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).

Free, but at what cost? How US crisis pregnancy centres provide services.

In the USA, the most popular form of anti-abortion activism, crisis pregnancy centres (CPCs), provide a variety of services to prevent abortions. Moving beyond debate about misinformation and the ethics of CPCs, this study considers the services they provide and given their popularity among state legislatures, their connection to the state. Using interviews with ten CPC staff in Ohio (a state providing support to CPCs) and supplemental data from both state and CPC organisations, we find three relevant themes. First, CPC services reflect ideas about personal responsibility and Christianity held by the CPC staff. Second, we show that CPCs have assumed a variety of state duties (e.g. pregnancy testing and parenting classes), appealing to lawmakers in conservative states eager to transfer responsibility for disadvantaged residents to other entities. Finally, we consider the future direction of CPCs, highlighting tension between organisational goals (focusing on abortion prevention) and the on-the-ground experience of CPC staff (where non-pregnant clients need material aid). Drawing theoretical connections between CPC staff and social service workers sheds light on whose responsibility it is to address poverty in a post-welfare era.

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.

Provider Mistrust and Telemedicine Abortion Care Preferences Among Patients in Ohio, West Virginia, and Kentucky.

Objectives: The convenience and privacy provided by telemedicine medication abortion may make this service preferable to patients who mistrust their abortion provider. We assessed associations between mistrust in the abortion provider and preferences for telemedicine abortion. Study Design: From April 2020 to April 2021, we surveyed patients seeking abortion in Ohio, West Virginia, and Kentucky. Using unconditional logistic regression models, we examined unadjusted and adjusted associations between mistrust in the abortion provider and preferences for telemedicine abortion among all participants, and among only participants undergoing medication abortion. Results: Of 1,218 patients who met inclusion criteria, 546 used medication abortion services. Just more than half (56%) of all participants and many (64%) of medication abortion participants preferred telemedicine services. Only 6% of medication abortion participants received telemedicine medication dispensing services. Only 1.4% of all participants and 1% of medication abortion participants mistrusted the abortion provider. Participants who mistrusted the abortion provider were somewhat more likely to prefer telemedicine abortion (unadjusted odds ratio [OR]: 2.5, 95% CI: 0.8-7.9; adjusted OR: 2.9, 95% CI: 0.9-9), and medication abortion participants who mistrusted the abortion provider were also somewhat more likely to prefer telemedicine abortion (unadjusted OR: 3.5, 95% CI: 0.4-28.9; adjusted OR: 5.0, 95% CI: 0.6-43), although these associations were not statistically significant. Conclusions: In three abortion-restrictive states, most patients expressed preferences for telemedicine abortion, but few accessed them. Provider mistrust was rare, but those experiencing mistrust trended toward preferring telemedicine services. Telemedicine may improve access to abortion services for patients experiencing medical mistrust.

Experiences of reproductive genetic counselors with abortion regulations in Ohio.

Since 2010, Ohio legislators have passed more than 15 legislative changes related to abortion and abortion providers, and nine procedural abortion clinics have closed. We investigated reproductive genetic counselors' perceptions, attitudes and self-reported practices regarding Ohio's current and proposed abortion regulations. We conducted five focus groups and two telephone interviews in 2019-2020, with a total of 19 reproductive genetic counselors. Participants discussed difficulties keeping current on abortion legislation and clinics' and hospitals' policies, resulting in anticipatory anxiety and leading to additional work to discuss the laws with patients. Participants articulated that practices of reproductive genetic counseling-and patient advocacy-are impeded by the legislation. Genetic counselors perceive negative impacts on patients' autonomy, particularly reflective of healthcare disparities of marginalized groups, which may contribute to frustration and anger. Ultimately, the mental and emotional burden on genetic counselors created by abortion legislation contributes to compassion fatigue and burnout. Our findings show that Ohio's abortion regulations negatively impact reproductive genetic counselors and their relationships with their patients. Repealing existing abortion regulations and preventing future restrictive legislation may ameliorate the negative effects of regulations on reproductive genetic counselors and their patients. In the event that these laws remain, innovative communication tools and proactive professional society advocacy are potential means to mitigate the negative impact on reproductive genetic counselors.

Housing Stability and Access to General Healthcare and Reproductive Healthcare Among Women in Ohio.

BACKGROUND: The relationship between housing instability and reproductive healthcare is understudied. We examined the association between housing insecurity and access and utilization of general healthcare, contraceptive healthcare, and abortion care. METHODS: Using data from a population-representative survey of adult reproductive-age Ohio women (N = 2,529), we assessed housing insecurity (not paying rent/mortgage on time in the past year). We examined associations between housing insecurity and the following outcomes: (1) not being able to access general healthcare in the past year; (2) experiencing delays or difficulties in accessing contraceptive healthcare in the past year; and (3) ever having an abortion. We used unadjusted and adjusted logistic regression models. We selected confounders a priori and included age, socioeconomic status, and healthcare status. RESULTS: Overall, 10.6% of Ohio women of adult reproductive age experienced housing insecurity. Approximately 27.5% of respondents were not able to access general healthcare and 10.4% experienced delays or difficulties in accessing contraceptive care. Compared to housing-secure respondents, housing-insecure women were less able to access general healthcare (adjusted odds ratio [aOR]:2.16; 95% confidence interval [CI]:1.45-3.23) and more likely to experience delays or difficulties when accessing contraceptive care (aOR:1.74; 95% CI:1.00-3.04). Insecure housing was not statistically associated with ever having an abortion (aOR:1.76; 95% CI:0.93-3.34). CONCLUSIONS: In this study, recent housing insecurity was associated with poorer access to general and contraceptive healthcare. Studies utilizing multidimensional measures of housing insecurity and other material insecurity measures are needed to further explore the relationship between material insecurity and access to general and contraceptive care.

Passage of abortion ban and women's accurate understanding of abortion legality.

BACKGROUND: Legislative and judicial procedures related to banning abortion after 6 weeks of gestation in Ohio occurred from November 2018 to July 2019. These activities could have increased the belief that abortion has become illegal even though the 6-week abortion ban has never been in effect to date. OBJECTIVE: We sought to determine the prevalence and correlates of holding the belief that abortion is illegal in Ohio and to evaluate whether this belief increased over the time in which the 6-week abortion ban was introduced, passed twice, and then blocked in Ohio. STUDY DESIGN: We analyzed data from the first wave of the Ohio Survey of Women, a population-based survey of adult, reproductive-aged Ohioan women conducted from October 2018 to June 2019. During each of the 8 survey months, a median of 240 women (range, 70-761) completed the survey, including the survey question "Based on what you know or have heard, is it legal to get an abortion in your state?" We used multivariable logistic regression to assess the prevalence and correlates of believing that abortion is illegal in the state of Ohio. In addition, we used multinomial logistic regression to evaluate whether this belief increased over the interval during which women completed the survey, which roughly corresponded to the interval marked by legislative and judicial activities surrounding the 6-week abortion ban. RESULTS: Most of the 2359 participants understood that abortion is legal in the state of Ohio (64.0%) with the remainder believing it to be illegal (9.8%) or being unsure (26.2%). Correlates of believing abortion to be illegal included younger age, lower socioeconomic status, never married or married status, and Black, non-Hispanic race and ethnicity. Being unsure about legality did not change over time; however, the proportion of women who believed that abortion is illegal increased from the first month (4.5%) to the last month (15.9%) of the study period. Each additional study month was associated with a 17% increase in the odds of believing abortion to be illegal, in both unadjusted and adjusted models (odds ratio, 1.17; 95% confidence interval, 1.08-1.27). CONCLUSION: Attempts to restrict abortion access could contribute to women mistakenly believing that abortion is illegal despite it being unsuccessful.

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.

'I guess I do have to take back what I said before, about television': pregnant women's understandings and use of televisual representations of childbearing.

Research on television as a source of childbearing information is divided on its importance. Drawing from a sample of 64 pregnant women in the greater New York and Connecticut metropolitan area, we examine how women understand the influence of television on their expectations for pregnancy and birth. A sizable minority (44%) regularly watched reality television programmes on childbearing; all engaged in active viewing practices, such as recognising programme formula and evaluating plausibility of depictions. We find clear educational differences in how viewers believed television influenced their pregnancy knowledge: women with higher levels of education generally disavowed all television as an information source, but used reality programming to educate their children about pregnancy and for entertainment. Women who had lower educational attainment were more likely to include reality programmes as part of their comprehensive approach to information gathering. Only one woman asserted that fictional television was a good source of pregnancy information. Although many devalued television, women referenced television programmes and imagery as they described their expectations and concerns for pregnancy. A large proportion of respondents were unaware of the influence television exerted on them. Health scholars must better engage with the complexities of media use.

Does state-level context matter for individuals' knowledge about abortion, legality and health? Challenging the 'red states v. blue states' hypothesis.

Recently, the hypothesis that state-level political context influences individuals' cultural values--the 'red states v. blue states' hypothesis--has been invoked to explain the hyper-polarisation of politics in the USA. To test this hypothesis, we examined individuals' knowledge about abortion in relation to the political context of their current state of residence. Drawing from an internet-survey of 586 reproductive-age individuals in the USA, we assessed two types of abortion knowledge: health-related and legality. We found that state-level conservatism does not modify the existing relationships between individual predictors and each of the two types of abortion knowledge. Hence, our findings do not support the 'red states' versus 'blue states' hypothesis. Additionally, we find that knowledge about abortion's health effects in the USA is low: 7% of our sample thought abortion before 12 weeks gestation was illegal.

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.

Seeking financial and practical support in an abortion-hostile state: Analysis of abortion fund data in Kentucky, 2014-2021: Analysis of abortion fund data in Kentucky.

OBJECTIVES: Philanthropic abortion funds are integral to accessing care in the United States, providing both financial and practical assistance. Yet relatively little is known about those who seek these essential services. In this study, we analyzed data from a Kentucky abortion fund to assess characteristics of abortion fund callers. METHODS: We analyzed 2014-2021 administrative data from the Kentucky Health Justice Network's (KHJN) Abortion Support Fund and compared them to abortion data from the Kentucky Department for Public Health (KDPH). We analyzed age, race, and pregnancy gestation at calling (KHJN) and abortion (KDPH), and calculated Z-scores and p-values to compare proportions in each category between the two data sources. RESULTS: The fund supported 6162 people from 2014 to 2021, when 28,741 people had abortions in Kentucky. Compared with KDPH data, KHJN had a higher percentage of callers who were under age 30, a higher percentage of callers who were Black or another race, and a higher percentage of callers at 14 weeks' gestation or higher. CONCLUSIONS: Compared with state data, KHJN supported a higher percentage of young people, people of color, and people at later gestations. These findings support evidence that structurally vulnerable groups are more likely to face barriers to care and that abortion funds provide essential support necessary for reproductive equity.

Assessing psychosocial costs: Ohio patients' experiences seeking abortion care.

OBJECTIVES: Existing research has not thoroughly characterized the psychosocial costs associated with seeking abortion care in restrictive states. Our study seeks to fill this gap by analyzing the accounts of Ohio abortion patients from 2018 to 2019. STUDY DESIGN: Using inductive and deductive approaches, we analyzed semi-structured in-depth qualitative interviews with 41 Ohio residents who obtained abortion care from one of three clinics in Ohio or Pennsylvania. RESULTS: Ohioans seeking abortion care often experienced fear of judgment, interpersonal strain, and stress as a result of efforts to overcome pre-Dobbs financial, geographic, and timing challenges. Those who needed financial assistance or traveled more than an hour generally reported greater exposure to psychosocial costs. CONCLUSIONS: Participants in this study incurred a complex set of psychosocial costs. Psychosocial costs often resulted from, or were exacerbated by, the financial, geographic, and time-sensitive burdens that patients experienced seeking care. IMPLICATIONS: The psychosocial costs incurred by patients seeking abortion care may be exacerbated in restrictive contexts, especially those who do not have access to insurance coverage for care. Psychosocial costs associated with care seeking are likely to increase as states implement more severe restrictions post-Dobbs. To fully understand abortion costs, researchers must examine costs comprehensively, including both financial and psychosocial costs.

Seeking abortion care in Ohio and Texas during the COVID-19 pandemic.

OBJECTIVES: Political and public health responses to the COVID-19 pandemic changed provision of abortion care and exacerbated existing barriers. We aimed to explore experiences of individuals seeking abortion care in 2 abortion-restrictive states in the United States where state policies and practice changes disrupted abortion provision during the pandemic. STUDY DESIGN: We conducted 22 semistructured interviews in Texas (n = 10) and Ohio (n = 12) to assess how state executive orders limiting abortion, along with other public health guidance and pandemic-related service delivery changes, affected individuals seeking abortion care. We included individuals 18 years and older who contacted a facility for abortion care between March and November 2020. We coded and analyzed interview transcripts using both inductive and deductive approaches. RESULTS: Participants reported obstacles to obtaining their preferred timing and method of abortion. These obstacles placed greater demands on those seeking abortion and resulted in delays in obtaining care for as long as 11 weeks, as well as some being unable to obtain an abortion at all. CONCLUSIONS: Political and public health responses to the COVID-19 pandemic - exacerbated pre-pandemic barriers and existing restrictions and constrained options for people seeking abortion in Ohio and Texas. Delays were consequential for all participants, regardless of their ultimate ability to obtain an abortion. IMPLICATIONS: During the COVID-19 pandemic, state executive orders and clinic practices exacerbated already constrained access to care. Findings highlight the importance of protecting timely care and the full range of abortion methods. Findings also preview barriers individuals seeking abortion may encounter in states that restrict or ban abortion.

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.

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.

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.

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.