July 29, 2015 —Summary of "State Abortion Context and U.S. Women's Contraceptive Choices, 1995-2010," Josephine Jacobs and Maria Stanfors, Perspectives on Sexual and Reproductive Health, June 11, 2015.
"The United States has one of the highest rates of unintended pregnancy in the developed world" (49%), with about 52% of such pregnancies "due to contraceptive nonuse, and 48% to imperfect use," according to Josephine Jacobs, a postdoctoral fellow at Western University's Ivey Business School, and Maria Stanfors, a professor at the Centre for Economic Demography at Lund University.
Meanwhile, the researchers noted that "there has been a substantial increase in the proportion of women of reproductive age who were exposed to restrictive abortion policies," particularly in the last decade. This "transition to a more restrictive abortion context can limit women's choices regarding abortion by increasing the financial, time and emotional costs of obtaining the procedure." The researchers wrote, "In light of the country's increasingly restrictive policy environments, exploring the association between state abortion context -- and changes thereto -- and contraceptive behavior should be of particular interest to policymakers."
In this study, Jacobs and Stanfors "explore[d] the role that abortion context plays in the contraceptive choices of all women aged 15-44," as well as "whether the transition to a more restrictive abortion context is associated with contraceptive choices." The study focused "on the period 1995-2010, which witnessed a significant increase in the proportion of women exposed to restrictive abortion policies and contexts."
The researchers hypothesized that women in states where "abortion is not widely accessible … will be more inclined to use a more effective contraceptive method than will a woman who lives in a state with greater accessibility" and that, "if a state transitions to a more restrictive abortion context ... women will adapt their behavior and choose more effective methods."
For the study, Jacobs and Stanfors used data from the 1995 and 2006-2010 cycles of the National Survey of Family Growth, as well as data from NARAL Pro-Choice America and two other publications, which furnished data about state-level abortion policies and access to abortion care. Women eligible to participate in the study were "at risk for an unintended pregnancy and met the following eligibility criteria: They were currently not pregnant or seeking to get pregnant, they and their partners were not sterile (because of natural causes), and they reported having had heterosexual intercourse in the three months preceding the interview." Overall, the study included "7,006 women from the 1995 cycle and 7,770 women from 2010."
The researchers divided women into three groups: those who used highly effective methods, such as surgical sterilization or the pill; those who used less effective methods, such as a diaphragm or condom; and those who did not use contraception. Women also were subdivided into categories based on state accessibility to abortion services: "women living in states with a low level of abortion access (i.e., at least 50% of women had no county provider), women living in states with medium access (i.e., 25-49% had no county provider) and women living in states with high access (i.e., 0-24% had no county provider)." The medium and high access categories were eventually combined because the researchers "did not observe significant variation between them over time."
The researchers also created an abortion hostility index for states, based on eight types of abortion restrictions; the index ranked states with two or fewer restrictions as less hostile, those with three restrictions as moderately hostile and those with at least four restrictions as hostile. The analysis eventually combined less hostile and moderately hostile states.
Jacobs and Stanfors also "captured the state abortion policy context by indicating whether a state had an enforceable mandatory delay law, parental consent law or Medicaid funding restriction in place." They also considered demographic information, socioeconomic data, women's degree of religiosity and the number of sexual partners a woman had over the previous year.
The study found that "[n]ine states transitioned from having medium abortion provider access to having low access over the study period, while one state (Florida) transitioned from high to medium access." Meanwhile, 19 "states had low provider access in 1995-1996" and "27 states had low access by 2007-2008," while one state, Ohio, "transitioned from low to high access, and two states went from medium to high access." According to the researchers, "[i]n the nine states that crossed the low access threshold, 39-49% of women lived in a county with no provider in 1995."
"In 1995, 12 states and the District of Columbia were less hostile to abortion, 13 states were moderately hostile and 25 states were hostile," and, "[b]y 2010, 13 states and the District of Columbia were less hostile, seven states were moderately hostile and 30 states were hostile," the researchers continued. Overall, they found that "two states transitioned from less hostile to moderately hostile over the study period, and seven states transitioned to having a hostile context," although six of those states "already had three restrictions in place in 1995."
Meanwhile, the researchers found that "[o]nly seven states had mandatory delay laws in 1995," but an additional 17 states enforced such laws by 2010. In addition, they found that 26 "states and the District of Columbia did not have parental consent or notice laws in 1995, and 14 states introduced such laws by 2010." Lastly, the study found that there was little variation in Medicaid restrictions between 1995 and 2010, with "17 states and the District of Columbia ... not hav[ing] such restrictions in 1995" and "17 states ... not hav[ing] them in 2010."
According to Jacobs and Stanfors, most of the 6,945 women in 1995 used contraception, with 61% of them using "highly effective methods." Of those women:
~ 58% lived in states with restrictions on Medicaid funding;
~ 49% "lived in the most hostile states";
~ 42% lived in states with parental involvement requirements;
~ "24% lived in states with low abortion access"; and
~ 12% were subject to mandatory delay laws.
Meanwhile, the researchers noted that 65% of the 7,578 women from the 2010 sample "were using highly effective contraceptive methods." Of those women:
~ 70% lived in states with parental involvement laws;
~ 65% lived in states with Medicaid funding restrictions;
~ 65% "lived in the most hostile states";
~ 55% "were exposed to mandatory delay laws"; and
~ "42% lived in states with low abortion access."
Jacobs and Stanfors found that "women living in states with a low level of provider access were more likely than women in states with greater provider access to use highly effective contraceptives rather than no method," although the coefficient lost significance when "state fixed effects were controlled for." Meanwhile, they found that "women in states where providers became less accessible over time did not change their contraceptive behavior."
In terms of abortion hostility, the researchers found that women in hostile states "had an elevated risk of using highly effective contraceptives as opposed to no method" compared with women in states that were less hostile or moderately hostile to abortion rights, although "this coefficient lost significance" when state fixed effects were included. They added that "no associations were found for the use of either highly effective or less effective [contraceptive] methods" in "states that had transitioned to a hostile abortion policy context."
The researchers also "found a positive association between Medicaid funding restrictions and women's use of highly effective contraceptives rather than no method," although the "coefficient was not significant" when state fixed effects were considered. According to the researchers, in the state fixed effects model, "[n]o associations were found for parental consent laws, while the presence of a mandatory delay law was correlated with the use of less effective methods, as opposed to none." They added that they "found that while the interactions with the delay law and Medicaid restrictions were significant for women's use of highly effective methods … these coefficients were not significant in models that included state fixed effects."
In a model that included state group fixed effects -- controlling "for state-specific factors that do not vary over time" -- the researchers found that:
~ Women were more likely to use highly effective methods rather than no method if they were age 18 to 24 or 25 to 34, compared with younger teenagers;
~ Black women were less likely than white women to use a highly effective contraceptive method rather than none; and
~ Women who had a husband or cohabitating partner were more likely than women without such relationships "to use highly effective methods and less effective methods as opposed to none."
Further, "[a]cross all ... state fixed effects ... models," the researchers found that women were more likely to use highly effective birth control methods as opposed to none if they:
~ Had two or more births, compared to women with no births;
~ Had private or public insurance, compared with no insurance;
~ Had at least some college education, compared with women who had less than a high school education; and
~ Worked full time or part time, compared with nonworking women.
Meanwhile, the researchers found that "women who attended religious services less than weekly had a greater likelihood of using a highly effective method than did women who attended weekly." They also found that women were less likely to use highly effective contraception, and more likely to use less effective methods, the more sexual partners they had over the prior year.
Further, the researchers "found that 18-25-year-olds in states with low abortion access and in states that had transitioned to a mandatory delay law were more likely than their counterparts to use highly effective methods as opposed to none," while such a likelihood increased only in the "older age-group" among women in states with Medicaid funding restrictions. However, "these associations lost significance" when state-fixed effects were considered.
Meanwhile, the researchers found in certain models "that having four or more restrictions in place was positively associated with hormonal contraceptive use," and there was "a smaller but still significant association when [the researchers] used a threshold of at least three restrictions."
According to the researchers, while the findings suggest that "provider access and legislative hostility appeared to be associated with the use of highly effective contraceptives, the inclusion of state group fixed effects rendered these associations insignificant." The finding indicates "that the associations ... identified may be attributable to other time-invariant state-level variables," such as "other reproductive health policies or women's attitudes."
In addition, they noted that "the transition to less accessible and more hostile abortion policy contexts was not associated with the use of highly effective methods," although that could be related to how such states "already had relatively low access and high hostility." As a result, "women in these states may have already adjusted their contraceptive behavior to fairly restrictive abortion environments," the authors wrote, adding that "[e]ven a cursory overview of the states that most frequently made antiabortion headlines in 2013 supports this idea."
Overall, the findings "seem to indicate that contraceptive choice is most strongly influenced by individual-level variables," Jacobs and Stanfors continued. The researchers wrote, "Our results indicate that women living in states with more restrictive abortion contexts tend to use highly effective contraceptives," although "increases in restrictiveness do not appear to be associated with the use of these methods." They concluded, "From a reproductive health policy standpoint, this implies that to avoid [unintended] pregnancies, it is important to ensure access to highly effective contraceptive methods for all women when access to abortions is limited."