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The Impact of Abortion Policy on Patient Safety: How Is It Measured?
Laura Elizabeth Britton
A Project presented to the faculty of The University of North Carolina at Chapel Hill
in fulfillment of the requirements for Undergraduate Honors
Date Completed: April 10, 2014
Honors Advisor Approval: ___________________________
Abstract
In 1973, the Supreme Court decision Roe vs. Wade established the constitutional right to abortion, but since 2010, the number of abortion laws has increased significantly. The impact of those laws on society has been conceptualized and evaluated in a variety of ways, but their impact on patient health remains obscure.
The purpose of this research is to examine measures that could be used to evaluate the impact of abortion policy on patient safety. The methodology used in this project was Bardach’s “eight-fold path” for conducting a policy analysis. A literature review was performed to identify measures from 20 studies evaluating the association between abortion policy and patient safety. Four common measures were identified: abortion fatality rate, abortion rate, unintended
pregnancy/birth rate, and delay in abortion timing. Each measure was systemically evaluated based on two criteria: (1) relevance and validity as a measure of patient safety and (2)
convenience. The most relevant and valid measure was delay in abortion timing. While
collecting data about abortion timing is inconvenient and costly, it may be worthwhile as long as the concept of “safety” is prominent in the political discourse around abortion and valid evidence for policy-making is desired. The first step toward evidence-based public policy is ensuring the use of valid, relevant measures.
The Impact of Abortion Policy on Patient Safety: How Is It Measured? In 1973, the United States (U.S.) Supreme Court decision in Roe vs. Wade established the constitutional right to abortion (Roe vs. Wade, 1973). Over the subsequent 40 years, federal and state laws governing abortion have proliferated. Both the number of abortion laws and their variation from state to state have increased markedly in the last three years (Nash, Gold, Rowan, Rathbun & Vierboom, 2013). The impact of these laws on society has been conceptualized and evaluated in a variety of ways, but their impact on patients remains obscure.
The purpose of this project is to evaluate measures that could be used to conduct a policy analysis to examine the impact of abortion policy on patient safety. I use Eugene Bardach’s “eightfold path” for policy analysis to establish the steps in my examination of abortion policy through the lens of patient safety: (1) define the problem, (2) provide the evidence, (3) select criteria, (4) offer alternatives, (5) project the outcomes, (6) confront the tradeoffs, (7) make a recommendation, and (8) then tell the story in my conclusion (2012).
Step One: Define the Problem
The impact of abortion policy on patient safety has largely gone unmeasured despite the fact that policy makers increasingly invoke patient safety as a rationale for abortion policy (Stam, 2012). A barrier to evidence-based policy-making is a lack of valid, relevant measures that capture patient safety. In this analysis, I examine what is known about patient safety in abortion services and how previous evaluation research has conceptualized the impact of abortion policy. I ask the question, "Do previous measures effectively capture the impact of abortion policy on patient safety?" then establish and apply criteria to answer the question. I
measures that would be valid, relevant, and useful for providing an objective evaluation of the impact of abortion laws on patient safety.
What is patient safety?
“Patient safety” is a lens for understanding how systems in health care contribute to preventable patient harm. The Institute of Medicine (IOM) defines “patient safety” as “the prevention of harm to patients” (IOM, 2004) and the Agency for Healthcare Research and Quality (ARHQ) as “freedom from accidental or preventable injuries produced by medical care” (Patient Safety, n.d.). Both definitions emphasize that patient safety is the absence of avoidable harm. Conceptually, patient safety encompasses both risk of avoidable harm and occurrence of avoidable harm. The inclusion of risk of avoidable harm is endorsed by the World Health
Organization (WHO, 2009). Near-risk incident reporting systems track errors that cause no harm by chance, prevention, or mitigation (IOM, 2004).
Characterizing patient safety as “a discipline in the health care professions that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery” and “an attribute of health care systems that minimizes the incidence and impact of adverse events and maximizes recovery from such events” (Emanuel et al., n.d.), AHRQ strongly emphasizes the responsibility of the system, rather than that of the individual practitioners. This conceptualization of patient safety has been instrumental for moving away from a response of blame and punishment that has not adequately improved outcomes (Emanuel et al., n.d.). The understanding that systems contribute to patient harm developed substantially over the last 30 years.
Step Two: Assemble the Evidence
Assembling the evidence related to abortion measures and policy required gathering information from a variety of sources. Key primary sources for abortion data include the Abortion Surveillance Report conducted by the Center for Disease Control (CDC); the Alan Guttmacher Institute; the Pregnancy Mortality Surveillance System (PMSS) conducted by the CDC; National Survey of Family Growth (NSFG) conducted by the National Center for Health Statistics in the CDC; Pregnancy Risk Assessment Monitoring System (PRAMS) conducted by the CDC; and World Health Organization (WHO).
What is abortion?
this definition involves an intervention aimed at terminating a pregnancy, which is distinct from the designation of “spontaneous abortion” or miscarriage, which result from natural causes and without intervention. Spontaneous abortions are politically and medically distinct from induced abortions and are excluded from this discussion. Thus, unless otherwise noted, the term
“abortion” will be used to refer to induced abortion.
Abortion includes an array of medical interventions that end a pregnancy. “Medication abortion” is the use of pharmaceuticals (mifepristone, methotrexate, misoprostol, prostaglandins, alone or in combination) without the practitioner’s physical manipulation of a woman’s tissue (ACOG, 2011). “Dilation and curettage” (D&C) involves opening a woman’s cervix and removing uterine contents surgically with a sharp tool (a curette) or with vacuum aspiration. Obstetricians and gynecologists also use these methods to manage spontaneous abortions. “Dilation and evacuation” (D&E) is used later in gestation and requires more cervical dilation and a larger cannula in order to remove the uterine contents surgically. Uterine instillation is a rarely used technique in which hypertonic and uterotonic solutions are injected into the uterus to induce contractions that expel uterine contents (Lock, 2012).
What abortion data are available?
The CDC’s annual Abortion Surveillance Report compiles data on trends in abortion prevalence, maternal demographics, and maternal mortality (CDC, 2012). The CDC’s goals are to use the data to identify populations at high risk of unintended pregnancy, evaluate the
The CDC has collected demographic and medical data about patients who have
undergone an abortion since 1969 as individual states began to liberalize abortion laws. While most hospitals, clinics, and physicians are required to report abortion vital statistics to a state agency, the data submission to the CDC from the reporting areas is voluntary. The 52 reporting areas are the 50 states, Washington DC, and New York City (CDC, 2012). In 2010, every area except California, Maryland, and New Hampshire shared their aggregated abortion data with the CDC. Thus, the CDC's report underestimates actual statistics, particularly since California is a large state with less restrictive abortion laws than other states.
The Alan Guttmacher Institute is a non-profit organization that surveys abortion
providers directly to obtain abortion counts. It collects data independently from the CDC and has reported that the CDC report underrepresented actual abortion statistics by up to 40-50% (Finer & Henshaw, 2006a). In 2010, the Guttmacher Institute reported that California alone had 191,550 abortions, a substantial number considering the CDC 2010 report of 765,651 abortions nationally. Thus, the CDC’s data set, while large and official, is not comprehensive.
Furthermore, despite guidance to the states from the National Association of Public Health Statistics and Information Systems, variation exists in the demographic and medical information reported, so analysis is limited by incomplete data sets (CDC, 2012).
deaths from maternal mortality review committees, professional and citizens groups, and the popular media. Cases are not assessed at the state level but undergo a uniform systematic assessment at the CDC where a pair of medical epidemiologists review clinical records and autopsy reports to determine the occurrence of "death resulting from a direct complication of an abortion (legal or illegal), an indirect complication caused by a chain of events initiated by an abortion, or an aggravation of a preexisting condition by the physiologic or psychologic effects of abortion” (Pazol et al., 2013). Deaths resulting from illegal induced abortions and
miscarriages are distinguished from those that may result from legal abortions.
Abortion rates are often framed in terms of the unintended pregnancy rates and birth rates that are measured by the National Center for Health Statistics through the National Survey for Family Growth and by the CDC through the Pregnancy Risk Assessment Monitoring System (PRAMS). These surveys sample pregnant women rather than collect data from every pregnant woman.
What is known about patient safety in abortion provision?
restrictions. Each technique has its own risks and benefits. It is important to remember that “abortion” is an umbrella term that includes techniques with varying risk levels.
The CDC's Abortion Surveillance Report has been used to improve medical practice. After abortion became legal nationwide in 1973, many physicians had to learn new techniques, generally only having experience with using sharp curettage for miscarriage management and obtaining uterine diagnostic samples. The national abortion surveillance data identified that patients had better outcomes with dilation and vacuum aspiration than with sharp curettage and better outcomes with D&E rather than intrauterine instillation past 13 weeks (Cates, Grimes, & Schulz, 2000).
The CDC’s Abortion Surveillance Report’s most recent data shows 8 deaths from the 784,507 legal abortions reported in 2009 (Pazol et al., 2013; Pazol, Creanga, Zane, Burley, & Jamieson, 2012). This finding is consistent with a general downward trend in abortion fatality since Roe vs. Wade. In 1972 when abortions were legal in some states but not all, the case-related fatality rate was 4.1 deaths per 100,000 legal abortions (Bartlett et al., 2004). In the three years following abortion legalization in all 50 U.S. states, the abortion case-related fatality rate was 2.09 deaths per 100,000 legal abortions. Over the next 25 years, case-related fatality rate further decreased to an average 1.1 deaths per 100,000 legal abortions as physicians gained experience (Bartlett et al., 2004). In the period of 2003–2009 the case-related fatality rate was 0.67 deaths per 100,000 legal abortions (Pazol et al., 2013).
In comparison, the case-fatality rate in the developing world is 220 deaths per 100,000 abortions (WHO, 2012). The WHO reported that 21.6 million unsafe abortions were performed in 2008 (2012). The WHO defines “unsafe abortion” as a “procedure for terminating an
environment that does not conform to minimal medical standards, or both” (WHO, 2003, p. 18). More than 47,000 women died from severe infections, bleeding, or organ damage after unsafe abortions in 2008. At its worst, abortion-related maternal mortality peaked at 520 deaths per 100,000 abortions in Sub-Saharan African (WHO, 2012). Unsafe abortions are concentrated in economically impoverished areas of the world where abortion is largely illegal. When patients cannot find someone to provide legal and safe abortion, they seek care from poorly equipped or poorly trained substitutes, and then morbidity and mortality can spike (WHO, 2003).
However, legality does not ensure safety. In countries where abortion is illegal, abortion may be highly dangerous for the patient. However, in countries where abortion is legalized it safety should not be assumed since patient safety is also affected by the economic structure in which health care is delivered. For example, abortion is legal in India, but poor medical infrastructure and poverty render certified facilities inaccessible to many women, so non-certified facilities provide 6.7 million unsafe abortions, causing half of maternal mortality for women ages 15-19 (Center for Reproductive Rights, 2008). Thus, although abortion is legal in the United States, patient safety outcomes should be measured, not simply extrapolated from the letter of the law, to provide a basis for understanding how abortion policy may affect society. To this end, I will examine the conceptual basis of commonly used measures and critique their validity for demonstrating the relationship between public policy and patient safety.
How much can data from one location be generalized to others?
scope of practice; gestational limits; mandatory waiting periods; mandatory informed consent; parental involvement, notification, or consent; and public funding limitations.
Because each state has a unique combination of abortion laws, analysis of the impacts of a law in one state cannot be generalized to the nation at large. For instance, mandatory waiting periods exemplify how slight differences in each state’s laws limit evaluation generalizability. Mandatory waiting periods require a clinic to conduct a counseling session with state-mandated content by phone or in person some amount of time before the patient may undergo an abortion. Proponents say the mandatory waiting periods are intended to ensure that a patient has “the time and information to make the best decision possible. These laws provide the opportunity for a person to change his or her mind,” using the same rationale that makes time to think a legal requirement for divorce or refinancing a home (Stam, 2012, p. 4).
The laws can also delay abortions, create barriers that result in preventing abortions, or create financial burdens for abortion facilities. Of the 26 states with a mandatory waiting period, 9 require an in-person visit, which can require abortion patients to pay for multiple trips or overnight stays, increase the personal costs associated with the abortion, and ultimately limit access to abortion, particularly for lower-income patients. The states of Arizona, Indiana, Louisiana, Mississippi, Missouri, Ohio, and Wisconsin allow no exceptions to the in-person requirement; Texas and Virginia waive the in-person requirement if a patient lives more than 100 miles from an abortion provider; Utah allows for counseling to be conducted in "any location in the state”; and the law is currently enjoined in South Dakota (Counseling and Waiting Periods, 2014).
gestational limits. In practice, the waiting period can be a more substantial barrier. About 87% of American women live in counties lacking an abortion provider, so the in-person visit requires many patients to coordinate travel (Facts on Induced Abortion in the United States, 2010). When fulfilling the mandatory waiting period requires an overnight stay, the patient must have the money to afford transportation and lodging, the flexibility to take off work, and the resources to pay for childcare of previous children, if needed. Even in states where state-mandated counseling can be obtained over the phone, the 24-hour mandatory waiting period can push a procedure back by a week if a doctor or nurse is unable to contact the patient because the patient is hard to reach on the phone. Women at lower income levels are more likely to lack a phone or to have a job where they lack the flexibility and privacy to take a call. When women at gestational limits are delayed, they may no longer be eligible for the safer, earlier procedures. Proponents and opponents of mandatory waiting periods identify many benefits and costs to patients but the discussion lacks clarity on which benefits and costs affect patient safety.
Each state has a unique combination of abortion laws and regulations that act in concert. Effects in one state with or without a mandatory waiting period cannot necessarily be generalized to other states with different mandatory waiting period requirements. No two states have
identical laws, and no single law acts alone. Thus, the diversity of state laws poses a challenge for generalizing from one state to the nation.
Step Three: Select Criteria
Public policy, health systems policy, and clinical policy influence health systems in which patients seek care and experience patient safety outcomes. This analysis is focused on the relationship between patient safety and public policy, which Eisenberg defined as “federal, state, and local initiatives that affect the entire population or certain segments of the public”
(Eisenberg, 1998, p. 101). Public policy with respect to abortion can be conceptualized as a “latent factor” in James Reason’s “Swiss Cheese” model. Latent factors are decisions of the “high-level decision makers, regulators, managers” that may not directly cause a problem in every scenario, but that, when combined with “local triggering factors,” such as health systems or clinical policies, may result in harm or risk of harm (Reason, 1990, p. 28). Public policy influences the health care systems in which care is delivered and the clinicians who provide it. Evaluation Criteria
decreased when policy compels a greater number of patients to undergo a medical experience with a greater risk of harm which they have not freely chosen.
Evaluation Methods
I reviewed the literature to determine the measures commonly used to examine the impact of abortion policy: abortion mortality rate, abortion rate, unintended pregnancy/birth rate, and delay in abortion timing. I evaluated how well these common measures reflect patient safety. I placed no historical limit on publication date, though only legal abortions were
examined. International work from the developing world was excluded because differences in the medical infrastructure and magnitude of poverty are confounding factors. International work in English from developed countries where abortion is legal was included, although the findings were considered with caution in light of different health systems affecting access to care as well as the United States’ unique cultural narrative with respect to abortion.
It is important to note that a major barrier to conducting research to measure and improve the safety of abortion is the Dickey-Wicker Amendment, which prevents the NIH from funding “research in which a human embryo or embryos are destroyed, discarded, or knowingly
Steps Four-Six: Alternatives, Projected Outcomes, and Tradeoffs Using literature about abortion policy outcomes and abortion service delivery, I will assess the validity of four measures of abortion policy’s impact on patient safety: abortion mortality rate, abortion rate, unintended pregnancy/birth rate, and delayed abortion timing. My primary criterion is that a measure should capture the degree of preventable harm, the occurrence and risk of harm, and the effect of systems. My secondary criterion is the practicality of
implementing the measure. Abortion Mortality Rate
The abortion mortality rate is a case-fatality rate, which is the proportion of deaths within the population of patients that had abortions. This is different from the maternal mortality rate which is the deaths per 100,000 live births from any cause related to pregnancy (Central
Intelligence Agency, n.d.a). The CDC's vital statistics form the largest body of data about patient safety in abortion services. In the first decade after Roe vs. Wade, the case-fatality rate was evaluated after Medicaid restrictions were implemented (Bragonier et al., 1979).
Since the case-fatality rate has remained consistently low in the United States, this is not a sensitive measure for detecting the impact of policy changes. In terms of effectiveness, this measure has not revealed policy-influenced changes that have occurred in the last 40 years and therefore is not likely to be ideal for measuring patient safety in the future.
as long as reporting remains voluntary, the CDC’s Abortion Surveillance Report will be incomplete.
Abortion Rate
The national abortion rate is the number of abortions per 1000 women ages 15-44, with the CDC supplying the numerator and the U.S. Census the denominator. Another way to convey this information is by using the abortion ratio, which is the number of abortions per 1000 live births from numbers reported to the CDC.
Many studies have evaluated the abortion rate, abortion ratio, and the number of abortions after a change in policy (Chrisman et al., 1980; Hansen, 1980; Trussell et al., 1980; Korenbrot et al., 1990; Meier and McFarlane, 1994; Haas-Wilson, 1993; Haas-Wilson 1996; Levine et al., 1996; Haas-Wilson 1997; Meier et al., 1996; Blank et al., 1996; Matthews et al., 1997; Cook et al., 1999; Bitler and Zovodny, 2001; and Medoff, 2008). For example, after Mississippi enacted a Women’s Right to Know Act (WRTKA) with a mandatory 24-hour waiting period, Joyce saw a reduced abortion rate unmatched in neighboring South Carolina and Georgia, which suggested that mandatory delay was responsible (1997). However, a rise in the number of abortions performed in neighboring states makes it difficult to determine whether the WRTKA’s reduced the number of abortions obtained overall, or if Mississippi women went elsewhere to obtain abortions.
In terms of convenience, abortion rate has advantages and disadvantages similar to those of the case-fatality rate because the CDC’s Abortion Surveillance Report supplies the data and the data are routinely collected. The disadvantage is that data are not collected from all states.
policy. This is because the abortion rate does not distinguish a change in demand from a change in access. For instance, a reduced abortion rate alone does not indicate whether the underlying change was a reduction in abortion demand, in which fewer patients sought abortions, or a reduction in access, in which patients who sought abortions were unable to obtain them. Conversely, a rise in the abortion rate could signal either an increase in unwanted pregnancies with a constant rate of abortion demand or a constant rate of unwanted pregnancies with an increase in access to abortion services.
When measuring patient safety as a characteristic of the health system, it is critical to distinguish risks resulting from autonomous choice from risks resulting from barriers to access. Birth is more dangerous than abortion, so in the simplest terms, if all other things are equal, a reduction in the abortion rate will mean more patients undergo live birth instead of desired abortions and are thus exposed to a greater risk of harm. In 2010, the maternal mortality rate was 21.11 deaths per 100,000 live births in the United States compared to 0.67 deaths per 100,000 legal abortions in 2003-2007 (Central Intelligence Agency, n.d.b; Pazol et al., 2013). Since 1986, the CDC has monitored pregnancy-related deaths, defined as a death during pregnancy or within 1 year regardless of duration of pregnancy from any cause related to or aggravated by the
us to distinguish between these two different sources of changes in the abortion rate. Thus, the number of patients who did not obtain desired abortions because of public policy is a meaningful element of the abortion rate that represents changes in patient safety but which is not currently possible to determine from the data collected.
This distinction is sometimes neglected but is essential for evaluating policy. For
example, the Legislative Fiscal note attached to the North Carolina Women’s Right to Know Act stated that if the bill were enacted, North Carolina would see 2,891 additional births based on the reduction in abortion rate following Mississippi’s enactment of its Women’s Right to Know Act (Stam, 2012). The intent of the law is to change women’s minds, but it is not possible to
distinguish whether those 2,891 women would be dissuaded or blocked. The former theoretically engaged in autonomous decision making; the latter were exposed to a greater risk of harm that appropriately counts as a reduction in patient safety.
Another reason that abortion demand may not be constant is that patients may seek abortions when they cannot afford another child, and economic conditions change over time (Finer, Frohwirth, Dauphinee, Singh, & Moore, 2005). American poverty is expanding: in 2000, 12.2% of Americans, 33.3 million people, lived below the poverty line; by 2012, that number rose to 15.9%, 48.8 million people (Bishaw, 2013). Since financial stability contributes to abortion decision making, it is plausible that economic downturns correspond to increased abortion demand. Women below the poverty line report unintended pregnancies at five times the rate of higher income women, but they have a lower rate of abortion (Finer & Henshaw, 2006b). Thus, abortion demand may increase in times of economic stress among women who have difficulty obtaining abortion services. These women may not be able to obtain abortions they desire, which would obscure the impact of national economic trends upon abortion demand.
It is also known that conception patterns fluctuate. In an examination of abortion rate, pregnancy rate, and conception timing in North Carolina from 1980-1993, seasonal variation was observed to occur through the calendar year (Parnell & Rodgers, 1998). Notably, these patterns occurred in a relatively less restrictive time period, in which there were no mandated waiting periods or parental notification laws, and funding was available through the State Abortion Fund after the Hyde Amendment eliminated federal Medicaid funding for abortion (Parnell &
Rodgers, 1998).
In summary, the abortion rate is easy to obtain, but it does not fully capture the
Rate of Unintended Pregnancy and Unintended Births
The rates of unintended pregnancy and unintended births are often used to characterize abortions in the U.S. For example, Coles (2010) found higher rates of unintended births reported by minors in states with parental involvement laws, mandatory waiting periods, and Medicaid funding restrictions than in states without these laws.
The primary data source is the National Survey of Family Growth (NSFG) survey, which was established by Public Health Service Act (42 USC 242) to collect “statistics on family formation, growth, and dissolution” to measure reproductive health status, to determine the need and effectiveness of health education programs, and for researchers to monitor American
families (Santelli et al., 2003; CDC, 2014). Pregnancy intention is an important public health question because women who have unwanted pregnancies are more likely to smoke during pregnancy, delay prenatal care, and give birth to low-weight infants in comparison to women with desired pregnancies or those who desire children but wished they had timed pregnancy differently (D’Angelo, 2001). Statistics about unintended pregnancy and unintended birth most commonly come from the NSFG; another survey used as a source is the CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS) survey (Santelli et al., 2003). Percentages and rates of unintended pregnancy and unintended birth are often used to frame abortion demand and give a sense of scale of the magnitude of abortion demand (Induced Abortion in the United States, 2014).
2005; Finer & Henshaw, 2006b). Furthermore, while an “unintended birth” represents a patient who wanted to abort an undesired pregnancy but could not, “unintended pregnancy” is more nebulous. “Unintended pregnancy” suggests a woman who was not trying to conceive but some researchers have proposed that the intended/unintended dichotomy oversimplifies the experience of many women. For example, a women may experience ambivalence about a pregnancy or be in a relationship where she has little power over the reproductive choices, or be in a situation where the decision about pregnancy was not made before conception, as interpreted by the use of effective contraception, but rather when the pregnancy became real (Santelli et al., 2003). Those women should not be assumed to represent abortion demand. “Unintended pregnancy” rate is a separate issue from abortion demand; one does not represent the other.
In terms of convenience, it is advantageous to mine data sources like the NSFG and PRAMS because they are already collected, though this data is weaker than case-fatality rate or abortion rate because data is collected from a sample rather than the entire population.
Furthermore, this data is beset by validity problems. It has been documented that participants may change their answers about pregnancy intention depending on when in the pregnancy they are surveyed. Once a child is born, parents may reconstruct their parenting narrative without incorporating their previous abortion desire. If a woman is surveyed after her baby is born, she is less likely to endorse that the pregnancy was unintended or unwanted than if she was surveyed before the baby was born (Joyce, Tan, & Zhang, 2013). These surveys thus underestimate the frequency of unintended pregnancies.
abortion rate but the survey methods chronically undercount. Neither unintended pregnancy rate nor unintended birth rate fulfills the criteria of representing trends about the occurrence or risk of preventable harm influenced by systems. When unintended birth rate and pregnancy rate are cited as representing abortion policy impact, they may represent an approximation of the scale of abortion demand without providing meaningful information about patient safety.
Abortion Timing
Abortion timing can be understood as the point in gestation when the abortion is obtained. Health care systems are known to play an important role in abortion timing. Most states have a legal gestational limit. Policies in health care systems and medical schools have contributed to how many providers are trained and practice, and fewer providers are qualified and willing to perform second trimester abortions than first trimester abortions (Henshaw & Finer, 2002). When services are rare, it can take patients longer to find them. Policy can have a mitigating or intensifying effect on the time that patients need to secure abortions later in gestation. For instance, availability of state funding is increasingly important because prices increase later in gestation. In 2008, average 10 week abortion was $543 while the average 20 week abortion was $1562 (Jones and Kooistra, 2011). Delays often exhibit a cyclic pattern: a patient cannot afford an abortion, the patient delays in order to raise the money, the price of the abortion goes up, and the patient must delay further. Because fewer providers perform abortions later in gestation, patients often must travel further or out of state, which can lengthen delays (Henshaw & Finer, 2002).
2001). More abortions were performed later in gestation after Mississippi enacted its mandatory 24-hour waiting period (Jones, 1997). When in-person informed consent was required 24 hours before the procedure in Ohio, Pennsylvania, and Mississippi, abortions before 8 weeks decreased and abortions after 12 weeks increased (Althaus & Henshaw, 1994).
“Abortion delay” has not been operationalized in the literature. One way to operationalize abortion delay would be to determine if a patient contacted the health system in the first trimester and had the abortion in the second trimester. Another way would be to identify the time between first contact and abortion performance. Those patients were exposed to greater risk and
diminished patient safety because of public policy, but further research would be needed to determine the cutoff points for how much delay is clinically significant.
Abortion mortality can increase when procedures are performed later in gestation. Between 1988-1997, the abortion case-fatality rate was overall 0.7 deaths per 100,000 legally induced abortion in the US, but risk increased by 38% for each additional week of gestation (Bartlett et al., 2004). The mortality rate rises through gestation: 0.1 at 8 weeks, 0.2 at 9-10 weeks, and 0.4 at 11-12 weeks. In the second trimester, mortality rate was 1.7 at 13-15 weeks, 3.4 at 16-20 weeks, and 8.9 above 21 weeks; the authors calculated that 87% of abortion deaths could have been avoided if women had terminated pregnancies in the first 8 weeks of gestation instead of later. Morbidity data shows the same trend of increasing complications with increasing gestation (Tietze and Henshaw, 1986). Delays in abortion timing reflect an increased risk of preventable harm.
individual patient factors and structural policy-influenced factor. One strategy to identify the independent contributions of individual factors and policy to abortion delay is to conceptualize abortion as a step-by-step process and analyze delaying factors pertinent at each step. Drey conceptualized the process as having three basic steps: the first step is recognizing pregnancy; the next step is making the first call to get an appointment; and the final step is having the abortion (2006). Multivariable logistic regression and survival analysis were used to identify independent contributors to delay from a data set of interviews with abortion patients at 5-23 weeks gestation in California (Drey et al., 2006; Foster et al., 2008). Factors associated with delays in recognizing pregnancy were largely personal patient factors, including obesity, substance abuse, prior second-trimester abortion, being unsure of last menstrual period, and having difficult emotions about abortion. Factors associated with delays in making the first call were structural, such as difficulty getting funding from California’s Medicaid, MediCal. They could also be personal, such as having difficulty making the decision. Factors associated with delay between initiating contact with the health care system and obtaining the abortion could be personal, including having an unsupportive partner. They could also be structural, such as receiving a referral to another clinic. They could also reflect an interaction between the two, such as difficulty paying for an abortion. Drey’s survey methods were able to distinguish personal factors from policy factors (2006).
The disadvantages to this measure come from the secondary criterion, convenience. There are challenges in precise operationalization and in distinguishing when patients are delayed by policy rather than personal factors. Another disadvantage to using abortion delays as a measurement of patient safety is the need for new data collection. Currently, there are no ongoing data collection procedures in place, and new procedures would require funding. In the examples cited previously, data were collected in research studies to evaluate abortion policy. While it would be valuable to routinely survey all abortion patients about the barriers they face, this would be logistically and financially challenging. Drey (2008) demonstrated the usefulness of patient interviews for distinguishing structural versus personal factors that affected delays.
Steps Seven & Eight: Recommendation and Conclusion
Abortion laws are increasing in the United States, and their impact on patient safety remains unknown. The impact of abortion policy has been measured in variety of ways: changes in abortion mortality rate, abortion rate, unintended pregnancy/birth rate, and delays in abortion timing. Many measures focus on politically salient dimensions of impact without capturing how policy may affect patient safety. Of these four measurements, delays in abortion timing is the most valid and relevant measure of abortion policy impact on patient safety.
of evidence of danger, voters are urged to err on the side of caution by supporting policies that are promoted as protective, when it is not clear from the evidence whether they really increase safety, decrease safety, or leave safety unchanged. Questions about the safety of abortion restrictions are often dismissed without citing any evidence, as in the testimony in support of North Carolina’s Women’s Right to Know Act that stated, “More than 30 states have enacted legislation similar to HB845, without apparent untoward effect on physician-patient
relationships” and “It appears from other states that implementation of this legislation does no harm to women” (Stam, 2012, p.29-32). Validated measures are necessary tools for determining if these claims are true or false.
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