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.

Meeting Preferences for Specific Contraceptive Methods: An Overdue Indicator.

Fertility surveys have rarely asked people who are using contraception about the contraceptive method they would like to be using, implicitly assuming that those who are contracepting are using the method they want. In this commentary, we review evidence from a small but growing body of work that oftentimes indicates this assumption is untrue. Discordant contraceptive preferences and use are relatively common, and unsatisfied preferences are associated with higher rates of method discontinuation and subsequent pregnancy. We argue that there is opportunity to center autonomy and illuminate the need for and quality of services by building on this research and investing in the development of survey items that assess which method people would like to use, as well as their reasons for nonpreferred use. The widespread adoption of questions regarding method preferences could bring indicators of reproductive health services into closer alignment with the needs of the people they serve.

Comparing preference for and use of medication abortion in Texas after policy changes in 2014 and 2018.

OBJECTIVES: Assess preferences for and use of medication abortion in Texas after implementation of two policy changes: a 2013 state law restricting medication abortion and the FDA label change for mifepristone in 2016 nullifying some of this restriction. STUDY DESIGN: We analyzed surveys conducted in 2014 and 2018 with abortion patients at 10 Texas abortion facilities. We calculated the percentage of all respondents with an initial preference for medication abortion by survey year, and the type of abortion obtained or planned to obtain among those who were at <10 weeks of gestation. We used multivariable-adjusted mixed-effects Poisson regression models to assess factors associated with medication abortion preference and actual/planned use. RESULTS: Overall, 156 (41%) of 376 respondents in 2014 and 247 (55%) of 448 respondents in 2018 reported initial preference for medication abortion (Prevalence ratio [PR]: 1.28; 95% CI 1.03-1.59). Among those who were <10 weeks of gestation and initially preferred medication abortion, 39 of 124 (31%) obtained or were planning to obtain the method in 2014, compared with 188 of 223 (84%) in 2018 (PR: 2.65; 95% CI: 1.69-4.15). After multivariable adjustment, respondents who initially preferred medication abortion and were 7 to 9 weeks of gestation at the time of their ultrasonography (vs <7 weeks) were less likely to obtain or plan to obtain the method (PR: 0.69; 95% CI: 0.57-0.84). CONCLUSIONS: Abortion patients were more likely to prefer and obtain or plan to obtain their preferred medication abortion after legal restrictions in Texas were nullified. IMPLICATIONS: State policies can affect people's ability to obtain their preferred abortion method. Efforts to provide both abortion options whenever possible, and inform people where each can be obtained, remains an important component of person-centered care despite increasing state abortion restrictions and bans following the reversal of Roe v Wade.

Evidence-based family planning services among publicly funded providers in Texas.

BACKGROUND: Healthy Texas Women (HTW) is a fee-for-service family planning program that excludes affiliates of abortion providers. The HTW network includes providers who participate in Title X or the state Family Planning Program (FPP) and primary care providers without additional family planning funding (HTW-only). The objective of this study is to compare client volume and use of evidence-based practices among HTW providers. METHODS: Client volume was determined from administrative data on unduplicated HTW clients served in fiscal year (FY) 2017. A sample of 114 HTW providers, stratified by region, completed a 2018 survey about contraceptive methods offered, adherence to evidence-based contraceptive provision, barriers to offering IUDs and implants, and counseling/referrals for pregnant patients. Differences by funding source were assessed using t-tests and chi-square tests. RESULTS: Although HTW-only providers served 58% of HTW clients, most (72%) saw < 50 clients in FY2017. Only 5% of HTW providers received Title X or FPP funding, but 46% served ≥ 500 HTW clients. HTW-only providers were less likely than Title X providers to offer hormonal IUDs (70% vs. 92%) and implants (66% vs 96%); offer same-day placement of IUDs (21% vs 79%) and implants (21% vs 83%); and allow patients to delay cervical cancer screening when initiating contraception (58% vs 83%; all p < 0.05). There were few provider-level differences in counseling/referrals for unplanned pregnancy (p > 0.05). CONCLUSIONS: HTW-only providers served fewer clients and were less likely to follow evidence-based practices. Program modifications that strengthen the provider network and quality of care are needed to support family planning services for low-income Texans.

Association of Texas' 2021 Ban on Abortion in Early Pregnancy With the Number of Facility-Based Abortions in Texas and Surrounding States.

Importance: Texas' 2021 ban on abortion in early pregnancy may demonstrate how patterns of abortion might change following the US Supreme Court's June 2022 decision overturning Roe v Wade. Objective: To assess changes in the number of abortions and changes in the percentage of out-of-state abortions among Texas residents performed at 12 or more weeks of gestation in the first 6 months following implementation of Texas Senate Bill 8 (SB 8), which prohibited abortions after detection of embryonic cardiac activity. Design, Setting, and Participants: Retrospective study of a sample of 50 Texas and out-of-state abortion facilities using an interrupted time series analysis to assess changes in the number of abortions, and Poisson regression to assess changes in abortions at 12 or more weeks of gestation. Data included 68 820 Texas facility-based abortions and 11 287 out-of-state abortions among Texas residents during the study period from September 1, 2020, to February 28, 2022. Exposures: Abortion care obtained after (September 2021-February 2022) vs before (September 2020-August 2021) implementation of SB 8. Main Outcomes and Measures: Primary outcomes were changes in the number of facility-based abortions for Texas residents, in Texas and out of state, in the month after implementation of SB 8 compared with the month before. The secondary outcome was the change in the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation during the 6-month period after the law's implementation. Results: Between September 2020 and August 2021, there were 55 018 abortions in Texas and 2547 out-of-state abortions among Texas residents. During the 6 months after SB 8, there were 13 802 abortions in Texas and 8740 out-of-state abortions among Texas residents. Compared with the month before implementation of SB 8, the number of Texas facility-based abortions significantly decreased from 5451 to 2169 (difference, -3282 [95% CI, -3171 to -3396]; incidence rate ratio [IRR], 0.43 [95% CI, 0.36-0.51]) in the month after SB 8 was implemented. The number of out-of-state abortions among Texas residents significantly increased from 222 to 1332 (difference, 1110 [95% CI, 1047-1177]; IRR, 5.38 [95% CI, 4.19-6.91]). Overall, the total documented number of Texas facility-based and out-of-state abortions among Texas residents significantly decreased from 5673 to 3501 (absolute change, -2172 [95% CI, -2083 to -2265]; IRR, 0.67 [95% CI, 0.56-0.79]) in the first month after SB 8 was implemented compared with the previous month. Out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation increased from 17.1% (221/1291) to 31.0% (399/1289) (difference, 178 [95% CI, 153-206]) during the period between September 2021 and February 2022 (P < .001 for trend). Conclusions and Relevance: Among a sample of abortion facilities, the 2021 Texas law banning abortion in early pregnancy (SB 8) was significantly associated with a decrease in the documented total of facility-based abortions in Texas and obtained by Texas residents in surrounding states in the first month after implementation compared with the previous month. Over the 6 months following SB 8 implementation, the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation significantly increased.

Satisfaction, Resignation, and Dissatisfaction with Long-Acting Reversible Contraception among Low-Income Postpartum Texans.

INTRODUCTION: Prior longitudinal studies of long-acting reversible contraception (LARC) satisfaction and continuation guaranteed their participants access to LARC removal. Under real-world conditions, LARC users who wish to discontinue may experience barriers to LARC removal. METHODS: A prospective cohort study recruited 1,700 postpartum Texans without private insurance from 8 hospitals in 6 cities. Our analysis included the 418 respondents who initiated LARC in the 24 months after childbirth. A content analysis of open-ended survey responses identified three categories of LARC users: satisfied, resigned, and dissatisfied. Satisfied LARC users were using their method of choice. Resigned users were using LARC as an alternative method when their preferred method was inaccessible. Dissatisfied users were unhappy with LARC. Multinomial logistic regression models identified risk factors for resignation and dissatisfaction. Cox proportional hazards models assessed differences in LARC discontinuation by satisfaction and sociodemographic characteristics. RESULTS: Participants completed 1,505 surveys while using LARC. LARC users were satisfied in 83.46% of survey responses, resigned in 5.25%, and dissatisfied in 11.30%. Resignation was more likely if respondents were uninsured or wanted sterilization at the time of childbirth. The risk of dissatisfaction increased with time using LARC and was higher among uninsured respondents. U.S.-born Hispanic LARC users were more likely than foreign-born Hispanic LARC users to be dissatisfied and less likely to discontinue when dissatisfied. Dissatisfaction-but not resignation-predicted discontinuation. Cost, lack of insurance, and difficulty obtaining an appointment were frequent barriers to LARC removal. CONCLUSIONS: Most postpartum LARC users were satisfied, but users who wished to discontinue frequently encountered barriers.

Impact of contraceptive counseling on Texans who can and cannot receive no-cost post-abortion contraception.

OBJECTIVE: To assess optimal timing, patient satisfaction, and 1-year contraceptive continuation associated with contraceptive counseling among Texans who could and could not receive no-cost long-acting reversible contraception (LARC) via a specialized funding program. STUDY DESIGN: In this prospective study conducted between October 2014 and March 2016, we evaluated participants' desire for contraceptive counseling during abortion visits, impact of counseling on change in contraceptive preference, satisfaction with counseling, and 1-year postabortion contraceptive continuation. We stratified participants into 3 groups by income, insurance status, and eligibility for no-cost LARC: (1) low-income eligible, (2) low-income ineligible, and (3) higher-income and/or insured ineligible. We examined the association between contraceptive counseling rating and 1-year method continuation by program eligibility and post-abortion contraceptive type. RESULTS: Among 428 abortion patients, 68% wanted to receive contraceptive counseling at their first abortion visit. Counseling led to a contraceptive preference change for 34%. Of these, 21% low-income eligible participants received a more effective method than initially desired, 10% received a less effective method, and 69% received the method they initially desired. No low-income ineligible participants received a more effective method than they initially desired, 55% received a less effective method, and 45% received the method they initially desired. Five percent of higher-income eligible participants received a more effective method than they initially desired, 48% received a less effective method, and 47% received the method they initially desired. Highest counseling rating was reported by 51%. Compared to those providing a lower rating in each group, highest counseling rating was significantly associated with lower 1-year contraceptive discontinuation for low-income eligible participants (aHR 0.34, 95% CI 0.14, 0.81), but not for low-income ineligible (aHR 1.56, 95% CI 0.83, 2.91) and higher-income (aHR 0.73, 95% CI 0.47,1.13) participants. Additionally, 1-year contraceptive continuation was associated with highest counseling rating (OR 1.72, 95% CI 1.09, 2.72) and post-abortion LARC use (OR 11.70, 95% CI 6.37, 21.48) in unadjusted models, but only postabortion LARC in adjusted models (aOR 1.55, 95% CI 0.90, 2.66 for highest counseling rating vs. aOR 11.83, 95% CI 6.29, 22.25 for postabortion LARC use). CONCLUSIONS: In Texas, where access to affordable postabortion contraception is limited, high quality contraceptive counseling is associated with 1-year contraceptive continuation only among those eligible for no-cost methods. IMPLICATIONS: State policies which restrict access to affordable post-abortion contraception limit the beneficial impact of patient-centered counseling and impede patients' ability to obtain their preferred method.

Improving assessment of demand for postpartum tubal ligation among publicly insured women in Texas.

OBJECTIVE: To assess an alternative method for estimating demand for postpartum tubal ligation and evaluate reproductive trajectories of low-income women who did not obtain a desired procedure. STUDY DESIGN: In a 2-year cohort study of 1700 publicly insured women who delivered at 8 hospitals in Texas, we identified those who had an unmet demand for tubal ligation prior to discharge from the hospital. We classified unmet demand as explicit or prompted based on survey questions that included a prompt regarding whether the respondent would like to have had a tubal ligation at the time of delivery. We assessed persistence of demand for permanent contraception, contraceptive use, and repeat pregnancies among all study participants who wanted but did not get a postpartum procedure. RESULTS: Some 426 women desired a postpartum tubal ligation; 219 (51%) obtained one prior to discharge. Among the 207 participants with unmet demand, 62 (30%) expressed an explicit preference for the procedure, while 145 (70%) were identified from the prompt. Most with unmet demand still wanted permanent contraception 3 months after delivery (156/184), but only 23 had obtained interval procedures. By 18 months, the probability of a woman with unmet demand conceiving a pregnancy that she would likely carry to term was 12.5% (95% CI: 8.3%-18.5%). CONCLUSIONS: The majority of unmet demand for postpartum tubal ligation among publicly insured women in Texas was uncovered via a prompt and would not have been evident in clinical records or from consent forms. Women unable to obtain a desired procedure had a substantial chance of pregnancy within 18 months after delivery. IMPLICATIONS: Estimates of unmet demand for postpartum tubal ligation based on clinical records and consent forms likely underestimate desire for permanent contraception. Among low-income women in Texas, those with unmet demand for postpartum tubal ligation require improved access to effective contraception.

Border-state abortions increased for Texas residents after House Bill 2.

OBJECTIVES: To assess changes in Texas-resident border-state abortions, medication abortions, and abortions ≥22 weeks from last menstrual period (LMP) before and after implementation of House Bill 2 (HB2) in November 2013 and before and after the US Supreme Court's decision regarding HB2 in June 2016. STUDY DESIGN: We conducted an interrupted time series analysis using 2012-2017 data on Texas-resident abortions in Arkansas, Louisiana, Oklahoma, and New Mexico. Data on procedure type and gestational age were available only for abortions in New Mexico. RESULTS: Border states reported 762 Texas-resident abortions in 2012, 1,673 in 2014, and 1,475 in 2017. Texas-resident abortions in all border states nearly doubled following HB2's implementation (incidence rate ratio [IRR]=1.92, 95% CI: 1.67-2.20). Border-state abortions then decreased by 19% after the 2016 US Supreme Court decision, compared to the period prior to the decision and after HB2's implementation (IRR=0.81, 95% CI: 0.73-0.91). From 2012 to 2014, the proportion of Texas-resident abortions in New Mexico that were medication abortion increased from 5% to 20% (p < 0.001) and the proportion that were ≥22 weeks from LMP decreased from 40% to 23% (p < p<0.001). Texas vital statistics undercounted annual out-of-state abortions, reporting only 13%-73% of abortions reported by border-state clinics during the study period. CONCLUSIONS: HB2 was associated with increases in border-state abortions for Texas residents, including in the number of those ≥22 weeks from LMP. Border-state abortions declined after the Supreme Court ruled HB2 unconstitutional yet remained higher than pre-HB2 levels. IMPLICATIONS STATEMENT: Abortion restrictions that severely curtail access may result in increases in travel out of state for care. Documenting out-of-state abortions is important for evaluating broader policy impacts and to prepare for future service disruptions. Texas residents may have more limited options for care if border states enact restrictive abortion laws.

Short-acting hormonal contraceptive continuation among low-income postpartum women in Texas.

OBJECTIVE: The objective was to assess continuation of the pill, patch, ring or injectable (i.e., short-acting hormonal contraception); characteristics associated with discontinuation; and subsequent method use among low-income postpartum women in Texas. STUDY DESIGN: Using a 24-month cohort study of 1700 women who delivered in eight Texas hospitals and were uninsured or publicly insured at the time of delivery, we focused on 456 women who used short-acting hormonal contraception within 6 months after delivery. We classified this sample according to characteristics and method preference, and estimated rates of discontinuation and associated predictors using life tables and Cox models. We assessed reasons for discontinuation and subsequent contraceptive use among those who discontinued. RESULTS: Roughly half used the pill and half used the injectable. One hundred seventy-eight (39%) expressed a baseline preference for the method they used, 162 (36%) preferred a long-acting reversible contraception method, and 41 (9%) preferred sterilization. After 1 year, 72% had discontinued [95% confidence interval (CI) 67.1-75.7]. Foreign-born Hispanic women were less likely to discontinue than U.S.-born Hispanics [adjusted hazard ratio (aHR), 0.65; 95% CI 0.50-0.84]. Those who wanted a more effective method (aHR, 1.44; 95% CI 1.12-1.85) and those who lost insurance coverage (aHR, 1.47; 95% CI 1.12-1.92) were more likely to discontinue. The most common reasons for discontinuation were side effects and access/cost. Of those who discontinued, 243 (68%) switched to a less effective or no method. Only 47 (13%) switched to their preferred method. CONCLUSIONS: Short-acting hormonal contraceptive discontinuation is high in this population. Many switch to less effective methods after discontinuation despite preferring methods at least as effective as the pill, patch, ring or injectable. IMPLICATIONS: Expanding contraceptive coverage in the 2 years after delivery should be a state and federal policy priority. In clinics, providers should discuss contraceptive preferences throughout pregnancy and the interpregnancy interval.

Patients' Experiences with an Immediate Postpartum Long-Acting Reversible Contraception Program.

INTRODUCTION: We compared the characteristics of postpartum women who recalled being offered or not offered intrauterine devices and implants and who obtained placement of these long-acting reversible contraceptive (LARC) devices at a county hospital before discharge. We assessed satisfaction and continuation among those who obtained LARC methods. METHODS: We interviewed 199 patients who delivered at a Texas hospital and tested for differences in who recalled being offered/not offered immediate postpartum LARC. We provide descriptive statistics on when offered and satisfaction, and assess continuation using Kaplan-Meier survival curves. RESULTS: There were 103 of 199 women (51.8%) who recalled providers offering them immediate postpartum LARC; English-speaking relative to Spanish-speaking Hispanic women had higher odds of recounting being offered immediate postpartum LARC (adjusted odds ratio [OR], 3.88; 95% confidence interval [CI], 1.33-11.23), as did women with two children versus one child (OR, 3.64; 95% CI, 1.13-11.67). Compared with women 18-24 years of age who wanted more children, women 30-34 years of age who wanted more children had lower odds (OR, 0.14; 95% CI, 0.03-0.59), as did sterilized women 18 to 44 (OR, 0.02; 95% CI, 0.00-0.10). Seventy-four women (37% of all and 72% of those who recalled being offered) received immediate postpartum LARC. Sixty percent of those who received immediate postpartum LARC recalled that they were first offered it during prenatal care. Satisfaction was high but decreased between 3 and 6 months postpartum, mainly owing to negative side effects. Continuation at 24 months postpartum was 76.9% (CI, 71.7%-81.4%), with no difference between intrauterine device and implant use. CONCLUSIONS: Language barriers may have hindered equal access to immediate postpartum LARC for Spanish-speaking patients; younger patients were more likely to recall being offered immediate postpartum LARC, possibly owing to providers' implicit biases or greater demand for LARC versus sterilization. Using formal interpretation services and patient-centered decision making may improve patient access to the contraception methods most aligned with their values and preferences.

Geographic Variation in Personality is Associated With Fertility Across the United States.

Levels of fertility and the shape of the age-specific fertility schedule vary substantially across U.S. regions with some states having peak fertility relatively early and others relatively late. Structural institutions or economic factors partly explain these heterogeneous patterns, but regional differences in personality might also contribute to regional differences in fertility. Here, we evaluated whether variation in extraversion, agreeableness, conscientiousness, neuroticism, and openness to experience measured at the U.S. state-level was associated with the level, timing, and context of fertility across states above and beyond sociodemographics, voting behavior, and religiosity. Generally, states with higher levels of agreeableness and conscientiousness had more traditional fertility patterns, and states with higher levels of neuroticism and openness had more nontraditional fertility patterns, even after controlling for established correlates of fertility (r ~ |.50|). Personality is an overlooked correlate that can be leveraged to understand the existence and persistence of fertility differentials.

Unsatisfied contraceptive preferences due to cost among women in the United States.

OBJECTIVES: To examine prevalence and characteristics associated with cost barriers to preferred contraceptive use. STUDY DESIGN: Among a nationally representative sample of women at risk of unplanned pregnancy in 2015-2017, we used Poisson regression to assess characteristics associated preferring a(nother) method in the absence of cost. RESULTS: Overall, 22% preferred to use a(nother) method. Women using less-effective methods, who were Black or Hispanic, ages 15-24 and had low incomes, were more likely to report cost barriers. CONCLUSIONS: Using a preferred method is an indicator of access to care and reproductive autonomy. These results provide a benchmark to track the impact of policy changes.

Breastfeeding Initiation, Duration, and Supplementation Among Mexican-Origin Women in Texas.

BACKGROUND: Mexican-origin women breastfeed at similar rates as white women in the United States, yet they usually breastfeed for less time. In our study, we seek to identify differences in Mexican-origin women's breastfeeding intentions, initiation, continuation, and supplementation across nativity and country-of-education groups. METHODS: The data are from a prospective cohort study of postpartum women ages 18 to 44 recruited from 8 Texas hospitals. We included 1235 Mexican-origin women who were born and educated in either Texas or Mexico. Women were interviewed at delivery and at 3, 6, 12, 18, and 24 months post partum. Breastfeeding intentions and initiation were reported at baseline, continuation was collected at each interview, and weeks until supplementation was assessed for both solids and formula. Women were classified into 3 categories: born and educated in Mexico, born and educated in the United States, and born in Mexico and educated in the United States. RESULTS: Breastfeeding initiation and continuation varied by nativity and country of birth, although all women reported similar breastfeeding intentions. Women born and educated in Mexico initiated and continued breastfeeding in higher proportions than women born and educated in the United States. Mexican-born and US-educated women formed an intermediate group. Early supplementation with formula and solid foods was similar across groups, and early supplementation with formula negatively impacted duration across all groups. CONCLUSIONS: Nativity and country of education are important predictors of breastfeeding and should be assessed in pediatric and postpartum settings to tailor breastfeeding support. Support is especially warranted among US-born women, and additional educational interventions should be developed to forestall early supplementation with formula across all acculturation groups.

Medication abortion use among low-income and rural Texans before and during state-imposed restrictions and after FDA-updated labeling.

BACKGROUND: In 2013, the Texas legislature passed House Bill 2, restricting use of medication abortion to comply with Food and Drug Administration labeling from 2000. The Food and Drug Administration updated its labeling for medication abortion in 2016, alleviating some of the burdens imposed by House Bill 2. OBJECTIVE: Our objective was to identify the impact of House Bill 2 on medication abortion use by patient travel distance to an open clinic and income status. MATERIALS AND METHODS: In this retrospective study, we collected patient zip code, county of residence, type of abortion, family size, and income data on all patients who received an abortion (medication or aspiration) from 7 Texas abortion clinics in 3 time periods: pre-House Bill 2 (July 1, 2012-June 30, 2013), during House Bill 2 (April 1, 2015-March 30, 2016), and post-Food and Drug Administration labeling update (April 1, 2016-March 30, 2017). Patient driving distance to the clinic where care was obtained was categorized as 1-24, 25-49, 50-99, or 100+ miles. Patient county of residence was categorized by availability of a clinic during House Bill 2 (open clinic), county with a House Bill 2-related clinic closure (closed clinic), or no clinic any time period. Patient income was categorized as ≤110% federal poverty level (low-income) and >110% federal poverty level. Change in medication abortion use in the 3 time periods by patient driving distance, residence in a county with an open clinic, and income status were evaluated using χ2 tests and logistic regression. We used geospatial mapping to depict the spatial distribution of patients who obtained a medication abortion in each time period. RESULTS: Among 70,578 abortion procedures, medication abortion comprised 26%, 7%, and 29% of cases pre-House Bill 2, during House Bill 2, and post-Food and Drug Administration labeling update, respectively. During House Bill 2, patients traveling 100+ miles compared to 1- 24 miles were less likely to use medication abortion (odds ratio, 0.21; 95% confidence interval, 0.15, 0.30), as were low-income compared to higher-income patients (odds ratio, 0.76; 95% confidence interval, 0.68, 0.85), and low-income, distant patients (adjusted odds ratio, 0.14; 95% confidence interval, 0.08, 0.25). Similarly, post-Food and Drug Administration labeling update, rebound in medication abortion use was less pronounced for patients traveling 100+ miles compared to 1-24 miles (odds ratio, 0.82; 95% confidence interval, 0.74, 0.91), low-income compared to higher-income patients (odds ratio, 0.77; 95% confidence interval, 0.72, 0.81), and low-income, distant patients (adjusted odds ratio, 0.80; 95% confidence interval, 0.68, 0.94). Post-Food and Drug Administration labeling update, patients residing in counties with House Bill 2-related clinic closures were less likely to receive medication abortion as driving distance increased (52% traveling 25-49 miles, 41% traveling 50-99 miles, and 26% traveling 100+ miles, P < .05). Geospatial mapping demonstrated that patients traveled from all over the state to receive medication abortion pre-House Bill 2 and post-Food and Drug Administration labeling update, whereas during House Bill 2, only those living in or near a county with an open clinic obtained medication abortion. CONCLUSION: Texas state law drastically restricted access to medication abortion and had a disproportionate impact on low-income patients and those living farther from an open clinic. After the Food and Drug Administration labeling update, medication abortion use rebounded, but disparities in use remained.

Quality of postpartum contraceptive counseling and changes in contraceptive method preferences.

OBJECTIVES: We examined the association between quality of postpartum contraceptive counseling and changes in contraceptive method preference between delivery and 3-months postpartum. STUDY DESIGN: We used data from 1167 postpartum women delivering at eight hospitals in Texas who did not initiate contraception in the hospital. We conducted baseline and 3-month follow-up interviews to ask women about the method they would prefer to use at 6-months postpartum, postpartum contraceptive counseling, reproductive history, and demographic characteristics. We measured quality of postpartum contraceptive counseling with seven items related to satisfaction and information received. High-quality counseling was defined as meeting all seven criteria. We used logistic regression to predict the primary outcome of changes in preferred method by contraceptive counseling and described contraceptive counseling and changes in preferred method by demographic characteristics. RESULTS: Receipt of high-quality postpartum contraceptive counseling was reported by 26%. At 3-months postpartum 70% of participants reported the same contraceptive preferences by category of effectiveness that they expressed at the time of delivery. Spanish-speaking, Hispanic foreign-born, and lower socioeconomic status women were less likely to receive high-quality counseling than their counterparts. High-quality counseling was associated with lower odds of preferring a less effective method (OR: 0.31, 95% CI: 0.18-0.52) and changing preference from an IUD or implant (OR: 0.34, 95% CI: 0.17-0.68). CONCLUSIONS: High-quality postpartum contraceptive counseling is relatively rare and occurs less often among low SES and immigrant women. High-quality counseling appears to reinforce preferences for effective contraception. IMPLICATIONS: Training healthcare providers to provide high-quality contraceptive counseling to all postpartum women may reduce contraceptive disparities related to race/ethnicity and social class.

Change in Second-Trimester Abortion After Implementation of a Restrictive State Law.

OBJECTIVE: To assess whether indicators of limited access to services explained changes in rates of second-trimester abortion after implementation of a restrictive abortion law in Texas. METHODS: We used cross-sectional vital statistics data on abortions performed in Texas before (November 1, 2011-October 31, 2012) and after (November 1, 2013-October 31, 2014) implementation of Texas' abortion law. We conducted monthly mystery client calls for information about abortion facility closures and appointment wait times to calculate distance from women's county of residence to the nearest open Texas facility, the number of open abortion facilities in women's region of residence (facility network size), and days until the next consultation visit. We estimated mixed-effects logistic regression models to assess the association between obtaining abortion care after the law's implementation and having a second-trimester abortion (12 weeks of gestation or more), after adjustment for distance, network size, and wait times. RESULTS: Overall, 64,902 Texas-resident abortions occurred in the period before the law was introduced and 53,174 occurred after its implementation. After implementation, 14.5% of abortions were performed at 12 weeks of gestation or more, compared with 10.5% before the law (P<.001; unadjusted odds ratio [OR] 1.45; 95% CI 1.40-1.50). Adjusting for distance to the nearest facility and facility network size reduced the odds of having a second-trimester abortion after implementation (OR 1.17; 95% CI 1.10-1.25). Women living 50-99 miles from the nearest facility (vs less than 10 miles) had higher odds of second-trimester abortion (OR 1.24; 95% CI 1.11-1.39), as did women in regions with less than one facility per 250,000 reproductive-aged women compared with women in areas that had 1.5 or more facilities (OR 1.57; 95% CI 1.41-1.75). After implementation, women waited 1 to 14 days for a consultation visit; longer waits were associated with higher odds of second-trimester abortion. CONCLUSION: Increases in second-trimester abortion after the law's implementation were due to women having more limited access to abortion services.

Rebound of medication abortion in Texas following updated mifepristone label.

BACKGROUND: In 2013, Texas House Bill 2 (HB 2) placed restrictions on the use of medication abortion, which later were nullified with the 2016 FDA-approved mifepristone label. METHODS: Using data collected directly from Texas abortion facilities, we evaluated changes in the provision and use of medication abortion during three 6-month time periods corresponding to the policy changes: before HB 2, after HB 2 and after the label change. RESULTS: Medication abortion constituted 28% of all abortions before HB 2, 10% after implementation of the restrictions and 33% after the label change. CONCLUSIONS: Use of medication abortion in Texas rebounded after the FDA label change.

Low-Income Texas Women's Experiences Accessing Their Desired Contraceptive Method at the First Postpartum Visit.

CONTEXT: Early access to contraception may increase postpartum contraceptive use. However, little is known about women's experiences receiving their desired method at the first postpartum visit or how access is associated with use. METHODS: In a 2014-2016 prospective cohort study of low-income Texas women, data were collected from 685 individuals who desired a reversible contraceptive and discussed contraception with a provider at their first postpartum visit, usually within six weeks of birth. Women's experiences were captured using open- and closed-ended survey questions. Thematic and multivariate logistic regression analyses were employed to examine contraceptive access and barriers, and method use at three months postpartum. RESULTS: Twenty-three percent of women received their desired method at the first postpartum visit; 11% a prescription for their desired pill, patch or ring; 8% a method (or prescription) other than that desired; and 58% no method. Among women who did not receive their desired method, 44% reported clinic-level barriers (e.g., method unavailability or no same-day provision), 26% provider-level barriers (e.g., inaccurate contraceptive counseling) and 23% cost barriers. Women who used private practices were more likely than those who used public clinics to report availability and cost barriers (odds ratios, 6.4 and 2.7, respectively). Forty-one percent of women who did not receive their desired method, compared with 86% of those who did, were using that method at three months postpartum. CONCLUSION: Eliminating the various barriers that postpartum women face may improve their access to contraceptives. Further research is needed to improve the understanding of clinic- and provider-level barriers.