between clinic visits," the researchers wrote. They used survey data to "describe the financial costs women incurred when accessing abortion, assess anticipated emotional response to a change in the law, and identify women who may be particularly affected by a 24-hour [mandatory delay]."


For the study, researchers examined data from a voluntary survey offered to women over 18 years of age seeking abortion care at a clinic in Tucson, Ariz., between June 2009 and June 2010. The survey included questions about demographic information, information on their decision to have an abortion, the costs and hardship associated with accessing abortion care, as well as their perception of the 24-hour mandatory delay and how it might affect them.


According to the researchers, 379 (72%) of women who sought abortion care at the clinic decided to complete the survey. Of the women who took the survey, 45% were Hispanic, 41% were non-Hispanic white, 8% were other and 6% were non-Hispanic black. Most women were low-income, "with 89% reporting income corresponding to below 200% of the [federal poverty line], and 15% reporting receipt of public assistance."

Costs Associated With Abortion

The researchers found that the "mean length of time travelled was 58 minutes, and 10% of the population travelled more than 2 hours to reach the clinic." According to the study, the "mean travel time was nearly 30 minutes greater among the participants below the FPL."

Respondents reported that the cost of an abortion performed in the first trimester was $450. When asked about additional costs, more than 50% of respondents "reported having to miss work," 33% "reported additional costs of transportation," 32% reported expenses related to missing work, 11% reported having to cover childcare costs and 4% said they had to make overnight arrangements.

According to the researchers, "Additional transportation and childcare costs were more likely to be reported among lower income women, whereas missed work expenses were more likely to be reported among higher income participants." Eighteen percent of respondents said paying these expenses was "very difficult," 48% said it was "difficult," 28% said it was "easy" and 6% said it was "very easy." Women reporting incomes below 100% of FPL "were more likely to report difficulty with paying the expenses than those in the other income groups." The study found that about 66% of women "reported having some assistance paying their expenses."

Meanwhile, when asked about economic tradeoffs, "women reported that the total abortion costs prevented or delayed them from paying other important expenses that month, including rent (17%), bills (40%), food (19%), childcare (5%), medical expenses (7%), and other expenses (12%)." Women who had incomes below 100% of FPL "were more likely to report forgoing payment for bills and food." Overall, 24% of respondents "reported that they were prevented or delayed from paying one expense to pay for the costs associated with abortion, 12% reported two, and 13% reported three or more." Women "who experienced more economic costs were also more likely to say that they found it difficult or very difficult to pay for all the costs of the procedure."

The researchers also found that "56% of women reported at least one reason that they were delayed from obtaining" an abortion earlier in their pregnancy, "with the most common reasons being the costs of the procedure (39%), not knowing they were pregnant (30%), and taking time off work (18%)." According to the researchers, "Income differences were significant for reporting delays owing to pregnancy recognition, knowing where to go to get an abortion, travel costs to get to the clinic, and finding childcare."

Perception of Mandatory Delay

When women were asked about the effect of being required to visit the clinic a second time to obtain abortion care, "participants reported that it would cost them more (51%), make them take an extra day off work (70%), prevent their support person from coming with them (55%), make them go to another state or to Mexico for abortion care (15%), make the[m] change their mind about wanting the abortion (8%), prevent them from getting the abortion (9%), further delay them from getting the abortion (31%), make them feel better about the decision (9%), or cause them to lose confidentiality by telling someone they did not want to tell (31%)." Women who reported incomes "above 200% of the FPL were more likely to perceive that they would need to miss work or lose a support person," while women who reported low incomes "reported higher rates of potentially feeling better about the decision," the researchers wrote.

Overall, 35% of respondents "reported that they would experience four or more hardships, 16% reported three, 21% reported two, 18% reported one, and 10% … reported that they would not experience any of the negative effects." Meanwhile, when women were questioned about how the mandatory delay would affect their emotional and psychological health, 2% "of women reported that it would have a very positive effect, 6% a somewhat positive effect, 38% no effect, 36% somewhat negative effect, and 17% a very negative effect." The researchers wrote that low-income women were more likely to report a very negative effect, while higher-income women were more likely to report no effect.

"When asked if they would prefer to have their counseling visit on the same day as the abortion procedure (1 day) or on a different day (2 days) 12% of participants reported preferring 2 days and 88% reported preferring 1 day," the researchers wrote. Women who reported a preference for 1 day were more likely to report that the mandatory delay would prevent them from bringing a support person and force them to seek care in a different state.

Additional Findings

The researchers determined that women "who experienced more economic tradeoffs ... and those who experienced delays in accessing abortion care ... were more likely to report that the [mandatory delay] and two-visit requirement would prevent [them] from obtaining an abortion." Further, women who reported more economic tradeoffs also were "more likely to anticipate the [mandatory delay] and two-visit requirement would result in further delay in accessing abortion care ... as were those who traveled more than 1 hour to the facility."

According to the researchers, "Additional economic tradeoffs ... and distance traveled ... were both significantly associated with perceptions that the [mandatory delay] and two-visit requirement would result in additional costs." Overall, "[f]ewer than 10% of women reported that they would change their mind about having an abortion or feel better given the 24-hour [mandatory delay]."


The researchers noted that the "majority of participants reported anticipating at least one negative outcome from the two-visit, 24-hour [mandatory delay] period, and felt that the law would negatively impact their well-being." According to the researchers, such concerns were more likely to be reported by "women already experiencing financial difficulties paying for the procedure or economic tradeoffs." In addition, "[w]omen who reported the most economic tradeoffs were more likely to report that the law would have prevented them from accessing care."

According to the researchers, the study shows that particular subgroups of women -- including those who are lower income and those who must travel long distances to access abortion care -- "are especially vulnerable to additional time and travel required to receive abortion care." While the researchers noted that some lower courts have used a travel distance of 150 miles as a standard to measure whether a restriction imposes an undue burden on abortion access, women's ability to access abortion care could still be significantly burdened by shorter travel distances.

Further, while "women's perceptions of the likely effects of the law were mixed," the "vast majority of women expected to be adversely affected by the [mandatory delay], with fewer than 10% of women expecting an emotional benefit," the researchers wrote. They added, "Given that it is a small minority of women who anticipate a benefit of waiting, it seems that these individualized approaches to abortion counseling and care have the best chances of ensuring that those who need more time to make their decision have this time, while also minimizing adverse consequences to other women who do not expect to benefit."

Noting that "most women already experience financial and other challenges in obtaining abortion care," the researchers conclude that such a "blunt policy instrument" as a mandatory delay "does not seem to be the best way to benefit [the] small group of women" who think such a requirement would be beneficial.