Women's Experience Obtaining Abortion Care in Texas after Implementation of Restrictive Abortion

14 Pages·2016·0.52 MB·English

RESEARCHARTICLE
Women’s Experience Obtaining Abortion
Care in Texas after Implementation of
Restrictive Abortion Laws: A Qualitative
Study
SarahE.Baum1,2*,KariWhite1,3,KristineHopkins1,4,JosephE.Potter1,4,
DanielGrossman1,5
1 TexasPolicyEvaluationProject,Austin,Texas,UnitedStatesofAmerica,2 IbisReproductiveHealth,
a11111
Oakland,California,UnitedStatesofAmerica,3 DepartmentofHealthCareOrganizationandPolicy,
SchoolofPublicHealth,UniversityofAlabamaatBirmingham,Birmingham,Alabama,UnitedStatesof
America,4 PopulationResearchCenter,UniversityofTexasatAustin,Austin,Texas,UnitedStatesof
America,5 AdvancingNewStandardsinReproductiveHealth(ANSIRH),BixbyCenterforGlobal
ReproductiveHealth,DepartmentofObstetrics,GynecologyandReproductiveSciences,Universityof
CaliforniaSanFrancisco,Oakland,California,UnitedStatesofAmerica
*[email protected]
OPENACCESS
Citation:BaumSE,WhiteK,HopkinsK,PotterJE,
Abstract
GrossmanD(2016)Women’sExperience
ObtainingAbortionCareinTexasafter
ImplementationofRestrictiveAbortionLaws:A
QualitativeStudy.PLoSONE11(10):e0165048.
Background
doi:10.1371/journal.pone.0165048
InNovember2013,TexasimplementedthreeabortionrestrictionsincludedinHouseBill2
Editor:SharonCameron,NHSlothianand
UniversityofEdinburgh,UNITEDKINGDOM (HB2).Withinsixmonths,thenumberoffacilitiesprovidingabortiondecreasedbyalmost
half,andtheremainingfacilitieswereconcentratedinlargeurbancenters.Thenumberof
Received:April22,2016
medicationabortionsdecreasedby70%comparedtothesameperiodoneyearpriordue
Accepted:October5,2016
torestrictionsonthismethodimposedbyHB2.Thepurposeofthisstudywastoexplore
Published:October26,2016 qualitativelytheexperiencesofwomenwhoweremostaffectedbythelaw:thosewhohad
Copyright:©2016Baumetal.Thisisanopen totravelfarthertoreachafacilityandthosedesiringmedicationabortion.
accessarticledistributedunderthetermsofthe
CreativeCommonsAttributionLicense,which
Methods
permitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginal InAugustandSeptember2014,weconducted20in-depthinterviewswithwomenrecruited
authorandsourcearecredited.
fromtenabortionclinicsacrossTexas.Thepurposivesampleincludedwomenwho
DataAvailabilityStatement:Shortqualitative obtainedorstronglypreferredmedicationabortionortraveled(cid:21)50milesonewaytothe
interviewexcerptsareavailablewithinthetext.Our
clinic.Theinterviewguidefocusedonwomen’sexperienceswithobtainingservicesfollow-
researchinstrumentsandcodebookavailableupon
request.PLOSONE’sdatapolicyexceptionpertains ingimplementationofHB2,andathematicanalysiswasperformed.
todatafromourstudy.Participantsinourin-depth
interviewssignedinformedconsentstoparticipate
Results
inthestudywhichstatedthatidentifying
informationwouldremainconfidential,andtheydid Womenfacedinformational,costandlogisticalbarriersseekingabortionservices,and
notprovideconsenttohavetheirfulltranscripts
theseobstacleswereoftencompoundedbypoverty.Twowomenfoundtheprocessoffind-
madepubliclyavailable.Publishingtheinterview
ingorgettingtoaclinicsoonerousthattheyconsiderednothavingtheprocedure,although
transcriptsbeyondtheillustrativeexcerptsincluded
inthemanuscriptwouldviolateourcommitmentto theyultimatelyhadanabortion;anotherwomandecidedtocontinueherpregnancy,inpart
PLOSONE|DOI:10.1371/journal.pone.0165048 October26,2016 1/14
Women’sExperiencewithAbortioninTexasafterRestrictiveLaw
thesubjects’confidentialityandobligationstoour becauseofchallengesingettingtotheclinic.Fortwowomen,arrangingtravelrequireddis-
ethicsreviewboard. closuretomorepeoplethandesired.Womenwhostronglypreferredmedicationabortion
Funding:Thisresearchwassupportedbyagrant werefrustratedbythedifficultyorinabilitytoobtaintheirdesiredmethod,especiallyamong
fromtheSusanThompsonBuffettFoundation thosewhowerenearorjustbeyondthegestationalagelimit.Therestrictedeligibilitycriteria
awardedtoJosephE.Potter,aswellasacenter
formedicationabortionanddifficultyfindingclinicsofferingthemethodcreatedsubstantial
grantfromtheEuniceKennedyShriverNational
InstituteofChildHealthandHumanDevelopment accessbarriers.
(5R24HD042849)awardedtothePopulation
ResearchCenterattheUniversityofTexasat
Conclusions
Austin.Thefundershadnoroleinstudydesign,
datacollectionandanalysis,decisiontopublish,or
MedicationabortionrestrictionsandclinicclosuresfollowingHB2createdsubstantialbarri-
preparationofthemanuscript.
ersforwomenseekingabortioninTexas.
CompetingInterests:Dr.DanielGrossmanandDr.
KristineHopkinsservedasexpertwitnessesinthe
caseWholeWoman’sHealthv.Hellerstedt.Dr.
Grossmanwasnotcompensatedforhistestimony;
Dr.Hopkinswascompensated.LeadauthorSarah Introduction
BaumisaffiliatedwithIbisReproductiveHealth
whichis“aninternationalnonprofitorganization Approximately56millionabortionsoccurworldwideannually,correspondingtoarateof35
withamissiontoimprovewomen’sreproductive abortionsper1000womenaged15–44years[1].Althoughabortioniscommon,manycoun-
autonomy,choices,andhealthworldwide”.All
triesimposelegalrestrictionsontheprocedure.Forexample,inabout58countries,abortionis
authorsareaffiliatedwiththeTexasPolicy
completelyillegalorallowedonlytosavethepregnantwoman’s life[1].IntheUnitedStates,
EvaluationProject(TxPEP),whosepurposeisto
despitelegalizationofabortionin1972,policyrestrictionsatthestatelevelhaveimposedbarri-
documentandevaluatetheimpactofreproductive
healthlegislationpassedbytheTexasLegislature. erstowomen’s accesstocare,includinglawsthatrestricthowabortionisprovided,knownas
BothIbisReproductiveHealthandTxPEPconduct TargetedRegulationsofAbortionProviders(TRAP)laws.Inrecentyears,thenumberof
rigorousresearchtoassesstheimpactof TRAPlawshasincreasedsubstantiallyintheUS[2].ExamplesofTRAPlawsincluderegula-
reproductivehealthpolicies.Thisdoesnotalterour
tionsonthetypeoffacilitythatcanprovideabortioncareorrequirementsthatprovidershave
adherencetoPLOSONEpoliciesonsharingdata
arelationshipwithanearbyhospital,includingadmittingprivileges.
andmaterials.
InJuly2013,theTexas legislaturepassedHouseBill2(HB2),oneoftheUnitedStates’most
restrictiveTRAPlaws.ByNovember1,2013,threecomponentsofthelawhadbeenimple-
mented:physicianswererequiredtohaveadmittingprivilegesatahospitalwithin30milesofthe
facilityprovidingabortion;administrationofmedicationabortionwasrestrictedtotheprotocol
describedinthemifepristonelabelapprovedbytheUSFoodandDrugAdministration(FDA)in
2000,withsomeallowancesformedicationdosages;andabortionsafter20weeks“postfertiliza-
tion”wereprohibitedinmostcases.ThefourthcomponentofHB2,whichrequiredallabortion
facilitiestomeetthestandardsofambulatorysurgicalcenters(ASCs),wentintoeffectbrieflyin
October2014beforetheUSSupremeCourtissuedastaytemporarilyblockingenforcementof
thisportionofthelaw.InJune2016,theSupremeCourtruledthattheadmittingprivilegesand
ASCrequirementsofHB2wereunconstitutionalbecausetheyplacedanundueburdenonwom-
en’s accesstoabortionwithoutofferinganyhealthorsafetybenefit[3].
BetweenAprilandNovember2013,whenthefirstthreeprovisionsofHB2hadbeen
enforced,thenumberofabortionfacilitiesprovidingcareinTexas fellfrom41to22[4].Clinic
closuresresultedinanincreasednumberofTexas womenofreproductiveagelivingfarther
fromanopenfacility,meaningthatmorewomenhadtotravellongerdistancesinorderto
obtainabortioncare.InApril2014,1,680,000Texas womenaged15–44(31%ofallTexas
womenofreproductiveage)livedmorethan50milesfromanopenfacility,comparedto
816,000women(15%)oneyearprior[4].Incomparison,anationallyrepresentativestudycon-
ductedin2008foundthat17%ofabortionpatientstraveledover50mileseachwaytothefacil-
ity[5].
Inadditiontoclinicclosures,thereweresubstantialshiftsintheuseofmedicationabortion
afterHB2.Medicationabortion,aprocedurewhichinvolvestheuseoftwomedications
PLOSONE|DOI:10.1371/journal.pone.0165048 October26,2016 2/14
Women’sExperiencewithAbortioninTexasafterRestrictiveLaw
(mifepristoneandmisoprostol)isgenerallyperformedintheUSuptonineortenweeks’gesta-
tion[6],althoughthemedicationsaresafeandeffectivelateringestationaswell[7,8].
Nationaldataindicatetherehasbeenasteadyincreaseintheproportionofnon-hospitalabor-
tionsperformedwithmedication,from17%in2008to23%in2011,representingapproxi-
mately36%ofallabortionsuptonineweeks’gestation[9].Inthesixmonthsfollowing
implementationofHB2,a70%declineinthenumberofmedicationabortionsinTexas was
observed,ascomparedtothesameperiodoneyearprior[4].Asteepdropintheproportionof
abortionsperformedwithmedicationwasalsoobservedinOhioafterasimilarlawwasimple-
mented[10].
TheobserveddeclineintheproportionofmedicationabortionsinTexas maybeattributed
tothreepartsofthenewregulations.First,becauseHB2restrictedprovisionofmedication
abortiontopregnanciesatorbelowsevenweeks’gestation,fewerwomenwereeligibleforthe
method.Second,HB2imposedlimitationsonthedoseofmifepristoneandthemedication
regimen.Eitherprovidershadtouseahigherdoseofmifepristonethanthatrecommendedby
currentevidence(600mgvs.200mg),whichincreasedthecostoftheservice,ortheyhadto
usearegimen(mifepristone200mgfollowedby800mcgofmisoprostoladministeredorally),
thathasnotbeenwellstudied[6,11].Third,duetobothHB2andpreviouslyenforcedabor-
tionrestrictionsinTexas,mostwomenwhoobtainedmedicationabortionwererequiredto
makefourvisitstothefacility:1)astate-mandatedpre-abortioncounselingandultrasound
visitatleast24hoursbeforetheprocedureifshelivedlessthan100milesfromthenearest
clinic,2)avisittotakethemifepristoneobservedbytheprovider,3)avisittotakethemiso-
prostolobservedbytheprovider,and4)avisittoconfirmabortioncompletion.Giventhechal-
lengestoprovision,somefacilitiesstoppedofferingmedicationabortionaltogetherafterHB2
wentintoeffect.Themorelimitedavailabilityofthemethodatclinics,compoundedbyclinic
closures,theprospectoffourvisits,andhighercostsfortheproceduremadeitharderfor
womenseekingmedicationabortiontoobtainone[12,13].Ofnote,inMarch2016,theFDA
updatedthemifepristonelabeltoallowforuseupto10weeks’gestationusingareduceddosage
ofthemedicationandhomeadministrationofmisoprostol[14],whichhasallowedTexas pro-
viderstoonceagainusethisevidence-basedprotocol.
Texas providesagoodsettingwithinwhichtoassesstheimpactofmultipleclinic-based
restrictionsimposedsimultaneously.TwopriorstudiesfocusedonTexas suggestthatTRAP
lawscanresultinasignificantdeclineintherateofabortionsperformedafterimplementation
[4,15].TRAPlawsmayimposegreaterobstaclestowomen’s accesstoabortioncarecompared
topatient-focusedrestrictionssuchasmandatedcounselingandultrasoundrequirements[9,
16].Theselawsthreatenwomen’s accesstosafelegalabortion;however,thereislimited
researchaddressingtheexperiencesofwomenfollowingtheimplementationofTRAPlaws.
Giventhenumerousclinicclosures,thereducedgeographicdistributionofprovidersandsig-
nificantdecreaseinmedicationabortionintheyearfollowingimplementationofHB2,this
qualitativestudyaimedtodocumenttheexperiencesofseekingandobtainingabortioncare
amongwomenwhoweremostlikelytobeaffectedbythelaw:thosewhohadtotravelfarther
toreachafacilityandthosewhodesiredmedicationabortion.
MaterialsandMethods
Sample&recruitment
We conductedsemi-structuredin-depthinterviewswithwomeninTexas abouttheirexperi-
encesseekingandobtainingabortionservicesafterthefirstthreeprovisionsofHB2wentinto
effect.Women wererecruitedfortheinterviewsfromamong439participantsinacross-sec-
tionalsurveyinTexas thataimedtoassessbarriersaccessingcareinthenewregulatory
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Women’sExperiencewithAbortioninTexasafterRestrictiveLaw
environment[13].SurveyparticipantswererecruitedbetweenMayandAugust2014atten
abortionclinicsinAustin,Dallas,FortWorth,Houston,andSanAntonio;theycompletedan
electronicsurveyonaniPadinclinicwaitingrooms.Eligibilitycriteriaforthesurveyincluded
abilitytospeakEnglishorSpanish,being18yearsofageorolder,andhavingcompletedthe
initialvisitwithultrasoundandcounseling[13].
Immediatelyfollowingcompletionofthesurvey,thestudycoordinatorinvitedallpartici-
pantstocompleteafollow-uptelephoneinterview.Ifinterested,participantsprovidedcontact
informationonanelectronicform.Women werethenpurposivelysampledbasedononeor
moreofthefollowingreportedcharacteristics:obtainedamedicationabortion,reportedthat
they“stronglywanted”orwere“leaningtoward”amedicationabortionpriortoobtainingcare,
ortraveled50milesormoreonewaytotheclinic.We sampledbasedonthesecharacteristics
inordertoconductinterviewswithwomenwhoweremostaffectedbyHB2,includingthose
whowereseekingorobtainedmedicationabortionandthosewhotraveledfartherthanthe
meandistance(46milesoneway)reportedinthesurvey[13].
Datacollection
Thesemi-structuredin-depthinterviewguideincludedopen-endedquestionsaboutwomen’s
experiencewithandopinionsabouttheprocessofobtainingabortionservicesfollowingimple-
mentationofHB2.We developedtheinterviewguidebasedonapreviousstudywithabortion
clientsinTexas [17],aswellasonthemesthatemergedfromopen-endedquestionsinthesur-
veyfromwhichthecurrentsamplewasdrawn,suchaswhyitwasdifficulttogettotheclinic
orwhywomenpreferredtheirdesiredabortionmethod.Interviewtopicsincluded:experience
findingaclinicandschedulinganappointment;logisticalfactorsconsideredingettingtothe
clinic(s);travelexperience,includingmultiplevisitsformedicationabortion;preferencesfor
anddecisionmakingaroundabortionmethod;abortionexperience;andopiniononTexas
abortionlaws.Interviewerscollectedparticipantdemographicinformationattheendofthe
interview.Copiesoftheresearchinstrumentareavailableuponrequest.
Therewere161womenwhoprovidedcontactinformationtoparticipateinanin-depth
interviewaftercompletingthesurvey,and50ofthosewomenmetourinclusioncriteria.
Women werere-contactedonetotwomonthsaftersurveycompletion.Afterreachingoutto
alleligiblewomenbytelephoneamaximumofthreetimes,wecompleted20interviews.Inter-
viewswereconductedbytwointerviewerswithtraininginqualitativemethodsandexperience
conductingresearchonaccesstoabortioncareinUSandglobalsettings.Immediatelybefore
theinterview,theinterviewerdiscussedtheaimsofthestudywithparticipants,reviewedthe
informedconsentandansweredparticipants’questions.Womenprovidedverbalconsentin
ordertoreducetheriskoflossofconfidentialityandbecausetheinterviewswereconductedby
telephone;theirconsentwasdocumentedbytheinterviewers.Participantsalsoprovidedper-
missiontodigitallyrecordtheinterview,whichwasidentifiedonlybystudyID.Interviews
werecompletedbytelephoneinEnglishandlastedbetween20–50minutes.Womenreceiveda
$30giftcardbymailfortheirparticipation.ThestudywasapprovedbytheInstitutional
ReviewBoardattheUniversityofTexas atAustin.
Dataanalysis
QualitativeinterviewsweretranscribedandcodedusingAtlas.ti6.2(Atlas.tiGmbH,Berlin,
Germany).Theresearchteamdevelopedacodebookusingaprioricodes,aswellascodesthat
emergednaturallyfromtheinterviews.Thecodebookandsubsequentanalysiswereguidedby
anaccesstocareframeworkthathighlightsfacilitatorsandbarrierstocarebasedontheinter-
actionbetweenhealthservice-deliveryfactors,suchasavailabilityandaffordabilityofservices,
PLOSONE|DOI:10.1371/journal.pone.0165048 October26,2016 4/14
Women’sExperiencewithAbortioninTexasafterRestrictiveLaw
anduserfactors,suchasdemandforcare,utilizationandacceptability[18,19].Twoqualitative
researcherscodedtwotranscriptsseparatelywiththeinitialcodebookandmettodiscussdis-
crepanciesandrevisethelistofcodes.Next,threeresearcherseachcodedonethirdofthetran-
scripts,wroteanalyticmemostodocumentobservations,andparticipatedinintermittent
meetingstodiscussemergentthemes,addorcollapsecodesandreachconsensusoncoding
disagreements.Theresearchteamconductedathematicanalysistoassesspatternsofexperi-
encesandopinionsacrossthemesandreachedagreementofinterpretation.Illustrativequotes
wereselectedforsalientthemesandarepresentedwithparticipantsidentifiedbyparticipant
number,age,abortionmethodobtained,recruitmentcity,andmilestraveledonewaytothe
clinic.
Results
Participantcharacteristics
Interviewparticipantsrangedfromtheagesof19–34years.EightwomenidentifiedasWhite,
fiveasAfricanAmerican,fiveasHispanic,oneasAsianAmerican,andoneasmorethanone
race.Atthetimeoftheinterview,12womenweresingle,threewerelivingwithpartnersbut
unmarried,andfiveweremarried.Thehighesteducationleveltheycompletedrangedfrom
incompletehighschooltosomecollegeortechnicalschool;twelvewomenwerecurrentlyin
school.Ten womenhadchildren,sixwomenreportedapreviousabortion(Table 1).
Eighteenwomenwereinthefirsttrimesterofpregnancy(range5–10weeks’gestation)at
thetimeoftheirultrasound,twelveofwhomwere(cid:20)7weeksandfivebetween8and10weeks.
Twowomenwereseekingabortioninthesecondtrimester(14and16weeks’gestation).Four
womenobtainedmedicationabortion,15obtainedsurgicalabortion,andonewomandecided
tocontinueherpregnancy.Elevenofthe15whoobtainedasurgicalabortionreportedthey
stronglypreferredamedicationabortionpriortoobtainingservices.Ten womentraveled50
milesormoreonewaytotheclinic,withanaverageof117milesandarangeof50–300miles
(Table 1).
Below,wediscussthemainthemesthatemergedinwomen’s narrativesabouttheimplica-
tionsoftravelduetoclinicclosuresandexperiencesseekingmedicationabortioninarestricted
environment.We alsoexplorewomen’s perceptionoftheTexas abortionlaw.
Implicationsoftravelduetoclinicclosures
Difficultyfindingandgettingtoanopenclinic. Women foundopenfacilitiesthat
offeredabortionservicesthroughtheinternet,telephonehotlines,wordofmouth,doctorrefer-
rals,andpreviousexperiencewithfamilyplanningandabortionservices.Whileafewwomen
wholivedinmetropolitanareasreportedthatschedulingandgettingtotheirappointments
wasrelativelyeasy,themajorityofwomeninthisstudyhadtomakemultiplecallsbecausethe
clinicstheyinitiallycontactedwereclosedornolongerofferingabortionservices.Onewoman
spokeofhereffortstoscheduleanappointmentbeforebeingreferredtoafacilitymorethan
100milesfromherhome:
Ihadgotten[thenumberfortheclinic]fromtheInternetandIkeptcallingandcallingand
nevergotananswer.SoIcalled[anotherclinic],andthey’retheonesthattoldmethatwe
nolongerhave[aclinic]inourtown.Andthen[they]gavemethenumberfortheclosest
one,whichwasinSanAntonio.(34yearsold,surgicalabortioninSanAntonio,traveled
123miles)
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Women’sExperiencewithAbortioninTexasafterRestrictiveLaw
Table1. Participantcharacteristics.
Participant Recruitment Age Race/ Highestlevel Relationship Previous Gestational Pregnancy Abortion Distance
City (years) Ethnicity ofeducation Status abortion ageat outcome Method traveled
completed ultrasound (mi)*
(weeks)
1 Dallas/Ft 26–29 Latina Completed Relationship; No (cid:20)7 Abortion Medical 30
Worth highschool livingtogether
2 SanAntonio 18–21 African Somecollege Single No (cid:20)7 Abortion Medical 70
American
3 SanAntonio 30–34 White Completed Married No (cid:20)7 Abortion Medical 200
college
4 SanAntonio 22–25 Indian -** - - (cid:20)7 Abortion Medical 15
and
Latina
5 SanAntonio 30–34 White Somehigh - Yes 8–9 Continued N/A 85
school Pregnancy
6 Austin 26–29 White Somecollege Single Yes 8–9 Abortion Surgical 3
7 Dallas/Ft 22–25 African Somecollege Relationship; - (cid:20)7 Abortion Surgical 50
Worth American livingtogether
8 Dallas/Ft 18–21 African Somecollege Single No 8–9 Abortion Surgical 16
Worth American
9 Dallas/Ft 22–25 White Somecollege Single Yes (cid:20)7 Abortion Surgical 20
Worth
10 Houston 22–25 Latina Somecollege Married No 8–9 Abortion Surgical 15
11 Houston 30–34 Asian Completed Married Yes (cid:20)7 Abortion Surgical 10
American college
12 SanAntonio 22–25 Latina Completed Single No 10–12 Abortion Surgical 180
highschool
13 SanAntonio 18–21 Latina Completed Single No 8–9 Abortion Surgical 300
highschool
14 SanAntonio 30–34 White Completed Single No (cid:20)7 Abortion Surgical 123
highschool
15 Austin 18–21 African Somecollege Single No >12 Abortion Surgical 62
American
16 Austin 26–29 Latina Completed Married Yes (cid:20)7 Abortion Surgical 15
highschool
17 Austin 22–25 White Somecollege Single Yes >12 Abortion Surgical 50
18 Austin 18–21 White Somecollege Single No (cid:20)7 Abortion Surgical 21
19 Austin 18–21 African Somecollege Single - (cid:20)7 Abortion Surgical 48
American
20 Austin 30–34 White Completed Married No (cid:20)7 Abortion Surgical 50
highschool
*Milestraveledoneway
**Missingdataarerepresentedby“-“
doi:10.1371/journal.pone.0165048.t001
Women describedthestressofhavingtogettounfamiliarcitiesandcoordinatetransporta-
tion.Twowomenwhoultimatelyobtainedanabortioninitiallyfoundtheprocessoffindingor
gettingtoaclinicsoonerousthattheyconsiderednothavingtheprocedure.Oneofthese
womensaidtheprocessoffindingaclinicmadeherhesitateabouthavingtheabortionatall:
Itwasaveryhardthingtodo,liketokeepcallingandcallingandcalling.Ialmostwaslike
youknow,wellforgetit.[...]ButthenbecauseIknewattheendofthedayitwassomething
thatIhadtodo.Notnecessarilyhadto,Ihadachoice,butitwaslikeoneoutweighedthe
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Women’sExperiencewithAbortioninTexasafterRestrictiveLaw
otheranditwaslikeIdon’t carehowmanypeopleIhavetocallorhowfarIhavetogo.I
havetodoit.(19yearsold,medicationabortioninSanAntonio,traveled70miles)
Inordertoavoidtheextracostofstayinginahotel,shepreferredmakingthedrivetoeach
ofherthreeappointmentsformedicationabortioninthecompanyofhersisterandfriend.
Theotherwomantraveled300milestoreachaclinic,whichwasthelongestdistancetraveled
amongwomeninoursample.Afterapositivepregnancytestatherlocalhealthcenter,shedis-
coveredthatthetwonearestabortionclinicshadclosed.Shedescribedherreactiontolearning
oftheclosestclinic:
TheonlytimeIthoughtaboutnotdoingitwasinthebeginningbecause,likeIsaid,driving
toSanAntoniowas–likewow,Ihavetodrivesixhourstodotheprocedure.Ithoughtitwas
alittlebitoutofmyleague,likedon’t doit,that’s toofar.Idon’t know.Soitwasalittle
stressful.ButonceIthoughtaboutitandItalkedtotheclinic,justgettingalltheinforma-
tionmademefeelalittlebitmorelike,okay,youcangothroughit.(21yearsold,surgical
abortioninSanAntonio,traveled300miles)
Anotherwoman,wholaterdecidedtocontinueherpregnancy,experiencedsimilarlogisti-
calchallengesgettingtoherultrasoundappointment.Hervanbrokedownandher85-mile
triptoSanAntoniorequiredacombinationofcab,citybusandGreyhoundbus.Hertravel
costsincreasedwhenherappointmentatthecliniclastedlongerthananticipatedandshe
missedherreturnbus.Shedescribedthistravelas“anightmare”.
[Gettingtotheclinic]tookatollonmeanditwasawful.Itwasrainingthatday,ofallthe
daysit’s raining[...]IwenttoaplaceIdon’t know,allthesebussesIdon’t know.Ihadto
taketwobusesjusttogettothatappointment.ItwasthelongestdaythatIcanremember
havingforalongtime.(31yearsold,continuedpregnancy,hadultrasoundinSanAntonio,
traveled85miles)
Theclinicwasnotabletoscheduleherprocedureappointmentforatleastthreeweeks.Feel-
ingthatshehadthesupportofsomeoneinherlifewithwhomtoshareparenting,aswellas
concernabouthowfaralongshewouldbeinherpregnancybythetimeshecouldreturntothe
clinicfortheprocedure,shedecidednottoreturnfortheabortion.
Fearofunwanteddisclosure. Insomecases,thelongtraveldistanceormultipleappoint-
mentsthatwererequiredputwomeninapositionwheretheywouldhavetodiscusstheirabor-
tiondecisionwithmorepeoplethantheywanted.Forthewomanwhotraveled300milesto
SanAntonio,inadditiontoquittingherseasonaljobbecauseofchallengesnegotiatingenough
timeoff,shedescribedherfearsaboutdisclosuretoherparents:
Thedoctordidtellmethattherewereclinicsclosingdownalreadybecausetheyweren’t
doing[abortions].AndIwasjustlikewellthisisgoingtomakeitmoredifficultforme
‘causethenofcoursemyparentsaregoingtobelike,“Whereareyougoing,whyareyou
goingoverthere,whoareyougoingwith,whatareyougoingtodo?”Itwasjustgoingtolift
upsomanyotherquestionsthatIwastryingtododgeandnotwantingtogetanybody
involved.(21yearsold,surgicalabortioninSanAntonio,traveled300miles)
A30-year-oldwomanwhotraveled50milesforhersurgicalprocedure,worriedaboutdis-
closingherabortiontoababysitter,andendeduppayinghersistertotakecareofherthree
children:“IhadtofindsomeoneIhadtoconfideinaboutthesituationandletthemknowif
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theycouldwatchthekids...Ibasically[hadto]discloseinformationaboutthesituationthat[I
didn’t] necessarilywantto,Imean,that’s kindof–that’s disturbing.”
Difficultywithout-of-pocketcostsassociatedwithtravel. Participantsdiscussedvarious
otherchallengesrelatedtotheirtravelexperiences,includingout-of-pocketcostsfortranspor-
tationandovernightstays.Mostwomenwereabletousetheirowncarorthatoffamilyor
friendstogettotheclinic,butmanyhadtoaskforhelppayingforgas.
Inordertoavoidadditionalout-of-pocketcostsforanovernightstayatahotelbetween
theirultrasoundandprocedurevisits,mostofthewomentravelingmorethan50milesmade
theround-tripdrivetotheclinictwoormoretimes,andtwowomenstayedwithfamily;only
onestayedovernightinahotel.Fortheabortionprocedurevisit,allwomenneededtohavea
drivertransportthem,whichoftenresultedinlostwagesfortheirsupportpeople.Onewoman
describedhowhercostsmultipliedbecauseherhusbandalsoaccompaniedheronthe200mile
tripeachwaytotheclinic:
Itcostnotonlythemoneyattheclinicbutthenthemoneythatitcostmyhusbandfortaking
offworkafullday,thenthegasandallthatstuffandthengoingagainandhimtakinganother
fulldayofworkoff.(31yearsold,medicationabortioninSanAntonio,traveled200miles)
One24-year-oldwoman,whowasbothworkingandstudying,commentedthatthecosts
maynotseemveryhigh,butwhentheyarecalculatedalongwiththeclinicfee,itwasvery
challenging:
Ihadthisjobandtheyreallydidn’t givemealotofhours.Ididn’t havealotofmoneyand
myboyfrienddoesn’tmakealotofmoney.IhadtopayforthegasandIknowmaybeit’s
onlylike40,50dollarsbutthat’s alotwhenyou’re notmakingthatmuch.(24yearsold,sur-
gicalabortioninDallas/FtWorth,traveled50miles)
Seekingmedicationabortioninarestrictedenvironment
Impactofmedicationabortionprotocolchanges. Severalwomenwereabletoovercome
theschedulingandtravelchallengestoobtaintheirwantedmedicationabortion.Thesewomen
weregenerallyknowledgeableaboutthegestationalagelimitandwerepersistentinfindingan
openclinicthatofferedmedicationabortionthattheycouldreachpriortosevenweeksofpreg-
nancy.Oneofthesewomenarrivedatherappointmenthavingresearchedthelawsandinsisted
onobtainingmedicationabortiondespitebeingclosetothegestationalagelimit.
DuringmyfirstvisitwhenIwasdiscussingtheprocedures,[thecounselor]toldmethatI
couldn’ttakethepill.AndIreallydidnotwanttodothevacuum[procedure]unlessitabso-
lutelycamedowntothat.AndsosheleftandshecamebackandthatwaswhenIremem-
beredreadingthatyoucandoitbeforesevenweeks.(26yearsold,medicationabortionin
Dallas/FtWorth,traveled30miles)
Anotherwomanstartedcallingclinicsatsixweeksgestationandcontactedthreefacilities
beforeshewasabletomakeanappointment.Althoughshestronglypreferredmedicationabor-
tionoveranaspirationprocedure,shealsoanticipatedthediscomfortoftravelingforoveran
houronherreturntriphomeaftertakingthemisoprostolattheclinicasrequiredbylaw:
Theygiveyoufourpills...andthenimmediatelyafteryouswallow,that’s whenyou’llhave
crampingandheavybleedingandeverything.SoseeingasthoughIwascommuting,itwas
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Women’sExperiencewithAbortioninTexasafterRestrictiveLaw
aboutlikeanhourand45minutesfrommyhouse,theytoldyouthatyouneededtohave
somebodytodriveyoubackhomebecausebythenyou’llbecrampingandbleedingandjust
beveryuncomfortablefordriving.(19yearsold,medicationabortioninSanAntonio,trav-
eled70miles)
Obtainingsurgicalabortiondespitepreferringmedication. Therewerevariousreasons
thatwomendidnotobtaintheirpreferredmedicationabortion.Somewomenwereineligible
becausetheywerebeyondthegestationalagelimitdefinedintheTexas law.Whilesomeof
themwerecomfortablegettingasurgicalprocedure,thechangeineligibilitywasparticularly
upsettingforonewomanwhostronglypreferredmedicationabortionbasedonherprevious
experience.Butshewasunabletoobtainthemethodattheclinicclosesttoher:
Ididn'trealizeuntilIcalledthislasttimetotryandsetupanappointmentthatIcouldno
longergetthemedicationabortionandthatitwassurgicalonly,whichwasevenmore
frighteningandIdidn'twanttodoit.Theytoldmethatduetothelegislationpassedlast
year,itwasnolongeravailableandtheycouldofferthesurgicalprocedure.Ididn'twantto
doit.(26yearsold;surgicalabortioninAustin;traveled3miles)
Otherwomenwereeligibleforthemethodunderthelowergestationalagelimitbutwere
unableorunwillingtotraveltoaclinicthatoffereditandobtainedasurgicalprocedureinstead.
Foronewoman,theuncertaintiesabouttravelingtoanotherclinictoobtainmedicationabortion
ledhertoreluctantlyoptforasurgicalprocedureclosertohomeateightweeksgestation:
Iconsidered[drivingtoDallas,whichis200milesaway]justbecauseitwouldbe,you
know,wellIcanjustdriveupthereandtakeapill.[But]Ididn’t knowifitwouldbemore
costly.Iknewthatthegaswouldbemorecostly.Ididn’t knowwhere[theclinic]was,hon-
estly.(30yearsold,surgicalabortioninAustin,traveled50miles)
Intheseinstances,women’s methodofabortiondidnotfeellikeachoice.Theyweremost
disappointedwhentheylearnedthattheirdesiredprocedurewouldnotbeavailableandreal-
izedtheydidnothavethemoneyortimetoseekoutanotherfacility,asonewomanexplained:
Well, IactuallyfoundoutwhenIwentinformytestthattheydon’t offer[medicationabor-
tion].Ijuststartedcryinghystericallyinfrontofthegirlwhowascounselingmeandshe
didn’t knowwhattodo.Itwaslike,“Icouldreferyousomewhereelsebut,youknow,you’re
likethreedaysawayfromthe[cutoff]day,” andIdidn’t havehalfthemoneyIneededforit
yet.(20yearsold,surgicalabortioninAustin,traveled21miles)
PerceptionofTexasabortionlaws
Women’s understandingofHB2varied.Manyexpressedconfusionaboutpartsofthelawor
werenotsureifwhattheyheardwastrue.Acoupleofwomenstatedthatpriortoobtaining
theirproceduretheydoubtedwhetherabortionwasstilllegalinTexas.Women tendedtobe
mostfamiliarwiththefactthatclinicshadclosedasaresultofthelaw.Theyexpressedcon-
cernsabouthowthisimpactedaccesstoservicesinthestate:
Well, Iheardthattheyweregoingtobetakingmoreclinicsaway, thattheyweregoingtobe
tryingtomakeitharderforwomentogetabortions.Ifsomeoneisn’t readytohaveachild
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thentheyshouldn’t havetobegoingtoadifferentstateoroutofthewayjusttodowhat
theyhavetodo.Idon’t feellikeit’s right.(19yearsold;surgicalabortioninAustin;traveled
48miles)
Onewomandescribedhowthiscouldpotentiallyleadtoincreasedunsafeabortionoutside
ofclinicsettings:
It’s notagoodideatoshutdownclinics,justbecauseofthepast.[Women]willfindwaysto
getridofthepregnancyandsometimesthatcanleadtodeath.You know,sotome,it’s actu-
allyscary.(24yearsold;surgicalabortioninDallas/FtWorth;traveled20miles)
WhenaskedabouttheiropinionontheabortionlawsinTexas,womentalkedaboutthe
compoundingbarriersimposedbylawspassedpriortoHB2,includingthetwo-visitrequire-
mentand24-hourwaitingperiodpassedin2011.Forexample,afrustrated19-year-old
womanexplained:
Thefirstactualday,IfeltlikeitwasawasteoftimebecauseIhadtodriveallthewaytoSan
Antoniotositandlistentoaguyreadoffapieceofpaperof,like,theTexas legislativelaws.
Andthatwasarequirement.I’mlike,that’s alongwaytodrivejusttolistentosomebody
talk.(19yearsold,medicationabortioninSanAntonio,traveled70miles)
Althoughonewomanexpressedsupportforthemedicationabortiongestationallimit,there
wasageneralconsensusamongthemajoritythatthelawswerecreatingadditionalandunnec-
essarybarriersforwomen,asdescribedbythiswoman:
Ifeellikethey’retryingtomakethewomennotgetit‘causethepriceissohighandthey
knowthattheywon’t beabletoaffordit.Sotheywanttomakethemstruggleandhave
morepeopleinthepovertylevelandstuff.Sothenthatmeanslikemorekidsintheadoption
clinics,morekidshomelessandorphansandallthatotherstuff.Soit’s like–it’s notevenlike
awin-winsituation.It’s likealose-lose.(19yearsold;surgicalabortioninDallas/FtWorth;
traveled16miles)
Discussion
Thisqualitativestudyprovidesinsightintowomen’s experiencestryingtoaccessabortioncare
inthefaceofthemultipleabortionrestrictionsimplementedaspartofHB2inTexas.Previous
researchhasdemonstratedthatimmediatelyafterHB2wasenforced,womenwereconfused
aboutwhichclinicswereopenandsomefacedlongertraveldistancestoreachclinics,which
createdobstaclestocare[12].Theresultsfromthisstudydemonstratethatsuchbarriersper-
sistedmorethansixmonthsafterHB2wasfirstenforced.Specifically,womenwhotraveled50
milesormoreandwomenwhopreferredmedicationabortionatthetimeofseekingservices
continuedtoencounterinformationalbarrierstofindaclinicofferingservicesandobtaintheir
preferredmethodofabortion.
ThesefindingsalsoshedlightontheextentandnatureoftheburdensfacedbyTexas
womenafterthefirstprovisionsofHB2wereimplemented,whichweredocumentedinthe
surveyfromwhichparticipantsinthisstudywereselected.Datafromthatsurveyindicatethat
the38%ofabortionclientswhosenearestclinichadclosedbetween2013and2014weresignif-
icantlymorelikelytohavetraveledfartherforservices,havehigherout-of-pocket-costsand
reportitwasdifficultgettingtotheclinic,comparedtowomenwhosenearestclinicremained
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