Ohio as a Window Into Recent US Trends on Abortion Access and Restrictions

Since the 1960s, abortion has been a political fault line in the United States. State legislatures have been most active in enacting the vast majority of abortion restrictions, with more than 1200 restrictions enacted since abortion was legalized in 1973. In this issue of AJPH, Norris et al. (p. 1228) provide further evidence of the negative effect of Ohio’s abortion restrictions. In Ohio, restrictions enacted in the past nine years—the state’s most active period of adopting restrictions since legalization—have amplified the effects of already existing abortion restrictions and further affected abortion access.

MAJOR THREATS TO ABORTION ACCESS

Despite its many abortion restrictions, Ohio is not an outlier. In fact, the state’s attacks on abortion mirror trends across the South, the Plains, and the Midwest. In this past decade (2011–2019), we have witnessed the nation’s longest sustained wave of abortion restrictions, with 38% of all abortion restrictions ever enacted adopted in the last nine years. Ohio is 1 of 29 states that the Guttmacher Institute categorizes as showing hostility to abortion.

Compounding the effects of restrictions is coronavirus disease 2019 (COVID-19). In spring 2020, Ohio is one of many states that attempted to use COVID-19 executive orders to close abortion clinics. A federal court permitted medication abortion but left access to procedural abortion drastically limited and little access to abortion after 11 weeks’ gestation. If Ohio’s abortion clinics closed, the average one-way driving distance to a clinic for an Ohio resident would increase from 15 to 120 miles¹ (or 700% longer).

Another potential threat to abortion access is the US Supreme Court, which recently became more conservative. In March 2020, the Court heard an abortion restriction case from Louisiana. A decision in that case is pending by June. With more cases on abortion restrictions and bans in the legal pipeline, decisions from the Court may open the door to further restrictions at the state level.

MEDICATION ABORTION

In September 2000, the US Food and Drug Administration approved mifepristone for abortion. Typically, mifepristone along with misoprostol make up a two-drug regimen used in medication abortion. By 2017, medication abortion accounted for nearly 40% of abortions in the United States.² Medication abortion is safe and effective³ and has transformed the way people access abortion. Removing state and federal barriers, such as limits on provision and telehealth,⁴ could greatly enhance access to medication abortion for those who face the most burdens in accessing care, including people with low incomes, people of color, and adolescents.

Ohio was one of two states that effectively banned medication abortion entirely, by requiring providers to use the outdated protocol listed in the drug’s label. That protocol had been superseded by another that requires less medication, has fewer side effects, has a longer time span for use (up to 70 days after a patient’s last menstrual period), and requires fewer visits to the provider. This ban lasted from 2011 to March 2016, when the US Food and Drug Administration amended the label to comport with this newer protocol.

Unable to continue banning medication abortion entirely, abortion opponents in Ohio are now attempting a more limited restriction: prohibiting telehealth for medication abortion, despite evidence that telehealth is also safe and effective for abortion. Before the pandemic, limits on telehealth for medication abortion were unconscionable and unnecessary. Continuing to pursue restrictions on telehealth for medication abortion during the COVID-19 pandemic—at a time when telehealth would allow for essential abortion care to be provided during social distancing and travel restrictions—shows policymakers’ willingness to put the health of patients and providers at risk in their eagerness to ban abortion.

CLINICS CLOSING

Between 2011 and 2017,⁵ Guttmacher research found that the number of abortion clinics in operation declined nationwide by less than 4% (from 839 to 808). However, this overall description misses the significant regional differences in the closing of abortion clinics. In the South, Midwest, and West, the number of clinics closed was 50, 33, and 7, respectively. Meanwhile, the Northeast added 59 abortion clinics during this period.

Ohio, specifically, had one of the most dramatic reductions in number of abortion clinics in the United States, with almost half of its abortion clinics closing because of new clinic regulations and stricter interpretation of existing regulations. As the article by Norris et al. shows, fluctuations in access resulting from overall closure of abortion clinics significantly increased barriers to timely abortion care. In short, these closures made it more difficult for patients to find care and likely forced patients to travel longer distances for services.

DECLINES IN ABORTION RATES

The abortion rate in Ohio remained lower than and declined at a somewhat faster pace than the national rate from 2011 to 2018. Clinic closures in Ohio were likely partially responsible for this decline, and those clinics that remained open were likely unable to meet the needs of patients seeking abortion services. Because Norris et al. use data for abortions provided in Ohio and not data for out-of-state abortions among Ohio residents, it is unclear how many Ohio residents traveled to other states for care and how many were unable to access services entirely.

However, factors beyond abortion restrictions also played a role in Ohio’s declining abortion rate. For example, access to contraceptives increased during this period. The Affordable Care Act required most private health plans to cover contraceptives without cost-sharing, and more people had private and public health coverage. In Ohio, the proportion of uninsured women of reproductive age (15–44 years) decreased from 14% to 8% between 2013 and 2018.⁶

Also, contraceptive method choice may account for some of the overall decline in abortions in Ohio. Specifically, the use of long-acting, reversible contraceptive methods increased, especially among women in their early 20s,⁷ a population that accounts for a significant proportion of all abortions. Finally, there has been a long-term decline in adolescent pregnancies and births. Other factors that may have affected abortion rates include changes in pregnancy desires and shifts in economic status.

THE FUTURE OF ACCESS IN OHIO

The work by Norris et al. provides insight into how abortion rights and access have been undermined in Ohio. Ohio’s existing restrictions already place unnecessary burden on those seeking abortion services. Specifically, patients are required to obtain in-person counseling at least 24 hours before the abortion; health plans provided through the Affordable Care Act marketplace, the state employee health plan, and Medicaid do not cover abortion; and clinic regulations limit where abortion can be provided, in addition to other medically unnecessary requirements. Cost is another barrier: a typical abortion costs about $500, and if a patient must travel for care, costs can increase by hundreds of dollars.

Yet policymakers in Ohio and in states across the United States continue to adopt more restrictions in an effort to significantly curtail, if not completely eliminate, access to legal abortion services. In 2019, Ohio, along with five other states, enacted bans on abortion early in pregnancy. To date, court orders have prevented these bans from taking effect. However, if the Supreme Court undermines abortion rights either this year or in the future, states—such as Ohio—where abortion opponents are in control of legislatures and governors’ offices may be able to adopt new abortion restrictions and bans that could ultimately eliminate access to abortion services for many people entirely.

Abortion opponents in state houses across most of the United States have for far too long been able to enact restrictions on abortion, making abortion difficult to provide and to obtain. The public health community must not only push back against additional restrictions in Ohio and across the United States but also stand up to ensure that new laws are enacted that protect abortion rights and improve access to services.