Report: North Carolina abortion law creates more administrative tasks, frustration and anxiety for clinic operators

Abortion care providers in North Carolina report spending more time on administrative tasks, voice frustration with new required consent forms, have feelings of anxiety and burnout, and fear for the future pipeline of providers since the state adopted regulations in 2023 limiting abortion care, according to a new RAND report.

In addition, abortion facilities reported reorganizing or changing clinical workflows, adjusting staffing, facing higher costs, and in some cases, physically relocating their clinics to adapt to the state's new abortion rules.

Providers reported that patients faced increased resource and time burdens, particularly with a requirement that consent be done only in person, with a disproportionate impact for historically marginalized populations. Additionally, providers reported that individuals seeking care faced limitations on decision-making inputs, combined with high levels of confusion and misinformation.

"Beyond shortening the gestational period when abortions may be performed, state laws often impose additional regulations on clinicians and clinic operators," said Julia Rollison, lead author of the report and a senior policy research at RAND, a nonprofit research organization. "This analysis provides new information about how those additional restrictions are affecting providers, clinics, and people's access to abortion."

In May 2023, North Carolina legislators approved Senate Bill 20, which set new restrictions on abortion services in the wake of the U.S. Supreme Court's Dobbs decision overturning the constitutional right to an abortion.

The legislation limits abortion to 12 weeks, 6 days, with exceptions for cases of rape, incest or medical emergency. Prior to legislation taking effect, abortions were broadly lawful in North Carolina during the first 20 weeks of a woman's pregnancy.

The 47-page bill also added an in-person counseling requirement to the already required 72-hour waiting period for both procedural and medication abortions, modified required consent language and signature requirements, mandated detailed reporting requirements for abortions performed after the 12th week of pregnancy, and established penalties for physicians and health care providers who violate the regulations. Some parts of the legislation are in flux as courts adjudicate challenges to the rules.

The legislation was seen as more moderate than laws adopted in many other states after the Dobbs decision. Since North Carolina is adjacent to other states with more-restrictive policies, some women travel to the state for abortions.

To better understand how the changes were affecting practice in North Carolina, RAND researchers used a variety of methods to gather information about the delivery of abortion services in the state.

They conducted interviews with clinicians who regularly provide abortion care and non-clinicians who work at facilities that provide abortion care or organizations that support abortion access. Participants worked at different types of clinics (independent, Planned Parenthood and hospital-based) or support organizations (policy advocacy, abortion funds).

Researchers also identified state and local policies and supporting documentation and reviewed published material about abortion care in the state, including peer-reviewed literature and news articles.

The research found that to manage the increased number of appointments based on the in-person consent requirements, some clinics needed to reorganize their patient waiting areas to improve the workflow of the clinic or set aside specific days and times for consent visits.

Interview participants also reported that the new law created the need for many new compliance functions that did not benefit patients, such as protocols for documenting medical emergencies.

In addition, since the new law requires clinicians to be involved in gathering consent in-person from patients with lengthy forms, some participants remarked that clinicians were now spending a significant amount of time on more-administrative tasks and less time on direct patient care.

Most respondents felt that the new law did not impact a patient's decision to have an abortion, just when and where. Specifically, they reported seeing patients earlier in their pregnancies than they might otherwise.

Those interviewed for the RAND study emphasized the disproportionate impact Senate Bill 20 had on individuals who already were marginalized, including low-income, immigrant, persons of color, adolescents and rural patients.

"There is not a lot of data on whether and to what extent state and local policies adopted in the wake of Dobbs have influenced providers' practices," Rollison said. "This initial study of one key state begins to fill that gap."