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Who loses access to legal abortion with a 6-week ban?

      Objective

      With the recent overturning of Roe vs Wade by the United States Supreme Court, some states are now banning abortion at any stage of pregnancy. Others have laws that ban abortion after detection of embryonic cardiac activity,
      Guttmacher Institute
      State bans on abortion throughout pregnancy.
      at approximately 6 weeks (42 days) of gestation. Under such laws, those who learn of pregnancy at or after 6 weeks will have no legal, in-state option to end pregnancy.

      Study Design

      We surveyed adults seeking medication or procedural abortions at 7 clinics in Ohio between April 2020 and April 2021. We captured participants’ reported dates of pregnancy discovery, clinic contact and termination, and gestation at termination. We assessed correlates of pregnancy discovery after 6 weeks’ gestation, and used a binary threshold of <6 weeks 0 days vs ≥6 weeks 0 days, although cardiac activity can be detected as early as 5 weeks 5 days.
      • Turocy J.
      • Williams Z.
      Early and recurrent pregnancy loss: etiology, Diagnosis, Treatment.
      All participants provided informed consent, and the project was approved by the University of Cincinnati Institutional Review Board.

      Results

      The response rate was 24%. Among n=1141 participants, 25% discovered their pregnancy after 6 weeks’ gestation; they had significantly lower income (P=.02) and lower educational attainment (P=.05) than those who detected pregnancy before 6 weeks. Young (P=.09) or unmarried (P=.09) participants were also somewhat more likely to detect pregnancy after 6 weeks (Table). Racial disparities reflecting structural racism were also evident, with Black respondents having been somewhat more likely to discover pregnancy after 6 weeks (P=.08).
      Overall, median gestation at pregnancy discovery was 34 days (Table). Median time between discovery and clinic contact was similar between the groups with pregnancy discovery before and after 6 weeks (3 vs 2 days, respectively; P=.41). Median time from discovery to termination was significantly longer among those discovering pregnancy before 6 weeks (22 days) than among those discovering pregnancy after 6 weeks (19 days; P<.01). Although 89% of respondents overall obtained abortions after 6 weeks, median gestation at termination was significantly earlier among those discovering pregnancy before 6 weeks (53 vs 74 days for discovery after 6 weeks; P<.01) (Table).
      TableParticipant characteristics, overall and by timing of pregnancy discovery
      CharacteristicsAllDiscovered pregnancy <42 dDiscovered pregnancy ≥42 dP value
      P values for categorical variables calculated using chi square or Fisher exact tests; P values for continuous variables calculated using Mann–Whitney tests
      N=1141(%)N=858(%)N=283(%)
      Race
      Participants could select >1 category, thus percentages may total >100%.
       Black509(45)370(43)139(49).08
       White617(54)469(55)148(52).49
       Asian29(3)24(3)5(2).34
       Other race29(3)23(3)6(2).60
       Missing34(3)27(3)7(2).56
      Ethnicity.64
       Hispanic61(5)43(5)18(6)
       Missing14(1)10(1)4(1)
      Sexuality
      Participants could select >1 category, thus percentages may total >100%.
       Heterosexual906(79)686(80)220(78).42
       Bisexual/pansexual/queer179(16)135(16)44(16).94
       Gay/lesbian8(0.7)5(0.6)3(1).40
       Asexual6(0.5)4(0.5)2(0.7).63
       Missing61(5)40(5)21(7).07
      Marital status
      Participants could select >1 category, thus percentages may total >100%.
       Married101(9)83(10)18(6).09
       Single499(44)368(43)131(46).32
       In relationship499(44)376(44)123(43).92
       Polyamorous4(0.4)3(0.4)1(0.4).99
       Separated/divorced/widowed57(5)45(5)12(4).50
       Missing12(1)6(0.7)6(2).04
      Highest completed education.05
       Less than high school diploma51(4)38(4)13(5)
       High school diploma/equivalent341(30)245(29)96(34)
       Some college/associate’s degree542(48)403(47)139(49)
       Bachelor’s or graduate degree204(18)169(20)35(12)
       Missing3(0.3)3(0.4)0(0)
      Age (y).09
       18–24416(36)303(35)113(40)
       25–29353(31)270(31)83(29)
       30–34225(20)168(20)57(20)
       35–39109(10)92(11)17(6)
       40–4435(3)24(3)11(4)
       45–492(0.2)1(0.1)1(0.4)
       ≥501(0.1)0(0)1(0.4)
      Annual income.02
       ≤$9999239(21)166(19)73(26)
       $10,000–$29,999443(39)331(39)112(40)
       $30,000–$49,999225(20)172(20)53(19)
       ≥$50,000162(14)136(16)26(9)
       Missing72(6)53(6)19(7)
      Parity.88
       0372(33)280(33)92(33)
       1322(28)245(29)77(27)
       ≥2447(39)333(39)114(40)
      Abortion history.51
       0375(33)275(32)100(35)
       ≥1765(67)582(68)183(65)
       Missing1(0.1)1(0.1)0(0)
      Median(IQR)Median(IQR)Median(IQR)P value
      P values for categorical variables calculated using chi square or Fisher exact tests; P values for continuous variables calculated using Mann–Whitney tests
      Gestation at pregnancy discovery (d)34(27–41)31(25–35)50(44–60)<.01
      Days between pregnancy discovery and clinic contact3(1–9)3(1–10)2(1–8).41
      Days between pregnancy discovery and termination22(13–35)22(14–35)19(11–31)<.01
      Gestation at termination (d)57(47–72)53(45–64)74(62–94)<.01
      Age, y27(23–31)27(23–31)26(23–31).25
      IQR, interquartile range.
      Turner. Who loses access to legal abortion with a 6-week ban? Am J Obstet Gynecol 2022.
      a P values for categorical variables calculated using chi square or Fisher exact tests; P values for continuous variables calculated using Mann–Whitney tests
      b Participants could select >1 category, thus percentages may total >100%.

      Conclusion

      By examining abortion timelines with reference to pregnancy discovery, these findings provide important insights about the possible effects of 6-week abortion bans, although the data may not be generalizable to other states. First, 25% of respondents discovered pregnancy after 6 weeks’ gestation. They would have no in-state option for legal abortion. Second, 6-week bans would disproportionally affect people with fewer economic and educational resources. Lack of resources is both a driver of abortion decision-making and a correlate of later presentation.
      • Biggs M.A.
      • Gould H.
      • Foster D.G.
      Understanding why women seek abortions in the US.
      Here we find it is also associated with pregnancy discovery after 6 weeks. Third, median gestation at pregnancy discovery was 34 days, meaning that most patients would have only 7 days before the 42-day limit. However, median time from discovery to termination was 22 days, not 7 days. Mandatory waiting periods, staff shortages and consequent reduced clinic availability, and (early in the pandemic) COVID-19–related scheduling changes likely exacerbate delays.
      • Jones R.K.
      • Jerman J.
      Abortion incidence and service availability in the United States, 2014.
      Finally, we note that 89% of terminations occurred after 6 weeks, and the overall median gestation at termination was 57 days—2 weeks after the 6-week threshold. Regardless of when pregnancy is detected, 6-week bans would disrupt care for nearly all patients.

      References

        • Guttmacher Institute
        State bans on abortion throughout pregnancy.
        (Available at:)
        • Turocy J.
        • Williams Z.
        Early and recurrent pregnancy loss: etiology, Diagnosis, Treatment.
        in: Gershenson D.M. Lentz G.M. Valea F.A. Lobo R.A. Comprehensive gynecology. 8th ed. Elsevier, New York, NY2022: 323-341
        • Biggs M.A.
        • Gould H.
        • Foster D.G.
        Understanding why women seek abortions in the US.
        BMC Womens Health. 2013; 13: 29
        • Jones R.K.
        • Jerman J.
        Abortion incidence and service availability in the United States, 2014.
        Perspect Sex Reprod Health. 2017; 49: 17-27