Summary of "Women's experiences seeking abortion care shortly after the closure of clinics due to a restrictive law in Texas," Fuentes et al., Contraception, Dec. 29, 2015.
"Understanding the impact of state-level restrictions on women in need of abortion services is critical to assess the range of consequences of" legislation like Texas' omnibus antiabortion-rights law (HB 2), according to Liza Fuentes, of the Texas Policy Evaluation Project and Ibis Reproductive Health, and colleagues.
According to the researchers, HB 2 resulted "in the immediate closure of 11 of the 33 open abortion facilities" in November 2013 when three of its four provisions took effect, including an admitting privileges requirement, a 20-week abortion ban and a requirement that medication abortion "follow the outdated labeling approved by" FDA. The law's fourth provision, an ambulatory surgical center building standards requirement that was briefly enforced in October 2014, resulted "in more clinic closures, until the US Supreme Court issued a ruling that allowed clinics to reopen while the case continued through the appellate process."
The researchers noted that while they have examined "the effect of HB2 on abortion services statewide, little is known about women's experiences with service disruptions in the wake of clinic closures across the state." For the study, the researchers interviewed "women who sought care in the periods shortly after the enforcement of HB2 at clinics that were no longer providing abortion services."
Methods
The researchers interviewed English- and Spanish-speaking women ages 18 and older seeking abortion care whose appointments were canceled or who had tried to make appointments at clinics up to two months after the facilities stopped providing abortion care under HB 2. The researchers also interviewed women who traveled to Albuquerque, New Mexico, to access abortion care. Interviews were conducted between November 2013 and June 2014 and between October 2014 and November 2014.
According to the study, the researchers questioned participants "with the objective of describing women's experiences with abortion services after clinic closures," focusing on "distance to services, timeliness of care, type of procedure and out-of-pocket costs." Specifically, participants were asked to describe their experiences seeking abortion care from when they first called a clinic. Participants were questioned about their travel to clinics and associated costs, whether they preferred medical or surgical abortion and whether and at what stage of pregnancy they ultimately received an abortion. The interview questions eventually were revised to include an additional question about whether participants had considered self-inducing an abortion.
Results
In total, the study included interviews with 23 participants. Of those:
- Five had appointments that were canceled by clinics that stopped providing abortion care following HB 2 first taking effect;
- 12 sought abortion care at clinics only after they had closed following HB 2 first taking effect;
- Three sought abortion services at clinics that closed after the temporary enforcement of the ambulatory surgical center building standards provision; and
- Three were Texas residents who sought care in Albuquerque.
Confusion about open clinics
According to the researchers, "After having appointments canceled or being turned away from closed clinics, more than half of women reported being confused about where they could go for abortion services and frustrated with the lack of clarity about which clinics remained open."
The researchers noted that many participants contacted several clinics to find an affordable provider within a reasonable travel distance. Among women who contacted clinics, five said they received insufficient information about where they could seek abortion services. In some cases, participants were referred to distant clinics when closer options were available.
According to the researchers, some participants cited concerns that they would not be able to obtain abortion care. The researchers noted that women whose appointments were canceled at the last minute were most concerned.
Increased cost and travel time
The researchers found "[m]ost women, especially those in West Texas and the Lower Rio Grande Valley (LRGV), spent more money and time than they would have before HB2 to obtain an abortion after their local clinics closed."
For example, the researchers noted that four LRGV-based women reported eight-hour round-trip travel time, and an average of $75 spent on gas, to drive to a San Antonio clinic after the Harlingen and McAllen clinics closed. Four women who had to take long trips to access care reported starting at 3:00 a.m. and driving back immediately after their procedure, while six women who could not complete the trip in one day reported spending between $60 and $200 on hotel stays.
Participants also reported feelings of discomfort and loneliness during the trip. According to the researchers, one LRGV-based woman explained that she decided to pay for a hotel "to avoid dealing with cramping, bleeding and other side effects during the drive home." That participant elaborated upon her experience, "[H]aving to go all the way there and not even feel comfortable, not even be where you're naturally from and being in a hotel afterwards ... that's the only experience I didn't like,'" but "we lived so far away that we didn't have a choice."
Participants also said "they needed to ask for more help than they would have if there had been a local provider, and in the process, they had to reveal their abortion decision to people they might not have told otherwise," the researchers wrote. For example, some participants said they asked to borrow a car, asked someone to drive them to appointments, or asked to borrow money for care or travel costs.
Delayed and forgone abortion care
"After being turned away from closed clinics or having appointments canceled," one study participant was able to make an appointment for the same day, but many experienced delays in accessing abortion care, the researchers wrote.
For example, eight participants said they were delayed by more than one week to obtain an abortion, and two of those eight women were not able to access abortion care until after 12 weeks of pregnancy. According to the researchers, of those two women, one was forced to choose between two costlier options: an appointment at a nearby clinic that cost $80 extra or a clinic four hours away that would have required a hotel stay. The delays in accessing care required her to have a second-trimester abortion rather than a first-trimester abortion, which cost an additional $200 and required her to take out a loan.
Moreover, two women who were seeking a medication abortion had to forgo care, despite trying to make an appointment. The researchers noted, "Insufficient information, time and money led these women to the decision to carry their pregnancies to term." One of the two women said she ontemplated self-inducing an abortion, but was concerned she might injure herself. The participant said she "felt unable to manage the added costs of child care, more time off work, and traveling farther to obtain an abortion after her local clinic closed."
Women considered self-induction
According to the researchers, five study participants said they considered trying to self-induce an abortion. "All five turned to the internet for information about self-induction methods, and two said that they also asked a family member," the researchers wrote. The researchers noted that all five women ultimately decided against self-inducing an abortion, citing "safety concerns or fear that it would not be effective."
Discussion
"The experiences of women in our study help to explain the decline in the number of abortions and increase in the proportion of second-trimester abortions observed in Texas in the period after HB2 was enforced and add to the limited qualitative literature describing patient experiences with abortion restrictions," the researchers wrote.
They explained, "In the period after clinics closed due to enforcement of HB2, women faced added informational, geographic and financial obstacles to abortion care." These obstacles "were costly in multiple ways," the researchers wrote, noting that the "[w]omen endured confusion, fear and frustration and had to compromise their privacy in the process of obtaining an abortion after clinic closures" and some were never able to obtain abortion care. Citing research on how women denied abortion care "have worse health and social outcomes compared to those who obtain wanted abortions," the researchers noted that their study "put a human face on the decline in the number of abortions" after HB 2's took effect.
The study also "contextualize[s]" a prior study "document[ing] a small but significant increase in second-trimester abortion in Texas in the 6 months after HB2 went into effect." While most women in this study were able to obtain abortion care within one additional week after an appointment was cancelled, two women were delayed until their second-trimester, the researchers wrote.
According to the researchers, "Results from this study give insight into the ways that abortion restrictions affect women in the early phase of implementation through the sudden closure of a large number of clinics." The researchers noted that if HB 2's ambulatory surgical center building provision is enforced, the number of clinics in the state would decrease to 10, and "the barriers described here would likely be compounded by limited capacity of the remaining clinics to absorb the demand for services, resulting in an even more disrupted service environment." The researchers called for more research "to explore the longer-term effects of the reduction in abortion access in Texas."
