Perspectives on Sexual and Reproductive Health最新文献

Introduction: The 2022 Massachusetts Shield Law protects telemedicine providers who care for abortion seekers in other states from criminal, civil, and licensure penalties. In this article we explore the characteristics of patients of The Massachusetts Medication Abortion Access Project (The MAP).

Methods: The MAP is an asynchronous telemedicine service that offers mifepristone/misoprostol to abortion seekers in all 50 states who are at or under 11 weeks pregnancy gestation on initial intake. The MAP charges USD250 using a pay-what-you-can model. We analyzed medical questionnaires and payments submitted by patients who received care from The MAP during its first 6 months of operations using descriptive statistics and for content and themes.

Results: From October 1, 2023-March 31, 2024, 1994 patients accessed care through The MAP. Almost all (n = 1973, 99%) identified as women/girls and about half (n = 984, 49%) were aged 20-29. The MAP cared for patients in 45 states; 84% (n = 1672) of these patients received pills in abortion ban or restricted southern states. Patients paid USD134.50 on average; 29% (n = 577) paid USD25 or less. Nearly two-thirds (n = 1293, 65%) received subsidized care; financial hardship featured prominently in patient comments.

Discussion: Considerable demand exists for medication abortion care from Shield Law providers. The MAP demonstrates that providers can trust women and other pregnancy capable people to decide for themselves whether to obtain medication abortion pills by mail and to pay what they can afford without being required to justify their need. Identifying ways to support Shield Law provision and further subsidize abortion care are needed.

A pillar of Mississippi's argument in Dobbs v. Jackson Women's Health was that there is no evidence of "societal reliance" on abortion, meaning no reason to believe that access to abortion impacts the ability of women to participate in the economic and social life of the nation. Led by economist Caitlin Myers and attorney Anjali Srinivasan, more than 150 economists filed an amicus brief seeking to assist the Court in understanding that this assertion is erroneous. The economists describe developments in causal inference methodologies over the last three decades, and the ways in which these tools have been used to isolate the measure of the effects of abortion legalization in the 1970s and of abortion policies and access over the ensuing decades. The economists argue that there is a substantial body of well-developed and credible research that shows that abortion access has had and continues to have a significant effect on birth rates as well as broad downstream social and economic effects, including on women's educational attainment and job opportunities. What follows is a reprint of this brief.

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. I then highlight the new contributions made by the articles contained in this special issue.

Background: Medicaid is the most common type of health insurance held by abortion patients, but the Hyde amendment prohibits the use of Medicaid to pay for this care. Seventeen states allow state Medicaid funds to cover abortion.

Methods: We used data from a national sample of 6698 people accessing abortions at 56 facilities across the United States between June 2021 and July 2022. We compare patient characteristics and issues related to payment for the abortion across patients residing in states where state Medicaid funds covered abortion (Medicaid states) and those where it did not (Hyde states). We also examine which abortion patient populations were most likely to use Medicaid in states where it covers abortion care.

Results: In Medicaid states, 62% of respondents used this method to pay for care while a majority of individuals in Hyde states, 82%, paid out of pocket. Some 71% of respondents in Medicaid states paid USD0 and this was substantially lower, 10%, in Hyde states. In Hyde states, two-thirds of respondents had to raise money for the abortion (e.g., by delaying bills) compared to 28% in Medicaid states. Within Medicaid states, groups most likely to rely on this method of payment included respondents who identified as Black (70%) or Latinx (66%), those in the lowest income group (78%) and those having second-trimester abortions (75%).

Discussion: When state Medicaid funds cover abortion, it substantially reduces the financial burden of care. Moreover, it may increase access for groups historically marginalized within the health care system.

Introduction: Financial costs remain one of the greatest barriers to abortion, leading to delays in care and preventing some from getting a desired abortion. Medication abortion is available through in-person facilities and telehealth services. However, whether telehealth offers a more affordable option has not been well-documented.

Methods: We used Advancing New Standards in Reproductive Health (ANSIRH)'s Abortion Facility Database, which includes data on all publicly advertising abortion facilities and is updated annually. We describe facility out-of-pocket prices for medication abortion in 2021, 2022, and 2023, comparing in-person and telehealth provided by brick-and-mortar and virtual clinics, and by whether states allowed Medicaid coverage for abortion.

Results: The national median price for medication abortion remained consistent at $568 in 2021 and $563 in 2023. However, medications provided by virtual clinics were notably lower in price than in-person care and this difference widened over time. The median cost of a medication abortion offered in-person increased from $580 in 2021 to $600 by 2023, while the median price of a medication abortion offered by virtual clinics decreased from $239 in 2021 to $150 in 2023. Among virtual clinics, few (7%) accepted Medicaid. Median prices in states that accept Medicaid were generally higher than in states that did not.

Discussion: Medication abortion is offered at substantially lower prices by virtual clinics. However, not being able to use Medicaid or other insurance may make telehealth cost-prohibitive for some people, even if prices are lower. Additionally, many states do not allow telehealth for abortion, deepening inequities in healthcare.

Context: Abortion assistance funds constitute an important part of the healthcare safety net by covering some of abortion patients' out-of-pocket costs. Few studies have examined the other ways abortion assistance fund staff and volunteers support callers who need help obtaining care.

Methods: Between June and September 2020, we conducted in-depth interviews with 23 staff and volunteers at 11 local abortion assistance funds that helped Texans seeking abortion care following a March 2020 state executive order that prohibited most abortions. Interviewers explored respondents' experiences with callers whose appointments had been canceled or who traveled out of state and subsequent operational changes. We used both inductive and deductive codes in the thematic analysis.

Results: Abortion assistance fund staff and volunteers bridged callers' information gaps about the services and financial resources available and helped create plans to secure care that accounted for callers' specific needs. They provided emotional support so callers felt it was possible to overcome logistical hurdles to get an abortion, even if that required out-of-state travel. Respondents described greater collaboration between Texas-based abortion assistance funds and out-of-state organizations to support callers' more complex logistical needs and increased costs. Some callers who encountered multiple barriers to care, including interpersonal violence, were unable to obtain an abortion, even with additional supports.

Conclusions: Local abortion assistance funds worked with Texas callers to co-create person-centered plans for care and expanded inter-organization collaborations. Initiatives that bolster local assistance funds' infrastructure and capacity will be needed as the abortion access landscape becomes further restricted and complex.

Objective: This study analyzes the economic impacts of Ohio's Senate Bill 23, which would ban abortion care after fetal cardiac activity is detected.

Methods: Leveraging previous research and publicly available datasets, a unique set of calculations were developed to determine abortion outcomes, individual costs, and public costs in three scenarios in which abortion care is banned in Ohio. Scenario 1 assumes that all abortion care is sought out-of-state. Scenario 2 assumes that all pregnancies result in a birth. Scenario 3 assumes that pregnancies either result in receiving out-of-state abortion care or result in a birth.

Results: The total additional economic impact of restricted abortion access in Ohio likely ranges between $98.8 million and $118.4 million, but could be up to $551.4 million per year.

Conclusion: Regardless of the three scenarios analyzed, restrictions to accessing abortion care result in negative economic impacts for both individuals and the state. Several policy recommendations are proposed for consideration by policymakers and communities.

Previous research on abortion-related crowdfunding campaigns found that they are impacted by stigma around abortion and rarely successful. This paper analyzes crowdfunding activity in the US following a leak of the Supreme Court decision in Dobbs. V. Jackson Women's Health Organization, a time period that saw increased financial support of abortion access funds. Crowdfunding campaigns that included "abort" or "abortion" and were created between May 2 and November 8, 2022 were recorded from the GoFundMe and GiveSendGo crowdfunding platforms. These campaigns were reviewed for whether they were US based and sought funding where abortion was used as a justification for support. Included campaigns were assigned a campaign recipient type: (1) Organizations providing abortion access; (2) Organizations seeking legal protection for abortion; (3) Individuals seeking abortion access; (4) Organizations seeking to reduce abortion access; and (5) Individuals with needs resulting from choosing not to access abortion. The authors also identified four types of rationale for supporting these campaigns. Following a leak of the Dobbs decision, 398 abortion-related crowdfunding campaigns in the US raised over $3.8 million from over 50,000 donations. Campaigns supporting abortion access organizations raised higher median amounts than organizations seeking to reduce abortion access. Individuals seeking abortion access raised higher median amounts than individuals who chose not to terminate a pregnancy. In a reversal from pre-Dobbs crowdfunding, abortion access campaigns tended to outperform other abortion-related campaigns. It is not clear how long-lived this change in support will be and campaigners remain vulnerable to changes in platforms' content moderation policies.

Objectives: To investigate the experiences of women with kidney disease, residing in the United Kingdom (UK), living through the first 18 months of the COVID-19 pandemic with specific focus on preconception decision-making, family planning, and parenting.

Methods: We conducted a mixed-methods study, comprising an online survey and follow-up interviews, with UK-resident women aged 18-50.

Results: We received 431 surveys and conducted 30 interviews. Half (n = 221, 51%) of the survey respondents considered that COVID-19 influenced the quality of communication with healthcare professionals and 68% (n = 295) felt that the pandemic disrupted their support networks. Interview participants indicated that delayed and canceled appointments caused anxiety, grief, and loss of pregnancy options. Women's perception of themselves as (good) mothers as well as their capacity to have and raise a child, meet partners, and sustain healthy relationships was negatively affected by the "clinically extremely vulnerable" label. Women's trust in their healthcare was dismantled by miscommunication and variation in lockdown rules that caused confusion and increased worry. Women reported that COVID-19 contributed to postnatal depression, excessive concern over infant mortality, preoccupation over others following rules, and catastrophising.

Conclusion: Some women in the UK with chronic kidney disease lost or missed their opportunity to have children during the pandemic. Future pandemic planners need to look more holistically and longer term at what is and is not classed as an emergency, both in how services are reconfigured and how people with chronic conditions are identified, communicated with, and treated.