Evaluating the impact of a mandatory pre-abortion ultrasound viewing law: A mixed methods study

Abstract

BackgroundSince mid-2013, Wisconsin abortion providers have been legally required to display and describe pre-abortion ultrasound images. We aimed to understand the impact of this law.MethodsWe used a mixed-methods study design at an abortion facility in Wisconsin. We abstracted data from medical charts one year before the law to one year after and used multivariable models, mediation/moderation analysis, and interrupted time series to assess the impact of the law, viewing, and decision certainty on likelihood of continuing the pregnancy. We conducted in-depth interviews with women in the post-law period about their ultrasound experience and analyzed them using elaborative and modified grounded theory.ResultsA total of 5342 charts were abstracted; 8.7% continued their pregnancies pre-law and 11.2% post-law (p = 0.002). A multivariable model confirmed the law was associated with higher odds of continuing pregnancy (aOR = 1.23, 95% CI: 1.01–1.50). Decision certainty (aOR = 6.39, 95% CI: 4.72–8.64) and having to pay fully out of pocket (aOR = 4.98, 95% CI: 3.86–6.41) were most strongly associated with continuing pregnancy. Ultrasound viewing fully mediated the relationship between the law and continuing pregnancy. Interrupted time series analyses found no significant effect of the law but may have been underpowered to detect such a small effect.Nineteen of twenty-three women interviewed viewed their ultrasound image. Most reported no impact on their abortion decision; five reported a temporary emotional impact or increased certainty about choosing abortion. Two women reported that viewing helped them decide to continue the pregnancy; both also described preexisting decision uncertainty.ConclusionsThis law caused an increase in viewing rates and a statistically significant but small increase in continuing pregnancy rates. However, the majority of women were certain of their abortion decision and the law did not change their decision. Other factors were more significant in women’s decision-making, suggesting evaluations of restrictive laws should take account of the broader social environment.

Consideration of and Reasons for Not Obtaining Abortion Among Women Entering Prenatal Care in Southern Louisiana and Baltimore, Maryland

“…By women's reports, the decision to continue the pregnancy after visiting an abortion clinic was typically influenced by structural and material barriers in Louisiana and by women's own decisions in Maryland. The fact that we did not find a large number of women by recruiting from prenatal care who had decided to continue a pregnancy after visiting an abortion clinic is consistent with previous research that has found that few women who attend a mandatory abortion information visit or attend the abortion appointment decide to continue the pregnancy and that those who do were typically conflicted about their decision when they presented for care (Cameron & Glasier, 2013;Gatter, Kimport, Foster, Weitz, & Upadhyay, 2014;Roberts et al, 2016;Upadhyay et al, 2017).…”

“…They were not policies targeting women's decision-making. This pattern of findings is consistent with extant literature that indicates that the restrictions that create financial and logistical barriers to abortion care-such as restrictions on Medicaid funding for abortion, gestational age limits, and two in-person-visit requirements-limit women's ability to obtain an abortion, whereas laws targeting women's decision-making-such as mandatory ultrasound viewing and waiting periodsmostly do not (Cook, Parnell, Moore, & Pagnini, 1999;Hajri, Raifman, Gerdts, Baum, & Foster, 2015;Joyce et al, 2009;Puri et al, 2015;Roberts et al, 2016;Upadhyay et al, 2017;Upadhyay, Weitz, Jones, Barar, & Foster, 2014).…”

“…Third, while our sample size was sufficient to detect effects across states, it may not have been sufficient to identify rarer events, such as being dissuaded from having an abortion due to mandated ultrasound viewing or mandated waiting periods, which research shows is extremely rare, to the extent it occurs at all (Roberts et al, 2016;Upadhyay et al, 2017).…”

“…Research using these newer methods has found, for example, that laws passed in the name of patient safety-such as requiring medication abortion to be provided according to the original FDA protocol rather than current evidence-based protocols-resulted in a greater need for medical intervention and more side effects (Upadhyay et al, 2016). This research has also found that laws such as 72-h waiting periods and mandatory ultrasound viewing that seek to dissuade women from having abortions do not typically affect women's decisionmaking, but can lead to delays and increased financial and emotional costs (Roberts et al, 2016;Upadhyay et al, 2017).…”

“…These changes include an increase in numbers of abortion restrictions, new and different types of abortion restrictions, and states that have multiple restrictions in place at the same time (Nash, Gold, Mohammed, Ansari-Thomas, & Cappello, 2018). Researchers seeking to understand and document the impact of state-level abortion restrictions have begun to complement existing research methods with newer research approaches, such as abortion-clinic-based medical chart reviews and surveys of women who present for an abortion (Roberts, Turok, Belusa, Combellick, & Upadhyay, 2016;Upadhyay et al, 2017). Research using these newer methods has found, for example, that laws passed in the name of patient safety-such as requiring medication abortion to be provided according to the original FDA protocol rather than current evidence-based protocols-resulted in a greater need for medical intervention and more side effects (Upadhyay et al, 2016).…”