Effects of Legislation Regulating Abortion in Arizona

Development of a Composite Risk Index of Reproductive Autonomy Using State Laws: Association With Maternal and Neonatal Outcomes

OBJECTIVE

We developed a composite index to quantify state legislation related to reproductive autonomy and examined its association with maternal and neonatal outcomes. We hypothesized that greater reproductive autonomy would be associated with lower rates of severe maternal morbidity (SMM), pregnancy-related mortality (PRM), preterm birth (PTB), and low birthweight.

DESIGN

A Delphi panel was used to inform development of the index. Restrictive policies were assigned values of -1 and enabling policies +1. Publicly available data were used to conduct a cross-sectional study among all live births in the 50 U.S. states to people aged 15 to 44 between January 1, 2016, and December 31, 2018, to examine the association between the risk index and PRM, SMM, PTB, and low birthweight. We used linear regression with state scores and quartiles, adjusted for state-level proportions of White, Black, and Hispanic live births; percent living in rural areas; percent of population foreign born; Health Resources and Services Administration spending on maternal and child health; and the Opportunity Index, a composite measure of indicators of the economy, education, and community.

RESULTS

From 2016 to 2018, there were 11,530,785 births, 2,846 pregnancy-related deaths, and 154,384 cases of SMM. The Delphi panel resulted in a summed state measure of 106 laws in 8 categories that could affect reproductive autonomy. In adjusted analyses, states in the most enabling (most reproductive autonomy) quartile had a 44.7 per 10,000 higher rate of SMM compared with the most restrictive quartile. However, the most enabling quartile was associated with a 9.87 per 100,000 lower rate of PRM and 0.67 per 100 lower rate of PTB compared with the most restrictive quartile (least reproductive autonomy).

CONCLUSIONS

A composite policy index of reproductive autonomy was found to be associated with higher rates of SMM but lower rates of PRM and PTB. Further research is needed to understand how reproductive autonomy in the cumulative index may influence these and other maternal and birth outcomes.

The Adolescent's Right to Confidential Care When Considering Abortion

The American Academy of Pediatrics reaffirms its position that the rights of adolescents under 18 years of age to confidential care when considering legal medical and surgical abortion therapies should be protected. Most adolescents voluntarily involve parents and other trusted adults in decisions regarding pregnancy termination and should be encouraged to do so when safe and appropriate. The legal climate surrounding abortion law is rapidly becoming more restrictive and threatens to adversely impact adolescents. Mandatory parental involvement, the judicial bypass procedure, and general restrictive abortion policies pose risks to adolescents' health by causing delays in accessing medical care, increasing volatility within a family, and limiting their pregnancy options. These harms underscore the importance of adolescents' access to confidential abortion care. This statement presents a summary of pertinent current information related to the impact of legislation requiring mandatory parental involvement in an adolescent's decision to obtain abortion services.

The impact of mandatory waiting periods on abortion-related outcomes: a synthesis of legal and health evidence

This review follows an established methodology for integrating human rights to address knowledge gaps related to the health and non-health outcomes of mandatory waiting periods (MWPs) for access to abortion. MWP is a requirement imposed by law, policy, or practice, to wait a specified amount of time between requesting and receiving abortion care. Recognizing that MWPs “demean[] women as competent decision-makers”, the World Health Organization recommends against MWPs. International human rights bodies have similarly encouraged states to repeal and not to introduce MWPs, which they recognize as operating as barriers to accessing sexual and reproductive healthcare. This review of 34 studies published between 2010 and 2021, together with international human rights law, establishes the health and non-health harms of MWPs for people seeking abortion, including delayed abortion, opportunity costs, and disproportionate impact. Impacts on abortion providers include increased workloads and system costs.

Variation in Restrictive Abortion Policies and Adverse Birth Outcomes in the United States from 2005 to 2015

BACKGROUND

Since 2011, U.S. states have enacted more than 400 policies restricting abortion access. As structural determinants, abortion policies have the potential to influence maternal and child health access, outcomes, and equity through multiple mechanisms. Limited research has examined their implications for birth outcomes.

METHODS

We created a state-level abortion restrictiveness index composed of 18 restrictive abortion policies and evaluated the association between this index and individual-level probabilities of preterm birth (PTB) and low birthweight (LBW) within the United States and by Census Region, using data from the 2005-2015 National Center for Health Statistics Period Linked Live Birth-Infant Death Files. We used logistic multivariable regression modeling, adjusting for individual- and state-level factors and state and year fixed effects.

RESULTS

Among 2,500,000 live births, 269,253 (12.0%) were PTBs and 182,960 (8.1%) were LBW. On average from 2005 to 2015, states had approximately seven restrictive abortion policies enacted, with more policies enacted in the Midwest and South. Nationally, relationships between state restrictiveness indices and adverse birth outcomes were insignificant. Regional analyses revealed that a 1-SD increase in a state's restrictiveness index was associated with a 2% increase in PTB in the Midwest (marginal effect [ME], 0.25; 95% confidence interval [CI], 0.04-0.45; p < .01), a 15% increase in LBW in the Northeast (ME, 1.24; 95% CI, 0.12-2.35; p < .05), and a 2% increase in LBW in the West (ME, 0.12; 95% CI, 0.01-0.25; p < .05).

CONCLUSION

Variation in restrictive abortion policy environments may have downstream implications for birth outcomes, and increases in abortion restrictions were associated with adverse birth outcomes in three out of four Census Regions.

Racial/ethnic and educational inequities in restrictive abortion policy variation and adverse birth outcomes in the United States

BACKGROUND

To examine racial/ethnic and educational inequities in the relationship between state-level restrictive abortion policies and adverse birth outcomes from 2005 to 2015 in the United States.

METHODS

Using a state-level abortion restrictiveness index comprised of 18 restrictive abortion policies, we conducted a retrospective longitudinal analysis examining whether race/ethnicity and education level moderated the relationship between the restrictiveness index and individual-level probabilities of preterm birth (PTB) and low birthweight (LBW). Data were obtained from the 2005-2015 National Center for Health Statistics Period Linked Live Birth-Infant Death Files and analyzed with linear probability models adjusted for individual- and state-level characteristics and state and year fixed-effects.

RESULTS

Among 2,250,000 live births, 269,253 (12.0%) were PTBs and 182,960 (8.1%) were LBW. On average, states had approximately seven restrictive abortion policies enacted from 2005 to 2015. Black individuals experienced increased probability of PTB with additional exposure to restrictive abortion policies compared to non-Black individuals. Similarly, those with less than a college degree experienced increased probability of LBW with additional exposure to restrictive abortion policies compared to college graduates. For all analyses, inequities worsened as state environments grew increasingly restrictive.

CONCLUSION

Findings demonstrate that Black individuals at all educational levels and those with fewer years of education disproportionately experienced adverse birth outcomes associated with restrictive abortion policies. Restrictive abortion policies may compound existing racial/ethnic, socioeconomic, and intersecting racial/ethnic and socioeconomic perinatal and infant health inequities.

Impact of State-Level Reproductive Health Legislation on Access to and Use of Reproductive Health Services and Reproductive Health Outcomes: A Systematic Scoping Review in the Affordable Care Act Era

INTRODUCTION

We systematically reviewed the literature to understand the associations between state-level reproductive health policies and reproductive health care outcomes and describe policy impacts on reproductive health outcomes among women aged 18 and older. We focused on research conducted after the implementation of the Patient Protection and Affordable Care Act to understand the influence of state-level policies in the context of existing federal policy.

METHODS

Standard search terms were used to search PubMed for studies published between March 10, 2010, and August 31, 2019. Studies were included that reflected original U.S.-based research testing associations between state-level policies (i.e., laws related to family planning, maternity care, and abortion) and reproductive health outcomes related to those services (e.g., prenatal care use) among adults. Reference lists of systematic reviews were searched to improve the identification of relevant studies. Studies were excluded if they were reviews, qualitative or mixed-methods studies, or descriptive studies, or if a state was not the unit of analysis. After dual review, agreement on inclusion of studies was 100%.

RESULTS

Search results returned 1,529 articles; 56 (3.59%) met the inclusion criteria for a full review based on title and abstract review. After dual independent review, eight were selected for inclusion. Two included all 50 states and Washington, DC; one included Oregon and Washington; and the remaining studies included single states (Texas, Arizona, Ohio, and Utah). One-half of the studies (n = 4) focused solely on restrictive abortion legislation. Restricting access to family planning and abortion services (e.g., mandatory waiting periods) were associated with negative outcomes (e.g., additional interventions for medication abortion). Expanding maternity care through Medicaid reform and autonomous midwifery laws were associated with positive outcomes (e.g., prenatal care use).

CONCLUSIONS

Our review identified eight studies that were largely focused on only one key aspect of reproductive health policy. Findings suggest that state-level legislation could have considerable impact on the reproductive health care that women have access to and receive, as well as the related outcomes. Research in this area remains limited. Rigorous evaluations of the relationship between the breadth of reproductive health policies and related health outcomes are needed, as is an exploration of barriers to the conduct of this type of research.