Nearly 6 months since the Supreme Court decision overturned the federal right to abortion in Dobbs v. Jackson Women’s Health Organization, abortion access has dwindled, sending patients outside the formal healthcare system for care.

Currently, more than a dozen states have instituted total bans on the procedure, and clinics in 15 states have stopped offering abortions. The latest issue of JAMA includes original research and eight scholarly viewpoints covering abortion access, and how that impacts other areas of healthcare.

Linda Brubaker, MD, MS, JAMA associate editor, and Kirsten Bibbins-Domingo, MD, PhD, MAS, JAMA editor-in-chief, noted in an editorial that the JAMA issue provides information about how abortion restrictions limit physician autonomy, and interfere with the clinician-patient relationship.

“The evolving patchwork of restrictive abortion laws in the U.S. does not align with modern medical care, poses risks to multiple groups of patients, and exacerbates injustices in health care,” they stated. “Legal interference between patients and their clinicians who are providing evidence-based care is unacceptable and ultimately harms patients, clinicians, and society at large.”

Longer Travel Times

The number of U.S. women who have to travel more than an hour to access an abortion clinic has risen significantly, with increases most pronounced in southern states that have total or 6-week abortion bans, researchers reported.

Yulin Hswen, ScD, of the University of California in San Francisco (UCSF), and colleagues, compared the post-Dobbs period with the pre-Dobbs period. They reported in JAMA that after Dobbs, 33% of all reproductive-age females lived in a census tract more than an hour away from an abortion clinic, up from 15% before the decision.

The average duration of time it took patients to travel to an abortion clinic skyrocketed between the two time periods, from a mean of about 28 minutes to a mean of around 100 minutes, they said.

“The percentage of women who have to travel over 60 minutes to an abortion facility has doubled,” Hswen told MedPage Today. “That’s a substantial number of women.”

Increased travel times to an abortion clinic varied by region. Southern states experienced the sharpest upswings in travel time, with Texas and Louisiana residents having an average travel time of approximately 7 hours to get to an abortion clinic after the Supreme Court ruling. Hswen added that women of racial or ethnic minority groups, those without insurance, or those who had lower incomes bore disproportionate travel-time increases.

The authors conducted a cross-sectional geographic analysis to measure median and average travel times from each U.S. census tract to an abortion clinic in the pre- and post-Dobbs period. They analyzed census tract demographics from the 2016-2020 American Community Survey, and obtained data on abortion clinics from the UCSF Advancing New Standards in Reproductive Health database.

The researchers simulated access to abortion clinics in the post-Dobbs period by assuming the closure of all abortion clinics in states that enacted a 6-week or total abortion ban.

They included 1,134 abortion clinics, with each state having at least one abortion clinic. There were 749 active abortion clinics in the pre-Dobbs period, and 671 in the post-Dobbs period. Nearly 64 million reproductive-age females lived in the contiguous U.S. during the study period.

Study limitations included the assumption that all patients had equal access to travel methods, such as cars or public transportation. Additionally, air travel was not modeled in this analysis.

Self-Managed Abortion

In a JAMA research letter, Abigail R. A. Aiken, PhD, of the University of Texas at Austin, and colleagues reported that requests for self-managed abortion options have also shot up, with more patients choosing to obtain abortion pills outside of the conventional healthcare system.

They analyzed the number of requests for self-managed medication abortion from Aid Access, the only telemedicine service providing self-managed medication abortion. They looked at requests before the Dobbs decision was leaked; after the leak but before a formal announcement; and after the final decision. They omitted requests for advance provision of medication abortion before pregnancy occurred in the analysis.

Aiken’s group looked at more than 42,000 self-managed abortion requests from 30 states. Daily requests to Aid Access for self-managed medication abortion jumped from a mean of 82.6 (95% CI 80.9-85.8) before the Dobbs decision was leaked to 137.1 (95% CI 128.8-145.5) after it was leaked. Following the official decision, average daily requests for self-managed medication abortion reached 213.7 (95% CI 191.5-235.8).

“Every state, regardless of abortion policy, showed a higher request rate during the periods after the leak and after the formal decision announcement, with the largest increases observed in states enacting total bans,” Aiken and colleagues wrote.

In states with total bans, 31% of patients who requested abortion medications cited “current abortion restrictions” as a reason why they accessed the service before the decision was leaked, compared to 62% after the final decision (difference 31.0%, P<0.001), they found.

Aiken’s group noted that possible reasons for the increases in abortion pill requests among states who did not experience changes in abortion restrictions could be increased awareness of the service, confusion about state laws, or disruption to in-state clinic services due to increased out-of-state patients.

States with the largest increases in self-managed abortion requests included Louisiana, Mississippi, Arkansas, Alabama, and Oklahoma.

Study limitations included the fact that it only included requests from 30 states and one self-managed abortion pathway so the findings may not represent all people who sought self-managed abortions.

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