Texas Policy Evaluation Project
TEXPEP upper righthand gray scale identity logo

TxPEP Publications

2020 - 2019  -  2018  -  2017  -  2016  -  2015  -  2014  -  2012

2020

ContraceptionUnsatisfied Preferences Due to Cost among Women in the United States

Burke KL, Potter JE, White K. Unsatisfied preferences due to cost among women in the United States. Contraception, 2020.

Published online ahead of print July 2020. Available as a PDF.
Read the Press Release

Abstract: Objectives: To examine prevalence and characteristics associated with cost barriers to preferred contraceptive use. Study design: Among a nationally representative sample of women at risk of unplanned pregnancy in 20152017, we used Poisson regression to assess characteristics associated preferring a(nother) method in the absence of cost. Results: Overall, 22% preferred to use a(nother) method. Women using less-effective methods, who were Black or Hispanic, ages 1524 and had low incomes, were more likely to report cost barriers. Conclusions: Using a preferred method is an indicator of access to care and reproductive autonomy. These results provide a benchmark to track the impact of policy changes.

ContraceptionDifferences in Abortion Rates by Race-Ethnicity after Implementation of a Restrictive Texas Law

Goyal, V, McLoughlin Brooks, IH, Powers, D. Differences in abortion rates by race-ethnicity after implementation of a restrictive Texas law. Contraception, 2020.

Published online ahead of print April 2020. Available online through Science Direct and as a PDF.
Read the Press Release

AbstractObjective: To evaluate the association between a restrictive Texas law, House Bill 2 (HB2), and receipt of in-clinic abortion by patient’s race-ethnicity. Study Design: In this retrospective cohort study, we collected Texas state statistics on number of abortions, abortions per county, and abortions per county by race-ethnicity for 2012, before HB2 was enacted, and 2015, after HB2 was in effect. Using female reproductive-aged population estimates, we calculated the abortion rate and percent change in the abortion rate between the two time periods by county, patient residence in a county with an open clinic or HB2-related clinic closure, and change in distance to an open clinic for each race-ethnicity. We also used geospatial analyses to depict the greatest decrease in abortion rate by race-ethnicity and county. Results: In Texas, there were 64,716 reported abortions in 2012 and 54,253 in 2015. Statewide, there was a 20% decrease in the abortion rate affecting all racial-ethnic groups, yet the reduction was greater among Hispanic women compared to White women (-25% vs. -16%, respectively). The abortion rate also decreased more among those living in a county with an HB2-related clinic closure, especially for Hispanic women (-41% Hispanic vs. -29% White vs. -30% Black vs. -3% Other). Hispanic women whose travel distance increased 100+ miles had the greatest reduction in the abortion rate (-43%). Geospatial mapping confirmed our quantitative findings. Conclusion: HB2 led to a disproportionate reduction in the abortion rate among Hispanic women in Texas, including those living in counties with a closed clinic or traveling long distances to obtain in-clinic abortion care. Implications: Restrictive abortion policies in Texas may disproportionately burden Hispanic women and those affected by clinic closures.

ajogMedication Abortion Use among Low-Income and Rural Texans Before and During State-Imposed Restrictions and After FDA-Updated Labeling

Goyal V, McLoughlin Brooks IH, Wallace R, Dermish A, Kumar B, Schutt-Aine A, Beasley A, Aiken A, Potter JE. Medication abortion use among low-income and rural Texans before and during state-imposed restrictions and after FDA-updated labeling. American Journal of Obstetrics and Gynecology, 2020.

Published online ahead of print April 2020. Available online through Science Direct and as PDF
Read the Press Release

Abstract: Background: In 2013, the Texas legislature passed House Bill 2 (HB2) restricting use of medication abortion to comply with FDA labeling from 2000. The FDA updated its labeling for medication abortion in 2016, alleviating some of the burdens imposed by HB2. Objective: Our objective was to identify the impact of HB2 on medication abortion use by patient travel distance to an open clinic and income status. Study Design: In this retrospective study, we collected patient zip code, county of residence, type of abortion, family size, and income data on all patients who received an abortion (medication or aspiration) from seven Texas abortion clinics in three time periods: pre-HB2 (July 1, 2012-June 30, 2013), during HB2 (April 1, 2015-March 30, 2016), and post-FDA labeling update (April 1, 2016-March 30, 85 2017). Patient driving distance to the clinic where care was obtained was categorized as 1-24, 25-49, 50-99, or 100+ miles. Patient’s county of residence was categorized by availability of a clinic during HB2 (open clinic), county with an HB2-related clinic closure (closed clinic), or no clinic any time period. Patient income was categorized as ≤110% federal poverty level (low-income) and >110% federal poverty level. Change in medication abortion use in the three time periods by patient driving distance, residence in a county with an open clinic, and income status were evaluated using chi-squared tests and logistic regression. We used geospatial mapping to depict the spatial distribution of patients who obtained medication abortion in each time period. Results: Among 70,578 abortion procedures, medication abortion comprised 26%, 7%, and 29% of cases pre-HB2, during HB2, and post-FDA labeling update, respectively. During HB2, patients traveling 100+ miles compared to 1-24 miles were less likely to use medication abortion, as were low compared to higher-income patients, and low-income, distant patients. Similarly, post-FDA labeling update, rebound in medication abortion use was less pronounced for patients traveling 100+ miles compared to 1-24 miles, lower compared to higher income patients, and low-income, distant patients. Post-FDA labeling update, patients residing in counties with HB2-related clinic closures were less likely to receive medication abortion as driving distance increased (52% traveling 25-49 miles, 41% traveling 50-99 miles, and 26% traveling 100+ miles). Geospatial mapping demonstrated that patients traveled from all over the state to receive medication abortion pre-HB2 and post-FDA labeling update, whereas during HB2, only those living in or near a county with an open clinic obtained medication abortion. Conclusions: Texas state law drastically restricted access to medication abortion and disproportionately impacted low-income patients and those living farther from an open clinic. After the FDA labeling update, medication abortion use rebounded, but disparities in use remained.

PediatricsBreastfeeding Initiation, Duration, and Supplementation Among Mexican-Origin Women in Texas

Eilers M, Hendrick CE, Pérez-Escamilla R, Powers D, Potter JE. Breastfeeding initiation, duration, and supplementation among Mexican-origin women in Texas. Pediatrics, 2020.

Published online ahead of print March 18, 2020. Available online through Pediatrics
Read the Press Release

Abstract: Background: Mexican-origin women breastfeed at similar rates as white women in the United States, yet they usually breastfeed for less time. In our study, we seek to identify differences in Mexican-origin women’s breastfeeding intentions, initiation, continuation, and supplementation across nativity and country-of-education groups. Methods: The data are from a prospective cohort study of postpartum women ages 18 to 44 recruited from 8 Texas hospitals. We included 1235 Mexican-origin women who were born and educated in either Texas or Mexico. Women were interviewed at delivery and at 3, 6, 12, 18, and 24 months post partum. Breastfeeding intentions and initiation were reported at baseline, continuation was collected at each interview, and weeks until supplementation was assessed for both solids and formula. Women were classified into 3 categories: born and educated in Mexico, born and educated in the United States, and born in Mexico and educated in the United States. Results: Breastfeeding initiation and continuation varied by nativity and country of birth, although all women reported similar breastfeeding intentions. Women born and educated in Mexico initiated and continued breastfeeding in higher proportions than women born and educated in the United States. Mexican-born and US-educated women formed an intermediate group. Early supplementation with formula and solid foods was similar across groups, and early supplementation with formula negatively impacted duration across all groups. Conclusions: Nativity and country of education are important predictors of breastfeeding and should be assessed in pediatric and postpartum settings to tailor breastfeeding support. Support is especially warranted among US-born women, and additional educational interventions should be developed to forestall early supplementation with formula across all acculturation groups.

Perspectives coverAdolescents Obtaining Abortion Without Parental Consent: Their Reasons and Experiences of Social Support

Coleman-Minahan K, Stevenson AJ, Obront E, Hays S. Adolescents obtaining abortion without parental consent: their reasons and experiences of social support. Perspectives, 2020.

Published online ahead of print March 1, 2020. Available online open access through Wiley and as a PDF.
Read the Press Release

Abstract: ContextMost states require adolescents younger than 18 to involve a parent prior to obtaining an abortion, yet little is known about adolescents’ reasons for choosing abortion or the social support received by those who seek judicial bypass of parental consent for abortion. Methods: In‐depth interviews were conducted with 20 individuals aged 16–19 who sought judicial bypass in Texas between 2015 and 2016 to explore why they chose to get an abortion, who they involved in their decision and what their experiences of social support were. Data were analyzed thematically using stigma and social support theories. Results: Participants researched their pregnancy options and involved others in their decisions. They chose abortion because parenting would limit their futures, and they believed they could not provide a child with all of her or his needs. Anticipated stigma motivated participants to keep their decision private, although they desired emotional and material support. Not all male partners agreed with adolescents’ decisions to seek an abortion, and agreement by some males did not guarantee emotional or material support; some young women described their partners’ giving them the “freedom” to make the decision as avoiding responsibility. After a disclosure of their abortion decision, some participants experienced enacted stigma, including shame and emotional abuse. Conclusions: Abortion stigma influences adolescents’ disclosure of their abortion decisions and limits their social support. Fears of disclosing their pregnancies and abortion decisions are justified, and policymakers should consider how laws requiring parental notification may harm adolescents. Further research is needed on adolescents’ experiences with abortion stigma.

journal_adohealthAvailability of Confidential Services for Teens Declined After the 2011-2013 Changes to Publicly Funded Family Planning Programs
in Texas

Coleman-Minahan K, Hopkins K, White K. Availability of confidential services for teens declined after the 2011-2013 changes to publicly funded family planning programs in Texas. Journal of Adolescent Health, 2020.

Published online ahead of print February 19, 2020. Available open access through ScienceDirect and as a PDF.
Read the Press Release.

Abstract: Purpose: Texas is one of 24 states that does not explicitly allow minors to consent to contraception. We explore changes in the provision of confidential reproductive health services after the implementation of state policies that cut and reorganized public family planning funding, including Title X. Methods: We use data from 3 waves of in-depth interviews, conducted between February 2012 and February 2015, with program administrators at publicly funded family planning organizations in Texas about changes in service delivery.We conducted a thematic analysis of transcripts from 47 organizations with segments related to the provision of services to minor teens. Results: Overall, 34 of the 47 organizations received Title X funding before 2013, and 79% lost this funding during the study period. Respondents at these organizations frequently reported a decrease in teen clients, which they attributed to loss of confidential services previously guaranteed under Title X. As the number of Title X-funded sites decreased, availability of confidential services became inconsistent. Most organizations offered confidential testing for pregnancy and sexually transmitted infections, but availability of confidential contraceptive services varied across and within organizations and often depended on insurance coverage. Respondents also reported challenges clarifying parental consent requirements after the changes in Title X and state funding. Conclusions: Loss of Title X funding decreased availability of quality family planning services for teens and burdened organizations. As the new Title X regulations are implemented, family planning organizations' experiences in Texas foreshadow what might occur nationally, particularly in states that do not allow minors to consent for contraception.

American Journal of Public Health coverDenials of Judicial Bypass Petitions for Abortion in Texas Before and After the 2016 Bypass Process Change: 2001–2018

Stevenson AJ, Coleman-Minahan K, Hays S. Denials of judicial bypass petitions for abortion in Texas before and after the 2016 bypass process change: 2001–2018. American Journal of Public Health, 2020.

Published online ahead of print January 16, 2020; available online open access through AJPH and as a PDF.
Read the Press Release.

Abstract: Objectives. To estimate the percentage of Texas judicial bypass petitions for abortion denied annually from 2001 to 2018, and to assess whether that fraction changed after the state’s 2016 bypass process change. Methods. Because official statistics on Texas judicial bypass case counts and outcomes are only available for 2016 and later, we systematically reviewed monthly internal reports from Jane’s Due Process (JDP), an organization providing legal representation to pregnant minors seeking bypass from 2001 to 2018. We report numbers and percentages of JDP cases denied for 2001 to 2018 and numbers and percentages of all cases denied from official Texas statistics for 2016 to 2018 (all available years). Results. At least 1 denial occurred in 11 out of 15 years observed before the bypass law changed in Texas (percentages = 0%–6.2%). After Texas made its bypass process more restrictive, the percentage denied increased (from 2.8% in 2015 to 10.3% in 2016 among JDP cases). Conclusions. We found the greatest percentages of judicial bypass for abortion petitions denied after the policy was implemented and after the bypass process changed. Judicial bypass for abortion may expose pregnant minors to judicial veto of their abortion decision.

BMC Women's HealthTexas Women’s Decisions and Experiences Regarding Self-Managed Abortion

Fuentes L, Baum S, Keefe-Oates B, White K, Hopkins K, Potter JE, Grossman D. Texas women’s decisions and experiences regarding self-managed abortion. BMC Women’s Health 2020, 20,6.

Published online January 6, 2020. Available onilne open access from BMC Women's Health.
Read the Press Release.

Abstract: Background: Prior research has shown that a small proportion of U.S. women attempt to self-manage their abortion. The objective of this study is to describe Texas women’s motivations for and experiences with attempts to self-manage an abortion. The objective of this study is to describe Texas women’s motivations for and experiences with attempts to self-manage an abortion. Methods: We report results from two data sources: two waves of surveys with women seeking abortion services at Texas facilities in 2012 and 2014 and qualitative interviews with women who reported attempting to self-manage their abortion while living in Texas at some time between 2009 and 2014. We report the prevalence of attempted self-managed abortion for the current pregnancy among survey respondents, and describe interview participants’ decision-making and experiences with abortion self-management. Results: 6.9% (95% CI 5.2–9.0%) of abortion clients (n = 721) reported they had tried to end their current pregnancy on their own before coming to the clinic for an abortion. Interview participants (n = 18) described multiple reasons for their decision to attempt to self-manage abortion. No single reason was enough for any participant to consider self-managing their abortion; however, poverty intersected with and layered upon other obstacles to leave them feeling they had no other option. Ten interview participants reported having a complete abortion after taking medications, most of which was identified as misoprostol. None of the six women who used home remedies alone reported having a successful abortion; many described using these methods for several days or weeks which ultimately did not work, resulting in delays for some, greater distress, and higher costs. Conclusion: These findings point to a need to ensure that women who may consider self-managed abortion have accurate information about effective methods, what to expect in the process, and where to go for questions and follow-up care. There is increasing evidence that given accurate information and access to clinical consultation, self-managed abortion is as safe as clinic-based abortion care and that many women find it acceptable, while others may prefer to use clinic-based abortion care.

2019

ContraceptionQuality of Postpartum Contraceptive Counseling and Changes in Contraceptive Method Preferences

Coleman-Minahan K and Potter JE. Quality of postpartum contraceptive counseling and changes in contraceptive method preferences, Contraception. Online First 2019.

Published online ahead of print September 4, 2019; available online through ScienceDirect.

Abstract: Objectives: We examined the association between quality of postpartum contraceptive counseling and changes in contraceptive method preference between delivery and 3-months postpartum. Study design: We used data from 1167 postpartum women delivering at eight hospitals in Texas who did not initiate contraception in the hospital. We conducted baseline and 3-month follow-up interviews to ask women about the method they would prefer to use at 6-months postpartum, postpartum contraceptive counseling, reproductive history, and demographic characteristics. We measured quality of postpartum contraceptive counseling with seven items related to satisfaction and information received. High-quality counseling was defined as meeting all seven criteria. We used logistic regression to predict the primary outcome of changes in preferred method by contraceptive counseling and described contraceptive counseling and changes in preferred method by demographic characteristics. Results: Receipt of high-quality postpartum contraceptive counseling was reported by 26%. At 3-months postpartum 70% of participants reported the same contraceptive preferences by category of effectiveness that they expressed at the time of delivery. Spanish-speaking, Hispanic foreign-born, and lower socioeconomic status women were less likely to receive high-quality counseling than their counterparts. High-quality counseling was associated with lower odds of preferring a less effective method (OR: 0.31, 95% CI: 0.18–0.52) and changing preference from an IUD or implant (OR: 0.34, 95% CI: 0.17–0.68). Conclusions: High-quality postpartum contraceptive counseling is relatively rare and occurs less often among low SES and immigrant women. High quality counseling appears to reinforce preferences for highly effective contraception. Implications: Training healthcare providers to provide high-quality contraceptive counseling to all postpartum women may reduce contraceptive disparities related to race/ethnicity and social class.

Obstetrics and GynecologyChange in Second-Trimester Abortion After Implementation of a Restrictive State Law

White K, Baum S, Hopkins K, Potter JE, and Grossman D. Change in second-trimester
abortion after implementation of a restrictive state law, Obstetrics & Gynecology. Online First 2019.

Published online ahead of print March 12, 2019; available online through Obstetrics & Gynecology and as a PDF.
Read the Press Release.

AbstractObjectiveTo assess whether indicators of limited access to services explained changes in rates of second-trimester abortion after implementation of a restrictive abortion law in Texas. MethodsWe used cross-sectional vital statistics data on abortions performed in Texas before (November 1, 2011–October 31, 2012) and after (November 1, 2013–October 31, 2014) implementation of Texas' abortion law. We conducted monthly mystery client calls for information about abortion facility closures and appointment wait times to calculate distance from women's county of residence to the nearest open Texas facility, the number of open abortion facilities in women's region of residence (facility network size), and days until the next consultation visit. We estimated mixed-effects logistic regression models to assess the association between obtaining abortion care after the law's implementation and having a second-trimester abortion (12 weeks of gestation or more), after adjustment for distance, network size, and wait times. ResultsOverall, 64,902 Texas-resident abortions occurred in the period before the law was introduced and 53,174 occurred after its implementation. After implementation, 14.5% of abortions were performed at 12 weeks of gestation or more, compared with 10.5% before the law (P<.001; unadjusted odds ratio [OR] 1.45; 95% CI 1.40–1.50). Adjusting for distance to the nearest facility and facility network size reduced the odds of having a second-trimester abortion after implementation (OR 1.17; 95% CI 1.10–1.25). Women living 50–99 miles from the nearest facility (vs less than 10 miles) had higher odds of second-trimester abortion (OR 1.24; 95% CI 1.11–1.39), as did women in regions with less than one facility per 250,000 reproductive-aged women compared with women in areas that had 1.5 or more facilities (OR 1.57; 95% CI 1.41–1.75). After implementation, women waited 1 to 14 days for a consultation visit; longer waits were associated with higher odds of second-trimester abortion. ConclusionIncreases in second-trimester abortion after the law's implementation were due to women having more limited access to abortion services.

ContraceptionChallenging Unintended Pregnancy as an Indicator of Reproductive Autonomy

Potter JE, Stevenson AJ, Coleman-Minahan K, Hopkins K, White K, Baum S, Grossman, D. Challenging unintended pregnancy as an indicator of reproductive autonomy, Contraception. Online first, 2019.

Published online ahead of print March, 2019. Available online through ScienceDirect and as a PDF.

Abstract: In this commentary, the authors argue for the replacement of unintended pregnancy as a prime indicator of reproductive autonomy. They write, “By treating high levels of unintended pregnancy as the problem motivating our scholarship our field reinforces a conception of abortions as health system failures, valorizes more effective contraceptive methods regardless of women’s desires, and contributes to the stigmatization of fertility among already-marginalized groups.” By including other measures, such as access to abortion and preferred contraception and the power to freely negotiate and engage in sexual activity, scholars can develop a more nuanced approach towards reproductive autonomy. The authors suggest that corrections can be made: first, abortion should be treated not as a failure but as a valid reproductive option. Second, responsibility for greater reproductive autonomy should be placed on the shoulders of the systems providing care, not on women themselves. The piece concludes that this “would change the incentives for healthcare providers, policy evaluators, and lawmakers away from public health interventions aimed at altering women’s behavior, and align them more directly with the goal of increasing reproductive autonomy.”

ContraceptionRebound of Medication Abortion in Texas Following Updated Mifepristone Label

Baum S, White K, Hopkins K, Potter JE, Grossman D. Rebound of medication abortion in Texas following updated mifepristone label, Contraception. Online First 2019.

Published online ahead of print February 25, 2019; available online open access through Elsevier and as a PDF.
Read the Press Release.

Abstract: Background: In 2013, Texas House Bill 2 (HB 2) placed restrictions on the use of medication abortion, which later were nullified with the 2016 FDA-approved mifepristone label. Methods: Using data collected directly from Texas abortion facilities, we evaluated changes in the provision and use of medication abortion during three 6-month time periods corresponding to the policy changes: before HB 2, after HB 2 and after the label change. Results: Medication abortion constituted 28% of all abortions before HB 2, 10% after implementation of the restrictions and 33% after the label change. Conclusions: Use of medication abortion in Texas rebounded after the FDA label change.

2018

Perspectives coverLow‐Income Texas Women's Experiences Accessing Their Desired Contraceptive Method at the First Postpartum Visit

Coleman-Minahan, K., Dillaway, C., Canfield, C., Kuhn, D., Strandberg, K., & Potter, J. E. Low-income Texas women's experiences accessing their desired contraceptive method at the first postpartum visit, Perspectives on Sexual and Reproductive Health. Online first 2018. 

Published online ahead of print December 3, 2018; available online through Wiley Online Library and as a PDF.
Read the Press Release
Read the Policy Brief

Abstract: Context: Early access to contraception may increase postpartum contraceptive use. However, little is known about women's experiences receiving their desired method at the first postpartum visit or how access is associated with use. Methods: In a 2014–2016 prospective cohort study of low‐income Texas women, data were collected from 685 individuals who desired a reversible contraceptive and discussed contraception with a provider at their first postpartum visit, usually within six weeks of birth. Women's experiences were captured using open‐ and closed‐ended survey questions. Thematic and multivariate logistic regression analyses were employed to examine contraceptive access and barriers, and method use at three months postpartum. Results: Twenty‐three percent of women received their desired method at the first postpartum visit; 11% a prescription for their desired pill, patch or ring; 8% a method (or prescription) other than that desired; and 58% no method. Among women who did not receive their desired method, 44% reported clinic‐level barriers (e.g., method unavailability or no same‐day provision), 26% provider‐level barriers (e.g., inaccurate contraceptive counseling) and 23% cost barriers. Women who used private practices were more likely than those who used public clinics to report availability and cost barriers (odds ratios, 6.4 and 2.7, respectively). Forty‐one percent of women who did not receive their desired method, compared with 86% of those who did, were using that method at three months postpartum. Conclusion: Eliminating the various barriers that postpartum women face may improve their access to contraceptives. Further research is needed to improve the understanding of clinic‐ and provider‐level barriers.

ContraceptionCounseling and Referrals for Women with Unplanned Pregnancies at Publicly Funded Family Planning Organizations in Texas

White K, Adams K, Hopkins K. Counseling and referrals for women with unplanned
pregnancies at publicly funded family planning organizations in Texas, Contraception. Online First 2018.

Published online ahead of print October 11, 2018; available through Science Direct and as a PDF.
Read the Press Release

Abstract: Objectives: To compare pregnancy options counseling and referral practices at state- and Title X-funded family planning organizations in Texas after enforcement of a policy restricting abortion referrals for providers participating in state-funded programs, which differed from Title X guidelines to provide referrals for services upon request. Study design: Between November 2014 and February 2015, we conducted in-depth interviews with administrators at publicly funded family planning organizations in Texas about how they integrated primary care and family planning services, including pregnancy options counseling and referrals for unplanned pregnancies. We conducted a thematic analysis of transcripts related to organizations' pregnancy options counseling and referral practices, and compared themes across organizations that did and did not receive Title X funding. Results: Of the 37 organizations with transcript segments on options counseling and referrals, 15 received Title X and 22 relied on state funding only. All Title X-funded organizations but only nine state-funded organizations reported offering pregnancy options counseling. Respondents at state-only-funded organizations often described directing pregnant women exclusively to prenatal care. Regardless of funding source, most organizations provided women a list of agencies offering abortion, adoption and prenatal care. However, some respondents expressed concern that providing other information about abortion would threaten their state funding. In contrast, respondents indicated staff would make appointments for prenatal care, assist with Medicaid applications and, in some instances, directly connect women with adoption-related services. Conclusions: Pregnancy options counseling varied by organizations' funding guidelines. Additionally, abortion referrals were less common than referrals for other pregnancy-related care. Implications: Programmatic guidelines restricting information on abortion counseling and referrals may adversely affect care for pregnant women at publicly funded family planning organizations.

journal_adohealthYoung Women's Experiences Obtaining Judicial Bypass for Abortion in Texas 

Coleman-Minahan K, Stevenson AJ, Obront, E, Hays, S. Young women’s experiences obtaining judicial bypass for abortion in Texas, Journal of Adolescent Health. Online First 2018.

Published online ahead of print September 5, 2018; available online through Journal of
Adolescent Health
and as a PDF
Read the Press Release
Read the Policy Brief

Abstract: Purpose: Like many states, Texas requires parental consent for adolescents under 18 to access abortion care. Adolescents who cannot obtain parental consent can try to obtain a judicial bypass of parental consent through the court system. Little is known about adolescents experiences with the judicial bypass process. Working with Janes Due Process, an organization providing legal representation for adolescents, we explored adolescents experiences with the judicial bypass process. Methods: We conducted phone interviews with 20 adolescents, 16 to 19 years old in Texas between September and December 2016 about their experiences trying to obtain a judicial bypass. Data analysis included inductive and deductive coding based on theories about engaging with the court system and stigma regarding abortion and adolescent sexuality. Results: In addition to unpredictability and logistic burdens such as finding time away from school and arranging transportation, participants described the bypass process as intimidating and ;scary and described judges and guardians-ad-litem who shamed them, preached at them, and discredited evidence of their maturity. Data suggest adolescents internalize stigma and trauma they experienced through rationalizing both the need for the bypass process and disrespectful treatment by authority figures. Conclusions: We found the bypass process functions as a form of punishment and allows state actors to humiliate adolescents for their personal decisions. The bypass process was implemented to protect adolescents from alleged negative emotional consequences of abortion, yet our results suggest the bypass process itself causes emotional harm through unpredictability and humiliation. Despite participants resilience, the process may have negative consequences for adolescent health.

Journal of American CollegeUnmet Demand for Short-Acting Hormonal and Long-Acting Reversible Contraception Among Community College Students in Texas

Hopkins, K., Hubert, C., Coleman-Minahan, K., Stevenson, A.J., White, K., Grossman, D., Potter, J.E. (2018). Unmet demand for short-acting hormonal and long-acting reversible contraception among community college students in Texas, Journal of American College Health, 66:5, 360-368.

Published online ahead of print March 12, 2018; available online through Taylor Francis Online and as a PDF.
Read the Press Release

Abstract: Objective: To identify preferences for and use of short-acting hormonal (e.g., oral contraceptives, injectable contraception) or long-acting reversible contraception (LARC) among community college students in Texas. Participants: Female community college students, ages 18 to 24, at risk of pregnancy, sampled in Fall 2014 or Spring 2015 (N = 966). Methods: We assessed characteristics associated with preference for and use of short-acting hormonal or LARC methods (i.e., more-effective contraception). Results: 47% preferred short-acting hormonal methods and 21% preferred LARC, compared to 21% and 9%, respectively, who used these methods. A total of 63% of condom and withdrawal users and 78% of nonusers preferred a more effective method. Many noted cost and insurance barriers as reasons for not using their preferred more-effective method. Conclusions: Many young women in this sample who relied on less-effective methods preferred to use more-effective contraception. Reducing barriers could lead to higher uptake in this population at high risk of unintended pregnancy.

2017

HSRProviding Family Planning Services at Primary Care Organizations after the Exclusion of Planned Parenthood from Publicly Funded Programs in Texas: Early Qualitative Evidence

White, K., Hopkins, K., Grossman, D., & Potter, J. E. (2017). Providing family planning services at primary care organizations after the exclusion of Planned Parenthood from publicly funded programs in Texas: Early qualitative evidence, Health Services Research

Published online ahead of print October 20, 2017; available online through Wiley and as a PDF.
Read the Press Release

Abstract: Objective: To explore organizations’ experiences providing family planning during the first year of an expanded primary care program in Texas. Data Sources: Between November 2014 and February 2015, in-depth interviews were conducted with program administrators at 30 organizations: 7 women's health organizations, 13 established primary care contractors (e.g., community health centers, public health departments), and 10 new primary care contractors. Study Design: Interviews addressed organizational capacities to expand family planning and integrate services with primary care. Data Extraction Interview transcripts were analyzed using a theme-based approach. Themes were compared across the three types of organizations. Principal Findings: Established and new primary care contractors identified several challenges expanding family planning services, which were uncommon among women's health organizations. Clinicians often lacked training to provide intrauterine devices and contraceptive implants. Organizations often recruited existing clients into family planning services, rather than expanding their patient base, and new contractors found family planning difficult to integrate because of clients’ other health needs. Primary care contractors frequently described contraceptive provision protocols that were not evidence-based. Conclusions: Many primary care organizations in Texas initially lacked the capacity to provide evidence-based family planning services that women's health organizations already provided.

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


White, K., Grossman, D., Stevenson, A., Hopkins, K., & Potter, J. (2017). Does information about abortion safety affect Texas voters' opinions about restrictive laws? A randomized study. Contraception, 96(6), 381-387.

Published online ahead of print Sept. 1 2017; available online through ScienceDirect; and as a PDF
Read the Press Release

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


Potter, J. E., Coleman-Minahan, K., White, K., Powers, D. A., Dillaway, C., Stevenson, A. J., Hopkins, K., & Grossman, D. (2017). Contraception after delivery among publicly insured women in Texas: Use compared with preference. Obstetrics & Gynecology, 130(2), 393-402. 


Published online ahead of print July 11, 2017; available online through Obstetrics and Gynecology; and as a PDF
Read the Press Release
Watch a Video Presentation on this article by Joseph Potter

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


Coleman-Minahan, K., Aiken, A., & Potter, J. (2017). Prevalence and predictors of prenatal and postpartum contraceptive counseling in two Texas cities. Women’s Health Issues, 27(6), 707-714. 

Published online ahead of print June 27, 2017; available online through Elsevier; and as a PDF

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


Goyal, V., Canfield, C., Aiken, A. R. A., Dermish, A., & Potter, J. E. (2017). Postabortion contraceptive use and continuation when long-acting reversible contraception is free. Obstetrics & Gynecology, 129(4), 655-662. 

Published online ahead of print March 9, 2017; available online through Obstetrics & Gynecology; 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


White, K., Campbell, A., Hopkins, K., Grossman, D., & Potter, J. E. (2017). Barriers to offering vasectomy at publicly funded family planning organizations in Texas. American Journal of Men's Health, 11(3), 757-766. 

Published online ahead of print January 27, 2017; available online as an open access version through SAGE Journals; and as a PDF
Read the Press Release

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


Grossman, D., White, K., Hopkins, K., & Potter, J. E. (2017). Change in distance to nearest facility and abortion in Texas, 2012 to 2014. JAMA, 317(4), 437-439. 

Published online ahead of print January 19, 2017; available online via JAMA Network; and as a PDF
Read the Press Release

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


Grossman, D. (2017). The use of public health evidence in Whole Woman's Health v Hellerstedt. JAMA Internal Medicine, 177(2), 155-156. 

Published online ahead of print November 7, 2016; available online via JAMA Network; and as a PDF

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


Baum, S., White, K., Hopkins, K., Potter, J., & Grossman, D. (2016). Women's experience obtaining abortion care in Texas after implementation of restrictive abortion laws: A qualitative study. Plos One, 11(10). 

Published online October 26, 2016; available online as a public access version through PLOS ONE; and as a PDF
Read the Press Release

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


Hendrick, C. E., & Potter, J. E. (2017). Nativity, country of education, and Mexican‐origin women's breastfeeding behaviors in the first 10 months postpartum. Birth, 44(1), 68-77. 

Published online October 25, 2016; available online through Wiley Online Library; and as a PDF

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


Potter, J. E., Hubert, C., & White, K. (2017). The availability and use of postpartum LARC in Mexico and among Hispanics in the United States. Maternal and Child Health Journal, 21(9), 1744-1752. 

Published online ahead of print August 26, 2016; available online through SpringerLink; and as a PDF
Read the Press Release

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


White, K., Potter, J. E., Stevenson, A. J., Fuentes, L., Hopkins, K., & Grossman, D. (2016). Women's knowledge of and support for abortion restrictions in Texas: Findings from a statewide representative survey. 

Published online ahead of print April 15, 2016; available online through Wiley Online Library; and as a PDF
Read the Press Release

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 coverImpact of Clinic Closures on Women Obtaining Abortion Services After Implementation of a Restrictive Law in Texas


Gerdts, C., Fuentes, L., Grossman, D., White, K., Keefe-Oates, B., Baum, S., Hopkins, K., Stolp, C., Potter, J. (2016). Impact of clinic closures on women obtaining abortion services after implementation of a restrictive law in Texas. American Journal of Public Health, 106(5), 857-864. 

Published online ahead of print March 17, 2016; available online through the American Journal of Public Health; and as a PDF
Read the Press Release

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


Stevenson, A., Flores-Vazquez, I., Allgeyer, R., Schenkkan, P., & Potter, J. (2016). Effect of removal of Planned Parenthood from the Texas Women's Health Program. New England Journal of Medicine, 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
Read the Press Release

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


Fuentes, L., Lebenkoff, S., White, K., Gerdts, C., Hopkins, K., Potter, J., & Grossman, D. (2016). Women's experiences seeking abortion care shortly after the closure of clinics due to a restrictive law in Texas. Contraception, 93(4), 292-297. 

Published online ahead of print January 6, 2016; available online through ScienceDirect; and as a PDF
Read the Press Release

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


Potter, J., Hubert, C., Stevenson, A., Hopkins, K., Aiken, A., White, K., & Grossman, D. (2016). Barriers to postpartum contraception in Texas and pregnancy within 2 years of delivery. Obstetrics and Gynecology, 127(2), 289-296. 

Published online ahead of print January 7, 2016; available online through Obstetrics & Gynecology; and as a PDF
Read the Press Release

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


Woo, C., Alamgir, H., & Potter, J. (2016). Women's experiences after Planned Parenthood’s exclusion from a family planning program in Texas. Contraception, 93(4), 298-302. 

Published online ahead of print December 8, 2015; available online through ScienceDirect; 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


White, K., Carroll, E., & Grossman, D. (2015). Complications from first-trimester aspiration abortion: A systematic review of the literature. Contraception, 92(5), 422-438.

Published online ahead of print July 31, 2015; available online through ScienceDirect; and as a PDF
Read the Press Release

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


White, K., Hopkins, K., Aiken, A., Stevenson, A., Hubert, C., Grossman, D., & Potter, J. (2015). The impact of reproductive health legislation on family planning clinic services in Texas. American Journal of Public Health, 105(5), 851-858. 

Published online ahead of print March 19, 2015; available online through American Journal of Public Health; and as a PDF
Read the Press Release

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


Hopkins, K., White, K., Linkin, F., Hubert, C., Grossman, D., & Potter, J. E. (2015). Women's experiences seeking publicly funded Family Planning services in Texas. Perspectives on Sexual and Reproductive Health, 47(2), 63-70. 

Published online ahead of print January 30, 2015; available online through Wiley Online Library; 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


Grossman, D., White, K., Hopkins, K., & Potter, J. (2014). The public health threat of anti-abortion legislation. Contraception, 89(2), 73-74. 

Published online ahead of print February 2014; available online through ScienceDirect; 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


Potter, J., Hopkins, K., Aiken, A., Hubert, C., Stevenson, A., White, K., & Grossman, D. (2014). Unmet demand for highly effective postpartum contraception in Texas. Contraception, 90(5), 488-495. 

Published online ahead of print November 2014; available online through ScienceDirect; and as a PDF
Read the Press Release

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


Stevenson, A. (2014). Finding the twitter users who stood with Wendy. Contraception, 90(5), 502-507. 

Published online ahead of print November 2014; available online through ScienceDirect; and as a PDF
Read the Press Release

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


Grossman, D., Baum, S., Fuentes, L., White, K., Hopkins, K., Stevenson, A., & Potter, J. (2014). Change in abortion services after implementation of a restrictive law in Texas. Contraception, 90(5), 496-501. 

Published online ahead of print November 2014; available online through ScienceDirect; and as a PDF
Read the Press Release

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


White, K., Grossman, D., Hopkins, K., & Potter, J. (2012). Cutting family planning in Texas. New England Journal of Medicine, 367(13), 1179-1181. 

Published online ahead of print September 27, 2012; 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.


  • Texas Policy Evaluation Project

    Population Research Center
    University of Texas at Austin
    305 E. 23rd Street
    Stop G1800
    Austin, Texas 78712