Prior knowledge and experience with self-managed abortion among people seeking abortion care in US Midwestern states.

OBJECTIVES: This study seeks to understand what methods people use and/or have heard of others using for self-managed abortion (SMA) prior to coming to a health facility for abortion care. STUDY DESIGN: We collected survey data on sociodemographics, gestational stage, and SMA awareness and methods from patients seeking care in 17 abortion facilities in Ohio, West Virginia, Kentucky, Pennsylvania, and Illinois from April 2020 to April 2022. We used descriptive statistics to examine the proportion of participants who had attempted SMA and, separately, who had heard of people attempting SMA. RESULTS: In total, 71 respondents (4.2%) had attempted SMA, and 416 (25.5%) had heard of others attempting SMA. The most frequently attempted methods for self-management were taking herbs and/or vitamins (31% each) or hitting oneself/being hit (22.5%). About a third of those who tried SMA reported trying more than one method (30%). CONCLUSIONS: Our findings suggest that people who attempt SMA are committed to self-managing their abortion. More research is needed to better understand sociodemographic characteristics of people who have attempted or heard of people attempting SMA research.

State of Confusion: Ohio's Restrictive Abortion Landscape and the Production of Uncertainty in Reproductive Health Care.

This study examines an underexplored source of medical uncertainty: the political context of care. Since 2011, Ohio has passed over 16 abortion-restrictive laws. We know little about how this legislation affects reproductive health care outside of abortion clinics. Drawing on focus groups and interviews with genetic counselors and obstetrician-gynecologists, we examine how abortion legislation impacts their work. We find that interpretation and implementation of legislation is not straightforward and varies by institution and region of the state. An ever-changing legislative landscape combined with uneven implementation of restrictions into policy produces uncertainty in reproductive health care. We also found uncertainty about the legal consequences of abortion in restrictive contexts, with obstetrician-gynecologists reporting greater concerns given their proximity to care provision. We argue that uncertainty can result in stricter interpretations of regulations than necessitated by the law, thereby amplifying the impacts of an already restrictive context for abortion care.

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).

Unlimited Discretion: How Unchecked Bureaucratic Discretion Can Threaten Abortion Availability.

Previous research has assessed the impact of state regulations on abortion clinics and patients, but how bureaucrats implement them is less understood and is increasingly important as states arbitrate abortion regulation. The authors conducted a case study of how bureaucrats use discretion to implement state regulations on abortion, focusing on two abortion facilities in southwest Ohio from 2010 to 2022. Ohio abortion facilities are required to obtain a written transfer agreement, despite it offering no demonstrable health or safety benefits. The authors find that state requirements for obtaining variances-a process that allows abortion facilities to operate without a written transfer agreement-have become exceedingly difficult to comply with. The authors show how state statutes and administrative law have enabled bureaucrats to wield unlimited discretion and enforce arbitrary requirements. This unlimited bureaucratic discretion and accompanying administrative burden exacerbated clinic instability and threatened abortion availability in southwest Ohio for almost a decade. As implementation and interpretation of abortion policy is increasingly left to state bureaucrats and civil servants following the Supreme Court's Dobbs decision, how bureaucrats use discretion will influence clinic stability and abortion availability. The authors posit that unlimited bureaucratic discretion may exert greater influence on abortion availability across the nation as states scramble to clarify and implement policies after Dobbs.

The double-edged sword of abortion regulations: Decreasing training opportunities while increasing knowledge requirements.

PURPOSE: The authors explore how abortion regulations in Ohio, an abortion-restrictive state in the USA, impact obstetrician-gynecologists' (OB/GYNs) training in reproductive healthcare and describe what OB/GYNs believe to be the broader impact of Ohio's regulations on skill-building, skills maintenance, and professional retention of reproductive healthcare providers in the state. Authors discuss how their findings foreshadow abortion training limitations in Ohio and other abortion-restrictive states now that abortion regulations have returned to the states. METHODS: The authors conducted four semi-structured focus groups and five in-depth interviews between April 2019 and March 2020. Participants included OB/GYNs practicing obstetrics and gynecology in Ohio between 2010 and 2020. Thematic analysis was conducted using Atlas.ti. RESULTS: Twenty attending physicians and 15 fellows and residents participated in the study. Participants discussed the impact of Ohio's written transfer agreement, gestational-limit, and abortion method and facility bans on training and skill-building opportunities. Participants felt that Ohio's strict abortion regulations 1) limit opportunities to observe and perform abortion procedures during training; 2) require learning the ever-changing legality of abortion provision; 3) limit the number of abortions OB/GYNs can provide, leading to the atrophy of their skills over time; and 4) may prevent prospective medical students and residents from choosing to study in Ohio and may lead to physician attrition from the state. CONCLUSION: Prior to the reversal of federal protections for abortion in 2022, OB/GYNs in Ohio and other abortion-hostile states experienced barriers to training in abortion care. In returning abortion regulation to the states, access to training is likely to be increasingly restricted. This research demonstrates how abortion-restrictions hamper physicians' skills needed to care for patients, particularly in emergent situations. This puts patients at risk and places physicians in precarious ethical positions. Expanding protections and reducing restrictions on abortion will ensure OB/GYNs and trainees have the skills necessary to care for patients presenting for reproductive healthcare.