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.

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.

Ohio Abortion Regulations and Ethical Dilemmas for Obstetrician-Gynecologists.

OBJECTIVE: To analyze obstetrician-gynecologists' (ob-gyns') experiences with, and perspectives on, how Ohio's abortion-restrictive regulatory landscape affects their health care practices. METHODS: Between 2019 and 2020, we conducted qualitative interviews and focus groups with ob-gyns (N=35) who had practiced in Ohio for at least 6 months between 2010 and 2020. Discussions were recorded, transcribed, coded, and analyzed thematically using ATLAS.ti software. RESULTS: Participants perceived Ohio abortion regulations affecting their practice in three key ways: abortion regulations framed abortion and physicians who provide abortion as separate and distinct from other medical practices and physicians; many institutional interpretations of abortion regulations undermined physician expertise and professional autonomy; and the constellation of abortion regulations, institutional interpretations, physicians' trepidation, and their perceived inability to exercise clinical judgment worked together to limit abortion access and increase risks to patients' lives and health. The combined factors left participants feeling distraught that they were unable to practice medicine in an ethical and compassionate manner. CONCLUSION: Ohio abortion regulations limit ob-gyns' ability to provide comprehensive reproductive health care, creating ethical dilemmas for these physicians as they attempt to care for their patients. As Ohio's abortion laws increase in number and restrictiveness, they further undermine obstetric and gynecologic ethical practice guidelines. However, medical institutions play a key role in determining abortion provision in Ohio; through their interpretation of the law, institutions can demonstrate support or further limit ob-gyns' ability to exercise clinical judgment and provide ethical, compassionate care to their patients. Considerable work remains to bring Ohio's abortion regulations, institutional interpretations, and physician practices into alignment with professional clinical practice and ethics guidelines.