Researchers: As Ohio abortion regulations increased, disparities in care emerged
Ohio has seen a growing disparity between abortion rates in rural and urban communities, later abortions, and less use of medication abortion care as the state has heavily regulated abortion and clinics have closed, a new study has found.
Researchers say their study raises concerns about inadequate and inconsistent access to a full spectrum of reproductive health care.
The researchers looked at abortion services performed in Ohio from 2010 to 2018, a time when more than 15 new abortion regulations were instituted and when the number of surgical abortion clinics in the state dropped from 15 to eight. The study, led by Alison Norris of The Ohio State University, appears today (May 21, 2020) in the American Journal of Public Health.
In this study, researchers examined a variety of characteristics of those who received abortions during the eight-year study period, including how far along they were in their pregnancies, county of residence and what methods of abortion were used.
Nationally and in Ohio, abortion rates declined significantly during this time period. But a decrease in early first-trimester abortions and simultaneous increase in later first-trimester abortions was unique to Ohio, and may signal delays in women and teens receiving prompt care because of the burdens they have to overcome to get that care, said Norris, an associate professor of epidemiology in Ohio State's College of Public Health.
"Abortion care is one of the safest procedures that we have. Because it becomes more complex later in pregnancy, women benefit from quick access to abortion services when they choose to end a pregnancy," Norris said.
The research is part of a multidisciplinary reproductive health research consortium called the Ohio Policy Evaluation Network, or OPEN, which includes scientists from Ohio State, the University of Cincinnati, Cincinnati Children's Hospital and Case Western Reserve University.
Ohio's abortion laws include mandatory in-person counseling 24 hours before the procedure and limitations about how abortion can be funded, which can create significant obstacles to early care for some women, Norris said.
From 2010 to 2018, abortion ratios decreased sharply, and disproportionately, in most rural Ohio counties, the study found. In rural counties, the number of abortions per 1,000 live births dropped more than 32 percent compared to the 24 percent reduction seen in urban counties.
And in areas where clinics closed, use of abortion dropped off among women and teens living both within the county and in surrounding counties.
"This geographic inequity in abortion access is concerning, because it likely means that some people who have unintended pregnancies and want to end those pregnancies are not getting the care they want and deserve," Norris said, adding that regulations passed in Ohio during the study period, including requirements that clinics have a written patient transfer agreement with a private hospital, have created administrative hurdles for abortion providers.
Norris said there's no evidence that she's aware of to support the idea that abortions are happening less frequently in rural Ohio because there are fewer unintended pregnancies or less demand for services. In fact, she said, it's possible that unintended pregnancies are more common in some rural areas where access to contraceptive options could also be limited.
"It could actually be the case that there are higher rates of unintended pregnancy in some rural areas, because people who live in those areas have reduced access to all kinds of health care, including high-quality reproductive care," said Norris, adding that the OPEN research team hopes to explore that possibility in future work.
Medication abortion care also decreased significantly in Ohio during this time, likely largely due to the state's narrow interpretation of how the medications had to be dispensed, Norris said.
Nationally, annual abortion rates overall dropped from about 12 per 1,000 women of childbearing age to fewer than 10 per 1,000 during the study period.
"This national trend, one that has also been seen in Ohio, aligns with increased access to contraception and highly effective modes of contraception, particularly long-acting reversible contraceptives," Norris said.
"But declines in the use of abortion are being experienced differently by different groups of people, and that's what we found is happening in Ohio."
While this study focuses on Ohio, it likely has broader implications, Norris said.
"I think we can expect similar experiences for people who live in states with a high regulatory burden around abortion care. It's reasonable to imagine that the things that we see in Ohio are playing out in other places."