Dissertations and Theses

Date of Degree

9-30-2016

Document Type

Dissertation

Degree Name

Doctor of Public Health (DPH)

Department

Community Health and Social Sciences

Advisor(s)

Theodore Joyce

Committee Members

Diana Romero

Heidi Jones

Wendy Chavkin

Subject Categories

Demography, Population, and Ecology | Public Health | Women's Health

Keywords

abortion restrictions, abortion, travel, Texas, gestation, Supreme Court

Abstract

A record number of restrictive abortion laws, particularly those known as Targeted Regulation of Abortion Providers (TRAP), have been passed in US states in the past half-decade. TRAP laws differ from abortion laws that target patients, such as parental involvement and waiting period policies, because they are often expensive, difficult, or impossible for providers to comply with, resulting in the reduction or elimination of abortion services. This can result in farther travel to and higher costs of abortion services for patients; however, there are no studies assessing whether one consequence of reduced geographic accessibility of abortion services is delays in abortion care. Such evaluations are important since states continue to introduce, pass, and enforce TRAP laws, despite evidence that abortion is safe and the risk of complications from abortion increases with length of pregnancy. Moreover, the recent Supreme Court decision in Whole Woman’s Health v. Hellerstedt underscored the need for evidence that restrictive abortion laws’ benefits to women’s health outweigh the burdens for those laws to be permissible under the US constitution.

In order to contribute evidence to help illuminate the potential impact of TRAP laws that reduce or eliminate abortion services on women’s use of those services, I use a natural experiment approach and take advantage of sudden changes in geographic accessibility of abortion services in the United States after the enforcement of abortion laws to assess their effect on the timing of abortion. I use public health surveillance data on abortions performed in New York City (NYC) from 1972 to 1977 to assess the association of distance to NYC with length of pregnancy gestation at abortion before Roe v. Wade, when travel distance to NYC represented the minimum cost of obtaining a legal abortion for a substantial number of US women. I use public health surveillance data on abortions performed in Texas from 2000 to 2007 to assess the impact of the sudden loss of abortion services at 16 weeks of pregnancy gestation or greater following the enforcement of the 2004 Woman’s Right to Know (WTK) Act on the timing of later abortions. In 1972, each increase in the log odds of 100 miles to NYC was associated with an increase in pregnancy gestation at abortion of 1.93 days. This is equal to an increase of just over a day when distance increases from 281 to 381 miles, an increase that crosses the average distance to NYC for the 13 states most likely to rely on New York State for legal abortion pre-Roe. In Texas an increase of 100 miles to the nearest abortion provider was associated with an increase of 3.16 days in gestation (0.45 weeks) among abortions at 16 weeks of pregnancy or greater; however, this estimate was similar to the association with distance for abortions at 15 week or less, for which the WRTK Act should have no impact. These findings suggest that while distance may be associated with increased gestation at abortion, these increases are on the order of a few days. Although the increase in the distance to the nearest abortion provider caused by the WRTK Act had only a modest effect on the average gestation of abortions at ≥16 weeks, compared to the year 2000, the passage of the Act itself caused the average pregnancy gestation at abortion to increase by 1.5 weeks in 2005, 2.1 weeks in 2006, and 2.0 weeks in 2007. This increase in gestation represents a significant delay in abortion care. Although abortion is very safe, the risk of complications from abortion increases exponentially for each additional week of pregnancy, and the fee for abortion services increases on average 100 dollars per week of pregnancy in the second trimester. This research suggests that abortion laws that result in the reduction or elimination of abortion services can cause clinically significant delays in abortion care; this is of concern because later abortion carries higher risks of complications and imposes greater costs on women obtaining abortion services. Public health evidence for the potential impact of abortion laws is needed to inform the writing and debate of future abortion laws, and monitoring and evaluation of abortion laws should be done when they are enforced so possible harmful consequences can be avoided or addressed in real time. Future research should assess the timing of ≥16-week abortions in Texas after 2007 to understand the possible longer-term effects of the WRKT Act.)

Available for download on Monday, November 05, 2018

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