Advertisement

Passage of abortion ban and women’s accurate understanding of abortion legality

Open AccessPublished:February 09, 2021DOI:https://doi.org/10.1016/j.ajog.2021.02.009

      Background

      Legislative and judicial procedures related to banning abortion after 6 weeks of gestation in Ohio occurred from November 2018 to July 2019. These activities could have increased the belief that abortion has become illegal even though the 6-week abortion ban has never been in effect to date.

      Objective

      We sought to determine the prevalence and correlates of holding the belief that abortion is illegal in Ohio and to evaluate whether this belief increased over the time in which the 6-week abortion ban was introduced, passed twice, and then blocked in Ohio.

      Study Design

      We analyzed data from the first wave of the Ohio Survey of Women, a population-based survey of adult, reproductive-aged Ohioan women conducted from October 2018 to June 2019. During each of the 8 survey months, a median of 240 women (range, 70–761) completed the survey, including the survey question “Based on what you know or have heard, is it legal to get an abortion in your state?” We used multivariable logistic regression to assess the prevalence and correlates of believing that abortion is illegal in the state of Ohio. In addition, we used multinomial logistic regression to evaluate whether this belief increased over the interval during which women completed the survey, which roughly corresponded to the interval marked by legislative and judicial activities surrounding the 6-week abortion ban.

      Results

      Most of the 2359 participants understood that abortion is legal in the state of Ohio (64.0%) with the remainder believing it to be illegal (9.8%) or being unsure (26.2%). Correlates of believing abortion to be illegal included younger age, lower socioeconomic status, never married or married status, and Black, non-Hispanic race and ethnicity. Being unsure about legality did not change over time; however, the proportion of women who believed that abortion is illegal increased from the first month (4.5%) to the last month (15.9%) of the study period. Each additional study month was associated with a 17% increase in the odds of believing abortion to be illegal, in both unadjusted and adjusted models (odds ratio, 1.17; 95% confidence interval, 1.08–1.27).

      Conclusion

      Attempts to restrict abortion access could contribute to women mistakenly believing that abortion is illegal despite it being unsuccessful.

      Key words

      Introduction

      Under the 1973 Supreme Court decision Roe v. Wade, abortion is legal until viability, the point at which a fetus can sustain survival outside the womb.
      US Supreme Court
      Roe v. Wade, 410 U.S. 113 (1973). Justia. 1973.
      Legislation and regulations restricting abortion are increasingly common in the United States, with 479 restrictions enacted in 33 US states from 2011 to the first 5 months of 2019.
      • Nash E.
      Unprecedented wave of abortion bans is an urgent call to action. Guttmacher Institute.
      Commonly referred to as targeted regulation of abortion providers, these regulations have imposed, for example, mandatory waiting periods and ultrasound viewing, third-party authorizations, and reporting requirements in cases of rape.
      ACOG Committee Opinion no. 613: increasing access to abortion.
      Other legislation has involved bans on certain types of abortion, such as those sought because of fetal anomalies or after a certain gestational age.

      Why was this study conducted?

      We wanted to understand whether women mistakenly believe that abortion is illegal and whether proposed legislation might increase misunderstandings about legality.

      Key findings

      Many women (26.2%) in the state of Ohio were unsure whether abortion is illegal; moreover, a smaller subset of women (9.8%) believed it to be illegal. The prevalence of believing that abortion in Ohio is illegal increased during the study interval, which corresponded to the interval marked by legislative and judicial activities surrounding the 6-week abortion ban in Ohio.

      What does this add to what is known?

      Even if abortion restrictions never go into effect, the resulting discourse and debate about the legislation could lead to some women mistakenly believing that abortion has become illegal.
      The discourse and debate stirred up by proposed legislation can foster beliefs among the public that abortion has become illegal whether or not the legislation is enacted. Furthermore, some argue that abortion laws are written in ambiguous terms to discourage people from seeking an abortion.
      • Erdman J.
      The global abortion policies database: knowledge as a health intervention.
      Individuals with an unintended pregnancy who are uncertain about the legality of abortion may not seek a procedure because they assume the procedure is not obtainable or out of fear of prosecution for seeking or procuring it. Others might delay in seeking timely care or assume a greater burden of long-distance travel because of the belief that abortion is illegal in their own state. Few studies have measured people’s knowledge of abortion legality in the United States.
      • Lara D.
      • Holt K.
      • Peña M.
      • Grossman D.
      Knowledge of abortion laws and services among low-income women in three United States cities.
      • White K.
      • Potter J.E.
      • Stevenson A.J.
      • Fuentes L.
      • Hopkins K.
      • Grossman D.
      Women’s knowledge of and support for abortion restrictions in Texas: findings from a statewide representative survey.
      • Bessett D.
      • Gerdts C.
      • Littman L.L.
      • Kavanaugh M.L.
      • Norris A.
      Does state-level context matter for individuals’ knowledge about abortion, legality and health? Challenging the ‘red states v. blue states’ hypothesis.
      During November 2018 and December 2018, the Ohio House and Senate, respectively, passed a ban on abortion performed after 6 weeks of gestation, which the governor immediately vetoed (Figure 1). After a change in the gubernatorial administration in January 2019, the Ohio legislature again passed the ban on abortion and it was signed into law in April 2019.

      The Ohio General Assembly. Senate Bill 23. 2019. Available at: https://www.legislature.ohio.gov/legislation/legislation-summary?id=GA133-SB-23. Accessed February 28, 2021.

      Such “heartbeat bills” in other states have been struck down as unconstitutional under Roe v. Wade.
      Guttmacher Institute
      State bans on abortion throughout pregnancy.
      Consistent with these previous rulings, a federal court blocked the Ohio law before it took effect. Here, our objectives were to determine the prevalence and correlates of holding the belief that abortion is illegal in Ohio and to evaluate whether this belief increased over the time in which the 6-week abortion ban was introduced, passed twice, and then blocked in Ohio. Our hypothesis was that even though abortion has been and remains (at the time of this writing) legal up to 20 weeks of gestation in Ohio, the protracted legislative activity surrounding the 6-week abortion ban might have led people to believe that abortion was prohibited by law.
      Figure thumbnail gr1
      Figure 1Timeline of 6-week abortion bans in Ohio in from 2018 to 2019
      HB, House bill; SB, Senate bill.
      Gallo et al. Knowledge of abortion legality. Am J Obstet Gynecol 2021.

      Material and Methods

      Survey overview

      We analyzed data from the first wave of the Ohio Survey of Women, a population-based survey on contraceptive use and reproductive health practices of adult, reproductive-aged women (18–44 years) in Ohio. Women who were included in the analysis were surveyed only once; we assessed population-level shifts in knowledge about abortion legality over the interval in which the survey was fielded, October 11, 2018, and June 13, 2019. The survey employed the same methodology as similar surveys in several other states.

      Evaluation of the Delaware contraceptive access now initiative. DelCAN. Available at: https://popcenter.umd.edu/delcaneval. Accessed November 16, 2020.

      The National Opinion Research Center (NORC) at the University of Chicago conducted the survey and their institutional review board (IRB) approved it. The Ohio State University IRB determined the analysis of deidentified data to be exempt from review. Furthermore, women provided consent before participation.
      The survey used a multimodal design, in which households were randomly selected from a sampling frame consisting of households that received mail in June 2018 according to the computerized delivery sequence (CDS) file of the United States Postal Service. The NORC appended area-level demographic information from the American Community Survey (ACS) onto the geocoded households before matching the address frame to a list of addresses identified using the Marketing Systems Group, containing women aged 18 to 44 years. Moreover, the NORC oversampled women who were on both the CDS and the age-targeted lists. Consequently, the NORC recruited women aged 18 to 44 years in the randomly selected households via a letter sent through the postal service and asked them to complete the online questionnaire through a secure, web-based system. Nonrespondents were sent a paper survey to complete. Women in the 31 counties that compose the rural Appalachia region of Ohio were oversampled by ∼60%. The expected survey response rate was 26.5% with a target sample size of 2000; however, the actual survey response rate was 33.5% with a total of 2529 participants completing the survey. For all analyses, we used statistical weights provided by the NORC to adjust for the probabilities of selection, nonresponse, and poststratification imputation and raking, which were based on Ohio demographics from the ACS.

      Beliefs about abortion illegality in Ohio

      To measure understanding of abortion legality, we used the question “Based on what you know or have heard, is it legal to get an abortion in your state?” with response options “yes,” “no,” “do not know or not sure,” and “decline.” We excluded participants who declined to answer or who had no response. We evaluated the following demographic factors as potential correlates of believing abortion to be illegal: age, socioeconomic status (4-level composite variable based on educational level and income), marital status (never married vs married vs separated, widowed, or divorced), race and ethnicity (non-Hispanic Black vs other), and region of residence (rural Appalachia vs all other areas). We included rural Appalachia because of its unique identity in the state, often viewed as a culturally distinct and insular region.
      • Peine E.K.
      • Azano A.P.
      • Schafft K.A.
      Beyond cultural and structural explanations of regional underdevelopment: identity and dispossession in Appalachia.
      Rural Appalachian counties are economically depressed and its residents consistently have worse health access than those in rural non-Appalachian areas in the state of Ohio.
      • Smith L.H.
      • Holloman C.H.
      Health status and access to health care services: a comparison between Ohio’s rural non-Appalachian and Appalachian families.
      We used derived variables that the NORC created using hot-deck imputation to fill in missing data for age (n=31), socioeconomic status (n=290), marital status (n=32), and race and ethnicity (n=9). We conducted logistic regression with each potential correlate in an individual model with the outcome of believing abortion to be illegal; furthermore, we fit a multivariable model with all selected factors.
      For the primary analysis of the trend over time in women’s beliefs about abortion legality, we treated the independent variable, month, as a continuous variable in unadjusted and adjusted multinomial logistic regression models. To represent historic time, we created a continuous variable for the 8 months during which participants completed the survey (eg, month 1 was from October 11, 2018, to November 10, 2018). We excluded data captured after June 10, 2019, given that few surveys (n=5) were collected after that date. We first estimated the unadjusted trend and then repeated the analysis with adjustment for age, social economic status, marital status, region of residence, and race and ethnicity. As a secondary analysis, we used multinomial logistic regression with indicator variables for the 8 months to estimate changes over time in the odds of believing abortion to be illegal or being unsure (“do not know or not sure”) compared with the reference of believing abortion to be legal.

      Media exposure

      To illustrate the potential exposure to media coverage of the 6-week abortion ban in Ohio, we used NewsBank, a database of media reports (eg, newspaper titles, newswires, transcripts, and periodicals),
      NewsBank
      About NewsBank.
      to quantify the number of news reports related to abortion in Ohio during the 8 months in which the survey was fielded. Specifically, we searched NewsBank for reports in the United States with the terms “abortion” and “Ohio” in the headline. We reported the number of reports published each month and the cumulative number of reports published between the start of data collection (October 11, 2018) and the end of each month.

      Results

      Overall, 2529 women completed the survey. We excluded respondents who declined to answer (n=19) or provided multiple responses to the legality question (n=3), were missing the survey date (n=143) or answered the survey after June 10, 2019 (n=5); thus, the final analytical sample consisted of 2359 women. Weighted to reflect women aged 18 to 44 years in Ohio, nearly half of the women (44.5%) were aged 18 to 29 years, and 45.5% of the women were in the lowest socioeconomic status category (ie, had some college or less and an annual household income of <$75,000) (Table 1). Most women identified as White, non-Hispanic (75.6%) with a smaller proportion identifying as Black, non-Hispanic (13.8%). Over the study period, most women reported abortion in Ohio to be legal (64.0%) with the remaining reporting it to be illegal (9.8%) or responding that they were unsure (26.2%).
      Table 1Demographic characteristics, Ohio Survey of Women (N=2359)
      CharacteristicNumber (n)
      Unweighted numbers
      Percentage (%)
      Weighted percentages
      Age (y)
       18–2974644.5
       30–39103338.1
       40–4458017.4
      Socioeconomic status
       Some college or less, <$75,00088545.5
       Some college or less, ≥$75,00030810.6
       Bachelor’s degree or higher, <$75,00050123.6
       Bachelor’s degree or higher, ≥$75,00066520.3
      Marital status
       Never married90250.5
       Married125440.6
       Separated, divorced, or widowed2038.9
      Region of residence
       Rural Appalachia51314.6
       All other areas184685.4
      Race and ethnicity
       Black, non-Hispanic13113.8
       Other
      Other consists of White, non-Hispanic (75.6%); multiple or other races, non-Hispanic (6.6%); Hispanic (2.4%); Asian, non-Hispanic (1.5%)’ and Native Hawaiian or Pacific Islander, non-Hispanic (0.04%).
      222886.2
      Gallo et al. Knowledge of abortion legality. Am J Obstet Gynecol 2021.
      a Unweighted numbers
      b Weighted percentages
      c Other consists of White, non-Hispanic (75.6%); multiple or other races, non-Hispanic (6.6%); Hispanic (2.4%); Asian, non-Hispanic (1.5%)’ and Native Hawaiian or Pacific Islander, non-Hispanic (0.04%).
      In the unadjusted and adjusted analyses, each of the demographic factors evaluated were associated with believing abortion to be illegal in Ohio except for region of residence (Table 2). In the adjusted analysis, women who were 18 to 29 years of age had 1.28 times the odds of believing abortion to be illegal (95% confidence interval [CI], 1.27–1.30) compared with women who were 40 to 44 years of age. Those in the lowest socioeconomic status category had higher odds of believing abortion to be illegal than those in the highest category (adjusted odds ratio [aOR], 1.25; 95% CI, 1.24–1.27). Compared with those who were separated, divorced, or widowed, women who were never married (aOR, 1.29; 95% CI, 1.26–1.32) or married (aOR, 1.32; 95% CI, 1.29–1.34) also had higher odds of believing abortion to be illegal. Finally, Black, non-Hispanic women had 1.31 times the odds of believing abortion to be illegal (95% CI, 1.30–1.33) compared with women who were nonBlack.
      Table 2Correlates of believing abortion in Ohio to be illegal among adult, reproductive-age women in Ohio (N=2359)
      CharacteristicBelieves abortion is illegal in Ohio
      Unweighted
      Number (n)
      Weighted
      Percentage (%)
      Reference who believe abortion in Ohio is illegal compared with reference of those who believe abortion is legal or those who are unsure
      OR
      Reference who believe abortion in Ohio is illegal compared with reference of those who believe abortion is legal or those who are unsure
      95% CI
      Reference who believe abortion in Ohio is illegal compared with reference of those who believe abortion is legal or those who are unsure
      aOR
      Reference who believe abortion in Ohio is illegal compared with reference of those who believe abortion is legal or those who are unsure
      ,
      Adjusted for all variables listed in the table.
      95% CI
      Reference who believe abortion in Ohio is illegal compared with reference of those who believe abortion is legal or those who are unsure
      Age (y)
       18–298511.21.351.33–1.371.281.27–1.30
       30–39898.81.061.04–1.071.021.01–1.04
       40–44518.31.001.00
      Socioeconomic status
       Some college or less, <$75,0009411.01.361.34–1.371.251.24–1.27
       Some college or less, ≥$75,000289.21.141.12–1.161.071.05–1.09
       Bachelor’s degree or higher, <$75,000479.31.141.13–1.161.061.04–1.07
       Bachelor’s degree or higher, ≥$75,000568.11.001.00
      Marital status
       Never married9310.71.461.43–1.491.291.26–1.32
       Married1179.21.261.24–1.291.321.29–1.34
       Separated, divorced, or widowed157.31.001.00
      Region of residence
       Rural Appalachia589.81.010.99–1.021.000.99–1.02
       All other areas1679.81.001.00
      Race and ethnicity
       Black, non-Hispanic1612.51.331.31–1.351.311.30–1.33
       Other2099.41.001.00
      aOR, adjusted odds ratio; CI, confidence interval; OR, odd ratio.
      Gallo et al. Knowledge of abortion legality. Am J Obstet Gynecol 2021.
      a Unweighted
      b Weighted
      c Reference who believe abortion in Ohio is illegal compared with reference of those who believe abortion is legal or those who are unsure
      d Adjusted for all variables listed in the table.
      Focusing on the main concern of this research, the proportion of women believing abortion is illegal increased over the 8 months of the survey (Figure 2), from 4.5% in the first month to 15.9% in the last month. The percentage of women who were unsure about the legal status of abortion in Ohio remained essentially unchanged.
      Figure thumbnail gr2
      Figure 2Changes over time in beliefs about abortion legality in Ohio
      Gallo et al. Knowledge of abortion legality. Am J Obstet Gynecol 2021.
      In the multinomial logistic regression models with month modeled as a continuous predictor, we found no change over the 8 study months in the odds of women being unsure about abortion legality, compared with believing abortion to be legal, in both unadjusted (OR, 0.98; 95% CI, 0.93–1.04) and adjusted models (aOR, 0.97; 95% CI, 0.92–1.03). However, believing that abortion is illegal increased over time: each additional month in the study was associated with a 17% increase in the odds of believing abortion to be illegal, compared with believing abortion to be legal, in both unadjusted and adjusted models (OR, 1.17; 95% CI, 1.08–1.27).
      The adjusted multinomial models with month modeled as an indicator variable also indicated that the odds of being unsure about the legality of abortion (vs believing abortion to be legal) in Ohio did not change over time, whereas the odds of believing abortion to be illegal increased over the survey period (Table 3). Differences in estimates from the unadjusted and adjusted multinomial models were negligible. Compared with the referent of believing abortion to be legal in Ohio, women who completed the survey in months 4 to 8 had an aOR of believing abortion to be illegal that exceeded 2.0 in every month (with all but month 5 being statistically significant at 95% level). The OR increased over months 5 through 8. As time increased, the odds of believing abortion to be illegal, compared with believing abortion to be legal, increased. In the last month, the odds of women believing abortion to be illegal (vs believing abortion to be legal) were 3.86 (95% CI, 1.69–8.78) times that of the odds of women who completed the survey in the first month.
      Table 3Changes over time in beliefs about abortion legality in Ohio
      Estimates from a multinomial regression model using weights compared with referent of women believing abortion to be legal
      among adult, reproductive-age women in Ohio
      PeriodReferent of women who are unsure of abortion legality compared with referent of women who believe abortion is legalReferent of women who believe abortion is illegal compared with referent of women who believe abortion is legal
      OR (95% CI)Adjusted OR (95% CI)
      Adjusted for age, social economic status (education and household income), marital status, region of residence, and race and ethnicity.
      OR (95% CI)Adjusted OR (95% CI)
      Adjusted for age, social economic status (education and household income), marital status, region of residence, and race and ethnicity.
      Month 1 (Oct. 11, 2018–Nov. 10, 2018; referent)1.001.001.001.00
      Month 2 (Nov. 10, 2018–Dec. 10, 2018)0.63(0.29–1.39)0.63(0.28–1.40)2.56(0.91–7.18)2.57(0.88–7.47)
      Month 3 (Dec. 10, 2018–Jan. 10, 2019)1.12(0.71–1.75)1.07(0.68–1.70)1.82(0.83–3.99)1.88(0.85–4.15)
      Month 4 (Jan. 10, 2019–Feb. 10, 2019)0.95(0.67–1.34)0.92(0.65–1.31)2.38(1.26–4.49)2.34(1.24–4.43)
      Month 5 (Feb. 10, 2019–March 10, 2019)1.09(0.68–1.77)1.08(0.67–1.75)2.07(0.93–4.60)2.02(0.91–4.48)
      Month 6 (March 10, 2019–April 10, 2019)0.35(0.17–0.72)0.34(0.16–0.70)2.54(0.94–6.87)2.68(1.00–7.20)
      Month 7 (April 10, 2019–May 10, 2019)1.00(0.67–1.48)0.95(0.64–1.41)3.30(1.71–6.36)3.36(1.73–6.55)
      Month 8 (May 10, 2019–June 10, 2019)0.79(0.44–1.41)0.75(0.42–1.35)3.79(1.72–8.36)3.86(1.69–8.78)
      CI, confidence interval; OR, odds ratio.
      Gallo et al. Knowledge of abortion legality. Am J Obstet Gynecol 2021.
      a Estimates from a multinomial regression model using weights compared with referent of women believing abortion to be legal
      b Adjusted for age, social economic status (education and household income), marital status, region of residence, and race and ethnicity.
      Content analysis of NewsBank suggested that the timing of articles published in the United States with “abortion” and “Ohio” in the headlines (Figure 3) roughly corresponded to the legislative and judicial activities surrounding the 6-week abortion ban (Figure 1). The first month (October 11, 2018, to November 10, 2018) had only 1 article with these terms in the headline, whereas the second month (November 11, 2018, to December 10, 2018) had 55 new articles and a cumulative total of 56 articles. In the final month (May 11, 2019, to June 10, 2019), 100 new articles were published with a cumulative total of 537 articles.
      Figure thumbnail gr3
      Figure 3Media reports on abortion in Ohio from NewsBank, October 11, 2018, to June 10, 2019
      Gallo et al. Knowledge of abortion legality. Am J Obstet Gynecol 2021.

      Comment

      Over time, we found an increase in the fraction of women who mistakenly believed that abortion is illegal in Ohio. The period under study corresponded to the period in which a 6-week ban on abortion was passed by the state legislature, signed into law, and subsequently enjoined by the courts before ever being enacted. Although the monthly increase in the proportion of women who believe abortion to be illegal was only 17%, the proportion increased from 4.5% to 15.9% over the 8 months of the survey administration.
      Little evidence exists on people’s understanding of abortion laws. A recent systematic review on this topic revealed that there is no such study conducted in the United States.
      • Assifi A.R.
      • Berger B.
      • Tunçalp Ö.
      • Khosla R.
      • Ganatra B.
      Women’s awareness and knowledge of abortion laws: a systematic review.
      Subsequently, Lara et al
      • Lara D.
      • Holt K.
      • Peña M.
      • Grossman D.
      Knowledge of abortion laws and services among low-income women in three United States cities.
      analyzed older survey data collected in 2008 from a convenience sample of low-income women (N=1262) attending for medical care in San Francisco, Boston, or New York. They found that 47% of women underestimated the gestational age limit for accessing a legal abortion, with an additional 17% reporting that they did not know the legal gestational limit. In a population-based survey of adult, reproductive-age women (N=799) in Texas, White et al
      • White K.
      • Potter J.E.
      • Stevenson A.J.
      • Fuentes L.
      • Hopkins K.
      • Grossman D.
      Women’s knowledge of and support for abortion restrictions in Texas: findings from a statewide representative survey.
      reported that 36% of women were not “very aware” of the restrictive laws that had recently been passed in the state and 19% of women had not heard of them. Finally, in an Internet survey of reproductive-age adults in the United States, Bessett et al
      • Bessett D.
      • Gerdts C.
      • Littman L.L.
      • Kavanaugh M.L.
      • Norris A.
      Does state-level context matter for individuals’ knowledge about abortion, legality and health? Challenging the ‘red states v. blue states’ hypothesis.
      found that 17% of participants did not know that abortion before 12 weeks of gestation is legal. Here, the findings were consistent with earlier studies that demonstrated low levels of understanding of abortion laws.
      Our analysis identified several demographic characteristics that were correlated with holding the misconception of abortion illegality. Younger age, lower socioeconomic status measured by education and income, never married and married status (compared with being separated, divorced, or widowed), and Black, non-Hispanic race and ethnicity were associated with believing abortion to be illegal in Ohio. Consequently, people who already are vulnerable to disparities in accessing abortion
      • Dehlendorf C.
      • Weitz T.
      Access to abortion services: a neglected health disparity.
      might have an additional barrier to accessing the time-sensitive procedure.
      Besides holding an important role in influencing public opinion,
      • Rogers E.M.
      • Dearing J.W.
      • Bregman D.
      The anatomy of agenda-setting research.
      ,
      • Son Y.J.
      • Weaver D.H.
      Another look at what moves public opinion: media agenda setting and polls in the 2000 U.S. election.
      the news media likely serves as a key source for influencing people’s understanding of state-level legislation. According to NewsBank, media reports on abortion in Ohio seemed to occur during the study interval around the times of legislative and judicial activities related to the 6-week abortion ban. The function of news media is reporting new events and not informing the public about the status quo (ie, abortion remaining legal). Thus, even if the news media reports were accurate, the cumulative effect of these reports on the numerous, and potentially confusing, steps involved in the challenges to legal abortion in the state could have contributed to misunderstanding about the legal status of abortion. Communications via other modes, such as television, radio, direct mailings, or social media, by those who supported or opposed the law could have influenced women’s understanding of abortion legality. Future research could consider how multiple media forms, along with other information sources, such as family, friends, healthcare providers, websites, and social media posts, are associated with knowledge of abortion legality and the role they could play in disseminating accurate information.
      New attempts to restrict abortion access in Ohio continue: in late March 2020 when the Ohio Department of Health ordered all nonessential surgeries to stop because of the coronavirus disease 2019 pandemic, the Ohio Attorney General sent cease-and-desist letters to several abortion clinics interpreting the order as prohibiting almost all surgical abortions.
      • Bayefsky M.J.
      • Bartz D.
      • Watson K.L.
      Abortion during the Covid-19 pandemic—ensuring access to an essential health service.
      A temporary restraining order was issued on April 8, 2020, to allow abortion services to continue during the litigation process. Whether this new challenge has further contributed to people’s misunderstanding of the current legal status of abortion in Ohio is unknown. Given the frequency with which new abortion restrictions are proposed throughout the United States,
      • Nash E.
      Unprecedented wave of abortion bans is an urgent call to action. Guttmacher Institute.
      uncertainty and misconceptions about abortion legality could be widespread in other states as well.

      Strengths and limitations

      Primary strengths of our analyses included the large sample that was representative of adult, reproductive-age women in Ohio. The analysis took advantage of the timing of the survey completion, which spanned the interval of time with legislative and judicial activity related to the 6-week abortion ban. Recruitment to survey participation occurred in random “replicates,” random subsamples of the overall sample drawn for the survey. Thus, the timing of survey completion should be unbiased in terms of selection into the study. This is supported by our finding that the estimates for the changes in beliefs over time did not differ after adjustment for participant characteristics. A study weakness was the relatively low response rate. However, we used poststratification weights to adjust for nonresponse. Finally, the generalizability of the findings to other settings is unknown. Given the volume of proposed legislations on abortion, it would be helpful to conduct research in multiple states that examine how public understanding of abortion access is influenced by legislative activity and in the amount of media coverage the proposed legislations garner; to the best of our knowledge, most existing research examine the effect of enacted laws and policies.

      Conclusions

      The misconception that abortion is illegal could cause people to delay accessing abortion services. Abortion is a safe procedure
      • Raymond E.G.
      • Grimes D.A.
      The comparative safety of legal induced abortion and childbirth in the United States.
      • Upadhyay U.D.
      • Desai S.
      • Zlidar V.
      • et al.
      Incidence of emergency department visits and complications after abortion.
      • White K.
      • Carroll E.
      • Grossman D.
      Complications from first-trimester aspiration abortion: a systematic review of the literature.
      ; however, risks increase as gestational age advances.
      • Bartlett L.A.
      • Berg C.J.
      • Shulman H.B.
      • et al.
      Risk factors for legal induced abortion-related mortality in the United States.
      ,
      • Zane S.
      • Creanga A.A.
      • Berg C.J.
      • et al.
      Abortion-related mortality in the United States: 1998-2010.
      Ability to access timely abortion care is important for preventing maternal mortality among people with high-risk pregnancies because of comorbidities.
      • Aziz M.M.
      • Calfee A.
      • Albright C.
      • Gladstein N.
      • Houser M.V.
      Termination of pregnancy as a means to reduce maternal mortality in pregnant women with medical comorbidities.
      Regulations that restrict abortion, and the resulting closure of abortion clinics, cause people to have to travel further to access abortion care.
      • Gerdts C.
      • Fuentes L.
      • Grossman D.
      • et al.
      Impact of clinic closures on women obtaining abortion services after implementation of a restrictive law in Texas.
      ,
      • Ely G.E.
      • Hales T.W.
      • Jackson D.L.
      • Maguin E.
      • Hamilton G.
      Where are they from and how far must they go? Examining location and travel distance in U.S. Abortion Fund patients.
      It is unknown whether misconceptions about abortion legality leads people to travel to another state to obtain an abortion or to forgo seeking a legal abortion from a licensed medical provider and instead attempt self-managed abortion. Healthcare providers should not assume that people know that abortion remains legal; providers should consider providing information about the legality of abortion to patients.

      References

        • US Supreme Court
        Roe v. Wade, 410 U.S. 113 (1973). Justia. 1973.
        (Available at:) (Accessed February 28, 2021)
        • Nash E.
        Unprecedented wave of abortion bans is an urgent call to action. Guttmacher Institute.
        (Available at:)
      1. ACOG Committee Opinion no. 613: increasing access to abortion.
        Obstet Gynecol. 2014; 124: 1060-1065
        • Erdman J.
        The global abortion policies database: knowledge as a health intervention.
        BMJ. 2017; 359: j5098
        • Lara D.
        • Holt K.
        • Peña M.
        • Grossman D.
        Knowledge of abortion laws and services among low-income women in three United States cities.
        J Immigr Minor Health. 2015; 17: 1811-1818
        • White K.
        • Potter J.E.
        • Stevenson A.J.
        • Fuentes L.
        • Hopkins K.
        • Grossman D.
        Women’s knowledge of and support for abortion restrictions in Texas: findings from a statewide representative survey.
        Perspect Sex Reprod Health. 2016; 48: 189-197
        • Bessett D.
        • Gerdts C.
        • Littman L.L.
        • Kavanaugh M.L.
        • Norris A.
        Does state-level context matter for individuals’ knowledge about abortion, legality and health? Challenging the ‘red states v. blue states’ hypothesis.
        Cult Health Sex. 2015; 17: 733-746
      2. The Ohio General Assembly. Senate Bill 23. 2019. Available at: https://www.legislature.ohio.gov/legislation/legislation-summary?id=GA133-SB-23. Accessed February 28, 2021.

        • Guttmacher Institute
        State bans on abortion throughout pregnancy.
        (Available at:)
      3. Evaluation of the Delaware contraceptive access now initiative. DelCAN. Available at: https://popcenter.umd.edu/delcaneval. Accessed November 16, 2020.

        • Peine E.K.
        • Azano A.P.
        • Schafft K.A.
        Beyond cultural and structural explanations of regional underdevelopment: identity and dispossession in Appalachia.
        J Appalachian Stud. 2020; 26: 40-56
        • Smith L.H.
        • Holloman C.H.
        Health status and access to health care services: a comparison between Ohio’s rural non-Appalachian and Appalachian families.
        Fam Community Health. 2011; 34: 102-110
        • NewsBank
        About NewsBank.
        (Available at:)
        https://www.newsbank.com/about-newsbank
        Date accessed: November 16, 2020
        • Assifi A.R.
        • Berger B.
        • Tunçalp Ö.
        • Khosla R.
        • Ganatra B.
        Women’s awareness and knowledge of abortion laws: a systematic review.
        PLoS One. 2016; 11e0152224
        • Dehlendorf C.
        • Weitz T.
        Access to abortion services: a neglected health disparity.
        J Health Care Poor Underserved. 2011; 22: 415-421
        • Rogers E.M.
        • Dearing J.W.
        • Bregman D.
        The anatomy of agenda-setting research.
        J Commun. 1993; 43: 68-84
        • Son Y.J.
        • Weaver D.H.
        Another look at what moves public opinion: media agenda setting and polls in the 2000 U.S. election.
        Int J Public Opin Res. 2006; 18: 174-197
        • Bayefsky M.J.
        • Bartz D.
        • Watson K.L.
        Abortion during the Covid-19 pandemic—ensuring access to an essential health service.
        N Engl J Med. 2020; 382: e47
        • Raymond E.G.
        • Grimes D.A.
        The comparative safety of legal induced abortion and childbirth in the United States.
        Obstet Gynecol. 2012; 119: 215-219
        • Upadhyay U.D.
        • Desai S.
        • Zlidar V.
        • et al.
        Incidence of emergency department visits and complications after abortion.
        Obstet Gynecol. 2015; 125: 175-183
        • White K.
        • Carroll E.
        • Grossman D.
        Complications from first-trimester aspiration abortion: a systematic review of the literature.
        Contraception. 2015; 92: 422-438
        • Bartlett L.A.
        • Berg C.J.
        • Shulman H.B.
        • et al.
        Risk factors for legal induced abortion-related mortality in the United States.
        Obstet Gynecol. 2004; 103: 729-737
        • Zane S.
        • Creanga A.A.
        • Berg C.J.
        • et al.
        Abortion-related mortality in the United States: 1998-2010.
        Obstet Gynecol. 2015; 126: 258-265
        • Aziz M.M.
        • Calfee A.
        • Albright C.
        • Gladstein N.
        • Houser M.V.
        Termination of pregnancy as a means to reduce maternal mortality in pregnant women with medical comorbidities.
        Obstet Gynecol. 2019; 134: 1105-1108
        • Gerdts C.
        • Fuentes L.
        • Grossman D.
        • et al.
        Impact of clinic closures on women obtaining abortion services after implementation of a restrictive law in Texas.
        Am J Public Health. 2016; 106: 857-864
        • Ely G.E.
        • Hales T.W.
        • Jackson D.L.
        • Maguin E.
        • Hamilton G.
        Where are they from and how far must they go? Examining location and travel distance in U.S. Abortion Fund patients.
        Int J Sex Health. 2017; 29: 313-324