Texas Policy Evaluation Project
TEXPEP upper righthand gray scale identity logo

TxPEP Publications

*Contact Laura Dixon, TxPEP Media Liaison, to request a PDF of any of these articles.

Perspectives coverWomen's Knowledge of and Support for Abortion Restrictions in Texas: Findings from a Statewide Representative Survey

Kari White, Joseph E. Potter, Amanda J. Stevenson, Liza Fuentes, Kristine Hopkins, and Daniel Grossman.
Perspectives on Sexual and Reproductive Health; published online ahead of print April 15, 2016; available online through Wiley Online Library

Abstract: ContextStates have passed numerous laws restricting abortion, and Texas passed some of the most restrictive legislation between 2011 and 2013. Information about women's awareness of and support for the laws’ provisions could inform future debates regarding abortion legislation. MethodsBetween December 2014 and January 2015, some 779 women aged 18–49 participated in an online, statewide representative survey about recent abortion laws in Texas. Poisson regression analysis was used to assess correlates of support for a law that would make obtaining an abortion more difficult. Women's knowledge of specific abortion restrictions in Texas and reasons for supporting these laws were also assessed. ResultsOverall, 31% of respondents would support a law making it more difficult to obtain an abortion. Foreign-born Latinas were more likely than whites to support such a law (prevalence ratio, 1.5), and conservative Republicans were more likely than moderates and Independents to do so (2.3). Thirty-six percent of respondents were not very aware of recent Texas laws, and 19% had never heard of them. Among women with any awareness of the laws, 19% supported the requirements; 42% of these individuals said this was because such laws would make abortion safer. ConclusionsMany Texas women of reproductive age are unaware of statewide abortion restrictions, and some support these requirements because of misperceptions about the safety of abortion. Advocates and policymakers should address these knowledge gaps in efforts to protect access to legal abortion.

American Journal of Public Health cover Impact of Clinic Closures on Women Obtaining Abortion Services After Implementation of a Restrictive Law in Texas

Caitlin Gerdts, Liza Fuentes, Daniel Grossman, Kari White, Brianna Keefe-Oates, Sarah E. Baum, Kristine Hopkins, Chandler W. Stolp, and Joseph E. Potter.
American Journal of Public Health; published online ahead of print March 17, 2016; available online through the American Journal of Public Health

AbstractObjectives: To evaluate the additional burdens experienced by Texas abortion patients whose nearest in-state clinic was one of more than half of facilities providing abortion that had closed after the introduction of House Bill 2 in 2013. Methods: In mid-2014, we surveyed Texas-resident women seeking abortions in 10 Texas facilities (n = 398), including both Planned Parenthood–affiliated clinics and independent providers that performed more than 1500 abortions in 2013 and provided procedures up to a gestational age of at least 14 weeks from last menstrual period. We compared indicators of burden for women whose nearest clinic in 2013 closed and those whose nearest clinic remained open. Results: For women whose nearest clinic closed (38%), the mean one-way distance traveled was 85 miles, compared with 22 miles for women whose nearest clinic remained open (P ≤ .001). After adjustment, more women whose nearest clinic closed traveled more than 50 miles (44% vs 10%), had out-of-pocket expenses greater than $100 (32% vs 20%), had a frustrated demand for medication abortion (37% vs 22%), and reported that it was somewhat or very hard to get to the clinic (36% vs 18%; P < .05). Conclusions: Clinic closures after House Bill 2 resulted in significant burdens for women able to obtain care.

NEJM cover imageEffect of Removal of Planned Parenthood from the Texas Women's Health Program

Amanda J. Stevenson, Imelda M. Flores-Vazquez, Richard L. Allgeyer, Pete Schenkkan, and Joseph E. Potter.
New England Journal of Medicine; published online ahead of print Feburary 3, 2016; available online through the New England Journal of Medicine

AbstractBackground: Texas is one of several states that have barred Planned Parenthood affiliates from providing health care services with the use of public funds. After the federal government refused to allow (and courts blocked) the exclusion of Planned Parenthood affiliates from the Texas Medicaid fee-for-service family-planning program, Texas excluded them from a state-funded replacement program, effective January 1, 2013. We assessed rates of contraceptive-method provision, method continuation through the program, and childbirth covered by Medicaid before and after the Planned Parenthood exclusion. Methods: We used all program claims from 2011 through 2014 to examine changes in the number of claims for contraceptives according to method for 2 years before and 2 years after the exclusion. Among women using injectable contraceptives at baseline, we observed rates of contraceptive continuation through the program and of childbirth covered by Medicaid. We used the difference-in-differences method to compare outcomes in counties with Planned Parenthood affiliates with outcomes in those without such affiliates. Results:  After the Planned Parenthood exclusion, there were estimated reductions in the number of claims from 1042 to 672 (relative reduction, 35.5%) for long-acting, reversible contraceptives and from 6832 to 4708 (relative reduction, 31.1%) for injectable contraceptives (P<0.001 for both comparisons). There was no significant change in the number of claims for short-acting hormonal contraceptive methods during this period. Among women using injectable contraceptives, the percentage of women who returned for a subsequent on-time contraceptive injection decreased from 56.9% among those whose subsequent injections were due before the exclusion to 37.7% among those whose subsequent injections were due after the exclusion in the counties with Planned Parenthood affiliates but increased from 54.9% to 58.5% in the counties without such affiliates (estimated difference in differences in counties with affiliates as compared with those without affiliates, −22.9 percentage points; P<0.001). During this period in counties with Planned Parenthood affiliates, the rate of childbirth covered by Medicaid increased by 1.9 percentage points (a relative increase of 27.1% from baseline) within 18 months after the claim (P = 0.01). Conclusions: The exclusion of Planned Parenthood affiliates from a state-funded replacement for a Medicaid fee-forservice program in Texas was associated with adverse changes in the provision of contraception. For women using injectable contraceptives, there was a reduction in the rate of contraceptive continuation and an increase in the rate of childbirth covered by Medicaid.

ContraceptionWomen's Experiences Seeking Abortion Care Shortly After the Closure of Clinics Due to a Restrictive Law in Texas

Liza Fuentes, Sharon Lebenkoff, Kari White, Caitlin Gerdts, Kristine Hopkins, Joseph E. Potter, Daniel Grossman
Contraception; published online ahead of print January 6, 2016; available online through ScienceDirect

Abstract: Objective: In 2013, Texas passed legislation restricting abortion services. Almost half of the state's clinics had closed by April 2014, and there was a 13% decline in abortions in the 6 months after the first portions of the law went into effect, compared to the same period one year prior. We aimed to describe women's experiences seeking abortion care shortly after clinics closed and document pregnancy outcomes of women affected by these closures. Study Design: Between November 2013 and November 2014, we recruited women who sought abortion care at Texas clinics that were no longer providing services. Some participants had appointments scheduled at clinics that stopped offering care when the law went into effect; others called seeking care at clinics that had closed. Texas resident women seeking abortion in Albuquerque, New Mexico, were also recruited. Results: We conducted 23 in-depth interviews and performed a thematic analysis. As a result of clinic closures, women experienced confusion about where to go for abortion services, and most reported increased cost and travel time to obtain care. Having to travel farther for care also compromised their privacy. Eight women were delayed more than one week, two did not receive care until they were more than 12 weeks pregnant, and two did not obtain their desired abortion at all. Five women considered self-inducing the abortion, but none attempted this. Conclusions: The clinic closures resulted in multiple barriers to care, leading to delayed abortion care for some and preventing others from having the abortion they wanted. Implications: The restrictions on abortion facilities that resulted in the closure of clinics in Texas created significant burdens on women that prevented them from having desired abortions. These laws may also adversely affect public health by moving women who would have had abortions in the first trimester to having second-trimester procedures.

Obstetrics and GynecologyBarriers to Postpartum Contraception in Texas and Pregnancy Within 2 Years of Delivery

Joseph Potter, Celia Hubert, Amanda Jean Stevenson, Abigail R. A. Aiken, Kari White, and Daniel Grossman
Obstetrics and Gynecology; published online ahead of print January 7, 2016; available online through Ovid

Abstract: OBJECTIVE: To assess pregnancies that could have been averted through improved access to contraceptive methods in the 2 years after delivery. METHODS: In this cohort study, we interviewed 403 postpartum women in a hospital in Austin, Texas, who wanted to delay childbearing for at least 2 years. Follow-up interviews were completed at 3, 6, 9, 12, 18, and 24 months after delivery; retention at 24 months was 83%. At each interview, participants reported their pregnancy status and contraceptive method. At the 3- and 6-month interviews, participants were also asked about their preferred contraceptive method 3 months in the future. We identified types of barriers among women unable to access their preferred method and used Cox models to analyze the risk of pregnancy from 6 to 24 months after delivery. RESULTS: Among women interviewed 6 months postpartum (n=377), two thirds had experienced a barrier to accessing their preferred method of contraception. By 24 months postpartum, 89 women had reported a pregnancy; 71 were unintended. Between 6 and 24 months postpartum, 77 of 377 women became pregnant (20.4%), with 56 (14.9%) lost to follow-up. Women who encountered a barrier to obtaining their preferred method were more likely to become pregnant less than 24 months after delivery. They had a cumulative risk of pregnancy of 34% (95% confidence interval [CI] 0.25-0.43) as compared with 12% (95% CI 0.05-0.18) for women with no barrier. All but three of the women reporting an unintended pregnancy had earlier expressed interest in using long-acting reversible contraception or a permanent method. CONCLUSION: In this study, most unintended pregnancies less than 24 months after delivery could have been prevented or postponed had women been able to access their desired long-acting and permanent methods.

ContraceptionWomen's Experiences After Planned Parenthood's Exclusion from a Family Planning Program in Texas

Junda Woo, Hasanat Alamgir, Joseph E. Potter
Contraception; published online ahead of print December 8, 2015; available online through ScienceDirect

Abstract: Objective: We assessed the impact on depot medroxyprogesterone continuation when a large care provider was banned from a state-funded family planning program. Study Design: We used three methods to assess the effect of the ban: (a) In a records review, we compared how many state program participants returned to two Planned Parenthood affiliates for a scheduled dose of depot medroxyprogesterone acetate (DMPA) immediately after the ban; (b) We conducted phone interviews with 224 former Planned Parenthood patients about DMPA use and access to contraception immediately after the ban; (c) We compared current contraceptive method of our interviewees to that of comparable DMPA users in the National Survey of Family Growth 2006–2010 (NSFG). Results: (a) Fewer program clients returned for DMPA at a large urban Planned Parenthood, compared to a remotely located affiliate (14.4%, vs. 64.8%), reflecting different levels of access to alternative providers in the two cities. (b) Among program participants who went elsewhere for the injection, only 56.8% obtained it at no cost and on time. More than one in five women missed a dose because of barriers, most commonly due to difficulty finding a provider. (c) Compared to NSFG participants, our interviewees used less effective methods of contraception, even more than a year after the ban went into effect. Conclusions: Injectable contraception use was disrupted during the rollout of the state-funded family planning program. Women living in a remote area of Texas encountered more barriers. Implications: Requiring low-income family planning patients to switch healthcare providers has adverse consequences.

Contraception Journal imageComplications from First-Trimester Aspiration Abortion: A Systematic Review of the Literature

Kari White, Erin Carrol, Daniel Grossman
Contraception, published online ahead of print July 31, 2015; available online through ScienceDirect

Abstract: What happens when abortion access is severely restricted for 26 million Americans? Texas is about to find out. In July 2013, the Texas legislature passed one of the country’s most restrictive laws that not only bans most abortions after 22 weeks and limits the use of medical abortion but also contains several provisions that are likely to lead to the closure of most abortion clinics in the state. The law requires facilities to meet the standards of ambulatory surgery centers and mandates physicians to have admitting privileges at nearby hospitals. Proponents of the law claim it will improve safety, despite overwhelming evidence that abortions provided in outpatient clinics have a very low level of complications. This legislation comes on the heels of measures passed in 2011 that drastically reduced funding for family planning, effectively removed Planned Parenthood from all state-funded family planning programs and required women seeking abortion to make an extra visit at least 24 hours before the abortion in order to undergo an ultrasound and listen to a detailed description of its images.

American Journal of Public Health coverThe Impact of Reproductive Health Legislation on Family Planning Clinic Services in Texas

Kari White, Kristine Hopkins, Abigail R. A. Aiken, Amanda Stevenson, Celia Hubert, Daniel Grossman, Joseph E. Potter
American Journal of Public Health; published online ahead of print March 19, 2015; available online through American Journal of Public Health.

Abstract: We examined the impact of legislation in Texas that dramatically cut and restricted participation in the state’s family planning program in 2011 using surveys and interviews with leaders at organizations that received family planning funding. Overall, 25% of family planning clinics in Texas closed. In 2011, 71% of organizations widely offered long-acting reversible contraception; in 2012–2013, only 46% did so. Organizations served 54% fewer clients than they had in the previous period. Specialized family planning providers, which were the targets of the legislation, experienced the largest reductions in services, but other agencies were also adversely affected. The Texas experience provides valuable insight into the potential effects that legislation proposed in other states may have on low-income women’s access to family planning services.

Perspectives coverWomen's Experiences Seeking Publicly Funded Family Planning Services in Texas

Kristine Hopkins, Kari White, Fran Linkin, Celia Hubert, Daniel Grossman, Joseph E. Potter
Perspectives on Sexual and Reproductive Health 47(2) June 2015; available online through Wiley Online Library and as a public access version

Abstract: Little is known about low-income women's and teenagers’ experiences accessing publicly funded family planning services, particularly after policy changes are made that affect the cost of and access to such services. Eleven focus groups were conducted with 92 adult women and 15 teenagers in nine Texas metropolitan areas in July–October 2012, a year after legislation that reduced access to subsidized family planning was enacted. Although most women were not aware of the legislative changes, they reported that in the past year, they had had to pay more for previously free or low-cost services, use less effective contraceptive methods or forgo care. They also indicated that accessing affordable family planning services had long been difficult, that applying and qualifying for programs was a challenge and that obtaining family planning care was harder than obtaining pregnancy-related care. As a result of an inadequate reproductive health safety net, women experienced unplanned pregnancies and were unable to access screening services and follow-up care. Teenagers experienced an additional barrier, the need to obtain parental consent. Some women preferred to receive family planning services from specialized providers, while others preferred more comprehensive care. Women in Texas have long faced challenges in obtaining subsidized family planning services. Legislation that reduced access to family planning services for low-income women and teenagers appears to have added to those challenges.

Contraception Journal imageThe Public Health Threat of Anti-Abortion Legislation

Daniel Grossman, Kari White, Kristine Hopkins, Joseph E. Potter
Contraception 2014; 89(2):73–74; available online through ScienceDirect

Abstract: What happens when abortion access is severely restricted for 26 million Americans? Texas is about to find out. In July 2013, the Texas legislature passed one of the country’s most restrictive laws that not only bans most abortions after 22 weeks and limits the use of medical abortion but also contains several provisions that are likely to lead to the closure of most abortion clinics in the state. The law requires facilities to meet the standards of ambulatory surgery centers and mandates physicians to have admitting privileges at nearby hospitals. Proponents of the law claim it will improve safety, despite overwhelming evidence that abortions provided in outpatient clinics have a very low level of complications. This legislation comes on the heels of measures passed in 2011 that drastically reduced funding for family planning, effectively removed Planned Parenthood from all state-funded family planning programs and required women seeking abortion to make an extra visit at least 24 hours before the abortion in order to undergo an ultrasound and listen to a detailed description of its images.

Contraception Journal imageUnmet Demand for Highly Effective Postpartum Contraception in Texas

Joseph E. Potter, Kristine Hopkins, Abigail R.A. Aiken, Celia Hubert Lopez, Amanda J. Stevenson, Kari White, Daniel Grossman
Contraception 2014; 90(5): 488-495; available online through ScienceDirect and as a public access version

Abstract: We aimed to assess women's contraceptive preferences and use in the first 6 months after delivery. The postpartum period represents a key opportunity for women to learn about and obtain effective contraception, especially since 50% of unintended pregnancies to parous women occur within 2 years of a previous birth. Methods: We conducted a prospective cohort study of 800 postpartum women recruited from three hospitals in Austin and El Paso, TX. Women aged 18–44 who wanted to delay childbearing for at least 24 months were eligible for the study and completed interviews following delivery and at 3 and 6 months postpartum. Participants were asked about the contraceptive method they were currently using and the method they would prefer to use at 6 months after delivery. Results: At 6 months postpartum, 13% of women were using an IUD or implant, and 17% were sterilized or had a partner who had had a vasectomy. Twenty-four percent were using hormonal methods, and 45% relied on less effective methods, mainly condoms and withdrawal. Yet 44% reported that they would prefer to be using sterilization, and 34% would prefer to be using LARC. Conclusions: This study shows a considerable preference for LARC and permanent methods at six months postpartum. However, there is a marked discordance between women’s method preference and actual use, indicating substantial unmet demand for highly effective methods of contraception. Implications: In two Texas cities, many more women preferred long-acting and permanent contraceptive methods (LAPM) than were able to access these methods at six months postpartum. Women’s contraceptive needs could be better met by counseling about all methods, reducing cost barriers and by making LAPM available at more sites.

Contraception Journal imageFinding the Twitter Users that Stood With Wendy

Amanda Jean Stevenson
Contraception 2014; (90)5: 502-507; available online through ScienceDirect

Abstract: I examine Twitter discussion regarding the Texas omnibus abortion restriction bill before, during, and after Wendy Davis’ filibuster in summer 2013. This critical moment precipitated wide public discussion of abortion. Digital records allow me to characterize the spatial distribution of participants in Texas and the United States and estimate the proportion of participants who were Texans. Study design: Building a dataset based on all hashtags associated with the bill between June 19th and July 14th, 2013, I use GPS locations and text descriptions of locations, to classify users by county of residence. Mapping tweets from accounts within the continental US by day, I describe the residential composition of the conversation in total and over time. Using indirect estimation, I compute an estimate of the number of Texans who participated. Results: About 1.66 million tweets were sent using hashtags associated with the bill from 399,081 user accounts. I estimate counties of residence for 160,954 participants (40.3%). An estimated 115,500 participants (29%) were Texans and Texans sent an estimated 48.8% of all tweets. Tweets were sent from users estimated to live in every region of Texas, including 189 of Texas’ 254 counties. Texans tweeted more than non-Texans on every day except the filibuster and the day after. Conclusion: The analysis measures real-life responses to proposed abortion restrictions from people across Texas and the US. It demonstrates that Twitter users from across Texas counties opposed HB2 by describing the geographical range of US and Texan abortion rights supporters on Twitter. Implications: The Twitter discussion surrounding Wendy Davis’ filibuster revealed a geographically diverse population of individuals who strongly oppose abortion restrictions. Texans from across the state were among those who actively voiced opposition. Identifying rights supporters through online behavior may present a new way of classifying individuals’ orientations regarding abortion rights.

Contraception Journal imageChange in Abortion Services After Implementation of a Restrictive Law in Texas

Daniel Grossman, Sarah Baum, Liza Fuentes, Kari White, Kristine Hopkins, Amanda Stevenson, Joseph E. Potter
Contraception 2014; 90(5): 496-501; available online through ScienceDirect and as a public access version

Abstract: In 2013, Texas passed omnibus legislation restricting abortion services. Provisions restricting medical abortion, banning most procedures after 20 weeks and requiring physicians to have hospital admitting privileges were enforced in November 2013; by September 2014, abortion facilities must meet the requirements of ambulatory surgical centers (ASCs). We aimed to rapidly assess the change in abortion services after the first three provisions went into effect. Study Design: We requested information from all licensed Texas abortion facilities on abortions performed between November 2012 and April 2014, including the abortion method and gestational age (<12 weeks versus >12 weeks). Results: In May 2013, there were 41 facilities providing abortion in Texas; this decreased to 22 in November 2013. Both clinics closed in the Rio Grande Valley, and all but one closed in West Texas. Comparing November 2012-April 2013 to November 2013-April 2014, there was a 13% decrease in the abortion rate (from 12.9 to 11.2 abortions/1000 women age 15-44). Medical abortion decreased by 70%, from 28.1% of all abortions in the earlier period to 9.7% after November 2013 (p<0.001). Second-trimester abortion increased from 13.5% to 13.9% of all abortions (p<0.001). Only 22% of abortions were performed in the state’s six ASCs. Conclusions: The closure of clinics and restrictions on medical abortion in Texas appear to be associated with a decline in the in-state abortion rate and a marked decrease in the number of medical abortions. Implications: Supply-side restrictions on abortion—especially restrictions on medical abortion—can have a profound impact on access to services. Access to abortion care will become even further restricted in Texas when the ASC requirement goes into effect in 2014.

NEJM cover imageCutting Family Planning in Texas

Kari White, Daniel Grossman, Kristine Hopkins, Joseph E. Potter
New England Journal of Medicine 2012; 367: 1179-1181; available online through New England Journal of Medicine

Abstract: Four fundamental principles drive public funding for family planning. First, unintended pregnancy is associated with negative health consequences, including reduced use of prenatal care, lower breast-feeding rates, and poor maternal and neonatal outcomes. Second, governments realize substantial cost savings by investing in family planning, which reduces the rate of unintended pregnancies and the costs of prenatal, delivery, postpartum, and infant care. Third, all Americans have the right to choose the timing and number of their children. And fourth, family planning enables women to attain their educational and career goals and families to provide for their children. These principles led to the bipartisan passage of Title X in 1970 and later to other federal- and state-funded programs supporting family planning services for low-income women.

*Contact Laura Dixon, TxPEP Media Liaison, to request a PDF of any of these articles.