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Objectives 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.

Clinic closures after House Bill 2 resulted in significant burdens for women able to obtain care.

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 1 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 1 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.

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Introduction: Greater distance to abortion facilities is associated with greater out-of-pocket costs, emergency room follow-up care, negative mental health, and delayed care among U.S. abortion patients. However, the distance U.S. abortion patients travel has not been reported since 2008, and no study has examined reasons abortion patients choose the particular facility where they obtain their abortion.Materials and Methods: We analyzed data from the 2014 Abortion Patient Survey and Abortion Provider Census to report abortion patients' one-way travel from their resident zip code to their abortion clinic, whether they went to the closest clinic, and reasons for facility choice. We report unadjusted and adjusted associations of patients' characteristics with travel distance and differences in average travel distance by abortion patients' reported reasons for choosing their facility.Results: In 2014, 65% of abortion patients traveled less than 25 miles one-way, 17% traveled 25–49 miles, and 18% traveled more than 50 miles. Abortion patients who were white, college-educated, U.S.-born, ≥12 weeks pregnant, and lived outside metropolitan areas were more likely to travel farther. Nearly half of abortion patients went to their nearest provider and 32% chose their facility because it was the closest.Conclusion: These results indicate that travel distance is an important determinant of abortion care access in the United States. Nearly, one-fifth of U.S. abortion patients traveled more than 50 miles one-way and the most common reason reported for clinic choice was that it was the closest.

Purpose The purpose of this study was to describe adolescents’ and young adults’ concerns about confidential reproductive health care and experience with time alone with a provider, and examine the association of these confidentiality issues with receipt of contraceptive services. Methods Data from the 2013 to 2015 National Survey of Family Growth were analyzed using Poisson regression to describe 15- to 25-year-olds’ confidential reproductive health-care concerns and time alone with a provider at last health-care visit according to sociodemographic characteristics. We also assessed whether confidentiality issues were associated with obtaining contraceptive services among females. Results Concerns about confidential reproductive health care were less common among 15- to 17-year-olds who were covered by Medicaid compared to their parents’ private insurance (adjusted risk ratio [ARR] = .61, confidence interval [CI] .41–.91) and had high-school graduate mothers compared to college-graduate mothers (ARR = .68, CI .47–.99), and were more common among those who lived with neither parent compared to living with both parents (ARR = 2.0, CI 1.27–3.16). Time alone with a provider was more common among black girls than white girls (ARR = 1.57, CI 1.11–2.22) and less common among girls covered by Medicaid than those with parents’ private insurance (ARR = .72, CI .56–.92). Time alone was less common among boys living with neither parent compared to living with two parents (ARR = .48, CI .25–.91) and with high-school graduate mothers compared to college-graduate mothers (ARR = .59, CI .42–.84). Among sexually experienced girls and women, confidentiality concerns were associated with a reduced likelihood of having received a contraceptive service in the past year. Conclusions Greater efforts are needed to support young Americans in receiving confidential care.

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 selfmanaged abortion for the current pregnancy among survey respondents, and describe interview participants' decisionmaking 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 selfmanaging 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, selfmanaged 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.