Texas Policy Evaluation Project
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TxPEP Publications

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

20172016 - 2015 - 2014 - 2012

ContraceptionDoes Information about Abortion Safety Affect Texas Voters' Opinions about Restrictive Laws? A Randomized Study

Kari White, Daniel Grossman, Amanda Jean Stevenson, Kristine Hopkins, Joseph E. Potter
Contraception 2017; published online ahead of print Sept. 1 2017; available online through ScienceDirect
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Abstract: Objective: The objective was to assess whether information about abortion safety and awareness of abortion laws affect voters' opinions about medically unnecessary abortion regulations. Study Design: Between May and June 2016, we randomized 1200 Texas voters to receive or not receive information describing the safety of office-based abortion care during an online survey about abortion laws using simple random assignment. We compared the association between receiving safety information and awareness of recent restrictions and beliefs that ambulatory surgical center (ASC) requirements for abortion facilities and hospital admitting privileges requirements for physicians would make abortion safer. We used Poisson regression, adjusting for political affiliation and views on abortion. Results: Of 1200 surveyed participants, 1183 had complete data for analysis: 612 in the information group and 571 in the comparison group. Overall, 259 (46%) in the information group and 298 (56%) in the comparison group believed that the ASC requirement would improve abortion safety (p=.008); 230 (41%) in the information group and 285 (54%) in the comparison group believed that admitting privileges would make abortion safer (p<.001). After multivariable adjustment, the information group was less likely to report that the ASC [prevalence ratio (PR): 0.82; 95% confidence interval (CI): 0.72–0.94] and admitting privileges requirements (PR: 0.76; 95% CI: 0.65–0.88) would improve safety. Participants who identified as conservative Republicans were more likely to report that the ASC (82%) and admitting privileges requirements (83%) would make abortion safer if they had heard of the provisions than if they were unaware of them (ASC: 52%; admitting privileges: 47%; all p<.001). Conclusions: Informational statements reduced perceptions that restrictive laws make abortion safer. Voters' prior awareness of the requirements also was associated with their beliefs. Implications: Informational messages can shift scientifically unfounded views about abortion safety and could reduce support for restrictive laws. Because prior awareness of abortion laws does not ensure accurate knowledge about their effects on safety, it is important to reach a broad audience through early dissemination of information about new regulations.

Obstetrics and GynecologyContraception After Delivery Among Publicly Insured Women in Texas: Use Compared With Preference

Joseph E. Potter, Kate Coleman-Minahan, Kari White, Daniel A. Powers, Chloe Dillaway, Amanda J. Stevenson, Kristine Hopkins, Daniel Grossman
Obstetrics & Gynecology 2017; published online ahead of print July 11, 2017; available online through Obstetrics and Gynecology
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Abstract: Objective: To assess women's preferences for contraception after delivery and to compare use with preferences. Methods: In a prospective cohort study of women aged 18-44 years who wanted to delay childbearing for at least 2 years, we interviewed 1,700 participants from eight hospitals in Texas immediately postpartum and at 3 and 6 months after delivery. At 3 months, we assessed contraceptive preferences by asking what method women would like to be using at 6 months. We modeled preference for highly effective contraception and use given preference according to childbearing intentions using mixed-effects logistic regression testing for variability across hospitals and differences between those with and without immediate postpartum long-acting reversible contraception (LARC) provision. Results: Approximately 80% completed both the 3- and 6-month interviews (1,367/1,700). Overall, preferences exceeded use for both-LARC: 40.8% (n=547) compared with 21.9% (n=293) and sterilization: 36.1% (n=484) compared with 17.5% (n=235). In the mixed-effects logistic regression models, several demographic variables were associated with a preference for LARC among women who wanted more children, but there was no significant variability across hospitals. For women who wanted more children and had a LARC preference, use of LARC was higher in the hospital that offered immediate postpartum provision (P<.035) as it was for U.S.-born women (odds ratio [OR] 2.08, 95% CI 1.17-3.69) and women with public prenatal care providers (OR 2.04, 95% CI 1.13-3.69). In the models for those who wanted no more children, there was no significant variability in preferences for long-acting or permanent methods across hospitals. However, use given preference varied across hospitals (P<.001) and was lower for black women (OR 0.26, 95% CI 0.12-0.55) and higher for U.S.-born women (OR 2.32, 95% CI 1.36-3.96), those 30 years of age and older (OR 1.82, 95% CI 1.07-3.09), and those with public prenatal care providers (OR 2.04, 95% CI 1.18-3.51). Conclusion: Limited use of long-acting and permanent contraceptive methods after delivery is associated with indicators of health care provider and system-level barriers. Expansion of immediate postpartum LARC provision as well as contraceptive coverage for undocumented women could reduce the gap between preference and use.

Women's Health Issues Prevalence and Predictors of Prenatal and Postpartum Contraceptive Counseling in Two Texas Cities

Kate Coleman-Minahan, Abigail R. A. Aiken, Joseph E. Potter
Women's Health Issues 2017; published online ahead of print June 27, 2017; available online through ScienceDirect

Abstract: Objectives: We investigated the prevalence of and sociodemographic associations with receiving prenatal and postpartum contraceptive counseling, including counseling on intrauterine devices (IUDs) and implants. Methods: We used data from a prospective cohort study of 803 postpartum women in El Paso and Austin, Texas. We examined the prevalence of prenatal and postpartum counseling, provider discouragement of IUDs and implants, and associated sociodemographic characteristics using χ2 tests and logistic regression. Results: One-half of participants had received any prenatal contraceptive counseling, and 13% and 37% received counseling on both IUDs and implants prenatally and postpartum, respectively. Women with more children were more likely to receive any contraceptive counseling prenatally (odds ratio [OR], 1.99; p < .01). Privately insured women (OR, 0.53; p < .05) had a lower odds of receiving prenatal counseling on IUDs and implants than publicly insured women. Higher education (OR, 2.16; p < .05) and attending a private practice (OR, 2.16; p < .05) were associated with receiving any postpartum counseling. Older age (OR, 0.61; p < .05) was negatively associated with receiving postpartum counseling about IUDs and implants and a family income of $10,000 to $19,000 (OR, 2.21; p < .01) was positively associated. Approximately 20% of women receiving prenatal counseling and 10% receiving postpartum counseling on IUDs and implants were discouraged from using them. The most common reason providers restricted use of these methods was inaccurate medical advice. Conclusions: Prenatal and postpartum counseling, particularly about IUDs and implants, was infrequent and varied by sociodemographics. Providers should implement evidence-based prenatal and postpartum contraceptive counseling to ensure women can make informed choices and access their preferred method of postpartum contraception.

Obstetrics and GynecologyPostabortion Contraceptive Use and Continuation When Long-Acting Reversible Contraception Is Free

Vinita Goyal, Caitlin Canfield, Abigail R. A. Aiken, Amna Dermish, and Joseph E. Potter
Obstetrics & Gynecology 2017; published online ahead of print March 9, 2017; available online through Ovid; and as a PDF

Abstract: Objective: To compare preference for long-acting contraception (LARC) and subsequent use, year-long continuation, and pregnancy among women after induced abortion who were and were not eligible to participate in a specialized funding program that provided LARC at no cost. Methods: Between October 2014 and March 2016, we conducted a prospective study of abortion patients at Planned Parenthood in Austin, Texas (located in Travis County). We compared our primary outcome of interest, postabortion LARC use, among women who were eligible for the specialized funding program (low-income, uninsured, Travis County residents) and two groups who were ineligible (low-income, uninsured, non-Travis County residents, and higher income or insured women). Secondary outcomes of interest included preabortion preference for LARC and 1-year continuation and pregnancy rates among the three groups. Results: Among 518 women, preabortion preference for LARC was high among all three groups (low-income eligible: 64% [91/143]; low-income ineligible: 44% [49/112]; and higher income 55% [146/263]). However, low-income eligible participants were more likely to receive LARC (65% [93/143] compared with 5% [6/112] and 24% [62/263], respectively, P<.05). Specifically, after adjusting for age, race-ethnicity, and education, low-income eligible participants had a 10-fold greater incidence of receiving postabortion LARC compared with low-income ineligible participants (incidence rate ratio 10.13, 95% confidence interval [CI] 4.68-21.91). Among low-income eligible and higher income women who received postabortion LARC, 1-year continuation was 90% (95% CI 82-97%) and 86% (95% CI 76-97%), respectively. One-year pregnancy risk was higher among low-income ineligible than low-income eligible women (hazard ratio 3.28, 95% CI 1.15-9.31). Conclusion: Preference for postabortion LARC was high among all three eligibility groups, yet women with access to no-cost LARC were more likely to use and continue these methods. Low-income ineligible women were far more likely to use less effective contraception and become pregnant. Specialized funding programs can play an important role in immediate postabortion contraceptive provision, particularly in settings where state funding is limited.

AJMHBarriers to Offering Vasectomy at Publicly Funded Family Planning Organizations in Texas

Kari White, Anthony Campbell, Kristine Hopkins, Daniel Grossman, and Joseph E. Potter
American Journal of Men's Health 2017; published online ahead of print January 27, 2017; available online as an open access version through SAGE Journals; and as a PDF
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Abstract: Few publicly funded family planning clinics in the United States offer vasectomy, but little is known about the reasons this method is not more widely available at these sources of care. Between February 2012 and February 2015, three waves of in-depth interviews were conducted with program administrators at 54 family planning organizations in Texas. Participants described their organization’s vasectomy service model and factors that influenced how frequently vasectomy was provided. Interview transcripts were coded and analyzed using a theme-based approach. Service models and barriers to providing vasectomy were compared by organization type (e.g., women’s health center, public health clinic) and receipt of Title X funding. Two thirds of organizations did not offer vasectomy on-site or pay for referrals with family planning funding; nine organizations frequently provided vasectomy. Organizations did not widely offer vasectomy because they could not find providers that would accept the low reimbursement for the procedure or because they lacked funding for men’s reproductive health care. Respondents often did not perceive men’s reproductive health care as a service priority and commented that men, especially Latinos, had limited interest in vasectomy. Although organizations of all types reported barriers, women’s health centers and Title X-funded organizations more frequently offered vasectomy by conducting tailored outreach to men and vasectomy providers. A combination of factors operating at the health systems and provider level influence the availability of vasectomy at publicly funded family planning organizations in Texas. Multilevel approaches that address key barriers to vasectomy provision would help organizations offer comprehensive contraceptive services.

JAMAChange in Distance to Nearest Facility and Abortion in Texas, 2012 to 2014

Daniel Grossman, Kari White, Kristine Hopkins, and Joseph E. Potter
JAMA 2017; 317(4): 437-439; published online ahead of print January 19, 2017; available online through JAMA Network
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Abstract: This Research Letter demonstrates that increases in travel distance to the nearest abortion clinic caused by clinic closures between 2012 and 2014 were closely associated with decreases in the official number of abortions in Texas. Counties where the distance to the nearest facility increased 100 miles or more between 2012 and 2014 saw a 50% decline in abortions. Meanwhile, counties that did not have an abortion provider in 2014 and did not experience a change in distance to the nearest facility had essentially no change in the number of abortions.

2016

JAMAThe Use of Public Health Evidence in Whole Woman’s Health v Hellerstedt

Daniel Grossman
JAMA Internal Medicine 2017; 177(2): 155-156; published online ahead of print November 7, 2016; available online through JAMA Network

Abstract: [This piece, written for the JAMA Internal Medicine "Viewpoints" section, discusses the impacts of House Bill 2, as documented by TxPEP research, and the use of research-based evidence in Whole Woman's Health v Hellerstedt.The Supreme Court decision in the Whole Woman’s Health case provides a clearer judicial standard related to undue burden on women seeking abortion. The Court said laws restricting abortion cannot be considered in the abstract—or just because a legislature says they would be beneficial. Instead, courts must compare the benefit the law is likely to provide with the burden the law will impose on women. The Court’s decision shows that evidence matters, which hopefully heralds a new emphasis on data-driven policies for reproductive health.

PLOS ONEWomen’s Experience Obtaining Abortion Care in Texas after Implementation of Restrictive Abortion Laws: A Qualitative Study

Sarah E. Baum, Kari White, Kristine Hopkins, Joseph E. Potter, and Daniel Grossman.
PLOS ONE; published online October 26, 2016; available online as a public access version through PLOS ONE; and as a PDF
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AbstractBackground: In November 2013, Texas implemented three abortion restrictions included in House Bill 2 (HB 2). Within six months, the number of facilities providing abortion decreased by almost half, and the remaining facilities were concentrated in large urban centers. The number of medication abortions decreased by 70% compared to the same period one year prior due to restrictions on this method imposed by HB 2. The purpose of this study was to explore qualitatively the experiences of women who were most affected by the law: those who had to travel farther to reach a facility and those desiring medication abortion. Methods: In August and September 2014, we conducted 20 in-depth interviews with women recruited from ten abortion clinics across Texas. The purposive sample included women who obtained or strongly preferred medication abortion or traveled ≥50 miles one way to the clinic. The interview guide focused on women’s experiences with obtaining services following implementation of HB 2, and a thematic analysis was performed. ResultsWomen faced informational, cost and logistical barriers seeking abortion services, and these obstacles were often compounded by poverty. Two women found the process of finding or getting to a clinic so onerous that they considered not having the procedure, although they ultimately had an abortion; another woman decided to continue her pregnancy, in part because of challenges in getting to the clinic. For two women, arranging travel required disclosure to more people than desired. Women who strongly preferred medication abortion were frustrated by the difficulty or inability to obtain their desired method, especially among those who were near or just beyond the gestational age limit. The restricted eligibility criteria for medication abortion and difficulty finding clinics offering the method created substantial access barriers. ConclusionsMedication abortion restrictions and clinic closures following HB 2 created substantial barriers for women seeking abortion in Texas.

BirthNativity, Country of Education, and Mexican-Origin Women's Breastfeeding Behaviors in the First 10 Months Postpartum

C. Emily Hendrick and Joseph E. Potter.
Birth: Issues in Prenatal Care 2017; 44(1): 68-77; published online October 25, 2016; available online through Wiley Online Library

AbstractBackgroundBreastfeeding is associated with numerous health benefits for the infant and mother. Latina women in the United States have historically had high overall rates of initiation and duration of breastfeeding. However, these rates vary by nativity and time lived in the United States. Exclusive breastfeeding patterns among Latina women are unclear. In this study, we investigate the current and exclusive breastfeeding patterns of Mexican-origin women at four time points from delivery to 10 months postpartum to determine the combined association of nativity and country of education with breastfeeding duration and supplementation. MethodsData are from the Postpartum Contraception Study, a prospective cohort study of postpartum women ages 18–44 recruited from three hospitals in Austin and El Paso, Texas. We included Mexican-origin women who were born in either the United States or Mexico in the analytic sample (n = 593). ResultsWomen completing schooling in Mexico had higher rates of overall breastfeeding throughout the study period than women educated in the United States, regardless of country of birth. This trend held in multivariate models while diminishing over time. Women born in Mexico who completed their schooling in the United States were least likely to exclusively breastfeed. DiscussionCountry of education should also be considered when assessing Latina women's risk for breastfeeding discontinuation. Efforts should be made to identify the barriers and facilitators to breastfeeding among US-educated Mexican-origin women to enhance existing breastfeeding promotion efforts in the United States.

Maternal Child HealthThe Availability and Use of Postpartum LARC in Mexico and Among Hispanics in the United States

Joseph E. Potter, Celia Hubert, and Kari White.
Maternal and Child Health Journal 2016; 21(9), 1744-1752, published online ahead of print August 26, 2016; available online through SpringerLink
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Abstract: Objectives: In the 1980s, policy makers in Mexico led a national family planning initiative focused, in part, on postpartum IUD use. The transformative impact of this initiative is not well known, and is relevant to current efforts in the United States (US) to increase women’s use of long-acting reversible contraception (LARC). Methods: Using six nationally representative surveys, we illustrate the dramatic expansion of postpartum LARC in Mexico and compare recent estimates of LARC use immediately following delivery through 18 months postpartum to estimates from the US. We also examine unmet demand for postpartum LARC among 321 Mexican-origin women interviewed in a prospective study on postpartum contraception in Texas in 2012, and describe differences in the Mexican and US service environments using a case study with one of these women. Results: Between 1987 and 2014, postpartum LARC use in Mexico doubled, increasing from 9 to 19 % immediately postpartum and from 13 to 26 % by 18 months following delivery. In the US, <0.1 % of women used an IUD or implant immediately following delivery and only 9 % used one of these methods at 18 months. Among postpartum Mexican-origin women in Texas, 52 % of women wanted to use a LARC method at 6 months following delivery, but only 8 % used one. The case study revealed provider and financial barriers to postpartum LARC use. Conclusions: Some of the strategies used by Mexico’s health authorities in the 1980s, including widespread training of physicians in immediate postpartum insertion of IUDs, could facilitate women’s voluntary initiation of postpartum LARC in the US.

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 2016; 48(4): 189-197; published online ahead of print April 15, 2016; available online through Wiley Online Library; and as a PDF
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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 2016; 106(5): 857-864; published online ahead of print March 17, 2016; available online through the American Journal of Public Health; as an open access version; and as a PDF

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 2016; 374(9): 853-860; published online ahead of print Feburary 3, 2016; available online through the New England Journal of Medicine; and as a PDF

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 2016; 93(4): 292-297; published online ahead of print January 6, 2016; available online through ScienceDirect; as an open access version; and as a PDF

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, Kristine Hopkins, Abigail R. A. Aiken, Kari White, and Daniel Grossman
Obstetrics and Gynecology 2016; 127(2): 289-296; published online ahead of print January 7, 2016; available online through Obstetrics & Gynecology; as an open access version; and as a PDF

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.

2015

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

Junda Woo, Hasanat Alamgir, Joseph E. Potter
Contraception 2016; 93(4): 298-302; published online ahead of print December 8, 2015; available online through ScienceDirect; as an open access version; and as a PDF

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 2015; 92(5): 422-438; published online ahead of print July 31, 2015; available online through ScienceDirect; and as a PDF.

Abstract: Objective: We conducted a systematic review to examine the prevalence of minor and major complications following first-trimester aspiration abortion requiring medical or surgical intervention. Study Design: We searched PubMed, Cumulative Index to Nursing and Allied Health Literature, Scopus and the Cochrane Library for articles published between 1980 and April 2015 that reported on repeat aspiration, hemorrhage, infection, cervical/vaginal trauma, uterine perforation, abdominal surgery, hospitalization, anesthesia-related complications and death. We limited our review to studies that included ≥ 100 abortions performed by physicians in North America, Western Europe, Scandinavia and Australia/New Zealand. We compared the prevalence of complications that required additional interventions for abortions performed in office-based clinics and surgical center or hospital clinic settings. Results: From 11,369 articles retrieved, 57 studies met our inclusion criteria. Evidence from 36 studies suggests that ≤ 3.0% of procedures performed in any setting necessitates repeat aspiration. Hemorrhage not requiring transfusion occurred in 0–4.7% of office-based procedures and 0–4.1% of hospital-based procedures but was ≤ 1.0% in 23 studies. Major complications requiring intervention, including hemorrhage requiring transfusion and uterine perforation needing repair, occurred in ≤ 0.1% of procedures, and hospitalization was necessary in ≤ 0.5% of cases in most studies. Anesthesia-related complications occurred in ≤ 0.2% of procedures in six office-based studies and ≤ 0.5% of procedures performed in surgical centers or hospital-based clinics. No abortion-related deaths were reported. Conclusions: The percentage of first-trimester aspiration abortions that required interventions for minor and major complications was very low. Overall, the prevalence of major complications was similar across clinic contexts, indicating that this procedure can be safely performed in an office setting. Implications: Laws requiring abortion providers to have hospital admitting privileges or facilities to meet ambulatory surgical center standards would be unlikely to improve the safety of first-trimester aspiration abortion in office settings.

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 2015; 105(5): 851-858; published online ahead of print March 19, 2015; available online through American Journal of Public Health; as an open access version; and as a PDF

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 2015; 47(2): 63-70; available online through Wiley Online Library; as a public access version; and as a PDF

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.

2014

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; as an open access version; and as a PDF

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 an open access version; and as a PDF

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 and as an open access version; and as a PDF

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; as an open access version; and as a PDF

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.

2012

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; and as a PDF

Abstract: Recently, efforts to expand access to contraception through the Affordable Care Act ignited a broad debate regarding the proper role of government in this sphere, and proposals have been put forth to eliminate Title X. In 2011, Texas cut funding for family planning services by two thirds. The Texas legislature also imposed new restrictions on abortion care and reauthorized the exclusion of organizations affiliated with abortion providers from participation in the state Medicaid waiver program, the Women's Health Program (WHP). To implement the legislation and funding cuts, the Texas Department of State Health Services reduced the number of funded family planning organizations from 76 to 41. As part of a comprehensive 3-year evaluation of the legislative changes to family planning policy in Texas, we interviewed 56 leaders of organizations throughout the state that provided reproductive health services using Title X and other public funding before the cuts went into effect. We found that funding cuts led to the closure of 53 clinics and reduced hours at an additional 38. In addition, we found that providers restricted access to the most effective contraceptive methods and implemented systems that require clients to pay for services if they do not qualify for the WHP. Ostensibly, the purpose of the law was to defund Planned Parenthood in an attempt to limit access to abortion, even though federal and state funding cannot be used for abortion care. Instead, these policies are limiting women's access to a range of preventive reproductive health services and screenings.

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