Making sense of the economics of abortion in the United States.

In 2023 the editors of Perspectives on Sexual and Reproductive Health issued a special call for papers related to the economics of abortion. Ten of those submissions are included in this volume and address critical issues including: (1) the role Medicaid continues to play in abortion access and how changes in state Medicaid coverage of abortion have expanded and restricted abortion care use; (2) how low-income individuals without insurance coverage for abortion utilize resources from abortion funds and through crowdsourcing platforms; (3) how the price of medication abortion has decreased with the availability of telemedicine medication abortion and how providers of that service are making efforts to reduce those prices even further; and (4) how legally restricting abortion access has significant economic implications for state economies and the US society as a whole. In this introduction, I review the general scope of prior research on the economics of abortion in the US as it relates to stigma-induced silences, abortion seekers, abortion providers, and abortion assistance organizations.

Regulating Abortion Later in Pregnancy: Fetal-Centric Laws and the Erasure of Women's Subjectivity.

Context: In the United States, fetal development markers, including "viability" and the point when a fetus can "feel pain," have permeated the social imaginary of abortion, affecting public support for abortion and the legality and availability of care, but the extent to which these markers describe and orient the experience of abortion at later gestations is unclear.

Methods: Using interviews with 30 cisgender women in the United States who obtained an abortion after 24 weeks of pregnancy, the authors investigated whether and how notions of fetal viability and/or pain operated in the women's lived experiences of pregnancy and abortion.

Findings: According to respondents' accounts, fetal development-based laws restricting abortion based on purported points of fetal development operated as gestational limits, privileged the viability and pain status of the fetus over that of the prospective neonate, and failed to account for the viability and pain of the pregnant person.

Standardizing the classification of abortion incidents: the Procedural Abortion Incident Reporting and Surveillance (PAIRS) Framework.

Objectives: To develop and validate standardized criteria for assessing abortion-related incidents (adverse events, morbidities, near misses) for first-trimester aspiration abortion procedures and to demonstrate the utility of a standardized framework [the Procedural Abortion Incident Reporting & Surveillance (PAIRS) Framework] for estimating serious abortion-related adverse events.

Study Design: As part of a California-based study of early aspiration abortion provision conducted between 2007 and 2013, we developed and validated a standardized framework for defining and monitoring first-trimester (≤14weeks) aspiration abortion morbidity and adverse events using multiple methods: a literature review, framework criteria testing with empirical data, repeated expert reviews and data-based revisions to the framework.

Results: The final framework distinguishes incidents resulting from procedural abortion care (adverse events) from morbidity related to pregnancy, the abortion process and other nonabortion related conditions.

The Stratified Legitimacy of Abortions.

Roe v. Wade was heralded as an end to unequal access to abortion care in the United States. However, today, despite being common and safe, abortion is performed only selectively in hospitals and private practices.

Abortion Patients' Experience and Perceptions of Waiting Periods: Survey Evidence before Arizona's Two-visit 24-hour Mandatory Waiting Period Law.

Background: More than one-half of U.S. states now have laws requiring women to wait at least 24 hours between receiving information about abortion and the actual abortion procedure, with a few requiring longer waits, and one-fourth requiring that women receive this information in person.

Constructing the meaning of ultrasound viewing in abortion care.

As ultrasound scanning becomes increasingly routine in abortion care, scholars and activists have forwarded claims about how viewing the ultrasound image will affect pregnant women seeking abortion, speculating that it will dissuade them from abortion. These accounts, however, fail to appreciate how viewing is a social process. Little research has investigated how ultrasound workers navigate viewing in abortion care.

Incidence of emergency department visits and complications after abortion.

Objective: To conduct a retrospective observational cohort study to estimate the abortion complication rate, including those diagnosed or treated at emergency departments (EDs).

Methods: Using 2009-2010 abortion data among women covered by the fee-for-service California Medicaid program and all subsequent health care for 6 weeks after having an abortion, we analyzed reasons for ED visits and estimated the abortion-related complication rate and the adjusted relative risk. Complications were defined as receiving an abortion-related diagnosis or treatment at any source of care within 6 weeks after an abortion.

Beyond political claims: women's interest in and emotional response to viewing their ultrasound image in abortion care.

Context: In the United States, abortion opponents have supported legislation requiring that abortion patients be offered the opportunity to view their preprocedure ultrasound. Little research has examined women's interest in and emotional response to such viewing.

Methods: Data from 702 women who received abortions at 30 facilities throughout the United States between 2008 and 2010 were analyzed.

Out-of-pocket costs and insurance coverage for abortion in the United States.

Background: Since 1976, federal Medicaid has excluded abortion care except in a small number of circumstances; 17 states provide this coverage using state Medicaid dollars. Since 2010, federal and state restrictions on insurance coverage for abortion have increased. This paper describes payment for abortion care before new restrictions among a sample of women receiving first and second trimester abortions.

Development and validation of a reproductive autonomy scale.

No validated measures are currently available to assess women's ability to achieve their reproductive intentions, also referred to as "reproductive autonomy." We developed and validated a multidimensional instrument that can measure reproductive autonomy. We generated a pool of 26 items and included them in a survey that was conducted among 1,892 women at 13 family planning and 6 abortion facilities in the United States.

Relationship between ultrasound viewing and proceeding to abortion.

Objective: Ultrasound scanning is a routine part of preprocedure abortion care, and many health care providers offer patients the opportunity to view their ultrasound images. It has been speculated that ultrasound viewing will dissuade women from having an abortion. We examine whether viewing the image is associated with choosing to continue the pregnancy.

Prior family planning experiences of obese women seeking abortion care.

Background: The prevalence of obesity among women of reproductive age calls for research focused on strategies that ensure obese women receive high-quality reproductive health care. This study adds to this literature on service delivery by exploring obese women's experiences receiving or avoiding family planning care.

Methods: We included 651 women seeking abortion care who completed iPad surveys about their previous family planning experiences.

Patient viewing of the ultrasound image prior to abortion.

Background: Little research has investigated women's interest in and factors associated with viewing their ultrasound image in abortion care.

Study Design: Using medical records for all abortion care visits in 2011 (n = 15,575) at an urban abortion provider, we determined the proportion of women who chose to view by sociodemographic and pregnancy-related characteristics. We used bivariate and multivariable mixed-effects logistic regression models to examine associations between individual-level factors and the decision to view.

Disparities in abortion rates: a public health approach.

Women of lower socioeconomic status and women of color in the United States have higher rates of abortion than women of higher socioeconomic status and White women. Opponents of abortion use these statistics to argue that abortion providers are exploiting women of color and low socioeconomic status, and thus, regulations are needed to protect women. This argument ignores the underlying causes of the disparities.

Denial of abortion because of provider gestational age limits in the United States.

Objectives: We examined the factors influencing delay in seeking abortion and the outcomes for women denied abortion care because of gestational age limits at abortion facilities.

Methods: We compared women who presented for abortion care who were under the facilities' gestational age limits and received an abortion (n = 452) with those who were just over the gestational age limits and were denied an abortion (n = 231) at 30 US facilities. We described reasons for delay in seeking services.

At what cost? Payment for abortion care by U.S. women.

Background: Most U.S. abortion patients are poor or low-income, yet most pay several hundred dollars out of pocket for these services.

Multiple determinants of the abortion care experience: from the patient's perspective.

Because of the highly stigmatized nature of abortion care delivery and the restriction of abortion provision in most states, little is known about abortion care quality beyond procedural safety. This study examined which aspects of abortion care contributed to patient experiences. Data from a prospective, observational study of 9087 women aged 16 to 44 years, from 22 clinics across California, who responded to a postprocedure survey, were analyzed using mixed-effects logistic regression.

Safety of aspiration abortion performed by nurse practitioners, certified nurse midwives, and physician assistants under a California legal waiver.

Objectives: We examined the impact on patient safety if nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs) were permitted to provide aspiration abortions in California.

Methods: In a prospective, observational study, we evaluated the outcomes of 11 487 early aspiration abortions completed by physicians (n = 5812) and newly trained NPs, CNMs, and PAs (n = 5675) from 4 Planned Parenthood affiliates and Kaiser Permanente of Northern California, by using a noninferiority design with a predetermined acceptable risk difference of 2%. All complications up to 4 weeks after the abortion were included.

Effect of abortion protesters on women's emotional response to abortion.

Background: Little is known about women's experiences with and reactions to protesters and how protesters affect women's emotional responses to abortion.

Study Design: We interviewed 956 women seeking abortion between 2008 and 2010 at 30 U.S.

Women's perspectives on ultrasound viewing in the abortion care context.

Purpose: In recent years, states have passed a range of regulations regarding ultrasound procedures in abortion care. Abortion rights opponents have promoted ultrasound viewing, believing that women who view their own ultrasound images are likely to be dissuaded from abortion. Abortion rights advocates, in contrast, routinely oppose these regulations, citing concerns that ultrasound viewing in the abortion context will be emotionally difficult for women.

Attitudes and decision making among women seeking abortions at one U.S. clinic.

Context: Various restrictions on abortion have been imposed under the pretense that women may be uninformed, undecided or coerced in regard to their decision to terminate a pregnancy. Understanding whether certain women are at risk of low confidence in their abortion decision is useful for providing client-centered care and allocating counseling time to women with the greatest needs.

Methods: Data were abstracted from the precounseling needs assessment form and clinical intake form of 5,109 women who sought 5,387 abortions at one U.