COVID-19 and abortion in the Ohio River Valley: A case study of Kentucky, Ohio, and West Virginia.

INTRODUCTION: During early stages of COVID-19 in the United States, government representatives in Kentucky, Ohio, and West Virginia restricted or threatened to restrict abortion care under elective surgery bans. We examined how abortion utilization changed in these states. METHODOLOGY: We examined COVID-19 abortion-related state policies implemented in March and April 2020 using publicly available sources. We analyzed data on abortions by method and gestation and experiences of facility staff, using a survey of 14 facilities. We assessed abortions that took place in February-June 2020 and February-June 2021. RESULTS: In February-June 2020 the monthly average abortion count was 1916; 863 (45%) were medication abortions and 229 (12%) were ≥14 weeks gestation. Of 1959 abortions performed across all three states in April 2020, 1319 (67%) were medication abortions and 231 (12%) were ≥14 weeks gestation. The shift toward medication abortion that took place in April 2020 was not observed in April 2021. Although the total abortion count in the three-state region remained steady, West Virginia had the greatest decline in total abortions, Ohio experienced a shift from instrumentation to medication abortions, and Kentucky saw little change. Staff reported increased stress from concerns over health and safety and increased scrutiny by the state and anti-abortion protesters. DISCUSSION: Although abortion provision continued in this region, policy changes restricting abortion in Ohio and West Virginia resulted in a decrease in first trimester instrumentation abortions, an overall shift toward medication abortion care, and an increase in stress among facility staff during the early phase of COVID-19.

Kentucky's abortion landscape, 2010 to 2019: an analysis of pre-Dobbs abortion disparities in a rural, restrictive state.

Background: Since 2010, many US states have passed laws restricting abortion providers' ability to provide care. Such legislation has no demonstrated health benefits and creates inequitable barriers for patients. Methods: To examine how Kentucky's abortion policies coincided with facility closures and abortion utilisation, we conducted a review of state abortion policies from 2010 to 2019 using newspapers and websites. We calculated abortion rates (abortions per 1000 women ages 15-44) by state of residence and provision for Kentucky, the South, and the US using data from the CDC and Kentucky Department of Health. We calculated percentages leaving and from out-of-state, and analysed abortions by race, pregnancy duration, and method. Findings: Of 17 policies passed between 2010 and 2019, ten were enacted, including 20-week and telemedicine bans. One of Kentucky's two abortion facilities closed in 2017. The pooled average abortion rate in Kentucky (4.1) and for Kentuckians (5.8) was lower than national averages (11.8 and 11.1). An average of 38% of Kentuckians left their state for care, compared to 7% nationally. In 2019, the abortion rate in Kentucky was 5.8 times higher for Black patients than White patients (compared to 4.8 times nationally). The majority (62%) of abortions in Kentucky took place at 7-13 weeks' gestation. Interpretation: Abortions in Kentucky were less frequent than in the South and US. The larger Black-White abortion rate gap reflects race- and class-based structural inequities in healthcare. Without federal protections, abortion access in Kentucky will continue waning. Funding: This study was supported by a philanthropic foundation that makes grants anonymously.

Abortion-Related Laws and Concurrent Patterns in Abortion Incidence in Indiana, 2010-2019.

Objectives. To analyze abortion incidence in Indiana concurrent with changes in abortion-related laws. Methods. Using publicly available data, we created a timeline of abortion-related laws in Indiana, calculated abortion rates by geography, and described changes in abortion occurrence coincident with changes in abortion-related laws between 2010 and 2019. Results. Between 2010 and 2019, Indiana's legislature passed 14 abortion-restricting laws, and 4 of 10 abortion-providing clinics closed. The Indiana abortion rate decreased from 7.8 abortions per 1000 women aged 15 to 44 years in 2010 to 5.9 in 2019. At all time points, the abortion rate was 58% to 71% of the Midwestern rate and 48% to 55% of the national rate. By 2019, nearly 1 in 3 (29%) Indiana residents who obtained abortion care did so outside the state. Conclusions. Access to abortion in Indiana over the past decade was low, required increases in interstate travel to obtain care, and co-occurred with the passage of numerous abortion restrictions. Public Health Implications. These findings preview unequal abortion access and increases in interstate travel as state-level restrictions and bans go into effect across the country. (Am J Public Health. 2023;113(4):429-437. https://doi.org/10.2105/AJPH.2022.307196).

Factors associated with never-use of long-acting reversible contraception among adult reproductive-aged women in Ohio.

BACKGROUND: The number of women using long-acting reversible contraception (LARC)-intrauterine devices (IUDs) and implants-is increasing and 14% of contraceptive users in the United States adopt LARC. We examined correlates of LARC never-use in a population-based survey of reproductive-aged women in Ohio. METHODS: We analyzed data from the 2018-19 Ohio Survey of Women. We examined the prevalence of LARC never-use and reasons for never-use among ever users of contraception (N = 2388). Using Poisson regression to generate prevalence ratios (PRs), we examined associations between selected correlates (demographic factors, healthcare access/quality measures, and religious/political views) and LARC never-use. RESULTS: Most Ohio women (74%) had never used LARC. Commonly reported reasons for not using an IUD or an implant were preferring a different method (46% and 45%, respectively), not wanting an object inside their body (45% and 43%), side effect concerns (39% and 33%), insertion/removal concerns (31% and 25%), and unfamiliarity (13% and 20%). Conservative political views (PR: 1.12, 95% confidence interval [CI]: 1.04-1.22), pro-life affiliation (PR: 1.11, 95% CI: 1.02-1.20), placing high importance on religion in daily life (PR: 1.15, 95% CI: 1.06-1.26), and being non-Hispanic white as compared to non-Hispanic Black (PR: 1.20, 95% CI: 1.02-1.41) were significantly associated with LARC never-use. Findings were generally similar for models analyzing IUD and implant never-use separately. CONCLUSIONS: Among ever-users of contraception, LARC never-use was associated with having conservative political views, being religious, and having a pro-life affiliation. Except for race/ethnicity, demographic and healthcare measures were not associated with LARC never-use among women in Ohio.

How Ohio's proposed abortion bans would impact travel distance to access abortion care.

CONTEXT: Since March 2021, the Ohio legislature has been actively considering laws that would ban abortion if the United States Supreme Court overturns the Roe v. Wade decision that legalized abortion nationally in 1973. METHODS: We used a national database of publicly advertised abortion facilities to calculate driving distances for Ohioans before and after the activation of proposed abortion bans. Using a legal analysis of abortion laws following the overturn of Roe, we determined which states surrounding Ohio would continue providing abortion care. We calculated distances from each Ohio county centroid to the nearest open abortion facility in three scenarios: (1) as of February 2022, (2) the best-case post-Roe scenario (two of the five surrounding states continue to offer abortion care), and (3) worst-case post-Roe scenario (no surrounding states continue to offer abortion care). We calculated population-weighted distances using county-level data about women aged 15-44 years from the 2019 American Community Survey. RESULTS: In February 2022, all Ohio county centroids were at most 99 miles from an abortion facility (median = 50 miles). The best-case post-Roe scenario shows 62 of Ohio's 88 counties to be 115-279 miles away from the nearest facility (median = 146). The worst-case shows 85 counties to be 191-339 miles away from the nearest facility (median = 264). The current average population-weighted driving distance from county centroid to the nearest facility is 26 miles; the post-Roe scenarios would increase this to 157 miles (best-case) or 269 miles (worst-case). CONCLUSIONS: Ohio's proposed abortion bans would substantially increase travel distances to abortion care, impacting over 2.2 million reproductive-aged Ohioans.

Abortion travel within the United States: An observational study of cross-state movement to obtain abortion care in 2017.

Background: In the United States, abortion access is often more limited for people who live in states with few abortion facilities and restrictive abortion legislation. Pregnant people seeking an abortion thus often travel to access care. Methods: We calculated state-specific abortion rate (number of abortions per thousand women ages 15 to 44) and percentage of patients leaving for abortion care using CDC 2017 Abortion Surveillance data, the Guttmacher Institute's Abortion Provider Census and Pregnancies, Births and Abortions in the United States report, and US Census data. We categorized percent leaving by abortion policy landscape using the Guttmacher Institute's classification of state abortion laws, and by facility density (number of abortion facilities per million women ages 15 to 44), calculated using Census and Guttmacher data. We ran correlational tests between each of our variables (percent leaving, facility density, and policy environment), as well as between percent leaving and facility density within policy environment. Findings: In 2017, an average of 8% of US patients left their state of residence for abortion care. Percent leaving varied widely by state: 74% left Wyoming, 57% left South Carolina, and 56% left Missouri, while 13 states had fewer than 4% of patients leaving. States with more restrictive laws averaged 12% of patients leaving, while states with middle ground or supportive laws averaged 10% and 3% leaving, respectively. Pairwise correlations between percent leaving, facility density, and policy score were all statistically significant, though correlations between percent leaving and facility density within policy environment were not. Interpretation: Many patients travel across state lines for abortion care. While patients may leave for a range of reasons, restrictive state-level abortion policy and facility scarcity are associated with patients leaving their state of residence. Funding: This study was supported by a philanthropic foundation that makes grants anonymously.

Federal, state, and institutional barriers to the expansion of medication and telemedicine abortion services in Ohio, Kentucky, and West Virginia during the COVID-19 pandemic.

OBJECTIVES: We aimed to characterize the combined impact of federal, state, and institutional policies on barriers to expanding medication and telemedicine abortion care delivery during the COVID-19 pandemic in the abortion-restrictive states of Ohio, Kentucky, and West Virginia. STUDY DESIGN: We analyzed 4 state policies, 2 COVID-related state executive orders, and clinic-level survey data on medication abortion provision from fourteen abortion facilities in Ohio, Kentucky, and West Virginia from December 2019 to December 2020. We calculated the percent of medication abortions provided at these facilities during the study period by state, to assess changes in medication abortion use during the pandemic. RESULTS: We ascertained that COVID-19-executive orders in Ohio and West Virginia that limited procedural abortion in Spring 2020 coincided with an increase in the overall number and proportion of medication abortions in this region, peaking at 1613 medication abortions (70%) in April 2020. Ohio and West Virginia, which had executive orders limiting procedural abortion, saw relatively greater increases in April compared to Kentucky. Despite temporary lifting of the mifepristone REMS, prepandemic regulations banning telemedicine abortion in Kentucky and West Virginia and requiring in-person clinic visits for medication abortion distribution in Ohio limited clinics' ability to adapt to offer medication abortion by mail. CONCLUSIONS: Our findings illustrate how restrictive medication and telemedicine abortion policies in Ohio, Kentucky, and West Virginia created additional obstacles for patients seeking medication abortion during the pandemic. Permanently lifting federal regulations on in-clinic distribution of mifepristone would only advantage abortion seekers in states without restrictive telehealth and medication abortion policies. State policies that limit access to comprehensive abortion services should be central in larger efforts toward dismantling barriers that impinge upon reproductive autonomy. IMPLICATION STATEMENT: We find that abolishing the REMS on mifepristone would not be enough to expand access to patients in abortion-restrictive states with telemedicine and medication abortion laws. While the REMS is a barrier, it represents one of several hindrances to the expansion of telemedicine abortion distribution across the United States.

Use of nonpreferred contraceptive methods among women in Ohio.

OBJECTIVES: We describe the prevalence and correlates of nonuse of preferred contraceptive method among women 18-44 years of age in Ohio using contraception. STUDY DESIGN: The population-representative Ohio Survey of Women had 2529 participants in 2018-2019, with a response rate of 33.5%. We examined prevalence of preferred method nonuse, reasons for nonuse, and satisfaction with current method among current contraception users (n = 1390). We evaluated associations between demographic and healthcare factors and preferred method nonuse. RESULTS: About 25% of women reported not using their preferred contraceptive method. The most common barrier to obtaining preferred method was affordability (13%). Those not using their preferred method identified long-acting methods (49%), oral contraception (33%), or condoms (21%) as their preferred methods. The proportion using their preferred method was highest among intrauterine device (IUD) users (86%) and lowest among emergency contraception users (64%). About 16% of women using permanent contraception reported it was not their preferred method. Having the lowest socioeconomic status (versus highest) (prevalence ratio [PR]: 1.47, 95% CI: 1.11-1.96), Hispanic ethnicity (versus non-Hispanic white) (PR: 1.83, 95% CI: 1.15-2.90), reporting poor provider satisfaction related to contraceptive care (PR: 2.33, 95% CI: 1.02-5.29), and not having a yearly women's checkup (PR: 1.31, 95% CI: 1.01-1.68) were significantly associated with nonuse of preferred method. Compared to preferred-method nonusers, higher proportions of preferred-method users reported consistent contraceptive use (89% vs. 73%, p < 0.001) and intent to continue use (79% vs. 58%, p < 0.001). CONCLUSIONS: Affordability and poor provider satisfaction related to contraceptive care were associated with nonuse of preferred contraceptive method. Those using their preferred method reported more consistent use. IMPLICATIONS: Cost is an important barrier for women in obtaining their preferred contraceptive methods. Low quality birth control care may also be a barrier to preferred-method use. Removal of cost barriers and improvement in contraceptive counseling strategies may increase access to preferred contraceptive methods.

Abortion Access in Ohio's Changing Legislative Context, 2010-2018.

Objectives. To examine abortion utilization in Ohio from 2010 to 2018, a period when more than 15 abortion-related laws became effective.Methods. We evaluated changes in abortion rates and ratios examining gestation, geographic distribution, and abortion method in Ohio from 2010 to 2018. We used data from Ohio's Office of Vital Statistics, the Centers for Disease Control and Prevention's Abortion Surveillance Reports, the American Community Survey, and Ohio's Public Health Data Warehouse.Results. During 2010 through 2018, abortion rates declined similarly in Ohio, the Midwest, and the United States. In Ohio, the proportion of early first trimester abortions decreased; the proportion of abortions increased in nearly every later gestation category. Abortion ratios decreased sharply in most rural counties. When clinics closed, abortion ratios dropped in nearby counties.Conclusions. More Ohioans had abortions later in the first trimester, compared with national patterns, suggesting delays to care. Steeper decreases in abortion ratios in rural versus urban counties suggest geographic inequity in abortion access.Public Health Implications. Policies restricting abortion access in Ohio co-occur with delays to care and increasing geographic inequities. Restrictive policies do not improve reproductive health.