Abortion patients' decision making about where to obtain out-of-state care following Texas' 2021 abortion ban.

OBJECTIVE: To assess pregnant Texans' decisions about where to obtain out-of-state abortion care following the September 2021 implementation of Senate Bill 8 (SB8), which prohibited abortions after detectable embryonic cardiac activity. DATA SOURCE: In-depth telephone interviews with Texas residents ≥15 years of age who obtained out-of-state abortion care after SB8's implementation. STUDY DESIGN: This qualitative study explored participants' experiences identifying and contacting abortion facilities and their concerns and considerations about traveling out of state. We used inductive and deductive codes in our thematic analysis describing people's decisions about where to obtain care and how they evaluated available options. DATA COLLECTION: Texas residents self-referred to the study from flyers we provided to abortion facilities in Arkansas, Colorado, Kansas, Louisiana, Mississippi, New Mexico, and Oklahoma. We also enrolled participants from a concurrent online survey of Texans seeking abortion care. PRINCIPAL FINDINGS: Participants (n = 65) frequently obtained referral lists for out-of-state locations from health-care providers, and a few received referrals to specific facilities; however, referrals rarely included the information people needed to decide where to obtain care. More than half of the participants prioritized getting the soonest appointment and often contacted multiple locations and traveled further to do so; others who could not travel further typically waited longer for an appointment. Although the participants rarely cited state abortion restrictions or cost of care as their main reason for choosing a location, they often made sacrifices to lessen the logistical and economic hardships that state restrictions and out-of-state travel costs created. Informative abortion facility websites and compassionate scheduling staff solidified some participants' facility choice. CONCLUSIONS: Pregnant Texans made difficult trade-offs and experienced travel-related burdens to obtain out-of-state abortion care. As abortion bans prohibit more people from obtaining in-state care, efforts to strengthen patient navigation are needed to reduce care-seeking burdens as this will support people's reproductive autonomy.

Reasons for participation in abortion research in restrictive settings.

OBJECTIVES: Following the implementation of a restrictive abortion law in Texas (Senate Bill 8), we conducted in-depth interviews with pregnant people about their experiences seeking abortion care. In this analysis, we explore participants' motivations for taking part in a research study. STUDY DESIGN: Between October 2021 and August 2022, we conducted 120 in-depth interviews with Texans (aged ≥15 years) who, after considering abortion, had a facility-based abortion, self-managed their abortion, experienced miscarriage or ectopic pregnancy, or continued their pregnancy. We asked all interviewees, "Why did you decide to participate in the interview?" For analysis, we used inductive and deductive coding approaches to explore motivations for and concerns about participation. RESULTS: Most commonly, interviewees appreciated the opportunity to share their stories, frequently describing how their experiences highlight the nuance of abortion decision-making and challenge stigmatized views about abortion. Some described an emotional benefit of participating, as they had no one else to whom to disclose their experience without judgment. Many hoped to help others by participating, saying that access to other people's stories would have helped them feel less isolated. Relatedly, many viewed their participation as an opportunity to speak out against restrictive policies that caused them harm, hardship, and distress. Interviewees seldom cited the monetary incentive alone as motivation for participation. A few expressed concerns about participating out of fear of legal repercussions for others involved in their abortion process (e.g., ride-share driver). These themes were consistent across pregnancy outcomes. CONCLUSIONS: Research volunteers are motivated to participate for altruistic and self-benefiting reasons. IMPLICATIONS: This study provides insights into what people seeking abortion consider when deciding to participate in qualitative research. Research ethics committees evaluating and researchers conducting abortion research should weigh these motivations, perceived benefits, and concerns. Policies that enhance protections for participant data are needed to support knowledge generation from abortion research.

Abortion Clients' Perceptions of Alternative Medication Abortion Service Delivery Options in Mississippi.

OBJECTIVES: We assessed Mississippi abortion clients' perceptions of alternative medication abortion service delivery options that were restricted under state law but available elsewhere. METHODS: We conducted in-depth interviews with medication abortion clients between November 2020 and March 2021 at Mississippi's only abortion facility. We described alternative service delivery models: telemedicine, medications by mail, and follow-up care in their community versus returning to the facility. We asked if participants would be interested in using any of these models, if available, and how use of each model would have changed their abortion experience. We used thematic analysis, organizing codes into common themes based on participants' preferences and concerns for each option. RESULTS: Of the 25 participants interviewed, nearly all (n = 22) expressed interest in at least one option and reported that, had they been available, these would have alleviated cost, travel, and childcare barriers. Many believed these options would further ensure privacy, but a minority thought abortion was too sensitive for telemedicine or were concerned about mailing errors. Participants not interested in the alternative options also feared missing valued aspects of face-to-face care. Most did not return to the facility for follow-up (n = 19), citing financial and logistical barriers. Largely, participants were not interested in obtaining follow-up care in their community, citing concerns about provider judgment, stigma, and privacy. CONCLUSIONS: Mississippi abortion clients were interested in models that would make abortion care more convenient while ensuring their privacy and allowing for meaningful client-provider interaction. These features of care should guide the development of strategies aimed at helping those in restricted settings, such as Mississippi, to overcome barriers to abortion care following the implementation of abortion bans in many states following the overturn of Roe v. Wade.

Self-diagnosing the end of pregnancy after medication abortion.

This qualitative study conducted between November 2020 and March 2021 in the US state of Mississippi examines the experiences of 25 people who obtained medication abortion at the state's only abortion facility. We conducted in-depth interviews with participants after their abortions until concept saturation was reached, and then analysed the content using inductive and deductive analysis. We assessed how people use embodied knowledge about their individual physical experiences such as pregnancy symptoms, a missed period, bleeding, and visual examinations of pregnancy tissue to identify the beginning and end of pregnancy. We compared this to how people use biomedical knowledge such as pregnancy tests, ultrasounds, and clinical examinations to confirm their self-diagnoses. We found that most people felt confident that they could identify the beginning and end of pregnancy through embodied knowledge, especially when combined with the use of home pregnancy tests that confirmed their symptoms, experiences, and visual evidence. All participants concerned about symptoms sought follow-up care at a medical facility, whereas people who felt confident of the successful end of the pregnancy did so less often. These findings have implications for settings of restricted abortion access that have limited options for follow-up care after medication abortion.

Abortion Access and Medically Complex Pregnancies Before and After Texas Senate Bill 8.

OBJECTIVE: To evaluate how Texas health care professionals who care for patients experiencing medically complex pregnancies navigate abortion restrictions. METHODS: We conducted qualitative in-depth interviews with health care professionals across Texas who cared for patients with life-limiting fetal diagnoses or who had existing or developed health conditions that adversely affected pregnancy. We conducted the first round of interviews March-June 2021 and the second round of interviews January-May 2022 after the implementation of Texas Senate Bill 8 (SB8), which prohibited most abortions after detection of embryonic cardiac activity. We used inductive and deductive qualitative analysis to identify themes and changes in practice after the implementation of SB8. RESULTS: We conducted a total of 50 interviews: 25 before implementation of SB8 and 25 after the law's implementation. We interviewed 21 maternal-fetal medicine specialists, 19 obstetrician-gynecologists, eight physicians whose primary practice is the provision of abortion care, and two genetic counselors. Participants reported presenting their patients with information about health risks and outcomes of continued pregnancy in each policy period; however, counseling on these options was curtailed after implementation of SB8. Even in cases in which a patient's health and, in some cases, life would be compromised, narrow criteria for abortions at hospitals limited care before implementation of SB8, and criteria often became more stringent after implementation of SB8. Administrative approval processes and referrals for abortion delayed care and endangered patients' health, which worsened after in-state options were eliminated after implementation of SB8. Participants noted that patients with more limited resources who were unable to travel out of state often had to continue pregnancies, further increasing their risk of morbidity. CONCLUSION: Texas health care professionals' abilities to provide evidence-based abortion care to patients with medically complex pregnancies were constrained by institutional policies, and care options narrowed further after implementation of SB8. Abortion restrictions limit shared decision making, compromise patient care, and put pregnant people's health at risk.

Experiences with small and large numbers of protesters at abortion clinics in North Carolina.

OBJECTIVES: To analyze the association between number of antiabortion protesters and patients' and their companions' experiences accessing abortion clinics in North Carolina. STUDY DESIGN: In this concurrent mixed-methods study conducted in 2018-2019 at two independent abortion clinics in North Carolina, the author triangulated the methods of participant observation, descriptive statistical analysis of survey data, and thematic content analysis of open-ended responses to compare experiences of respondents who observed larger (>10) versus smaller (1-10) numbers of protesters at their clinic visit. The analytic sample contained experiences of patients and companions who saw protesters during the study period. RESULTS: Of 1530 people approached for the survey, 886 (58%) completed the questionnaire. Overall, 655 respondents were included in the analysis. Most respondents (n = 546, 83%) saw 1 to 10 protesters, versus those who saw >10 protesters (n = 109, 17%). Respondents who saw 1 to 10 protesters had their cars stopped at higher rates (53%) than those who saw >10 protesters (40%) but reported being physically approached at similar rates (22% vs. 23%). Respondents who saw >10 protesters indicated that it was more dangerous to drive into the clinic (44% vs. 23%) and more difficult to access the clinic (65% vs. 39%), when compared with people who saw 1 to 10 protesters. Respondents who saw >10 protesters also reported that they thought about leaving more frequently (21% vs. 12%), that the protesters made them feel unsafe (44% vs. 23%), made their visit more stressful (71% vs. 59%), and protesters negatively impacted their clinic experience at higher rates (47% vs. 31%). CONCLUSIONS: Respondents experienced logistical barriers to clinic access regardless of the number of protesters, though these worsened with larger numbers of protesters. Respondents perceived larger numbers of protesters as more intimidating and felt less safe navigating into the clinic. While all respondents made it to their appointments, these perceptions about larger numbers show how clinic protesting is an intimidating force that interferes with clinic access. IMPLICATIONS: Showing the ways that the number of protesters relates to logistical and emotional barriers can help clinics in planning mitigation measures to address issues of clinic access for their patients and their companions.

Real Men Love Babies: Protest Speech and Masculinity at Abortion Clinics in the Southern United States.

This article examines the politicized space outside the abortion clinic as a site where gender ideologies about male roles and responsibilities in abortion are contested, using anti-abortion protest rhetoric that targets men accompanying women. Protesters attempt to elicit reactions from men using gendered stereotypes, in hopes that men will change their minds about or prevent an abortion. Anti-abortion protest speech uses mixed messages about masculinity, strength, and fatherhood to shame male companions for their support of abortion. Protesters' rhetoric constructs men as inherently responsible for preventing abortion, where only by leaving the clinic space can these men gain power, controlling their reproductive futures by controlling their female companion's. However, men reacted in different ways to the words shouted by protesters: by ignoring them, agreeing with them, or occasionally by initiating physical or verbal altercations. I find that male companions often employ tropes of patriarchal masculinity within attempts to perform supportive masculinity in response to protest speech, while protesters simultaneously use patriarchal masculinity and contemporary gender ideologies on responsible fatherhood in attempts to prevent abortion. These conflicting rhetorical themes and diverse reactions are indicative of larger struggles in the U.S. pro-choice and pro-life movements about the role of men in abortion.