EXECUTIVE SUMMARY
Abortion access was hit hard by the Texas six-week abortion ban bill and by the Supreme Court’s decision to overturn Roe v. Wade in June 2022. But abortion demand remained high, and women increasingly sought telehealth and out-of-state abortion care.
- Immediately after the Supreme Court decision, abortions declined by 95% in states that banned nearly all legal abortions.
- The bans forced women into long travel times and mail-order options to obtain their abortions.
- Telehealth medication abortions increased from 1% pre-pandemic to 10% after the Dobbs v. Jackson Women’s Health decision.
Investigators who studied the immediate aftermath of the Texas six-week abortion ban noted new trends and outcomes from new abortion bans across the United States.
The authors of one new study found that 97% of pregnant women who were turned away from abortion care in Texas still wanted to seek the procedure. Some of the options they wanted to pursue are not currently available.1
Other research revealed that clinic-based abortions in Texas and out of state declined by one-third after the implementation of Texas Senate Bill 8 on Sept. 1, 2021.2,3
In the early months after the June 2022 Dobbs v. Jackson Women’s Health Organization decision, abortions declined by 95% in abortion-ban states and increased in most states that maintained legal abortion access. Nationally, legal abortions declined by 6%.2,3
“What we saw is not surprising: The number of abortions decreased by about 3% in the first month that SB 8 was in effect,” says Kari White, PhD, MPH, lead investigator of the Texas Policy Evaluation Project and an associate professor at the University of Texas at Austin and Steve Hicks School of Social Work. “A lot of people were not getting care in Texas or in surrounding states. They could have traveled farther, or they could have ordered abortion pills online, and some were forced to continue their pregnancies. Traveling out of state did not fully make up for the large decrease in abortion numbers inside Texas borders.”
White and colleagues found thousands fewer facility-based abortions were performed in Texas after the implementation of SB 8. They also found a large increase in abortions obtained by Texans in out-of-state clinics in that same period. Over the course of six months after SB 8 took effect, the percentage of out-of-state abortions among Texas residents at 12 or more weeks of gestation significantly increased.4
“At the time we did our study, people could still get abortions in Arkansas, Louisiana, and Oklahoma, and a good number of people still got their abortions in Texas very early in pregnancy,” White says.
With the Dobbs decision, all those options are gone. “With those options closed off, the travel burden for Texans to get to another state are far greater than they were before,” White explains. “Before, you could drive three hours, and now you have to drive 10 hours to New Mexico.”
Another change is that many people are obtaining abortions out of state and at a later point in pregnancy because of longer wait times for appointments. “That pushes people later into their pregnancy, where they may no longer be eligible for medication abortion or will be forced into surgical abortion. It’s an additional obstacle for people who need care,” White notes. “These bans aren’t doing anything to change people’s needs, but it is making people consider a range of options that they may not have considered before. It makes it difficult for them to obtain the care they need,” White says.
Similar Situations in Other States
Since the Dobbs decision, states that enacted abortion bans have been seeing similar situations. A #WeCount study from the Society of Family Planning revealed that in the first two months after the decision, 10,000 fewer people could obtain an abortion, says Terri-Ann Thompson, PhD, a senior research scientist with Ibis Reproductive Health in Cambridge, MA.
The first states to initiate abortion bans saw a 95% decrease in abortions, which researchers expected because the situation went from in-state abortion access to no abortion access in more than a dozen states.
“From #WeCount, we saw two interesting things. First, there has been an increase in abortion delivery in states where it’s still legal,” Thompson explains. “There was an 11% increase. [Secondly], telehealth for medication abortions was [becoming more common] in terms of abortion care delivery.”
The increase in telehealth medication abortions doubled from 1% before the COVID-19 pandemic to around 3% during the pandemic. After Dobbs, it increased to about 10% of all abortions in the United States.2
“It’s taking more of the pie than it has before, but it hasn’t replaced clinic abortions,” Thompson adds.
The telehealth data include medication abortions from international organizations, such as AidAccess. “As you think about utilization shifting over time, it’s important to know the share of it that grew during the pandemic and that has grown even more in the Dobbs era,” Thompson explains. “One reason we see that growth is because of changes the FDA made to allow direct-to-patient telehealth abortion.” (For more information, see the story in this issue about telehealth medication abortions.)
Other new data show the importance of abortion access to women in Texas. Investigators surveyed women in the beginning of June 2022 through July 2022. During the first few weeks, early abortions were still legal in Texas. But when the U.S. Supreme Court overturned Roe, a total abortion ban went into effect in Texas due to a trigger law.
“In June, there were people who could present for an abortion and were told they could not have one because embryonic cardiac activity was present,” says Anitra Beasley, MD, MPH, an associate professor in the division of gynecologic and obstetric specialists and an associate residency program director at the Baylor College of Medicine in Houston. “In July, people were told they could not have an abortion because they were banned in the state of Texas, and this is where people had to make decisions. Of the people we surveyed, 97% said they would consider getting an abortion a different way when the facility-based abortion they wanted was not available.”
Women Consider Other Options
In Texas, those surveyed said they would consider these options for obtaining an abortion:1
- 85% said they would obtain abortion pills via telehealth;
- 80% said they would travel out of state;
- 79% said they would access care through a mobile clinic on a ship in the Gulf of Mexico (which is not yet available);
- 70% said they would order pills online from another country;
- 65% said they would self-manage their abortion with misoprostol pills from Mexico.
After the Dobbs decision, telehealth for abortion care in Texas was no longer a legal option. “Texas now has abortion totally banned, but even before that, using telehealth for abortion care was banned in Texas,” Beasley says.
The mobile clinic on a ship also is not available, although it could be in the future, Beasley notes. That leaves travel out of state to a legal abortion clinic, using misoprostol pills from Mexico, or ordering pills from another country, such as the international AidAccess.org.
“About 80% would consider going out of state, but most people had concerns about being able to do that,” Beasley says. “They had concerns about paying for travel, missing pay at work, navigating to a new place they were unfamiliar with, getting time off work, explaining absences, and having to arrange for childcare.”
Border Crossings Are an Issue
For pregnant people who lack documentation, there is an even bigger concern: ramifications of crossing border checkpoints.
“Within 100 miles of any interior border of the Texas/Mexico border, immigration enforcement can stop anybody they think might have some immigration infraction and ask about their immigration status,” Beasley explains. “People living within 100 miles of the border may exist in that space but are not really going into more interior Texas.”
For a pregnant person to leave that 100-mile space, it would mean they would be risking losing their home and family. “That’s a big deal for people who don’t have documentation, or for people who are depending on someone who doesn’t have documentation to be their support person,” Beasley says.
For those who live near El Paso, this may not be a burden because they could travel to New Mexico to obtain an abortion without leaving the 100-mile border. But traveling to El Paso from the other end of Texas would be the same distance as traveling from Houston to Atlanta, she adds.
The study shows that when people want and need an abortion, they will try to find a way to obtain one. Abortion bans do not stop all procedures, but they create severe economic hardships for many people.
“In our study, over half reported they had experienced at least one economic hardship in the past year, like not being able to pay rent in full, or pay for gas, or phone services being turned off,” Beasley explains. “Almost half of the people surveyed are living on incomes of less than 100% of the federal poverty level. Having to go out of state for an abortion, or source pills from somewhere else, means they have to make tradeoffs about what they can and can’t do, but they’re still making the abortion happen because that is what they need.”
REFERENCES
- Beasley A, Nagle A, Lerma K, et al. Pregnant Texans’ interest in other models of abortion care after the fall of Roe. Texas Policy Evaluation Project. January 2023.
- Society of Family Planning. #WeCount. Oct. 28, 2022.
- Sanger-Katz M, Miller CC. Legal abortions fell around 6 percent in two months after end of Roe. The New York Times. Oct. 30, 2022.
- White K, Sierra G, Lerma K, et al. Association of Texas’ 2021 ban on abortion in early pregnancy with the number of facility-based abortions in Texas and surrounding states. JAMA 2022;328:2048-2055.
Abortion access was hit hard by the Texas six-week abortion ban bill and by the Supreme Court’s decision to overturn Roe v. Wade in June 2022. But abortion demand remained high, and women increasingly sought telehealth and out-of-state abortion care.
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