Publications
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2020 - 2019 - 2018 - 2017 - 2016 - 2015 - 2014 - 2012
2021
Obtaining buy-in for immediate postpartum long-acting reversible contraception programs in Texas hospitals: A qualitative study
Hopkins, K, Reminton C, Eilers , M, Rivas, S, Wallace Huff, C, Moore, L. D., Moss Hampton, R, Ogburn, T. Obtaining buy-in for immediate postpartum long-acting reversible contraception programs in Texas hospitals: A qualitative study. Contraception, 2021.
Published online ahead of print, November 2021. Available online through ScienceDirect.
Revealing Economic and Racial Injustices: Demographics of Abortion Fund Callers on the US-Mexico Border
Leyser-Whalen, O, Torres, L, Gonzales Dickman, B. Revealing Economic and Racial Injustices: Demographics of Abortion Fund Callers on the US-Mexico Border. Women's Reproductive Health, 2021.
Published online ahead of print, October 2021.
Affordability and Access to Abortion Care in the United States
Dickman, S, White, K, Grossman, D. Affordability and Access to Abortion Care in the United States. JAMA, 2021.
Published online ahead of print, July 2021. Available online through JAMA.
Access to medical services is a critical element of a country’s health care system. Access to care has multiple dimensions, including the quality and types of services available, how far an individual must travel for care, and the convenience of scheduling and attending appointments. In the United States, affordability is a crucial determinant of health care access: approximately 30 million people in the US lacked health insurance in 2020, and approximately 30 million live below the federal poverty level, which in 2021 is defined as a combined income of $26 500 for a family of 4.
Improving Assessment of Demand for Postpartum Tubal Ligation Among Publicly Insured Women in Texas
Potter, J, Burke, K, Broussard, K, Hopkins, K, Grossman, D, White, K. Improving assessment of demand for postpartum tubal ligation among publicly insured women in Texas, Contraception, 2021.
Published online ahead of print May 2021; available online through Contraception.
Abstract: Objective: To assess an alternative method for estimating demand for postpartum tubal ligation and evaluate reproductive trajectories of low-income women who did not obtain a desired procedure. Study Design: In a 2-year cohort study of 1700 publicly insured women who delivered at 8 hospitals in Texas, we identified those who had an unmet demand for tubal ligation prior to discharge from the hospital. We classified unmet demand as explicit or prompted based on survey questions that included a prompt regarding whether the respondent would like to have had a tubal ligation at the time of delivery. We assessed persistence of demand for permanent contraception, contraceptive use, and repeat pregnancies among all study participants who wanted but did not get a postpartum procedure. Results: Some 426 women desired a postpartum tubal ligation; 219 (51%) obtained one prior to discharge. Among the 207 participants with unmet demand, 62 (30%) expressed an explicit preference for the procedure, while 145 (70%) were identified from the prompt. Most with unmet demand still wanted permanent contraception 3 months after delivery (156/184), but only 23 had obtained interval procedures. By 18 months, the probability of a woman with unmet demand conceiving a pregnancy that she would likely carry to term was 12.5%. Conclusions: The majority of unmet demand for postpartum tubal ligation among publicly insured women in Texas was uncovered via a prompt and would not have been evident in clinical records or from consent forms. Women unable to obtain a desired procedure had a substantial chance of pregnancy within 18 months after delivery. Implications: Estimates of unmet demand for postpartum tubal ligation based on clinical records and consent forms likely underestimate desire for permanent contraception. Among low-income women in Texas, those with unmet demand for postpartum tubal ligation require improved access to effective contraception.
Impact of Contraceptive Counseling on Texans Who Can and Cannot Receive No-Cost Post-Abortion Contraception
Goyal, V, Madison, A, Powers, D, Potter, J. Impact of contraceptive counseling on Texans who can and cannot receive no-cost post-abortion contraception, Contraception, 2021.
Published online ahead of print May 2021; available online through Contraception.
Abstract: Objective: To assess optimal timing, patient satisfaction, and 1-year contraceptive continuation associated with contraceptive counseling among Texans who could and could not receive no-cost long-acting reversible contraception (LARC) via a specialized funding program. Study Design: In this prospective study conducted between October 2014 and March 2016, we evaluated participants’ desire for contraceptive counseling during abortion visits, impact of counseling on change in contraceptive preference, satisfaction with counseling, and 1-year postabortion contraceptive continuation. We stratified participants into 3 groups by income, insurance status, and eligibility for no-cost LARC: (1) low-income eligible, (2) low-income ineligible, and (3) higher-income and/or insured ineligible. We examined the association between contraceptive counseling rating and 1-year method continuation by program eligibility and post-abortion contraceptive type. Results: Among 428 abortion patients, 68% wanted to receive contraceptive counseling at their first abortion visit. Counseling led to a contraceptive preference change for 34%. Of these, 21% low-income eligible participants received a more effective method than initially desired, 10% received a less effective method, and 69% received the method they initially desired. No low-income ineligible participants received a more effective method than they initially desired, 55% received a less effective method, and 45% received the method they initially desired. Five percent of higher-income eligible participants received a more effective method than they initially desired, 48% received a less effective method, and 47% received the method they initially desired. Highest counseling rating was reported by 51%. Compared to those providing a lower rating in each group, highest counseling rating was significantly associated with lower 1-year contraceptive discontinuation for low-income eligible participants, but not for low-income ineligible and higher-income participants. Additionally, 1-year contraceptive continuation was associated with highest counseling rating and post-abortion LARC use in unadjusted models, but only postabortion LARC in adjusted models. Conclusions: In Texas, where access to affordable postabortion contraception is limited, high quality contraceptive counseling is associated with 1-year contraceptive continuation only among those eligible for no-cost methods. Implications: State policies which restrict access to affordable post-abortion contraception limit the beneficial impact of patient-centered counseling and impede patients’ ability to obtain their preferred method.
Contraindications to Hormonal Contraception among Postpartum Women in Texas
Coleman-Minahan, K, Ela, E, White, K, Grossman, D. Contraindications to Hormonal Contraception Among Postpartum Women in Texas, Obstetrics & Gynecology. Online First 2021.
Published online ahead of print April 2021; available online through Obstetrics & Gynecology.
Abstract: Objective: To examine the prevalence of contraindications to hormonal contraception among postpartum women. Methods: Low-income postpartum women who planned to delay childbearing for 2 years or longer after delivery were recruited for a prospective cohort study from eight Texas hospitals. Women self-reported health conditions that corresponded to category 3 and 4 contraindications to combined hormonal contraception and progestin-only methods, based on the Centers for Disease Control and Prevention’s 2016 Medical Eligibility Criteria for Contraceptive Use. We used mixed-effects Poisson regression models to assess characteristics associated with reporting any contraindication 6 months after delivery. We examined the proportion of women who used a contraindicated method. Results: Of 1,452 women who completed the 6-month interview, 19.1% reported a category 3 or 4 contraindication to combined hormonal contraception (16.8% category 4) and 5.4% reported a contraindication to depot medroxyprogesterone acetate (0.1% category 4). Only 0.8% had any category 3 or 4 contraindication to progestin-only pills and 0.6% to the implant. Migraine with aura (12.4%) and hypertension (4.8%) were the most common contraindications. The prevalence of any contraindication was higher among women who were 30 years or older, overweight, obese, and insured. Compared with U.S.-born Latina women, the prevalence of contraindications was higher among Black women and lower among foreign-born Latina women. Among women with contraindications, 28 (10.3%) were using combined hormonal contraception; six (8%) were using a contraindicated progestin-only method. Conclusion: Nearly one in five participants had a category 3 or 4 contraindication to combined hormonal contraception. Patients at higher risk for adverse birth outcomes are more likely to have contraindications. Clinicians should counsel on contraception and contraindications prenatally to facilitate the most informed postpartum decision.
Border-state Abortions Increased for Texas Residents After House Bill 2
Raifman, S, Gracia, S, Grossman, D, Baum, S, Hopkins, K, Potter, J, White, K. Border-state abortions increased for Texas residents after House Bill 2. Contraception, 2021.
Published online ahead of print, March 2021. Available online through ScienceDirect.
Abstract: Objectives: To assess changes in Texas-resident border-state abortions, medication abortions, and abortions ≥22 weeks from last menstrual period (LMP) before and after implementation of House Bill 2 (HB2) in November 2013 and before and after the US Supreme Court's decision regarding HB2 in June 2016. Study design: We conducted an interrupted time series analysis using 2012-2017 data on Texas-resident abortions in Arkansas, Louisiana, Oklahoma, and New Mexico. Data on procedure type and gestational age were available only for abortions in New Mexico. Results: Border states reported 762 Texas-resident abortions in 2012, 1,673 in 2014, and 1,475 in 2017. Texas-resident abortions in all border states nearly doubled following HB2’s implementation. Border-state abortions then decreased by 19% after the 2016 US Supreme Court decision, compared to the period prior to the decision and after HB2’s implementation. From 2012 to 2014, the proportion of Texas-resident abortions in New Mexico that were medication abortion increased from 5% to 20% and the proportion that were ≥22 weeks from LMP decreased from 40% to 23%. Texas vital statistics undercounted annual out-of-state abortions, reporting only 13%-73% of abortions reported by border-state clinics during the study period. Conclusions: HB2 was associated with increases in border-state abortions for Texas residents, including in the number of those ≥22 weeks from LMP. Border-state abortions declined after the Supreme Court ruled HB2 unconstitutional yet remained higher than pre-HB2 levels. Implications statement: Abortion restrictions that severely curtail access may result in increases in travel out of state for care. Documenting out-of-state abortions is important for evaluating broader policy impacts and to prepare for future service disruptions. Texas residents may have more limited options for care if border states enact restrictive abortion laws.
Perspectives on Self-managed Abortion among Providers in Hospitals along the Texas–Mexico Border
Raifman, S, Baum, S, White, K, Hopkins, K, Ogburn, T, Grossman, D. Perspectives on self-managed abortion among providers in hospitals along the Texas–Mexico border. BMC Women's Health, 2021.
Published online ahead of print, March 2021. Available online through BMC Women's Health.
Abstract: Background: Following self-managed abortion (SMA), or a pregnancy termination attempt outside of the formal health system, some patients may seek care in an emergency department. Information about provider experiences treating these patients in hospital settings on the Texas-Mexico border is lacking. Methods:
The study team conducted semi-structured interviews with physicians, advanced practice clinicians, and nurses who had experience with patients presenting with early pregnancy complications in emergency and/or labor and delivery departments in five hospitals near the Texas-Mexico border. Interview questions focused on respondents’ roles at the hospital, knowledge of abortion services and laws, perspectives on SMA trends, experiences treating patients presenting after SMA, and potential gaps in training related to abortion. Researchers conducted interviews in person between October 2017 and January 2018, and analyzed transcripts using a thematic analysis approach. Results: Most of the 54 participants interviewed said that the care provided to SMA patients was, and should be, the same as for patients presenting after miscarriage. The majority had treated a patient they suspected or confirmed had attempted SMA; typically, these cases required only expectant management and confirmation of pregnancy termination, or treatment for incomplete abortion. In rare cases, further clinical intervention was required. Many providers lacked clinical and legal knowledge about abortion, including local resources available. Conclusions: Treatment provided to SMA patients is similar to that provided to patients presenting after early pregnancy loss. Lack of provider knowledge about abortion and SMA, despite their involvement with SMA patients, highlights a need for improved training.
Patients’ Experiences with an Immediate Postpartum Long-Acting Reversible Contraception Program
Huff, C, Potter, J, Hopkins K. Patients’ Experiences with an Immediate Postpartum Long-Acting Reversible Contraception Program. Women’s Health Issues, 2021.
Published online ahead of print, December 2020. Available online through Women’s Health Issues.
Abstract: Introduction: We compared the characteristics of postpartum women who recalled being offered or not offered intrauterine devices and implants and who obtained placement of these long-acting reversible contraceptive (LARC) devices at a county hospital before discharge. We assessed satisfaction and continuation among those who obtained LARC methods. Methods: We interviewed 199 patients who delivered at a Texas hospital and tested for differences in who recalled being offered/not offered immediate postpartum LARC. We provide descriptive statistics on when offered and satisfaction and assess continuation using Kaplan-Meier survival curves. Results: There were 103 of 199 women who recalled providers offering them immediate postpartum LARC; English-speaking relative to Spanish-speaking Hispanic women had higher odds of recounting being offered immediate postpartum LARC, as did women with two children versus one child. Compared with women 18–24 years of age who wanted more children, women 30–34 years of age who wanted more children had lower odds, as did sterilized women 18 to 44. Seventy-four women (37% of all and 72% of those who recalled being offered) received immediate postpartum LARC. Sixty percent of those who received immediate postpartum LARC recalled that they were first offered it during prenatal care. Satisfaction was high but decreased between 3 and 6 months postpartum, mainly owing to negative side effects. Continuation at 24 months postpartum was 76.9%, with no difference between intrauterine device and implant use. Conclusions: Language barriers may have hindered equal access to immediate postpartum LARC for Spanish-speaking patients; younger patients were more likely to recall being offered immediate postpartum LARC, possibly owing to providers’ implicit biases or greater demand for LARC versus sterilization. Using formal interpretation services and patient-centered decision-making may improve patient access to the contraception methods most aligned with their values and preferences.
2020
Short-acting Hormonal Contraceptive Continuation among Low-Income Postpartum Women in Texas
Lagasse Burke, K, Thaxton, L, Potter, J. Short-acting hormonal contraceptive continuation among low-income postpartum women in Texas. Contraception: X, 2021.
Published online ahead of print, December 2020. Available online through ScienceDirect.
Abstract: Objective: The objective was to assess continuation of the pill, patch, ring or injectable (i.e., short-acting hormonal contraception); characteristics associated with discontinuation; and subsequent method use among low-income postpartum women in Texas. Study design: Using a 24-month cohort study of 1700 women who delivered in eight Texas hospitals and were uninsured or publicly insured at the time of delivery, we focused on 456 women who used short-acting hormonal contraception within 6 months after delivery. We classified this sample according to characteristics and method preference, and estimated rates of discontinuation and associated predictors using life tables and Cox models. We assessed reasons for discontinuation and subsequent contraceptive use among those who discontinued. Results: Roughly half used the pill and half used the injectable. One hundred seventy-eight (39%) expressed a baseline preference for the method they used, 162 (36%) preferred a long-acting reversible contraception method, and 41 (9%) preferred sterilization. After 1 year, 72% had discontinued. Foreign-born Hispanic women were less likely to discontinue than U.S.-born Hispanics. Those who wanted a more effective method and those who lost insurance coverage were more likely to discontinue. The most common reasons for discontinuation were side effects and access/cost. Of those who discontinued, 243 (68%) switched to a less effective or no method. Only 47 (13%) switched to their preferred method. Conclusions: Short-acting hormonal contraceptive discontinuation is high in this population. Many switch to less effective methods after discontinuation despite preferring methods at least as effective as the pill, patch, ring, or injectable. Implications: Expanding contraceptive coverage in the 2 years after delivery should be a state and federal policy priority. In clinics, providers should discuss contraceptive preferences throughout pregnancy and the interpregnancy interval.
Changes in Abortion in Texas Following an Executive Order Ban During the Coronavirus Pandemic
White, K, Kumar, B, Goyal, V, Wallace, R, Roberts, SCM, Grossman, D. Changes in abortion in Texas following an executive order ban during the coronavirus pandemic. JAMA, 2021.
Published online ahead of print, January 2021. Available online through JAMA.
In-state abortion declined 38% during the COVID-19 executive order. Patients also sought care out of state and were delayed later into pregnancy. The number of abortions in Texas declined 38% in April 2020, while the executive order was in effect, compared to April 2019 (4,608 to 2,856). Texas residents receiving care at out-of-state facilities in the study increased from 157 in February 2020 to 947 in April 2020. After the Governor’s order expired in May 2020, there was an 61% increase in second-trimester abortion.
Factors Associated with Abortion at 12 or More Weeks Gestation After Implementation of a Restrictive Texas Law
Goyal, V, Wallace, R, Dermish AI, Kumar, B, Schutt-Aine, A, Beasley, A, Aiken ARA. Factors associated with abortion at 12 or more weeks gestation after implementation of a restrictive Texas law. Contraception, 2020.
Published online ahead of print, October 2020. Available online through Science Direct.
Abstract: Objective: To examine factors associated with obtaining abortion at 12 or more weeks gestation in Texas after implementation of a restrictive law. Study Design: In this retrospective cohort study, we collected data from eight Texas abortion clinics that provided services at 12 or more weeks gestation from April 1, 2015 to March 30, 2016, after a restrictive abortion law enacted in November 2013 shuttered many of the state’s clinics. We examined factors associated with obtaining in-clinic abortion services between 3–11 versus 12–24 weeks gestation including patient race-ethnicity, income level, and driving distance to the clinic using chi-square tests and calculating odds ratios. We further subcategorized abortion between 15–24 weeks to determine who may be most affected by a Texas law banning dilation and evacuation (D&E). Results: Among 24,555 in-clinic abortions, 19.2% (n = 4,714) occurred at 12 or more weeks gestation. Compared to patients who obtained care between 3–11 weeks, those who obtained care at 12 or more weeks were more likely to be Black than White, live ≤110% of the federal poverty level than have higher income, and drive 50+ miles than 1–24 miles to obtain care. These associations remained for those obtaining care between 15–24 weeks. Even after adjusting for race-ethnicity and driving distance, low-income patients had greater odds of obtaining care in between 15–24 weeks. Conclusions: Patients obtaining abortion at 12 or more weeks gestation in Texas are more likely to be Black, low-income, and travel far distances to obtain in-clinic care. Implications: In Texas, patients who are Black, low-income, and travel the farthest are more likely to obtain in-clinic abortion between 15–24 weeks gestation, commonly performed via D&E. If Texas Senate Bill 8 (SB8) banning D&E goes into effect, these patients may be prevented from obtaining care.
Unsatisfied 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.
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Abstract: Objective: 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 2015–2017, 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 15–24 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.
Differences 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.
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Abstract: Objective: 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.
Medication 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.
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Breastfeeding 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.
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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.
Adolescents 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.
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Abstract: Context: Most 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.
Availability 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.
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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.
Denials 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.
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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.
Texas 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.
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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
Quality 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 and changing preference from an IUD or implant. 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.
Change 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.
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Abstract: Objective: To 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. Methods: We 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. Results: Overall, 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. Adjusting for distance to the nearest facility and facility network size reduced the odds of having a second-trimester abortion after implementation. Women living 50–99 miles from the nearest facility (vs less than 10 miles) had higher odds of second-trimester abortion, 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. After implementation, women waited 1 to 14 days for a consultation visit; longer waits were associated with higher odds of second-trimester abortion. Conclusion: Increases in second-trimester abortion after the law's implementation were due to women having more limited access to abortion services.
Challenging 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.”
Rebound 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.
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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
Low‐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.
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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.
Counseling 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.
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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.
Young 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.
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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.
Unmet 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.
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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
Providing 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.
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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.
Does 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
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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