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Texas House Bill 2, enacted in 2013, was one of the most restrictive abortion laws in the country before the US Supreme Court ruled in June 2016 that 2 provisions were unconstitutional.
Following introduction and passage of the bill, the number of Texas facilities providing abortions declined,1 from 41 in 2012 to 17 in June 2016. Women whose nearest clinic closed traveled farther to access abortion services than those whose nearest clinic remained open.2 Overall, abortions declined 14% in Texas between 2013 and 2014.3
We hypothesized that the decline in abortions would be greater as the change in distance to the nearest open facility increased.
This study was approved by the institutional review board of the University of Texas at Austin. Since 2012, we have tracked the number and location of facilities providing abortions in Texas.1 Information on the location of abortion-providing facilities in Arkansas, Louisiana, New Mexico, and Oklahoma was also obtained. County-level data on abortions received by Texas residents both in and out of state in 2012 and 2014 were obtained from the website of the Department of State Health Services.3 The distance from the centroid of each Texas county to the nearest open facility providing abortions in 2012 and 2014 was calculated using the geodist module in Stata (StataCorp), version 13. Any facility open for at least 6 months in a year was considered open.
Counties were categorized according to whether they had a facility providing abortions in 2014. Those that did not were grouped into 5 categories based on change in distance to the nearest facility, ranging from 0 to 100 miles or greater. For each category, the percentage of change in the number of abortions occurring in 2012 and 2014 to residents of those counties was calculated along with 95% CIs4; P value for trend was assessed using linear regression in Stata. Two-sided P values less than .05 were considered significant. Counties with an open facility in 2014 were not included because distance to the nearest facility was not a comparable determinant of access.
In 2012, 66 098 abortions were performed among Texas residents (97 out of state). In 2014, 53 882 abortions were performed among Texas residents (754 out of state). Of 254 counties, there were 41 facilities in 17 counties in 2012 and there were 21 facilities in 6 counties in 2014.
Counties in West and South Texas had the greatest change in distance to a facility (Figure). The mean distance change was 51 miles (SD, 68) and the median change was 13 miles (interquartile range, 0-85). Counties that had an open facility in 2014 (all in large metropolitan areas) had minimal distance changes (0-5 miles) and a 15.9% (95% CI, 14.8%-17.0%) decline in abortions (Table).
Among counties without an open facility in 2014, the decline in abortions increased as the distance change to the nearest facility increased (P < .001 for trend). Counties with no facility in 2014 but no change in distance to a facility between 2012 and 2014 had a 1.3% (95% CI, −1.5% to 4.0%) decline in abortions. When the change in distance was 100 miles or more, the number of abortions decreased 50.3% (95% CI, 48.0% to 52.7%).
In Texas counties without a facility in 2014, an increase in distance to the nearest facility was associated with a decline in abortions between 2012 and 2014. However, abortions also declined among women in counties with an open facility in 2014, indicating that there were other factors related to the decrease, such as limited capacity to meet demand for services.5 In counties with no facility and no change in distance, the decline in abortion was minimal. Many of these counties were in East Texas where family planning services were disrupted,6 likely leading to increased demand for abortion that offset the increased capacity barriers women faced.
Limitations include that official statistics may underestimate out-of-state abortions and not capture abortions among women who self-induced or traveled to Mexico for care. Distance to the nearest facility may not reflect actual distance traveled for women seeking second-trimester or medication abortion, which are not available at every facility.
Corresponding Author: Daniel Grossman, MD, Advancing New Standards in Reproductive Health, University of California-San Francisco, 1330 Broadway, Ste 1100, Oakland, CA 94612 (firstname.lastname@example.org).
Published Online: January 19, 2017. doi:10.1001/jama.2016.17026
Author Contributions: Drs Grossman and Potter had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Grossman, Hopkins, Potter.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Grossman, White, Potter.
Critical revision of the manuscript for important intellectual content: White, Hopkins, Potter.
Statistical analysis: White, Potter.
Obtained funding: Grossman, Potter.
Administrative, technical, or material support: Grossman, Hopkins, Potter.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Drs Grossman and Hopkins were expert witnesses for the plaintiffs in Whole Woman’s Health v Hellerstedt during the federal district court trial. Dr Grossman was not compensated for his testimony; Dr Hopkins was compensated. No other disclosures are reported.
Funding/Support: This research was supported by a grant from the Susan Thompson Buffett Foundation, as well as center grant 5 R24 HD042849 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development awarded to the Population Research Center at the University of Texas at Austin.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.
Grossman D, White K, Hopkins K, Potter JE. Change in Distance to Nearest Facility and Abortion in Texas, 2012 to 2014. JAMA. 2017;317(4):437–439. doi:10.1001/jama.2016.17026