Abstract
Objective
In 2013, Texas passed legislation restricting abortion services. Almost half of the state’s clinics had closed by April 2014, and there was a 13% decline in abortions in the 6 months after the first portions of the law went into effect, compared to the same period 1 year prior. We aimed to describe women’s experiences seeking abortion care shortly after clinics closed and document pregnancy outcomes of women affected by these closures.
Study design
Between November 2013 and November 2014, we recruited women who sought abortion care at Texas clinics that were no longer providing services. Some participants had appointments scheduled at clinics that stopped offering care when the law went into effect; others called seeking care at clinics that had closed. Texas resident women seeking abortion in Albuquerque, New Mexico, were also recruited.
Results
We conducted 23 in-depth interviews and performed a thematic analysis. As a result of clinic closures, women experienced confusion about where to go for abortion services, and most reported increased cost and travel time to obtain care. Having to travel farther for care also compromised their privacy. Eight women were delayed more than 1 week, two did not receive care until they were more than 12 weeks pregnant and two did not obtain their desired abortion at all. Five women considered self-inducing the abortion, but none attempted this.
Conclusions
The clinic closures resulted in multiple barriers to care, leading to delayed abortion care for some and preventing others from having the abortion they wanted.
Implications
The restrictions on abortion facilities that resulted in the closure of clinics in Texas created significant burdens on women that prevented them from having desired abortions. These laws may also adversely affect public health by moving women who would have had abortions in the first trimester to having second-trimester procedures.
Keywords: Abortion, Policy evaluation, Abortion restrictions, Qualitative, Texas
1. Introduction
In 2013, Texas passed one of the most restrictive abortion laws in the US, House Bill 2 (HB2), that included four abortion restrictions: requiring physicians performing abortion to have admitting privileges at a nearby hospital, requiring the provision of medical abortion to follow the outdated labeling approved by the Food and Drug Administration, banning most abortions after 20 weeks “postfertilization” and requiring that all abortion facilities meet the standards of an ambulatory surgical center (ASC). The first three provisions of HB2 went into effect by November 1, 2013, resulting in the immediate closure of 11 of the 33 open abortion facilities1 [1]. The ASC requirement was enforced briefly in October 2014, resulting in more clinic closures, until the US Supreme Court issued a ruling that allowed clinics to reopen while the case continued through the appellate process2.
Understanding the impact of state-level restrictions on women in need of abortion services is critical to assess the range of consequences of such laws. While our previous research documented the effect of HB2 on abortion services statewide [1], little is known about women’s experiences with service disruptions in the wake of clinic closures across the state. In this study, we report on the results of qualitative interviews conducted with women who sought care in the periods shortly after the enforcement of HB2 at clinics that were no longer providing abortion services.
2. Methods
2.1. Participant recruitment
Between November 2013 and June 2014 and again in October–November 2014, we conducted semistructured, qualitative interviews with English- or Spanish-speaking women aged 18 years and over whose abortion appointments were canceled or who sought appointments at clinics that stopped providing abortion services due to enforcement of HB2. In addition, we interviewed Texas residents who traveled to Albuquerque, New Mexico, to obtain an abortion procedure. The Albuquerque clinics were the closest large-volume abortion facilities for some women living in West Texas, and some of these facilities provided abortion after 20 weeks gestation.
Women whose appointments were canceled or who called closed clinics up to 2 months after the closure were contacted by clinic staff at 9 facilities, who used a standard script to invite them to participate in the study. When the ASC requirement was briefly enforced, we only recruited participants for the time that clinics were closed.
Those interested in participating provided their name (or a pseudonym) and a phone number. If we did not reach a woman on the first phone call, we called back and left a voicemail when possible, up to four times before removing her from the pool of potential participants. Texas resident women traveling to clinics in Albuquerque were provided with study flyers, and those interested contacted the study coordinator.
2.2. Data collection and analysis
We adapted the interview guide from a previous study on abortion clients [2]. We developed further interview topics and the analytical approach with the objective of describing women’s experiences with abortion services after clinic closures using a health care access framework, focusing on several dimensions of access, including distance to services, timeliness of care, type of procedure and out-of-pocket costs [3]. We asked participants to recount their story of looking for abortion services, starting with the first call they made to a clinic. We also asked about their preferred type of abortion (medical or surgical), travel to the clinic and associated costs and whether and at what gestational age they ultimately obtained an abortion. After several interviews, the guide was revised to include a question on whether women had considered ways to induce an abortion on their own. Interviews were conducted by telephone and lasted 20–40 min. With participant consent, interviews were recorded and transcribed. Participants received a US$30 gift card for their time.
We coded transcripts using Atlas.ti 8.1 (Berlin, Germany) and conducted a thematic analysis [4]. First, we developed a priori codes based on the interview guide. During coding, we added codes to capture emerging domains, such as women’s recovery from the abortion and their desire for privacy. To increase intercoder reliability, two coders independently coded two interviews and then compared their application of codes. Discussion between coders provided consensus in cases of coding differences, to add or collapse codes and refine code definitions. The remaining transcripts were then coded independently. We summarized codes in analytic memos interpreting main themes, including cases that countered our initial interpretation of a theme. We present quotes that highlight the main themes. The study was approved by the institutional review board at the University of Texas at Austin.
3. Results
Six facilities provided contact information for 122 women (1–30 from each clinic). Of these, 23 completed interviews, 74 did not respond and 25 declined or were ineligible. We were unable to collect information about the number of women invited to the study by clinic staff, and we did not collect information about women who declined participation. Five participants had appointments that were canceled at clinics that ceased providing services after HB2 first went into effect, and twelve sought an abortion at clinics after they had closed. Three interviews were with women who sought appointments at clinics that closed after the ASC provision briefly went into effect, and three were with Texas residents recruited from clinics in Albuquerque. Participant characteristics are presented in the Table 1, and the main themes of the interviews are described below.
Table 1.
Participant characteristics
| N (%) | |
|---|---|
| Age (years) | |
| 18–25 | 15 (65) |
| > 25 | 8 (35) |
| Children | |
| 0 | 12 (52) |
| 1 | 3 (13) |
| 2 | 5 (22) |
| 3 | 3 (13) |
| Previous abortion | 6 (26) |
| Race/ethnicity | |
| Latina | 15 (65) |
| White | 4 (17) |
| Chinese | 1 (4) |
| Black | 1 (4) |
| Mixed race/ethnicity | 2 (9) |
| Cohabiting or married | 4 (17) |
| Employed | 12 (52) |
| Student | 10 (43) |
| Education | |
| Middle school | 1 (4) |
| Some high school | 2 (9) |
| Completed high school or general educational development | 7 (30) |
| Some college or technical school | 7 (30) |
| Completed bachelor’s, associate’s, technical school or higher | 6 (26) |
| Region of residence in Texas | |
| LRGV | 6 (26) |
| Central | 6 (26) |
| West | 4 (17) |
| East | 3 (13) |
| North | 2 (9) |
| Panhandle | 1 (4) |
| Othera | 1 (4) |
One woman lived in southeastern New Mexico and sought care at a closed clinic in El Paso, Texas.
3.1. Confusion about open clinics
After having appointments canceled or being turned away from closed clinics, more than half of women reported being confused about where they could go for abortion services and frustrated with the lack of clarity about which clinics remained open. Some expressed fear that they would not be able to obtain an abortion at all. Many women called several clinics in an effort to find a provider that they were able to travel to and afford. A 24-year-old woman from El Paso described her emotions when she found out that a clinic in that city was no longer providing abortion services:
“My heart dropped because I was like, ‘what am I going to do now,’ you know? I don’t know why I just…assumed that was the only clinic. You know, I didn’t know that there were a lot of clinics. So I was calling around and every call I made, ‘oh, we’re closed, we don’t do that anymore,’…and I started getting scared.”
Five women reported receiving incomplete information from closed clinics about where to go for abortion services, and sometimes, they were even referred to a more distant clinic when closer facilities were open. Women whose abortion appointments were canceled at the last minute were especially fearful. For example, a 22-year-old woman from Austin explained:
“Everything was pretty simple in the beginning. It was supposed to be on…a Thursday, but I got a call Wednesday night that said it was canceled; to not come in…it was pretty scary. They said that they would give me the number to the Dallas location that I could go to, but, I mean, Dallas is 4 h away, so I just knew it was going to be a little bit more difficult for me…is that clinic going to be booked up? Was I going to get in, in time? How was I going to pay to get there? How was I going to get there?”
3.2. Increased cost and travel time
Most women, especially those in West Texas and the Lower Rio Grande Valley (LRGV), spent more money and time than they would have before HB2 to obtain an abortion after their local clinics closed. For example, after the clinics closed in Harlingen and McAllen, four women in the LRGV had to drive nearly 4 h each way to San Antonio to obtain care, and they reported spending an average of US$75 on gas. Because appointments were generally scheduled early in the morning, four women tried to avoid the cost of a hotel by starting their journey around 3:00 a.m. and driving home directly after the procedure. Six women reported spending between US$60 and US$200 on hotel stays because the trip was too far to make in 1 day.
Women also described being uncomfortable, lonely and feeling sick while traveling far from home. One of these women, a 24-year-old from the LRGV, explained that her reason for staying overnight was to avoid dealing with cramping, bleeding and other side effects during the drive home:
“We didn’t know how long it was going to take, ’cause we can drive 4 h over there, do the procedure and then drive 4 h back, but we didn’t know how I was going feel…we didn’t want to be on the road and then I start — I keep bleeding… you know?…before you could just go to McAllen. It wasn’t so far away, and you could come back to your home and be comfortable…but having to go all the way there and not even feel comfortable, not even be where you’re naturally from and being in a hotel afterwards…that’s the only experience I didn’t like, the whole traveling and then having to stay somewhere we didn’t want to stay, but since we lived so far away that we didn’t have a choice.”
Women also reported that they needed to ask for more help than they would have if there had been a local provider, and in the process, they had to reveal their abortion decision to people they might not have told otherwise. Some discussed needing to borrow a vehicle or ask someone to drive them to their appointments, and others mentioned that they had to borrow money from friends to help pay for the abortion and travel costs. A few women compromised their desire for privacy in order to make arrangements to obtain an abortion. For example, an 18-year-old woman from the LRGV who lived with her parents explained that she did not want them to know about the abortion; however, it was difficult to be discreet while figuring out how to travel to San Antonio on her own. She ended up telling her parents about the abortion appointment:
“Well, [my father] wasn’t going to find out. Like I wanted to do this on my own ’cause it was my fault that this happened… and I didn’t want them to find out ’cause they’re not really with me on this. They’re kind of against abortion too but I told them that it happened…that’s when they told me that, ‘well, we’ll take you. Like what if something happens to you on the bus or something?’ So he’s decided to take me.”
3.3. Delayed and forgone abortion care
After being turned away from closed clinics or having appointments canceled, one woman was able to schedule another appointment the same day; however, women who had to arrange transportation or could not take time off of work on the day of the next available appointment were delayed even further. Eight women described having to wait more than an additional week before obtaining an abortion, two of whom had sought care early but were unable to obtain an abortion until after 12 weeks gestation.
One woman who was delayed was a 22-year-old woman from El Paso who looked online to find other options after being turned away from a closed clinic. She found an open abortion facility nearby that cost US$80 more than the closed clinic and another provider almost 4 h away in New Mexico, where she would have had to stay in a hotel. Faced with two costly options, she kept looking but ultimately decided to go to the closer provider because she was offered a job and could not take time off to travel to New Mexico. By the time she obtained an abortion — 3 weeks after she initially sought care — she was just over 12 weeks pregnant, and the price of the procedure had increased by more than US$200. To cover the added cost, she took out a loan.
Two women who wanted an abortion did not obtain one despite attempting to schedule an appointment. Insufficient information, time and money led these women to the decision to carry their pregnancies to term. Both women had initially strongly preferred medical abortion and recognized the pregnancy early enough to be eligible, but they could not locate a facility within their reach. One of them, a 23-year-old married woman from Waco with two children, made appointments at two different clinics, anticipating keeping the appointment that was most affordable, but both of them were canceled when the clinics closed due to HB2.
“I called Dallas, I called San Antonio. I think in Austin and here in Waco they weren’t doing nothing, and they said they didn’t have a surgeon or a doctor for that here. They used to have one. I don’t know what happened but they didn’t have one at the time. I also did look at ways that I could do it myself at home but it was like either you do it, you might hurt yourself or you might, you know, hurt the baby. I called back, and I think they told me that they weren’t doing [medical or surgical procedures], that the government had put a stop or something…I was pretty upset, but I just decided that I guess I’ll have to just ride it out. I didn’t know what else to do, who else to call.”
The other participant who decided to continue her pregnancy was a 24-year-old college student and divorced mother of two children in the LRGV. She was working part time, and her job did not provide paid sick leave or health insurance. When she found out that the nearest place to obtain an abortion was a 4-h drive from her home, she felt it was impossible for her to travel:
“I wanted to get the medication procedure but they said I couldn’t because it requires at least two visits to go back to the doctor and I wouldn’t be able to travel back to San Antonio… because I work and I wouldn’t be able to have so many days off to go…I just kind of, you know, forgot about having that done…like I really wanted to get it done, but it was real expensive and then I would have to travel a long time, for like, I think it’s like a 4-h drive or a 6-h drive.”
She expressed that she felt unable to manage the added costs of child care, more time off work, and traveling farther to obtain an abortion after her local clinic closed.
3.4. Women considered self-induction
When women were asked if they considered trying to end the pregnancy on their own without medical assistance, most said that they never thought about this. However, five women said they considered abortion self-induction. All five turned to the internet for information about self-induction methods, and two said that they also asked a family member.
In the end, all five women decided against self-induction because of safety concerns or fear that it would not be effective. An 18-year-old woman from the LRGV discovered she was pregnant after leaving college mid-semester to get away from an abusive boyfriend. Her local clinic had closed after HB2 enforcement, and she lived more than a 3-h drive from the nearest provider. She was unsure if she could cover the cost of the procedure and travel expenses, which led her to consider self-induction:
“Well me and my sister were talking about this…she was the only one that could be there for me. So I told her, ‘this is a lot of money and…is there any other way?’ She’s like, ‘Well, in Mexico they have this pill’ and then [we] researched that and they said that, something that — it harms the woman.”
4. Discussion
The experiences of women in our study help to explain the decline in the number of abortions and increase in the proportion of second-trimester abortions observed in Texas in the period after HB2 was enforced and add to the limited qualitative literature describing patient experiences with abortion restrictions [1,5,6]. In the period after clinics closed due to enforcement of HB2, women faced added informational, geographic and financial obstacles to abortion care.
These barriers were costly in multiple ways. Women endured confusion, fear and frustration and had to compromise their privacy in the process of obtaining an abortion after clinic closures. Some women traveled long distances or out of state to obtain care, but two women in this sample never obtained the abortion they wanted. A growing body of evidence indicates that women who are denied an abortion have worse health and social outcomes compared to those who obtain wanted abortions [7,8,9]. While our data cannot quantify how commonly women could not access desired abortion care in Texas during this period (or after), these stories put a human face on the decline in the number of abortions performed in Texas that we observed over the 6 months following the implementation of HB2 [1].
Prior research documented a small but significant increase in second-trimester abortion in Texas in the 6 months after HB2 went into effect [1]. Our results contextualize those findings. After experiencing an appointment cancelation or discovering a clinic closure, most women in our study were able to obtain an abortion within 1 week. However, several were delayed longer, and two experienced significant delays that resulted in obtaining abortions in the second trimester when their initial attempt to access care would have allowed for a first-trimester procedure. Although second-trimester abortion is very safe, it is associated with a higher risk of complications and death compared to first-trimester abortion [10]; later abortion is also more expensive [11].
None of the participants reported attempting to self-induce abortion, although some did consider it. Other research from Texas suggests that barriers to clinic-based care are an important reason why some women attempt to end a pregnancy on their own [12,13].
This study has several limitations. The response rate was low despite systematic efforts to contact women several times. We were also unable to include minors, since it would have been logistically difficult for the clinic staff to obtain parental consent for us to perform the interview. We know that there are important experiences, such as those of minors and non-English-speaking and undocumented immigrant women that are not included here. Additionally, for some themes, we did not reach saturation due to our limited recruitment period and low response rate; for example, we interviewed just four women who traveled out of state to obtain an abortion. In addition, it is possible that as time passed and people became aware of which clinics were open and closed, informational barriers to care diminished. However, other barriers such as travel distance to open clinics or wait times for abortion appointments remained or even worsened over time [14].
This is the first study to our knowledge to describe women’s experiences shortly after abortion clinic closures due to a restrictive abortion law. Previous research suggests that some restrictions do prevent women from obtaining abortions, especially when they force women to travel farther to obtain services [1,15,16,17]; however, none has documented the experiences of women unable to obtain their desired abortion. We collaborated with providers to implement a novel recruitment strategy and were able to conduct interviews with women from this difficult-to-study group.
Results from this study give insight into the ways that abortion restrictions affect women in the early phase of implementation through the sudden closure of a large number of clinics. If the ASC requirement of HB2 is enforced, which would further reduce the number of facilities providing abortion care in Texas to 10, the barriers described here would likely be compounded by limited capacity of the remaining clinics to absorb the demand for services [14], resulting in an even more disrupted service environment. Further research is needed to explore the longer-term effects of the reduction in abortion access in Texas, including studying whether these policies result in an increase in unwanted births, second-trimester procedures and abortion self-induction.
Acknowledgements
We thank Sarah Baum for her helpful comments on the analysis. This work was presented at the annual meeting of the American Public Health Association, New Orleans, LA, November 17, 2014.
Footnotes
Conflicts of interest: None.
Role of the funding source: This project was supported by a grant from the Susan Thompson Buffett Foundation and a center grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (5 R24 HD042849) awarded to the Population Research Center at the University of Texas at Austin. These funders played no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.
In April 2013, before the introduction of HB2, there were 41 facilities providing abortion care in Texas. During the period between May 1 and October 31, 2013, during which HB2 was debated and passed, 8 facilities closed. Several factors contributed to these closures, including clinic owners anticipating that HB2 would be too onerous to be able to comply with when enforcement began. When the admitting privileges provision of HB2 went into effect late on October 31, 2013, 11 clinics closed, leaving 22 open facilities. Between November 2013 and the end of September 2014, there were 10 closures of clinics at various time points when physicians lost admitting privileges, when physicians stopped working at certain facilities or due to other reasons. During that same period, 7 facilities were able to reopen when physicians obtained admitting privileges or physicians with admitting privileges began working at clinics. In addition, the clinic in McAllen reopened for a brief period in September 2014, after a district court enjoined enforcement of the ASC and admitting privileges requirements throughout the state. This left 19 open facilities by the end of September 2014.
When the ASC provision was enforced in October 2014, 9 facilities closed. When the US Supreme Court issued an order blocking this portion of the law later that month, 8 clinics were able to reopen, leaving 18 open facilities by November 2014.
References
- [1].Grossman D, Baum S, Fuentes L, White K, Hopkins K, Stevenson A, et al. Change in abortion services after implementation of a restrictive law in Texas. Contraception. 2014;90:496–501. doi: 10.1016/j.contraception.2014.07.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [2].Texas Policy Evaluation Project [Accessed December 20, 2015];Impact of Abortion Restrictions in Texas. Available at http://www.utexas.edu/cola/txpep/_files/pdf/TxPEP-ResearchBrief-ImpactofAbortionRestrictions.pdf.
- [3].Penchansky T, Thomas W. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981;19:127–40. doi: 10.1097/00005650-198102000-00001. [DOI] [PubMed] [Google Scholar]
- [4].Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods. 2006;5:80–92. [Google Scholar]
- [5].Kimport K, Preskill F, Cockrill K, Weitz TA. Women’s perspectives on ultrasound viewing in the abortion care context. Womens Health Issues. 2012;22:e513–7. doi: 10.1016/j.whi.2012.09.001. [DOI] [PubMed] [Google Scholar]
- [6].Kavanagh EK, Hasselbacher LA, Betham B, Tristan S, Gilliam ML. Abortion-seeking minors’ views on the Illinois parental notification law: a qualitative study. Perspect Sex Reprod Health. 2012;44:159–66. doi: 10.1363/4415912. [DOI] [PubMed] [Google Scholar]
- [7].Gerdts C, Dobkin L, Foster DG, Schwarz EB. Side effects, physical health consequences, and mortality associated with abortion and birth after an unwanted pregnancy. Womens Health Issues. 2015;26:55–9. doi: 10.1016/j.whi.2015.10.001. [DOI] [PubMed] [Google Scholar]
- [8].Upadhyay UD, Biggs MA, Foster DG. The effect of abortion on having and achieving aspirational one-year plans. BMC Womens Health. 2015;15:102. doi: 10.1186/s12905-015-0259-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [9].Roberts SC, Biggs MA, Chibber KS, Gould H, Rocca CH, Foster DG. Risk of violence from the man involved in the pregnancy after receiving or being denied an abortion. BMC Med. 2014;12:144. doi: 10.1186/s12916-014-0144-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [10].Zane S, Creanga AA, Berg CJ, Pazol K, Suchdev DB, Jamieson DJ, et al. Abortion-related mortality in the United States: 1998-2010. Obstet Gynecol. 2015;126:258–65. doi: 10.1097/AOG.0000000000000945. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [11].Jerman J, Jones RK. Secondary measures of access to abortion services in the United States, 2011 and 2012: gestational age limits, cost, and harassment. Womens Health Issues. 2014;24:e419–24. doi: 10.1016/j.whi.2014.05.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [12].Grossman D, Holt K, Peña M, Lara D, Veatch M, Córdova D, et al. Self-induction of abortion among women in the United States. Reprod Health Matters. 2010;18:136–46. doi: 10.1016/S0968-8080(10)36534-7. [DOI] [PubMed] [Google Scholar]
- [13].Texas Policy Evaluation Project [Accessed January 21, 2016];Texas women’s experiences attempting self-induced abortion in the face of dwindling options. Available at http://www.utexas.edu/cola/txpep/_files/pdf/TxPEP-Research-Brief-WomensExperiences.pdf.
- [14].Texas Policy Evaluation Project [Accessed January 21, 2016];Abortion Wait Times in Texas: The Shrinking Capacity of Facilities and the Potential Impact of Closing Non-ASC Clinics. Available at http://sites.utexas.edu/txpep/files/2016/01/Abortion_Wait_Time_Brief.pdf.
- [15].Colman S, Joyce T. Regulating abortion: impact on patients and providers in Texas. J Policy Anal Manage. 2011;4:775–97. [Google Scholar]
- [16].Dennis A, Henshaw SK, Joyce TJ, Finer LB, Blanchard K. The impact of laws requiring parental involvement for abortion: a literature review. Guttmacher; New York: 2009. [Google Scholar]
- [17].Joyce TJ, Henshaw SK, Dennis A, Finer LB, Blanchard K. The impact of state mandatory counseling and waiting period laws on abortion: a literature review. Guttmacher Institute; New York: 2009. [Google Scholar]