Texas House Bill 2, enacted in 2013, was one of the most restrictive abortion laws in the country before the US Supreme Court ruled in June 2016 that 2 provisions were unconstitutional.
Following introduction and passage of the bill, the number of Texas facilities providing abortions declined,1 from 41 in 2012 to 17 in June 2016. Women whose nearest clinic closed traveled farther to access abortion services than those whose nearest clinic remained open.2 Overall, abortions declined 14% in Texas between 2013 and 2014.3
We hypothesized that the decline in abortions would be greater as the change in distance to the nearest open facility increased.
Methods
This study was approved by the institutional review board of the University of Texas at Austin. Since 2012, we have tracked the number and location of facilities providing abortions in Texas.1 Information on the location of abortion-providing facilities in Arkansas, Louisiana, New Mexico, and Oklahoma was also obtained. County-level data on abortions received by Texas residents both in and out of state in 2012 and 2014 were obtained from the website of the Department of State Health Services.3 The distance from the centroid of each Texas county to the nearest open facility providing abortions in 2012 and 2014 was calculated using the geodist module in Stata (StataCorp), version 13. Any facility open for at least 6 months in a year was considered open.
Counties were categorized according to whether they had a facility providing abortions in 2014. Those that did not were grouped into 5 categories based on change in distance to the nearest facility, ranging from 0 to 100 miles or greater. For each category, the percentage of change in the number of abortions occurring in 2012 and 2014 to residents of those counties was calculated along with 95% CIs4; P value for trend was assessed using linear regression in Stata. Two-sided P values less than .05 were considered significant. Counties with an open facility in 2014 were not included because distance to the nearest facility was not a comparable determinant of access.
Results
In 2012, 66 098 abortions were performed among Texas residents (97 out of state). In 2014, 53 882 abortions were performed among Texas residents (754 out of state). Of 254 counties, there were 41 facilities in 17 counties in 2012 and there were 21 facilities in 6 counties in 2014.
Counties in West and South Texas had the greatest change in distance to a facility (Figure). The mean distance change was 51 miles (SD, 68) and the median change was 13 miles (interquartile range, 0–85). Counties that had an open facility in 2014 (all in large metropolitan areas) had minimal distance changes (0–5 miles) and a 15.9% (95% CI, 14.8%-17.0%) decline in abortions (Table).
Figure.
Change in Travel Distance From a Texas County to the Nearest US Facility Offering Abortion, 2012 to 2014
Table.
Change in Number of Abortions to Residents of Texas Counties by Change in Distance to Nearest US Facility Providing Abortion, 2012 to 2014
| No. of Counties | No. of Abortions by Year | Decrease in No. of Abortions, % (95% CI)c | ||
|---|---|---|---|---|
| 2012a | 2014b | |||
| County had ≥1 open facility in 2014 | 6 | 43 304 | 36421 | 15.9 (14.8 to 17.0) |
| Change in distance to nearest facility between 2012 and 2014 in counties with no facility in 2014, mile | ||||
| 0 | 79 | 8627 | 8516 | 1.3 (−1.5 to 4.0) |
| 1–24 | 55 | 3987 | 3479 | 12.7 (9.0 to 16.4) |
| 25–49 | 25 | 1671 | 1249 | 25.3 (20.1 to 30.4) |
| 50–99 | 33 | 2538 | 1633 | 35.7 (31.9 to 39.4) |
| ≥100 | 56 | 4589 | 2279 | 50.3 (48.0 to 52.7) |
| Totald | 254 | 64 716 | 53 577 | 17.2 (16.3 to 18.1) |
Column does not include 1382 abortion cases with missing information on Texas county of residence.
Column does not include 305 abortion cases with missing information on Texas county of residence.
P value for trend for percentage of decrease in number of abortions among counties with no open facility in 2014 was less than .001. The 95% CIs were estimated using the delta method assuming a binomial distribution, a constant proportion of pregnancies ending in induced abortion across groups, and no change in the number of pregnancies between 2012 and 2014.
Indicates total No. of counties in Texas and total No. of abortions for 2012 and 2014.
Among counties without an open facility in 2014, the decline in abortions increased as the distance change to the nearest facility increased (P < .001 for trend). Counties with no facility in 2014 but no change in distance to a facility between 2012 and 2014 had a 1.3% (95% CI, −1.5% to 4.0%) decline in abortions. When the change in distance was 100 miles or more, the number of abortions decreased 50.3% (95% CI, 48.0% to 52.7%).
Discussion
In Texas counties without a facility in 2014, an increase in distance to the nearest facility was associated with a decline in abortions between 2012 and 2014. However, abortions also declined among women in counties with an open facility in 2014, indicating that there were other factors related to the decrease, such as limited capacity to meet demand for services.5 In counties with no facility and no change in distance, the decline in abortion was minimal. Many of these counties were in East Texas where family planning services were disrupted,6 likely leading to increased demand for abortion that offset the increased capacity barriers women faced.
Limitations include that official statistics may underestimate out-of-state abortions and not capture abortions among women who self-induced or traveled to Mexico for care. Distance to the nearest facility may not reflect actual distance traveled for women seeking second-trimester or medication abortion, which are not available at every facility.
Acknowledgments
Funding/Support: This research was supported by a grant from the Susan Thompson Buffett Foundation, as well as center grant 5 R24 HD042849 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development awarded to the Population Research Center at the University of Texas at Austin.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.
Footnotes
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Drs Grossman and Hopkins were expert witnesses for the plaintiffs in Whole Woman’s Health v Hellerstedt during the federal district court trial. Dr Grossman was not compensated for his testimony; Dr Hopkins was compensated. No other disclosures are reported.
Contributor Information
Daniel Grossman, Advancing New Standards in Reproductive Health, University of California-San Francisco, San Francisco.
Kari White, School of Public Health, University of Alabama at Birmingham, Birmingham.
Kristine Hopkins, Population Research Center, University of Texas at Austin, Austin.
Joseph E. Potter, Population Research Center, University of Texas at Austin, Austin.
References
- 1.Grossman D, Baum S, Fuentes L, et al. Change in abortion services after implementation of a restrictive law in Texas. Contraception. 2014;90(5):496–501. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Gerdts C, Fuentes L, Grossman D, et al. The impact of clinic closures on women obtaining abortion services after implementation of a restrictive law in Texas. Am J Public Health. 2016;106(5):857–864. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Texas Department of State Health Services. Induced terminations of pregnancy by age and county of residence Texas, 2014. http://www.dshs.texas.gov/chs/vstat/vs14/t34.aspx. Accessed July 7, 2016.
- 4.Brillinger DR. The natural variability of vital rates and associated statistics. Biometrics. 1986;42(4):693–734. [PubMed] [Google Scholar]
- 5.University of Texas. Abortion wait times in Texas: the shrinking capacity of facilities and the potential impact of closing non-ASC clinics. https://utexas.app.box.com/AbortionWaitTimeBrief. Accessed November 29, 2015.
- 6.White K, Hopkins K, Aiken ARA, et al. The impact of reproductive health legislation on family planning clinic services in Texas. Am J Public Health. 2015; 105(5):851–858. [DOI] [PMC free article] [PubMed] [Google Scholar]