Abortion care preferences and trade-offs when traveling out-of-state for facility-based services: findings from a discrete choice experiment.

Publisher: BioMed Central Country of Publication: England NLM ID: 101088677 Publication Model: Electronic Cited Medium: Internet ISSN: 1472-6963 (Electronic) Linking ISSN: 14726963 NLM ISO Abbreviation: BMC Health Serv Res Subsets: MEDLINE

Original Publication: London : BioMed Central, [2001-

Health Services Accessibility* ; Choice Behavior* ; Abortion, Induced*/psychology ; Patient Preference*; Humans ; Female ; Pregnancy ; Adult ; United States ; Texas ; Adolescent ; Young Adult ; Bayes Theorem ; Surveys and Questionnaires ; Abortion, Legal ; Travel

Background: Pregnant people living in states that banned abortion after the US Supreme Court's decision overturning Roe v Wade (Dobbs v Jackson Women's Health Organization -Dobbs decision) may evaluate multiple factors when deciding where to obtain facility-based abortion care in another state. We examine Texans' stated preferences for out-of-state facility-based abortion care and quantify the trade-offs they would make when choosing between out-of-state facilities following a 2022 abortion ban.
Methods: In August 2022, we surveyed Texans ≥ 16 years old seeking abortion at in-state facilities or who were searching online for information about accessing abortion care. We used a Bayesian discrete choice experiment to analyze 12 choice sets for out-of-state facility-based abortion care and to assess preferences for three care attributes: wait time to appointment, distance to facility, and cost. We estimated conditional, multinomial, and mixed logit models to examine respondents' attribute preferences and how these differed across subgroups. We used marginal rates of substitution to express Texans' tradeoffs in terms of willingness to pay and willingness to travel for different attributes.
Results: Among 136 respondents (1,362 observations), time to next appointment was the most important attribute (β = -0.887, p < 0.001), followed by cost (β = -0.006, p < 0.001) and distance (β = -0.001, p < 0.001). Respondents were willing to pay an additional $248 (95% CI: $220, $278) and travel 917 miles (95% CI: 711, 1123) further to get an appointment one week sooner. The willingness to pay for a one-week reduction in wait time to appointment was higher among respondents who did not report any economic hardships ($313, 95% CI: $255, $371) than among those who had one or more economic hardships ($175, 95% CI: $142, $208).
Conclusion: This discrete choice experiment examining Texans' preferences for out-of-state facility-based abortion care demonstrates that people seeking abortion prioritize wait time to appointment when deciding where to obtain care. Efforts to make timely care a more feasible option for all those seeking abortion care are needed to mitigate the potential widening of disparities in access to care now that more states have banned abortion.
Competing Interests: Declarations. Ethics approval and consent to participate: The University of Texas at Austin institutional review board, which provides ethical oversight of research studies approved procedures for informed consent and other study activities. All participants ≥ 18 years of age provided informed consent to participate in the study. In the case of minors, we only obtained participant assent. Parental consent was not obtained since requiring this may have put minors at risk if they had not disclosed their abortion decision and completely precluded them from participating in the study. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.
(© 2024. The Author(s).)

Maddow-Zimet I, Kost K. Even before Roe was overturned, nearly one in 10 people obtaining an abortion traveled across state lines for care. New York, NY: Guttmacher Institute; 2022 [cited 2024 Feb 18]. Available from: https://www.guttmacher.org/article/2022/07/even-roe-was-overturned-nearly-one-10-people-obtaining-abortion-traveled-across.
Guttmacher Institute. The High Toll of US Abortion Bans: Nearly One in Five Patients Now Traveling Out of State for Abortion Care. New York, NY: Guttmacher Institute; 2023 [cited 2024 Feb 18]. Available from: https://www.guttmacher.org/2023/12/high-toll-us-abortion-bans-nearly-one-five-patients-now-traveling-out-state-abortion-care.
Rader B, Upadhyay UD, Sehgal N, Reis B, Brownstein J, Hswen Y. Estimated travel time and spatial access to abortion facilities in the US before and after the Dobbs v Jackson Women’s Health decision. JAMA. 2022;328(20):2041–7. (PMID: 10.1001/jama.2022.20424363181949627517)
White K, Vizcarra E, Palomares L, Dane’el A, Beasley A, Ogburn T. Initial impacts of Texas’ Senate Bill 8 on abortions in Texas and at out-of-state facilities. 2021 [cited 2024 Mar 7]. Available from: https://sites.utexas.edu/txpep/files/2021/11/TxPEP-brief-SB8-inital-impact.pdf.
White K, Dane’el A, Vizcarra E, Dixon L, Lerma K, Beasley AD, et al. Out-of-state travel for abortion following implementation of Texas Senate Bill 8. Austin, TX: Texas Policy Evaluation Project; 2022 [cited 2024 May 9]. Available from: http://sites.utexas.edu/txpep/files/2022/03/TxPEP-out-of-state-SB8.pdf.
Lindo J, Myers C, Schlosser A, Cunningham S. How far is too far? New evidence on abortion clinic closures, access and abortions. J Hum Resour. 2020;55(4):1137–60. (PMID: 10.3368/jhr.55.4.1217-9254R3)
Upadhyay UD, Ahlbach C, Kaller S, Cook C, Muñoz I. Trends in self-pay charges and insurance acceptance for abortion in the United States, 2017–20. Health Aff (Millwood). 2022;41(4):507–15. (PMID: 10.1377/hlthaff.2021.0152835377750)
Kaiser Family Foundation. Coverage for abortion services in Medicaid, Marketplace plans and private plans. San Francisco, CA: Kaiser Family Foundation; 2019 [cited 2024 Feb 18]. Available from: https://www.kff.org/womens-health-policy/issue-brief/coverage-for-abortion-services-in-medicaid-marketplace-plans-and-private-plans/.
Kimport K. Reducing the burdens of forced abortion travel: referrals, financial and emotional support, and opportunities for positive experiences in traveling for third-trimester abortion care. Soc Sci Med. 2021;293:114667. (PMID: 10.1016/j.socscimed.2021.11466734954671)
Heymann O, Odum T, Norris AH, Bessett D. Selecting an abortion clinic: the role of social myths and risk perception in seeking abortion care. J Health Soc Behav. 2022;63(1):90–104. (PMID: 10.1177/0022146521104441334605701)
Seymour J, Higgins JA, Roberts SCM. What attributes of abortion care affect people’s decision-making? Results from a discrete choice experiment. Contraception. 2023;131:110327. (PMID: 10.1016/j.contraception.2023.11032737979644)
White K, Arey W, Whitfield B, Dane’el A, Dixon L, Potter JE, et al. Abortion patients’ decision making about where to obtain out-of-state care following Texas’ 2021 abortion ban. Health Serv Res. 2024;59(1):e14226. (PMID: 10.1111/1475-6773.1422637700552)
Fuentes L, Jerman J. Distance traveled to obtain clinical abortion care in the United States and reasons for clinic choice. J Womens Health. 2019;28(12):1623–31. (PMID: 10.1089/jwh.2018.7496)
O’Donnell J, Goldberg A, Lieberman E, Betancourt T. “I wouldn’t even know where to start”: unwanted pregnancy and abortion decision-making in Central Appalachia. Reprod Health Matters. 2018;26(54):98–113.
Sierra G, Berglas NF, Holfer LG, Grossman D, Roberts SCM, White K. Out-of-state travel for abortion among Texas residents following an executive order suspending in-state services during the coronavirus pandemic. Int J Environ Res Public Health. 2023;20(4):3679.
Myers C, Bennett L, Vale F, Nieto A. Abortion access dashboard. 2023 [cited 2024 Mar 11]. Available from: https://about-the-abortion-access-dashboard-analysis-1.hub.arcgis.com/.
Alterio M, Von Davies R, Tobias M, Koehl A, Tang J, Kopp D. A geospatial analysis of abortion access in the United States after the reversal of Roe v Wade. Obstet Gynecol. 2023;142(5):1077–85. (PMID: 37499266)
Jones RK, Chiu DW. Characteristics of abortion patients in protected and restricted states accessing clinic-based care 12 months prior to the elimination of the federal constitutional right to abortion in the United States. Perspect Sex Reprod Health. 2023;55(2):80–5. (PMID: 10.1363/psrh.1222437038835)
Bhutta, Dettling L. Money in the bank? Assessing families’ liquid savings using the Survey of Consumer Finances. Washington, D.C.: Board of Governors of the Federal Reserve System; 2018 Nov [cited 2024 Feb 18]. Available from: https://www.federalreserve.gov/econres/notes/feds-notes/assessing-families-liquid-savings-using-the-survey-of-consumer-finances-20181119.htm.
Ely GE, Hales T, Jackson DL, Maguin E, Hamilton G. The undue burden of paying for abortion: An exploration of abortion fund cases. Soc Work Health Care. 2017;56(2):99–114. (PMID: 10.1080/00981389.2016.126327027960652)
Upadhyay UD, Weitz TA, Jones RK, Barar RE, Greene FD. Denial of abortion because of provider gestational age limits in the United States. Am J Public Health. 2013;112(9):1305–12. (PMID: 10.2105/AJPH.2013.301378)
Jerman J, Frohwirth L, Kavanaugh ML, Blades N. Barriers to abortion care and their consequences for patients traveling for services: Qualitative findings from two states. Perspect Sex Reprod Health. 2017;49(2):95–102. (PMID: 10.1363/psrh.12024283944635953191)
White K, Sierra G, Lerma K, Beasley A, Hofler LG, Tocce K, et al. Association of Texas’ 2021 ban on abortion in early pregnancy with the number of facility-based abortions in Texas and surrounding states. JAMA. 2022;328(20):2048–55. (PMID: 10.1001/jama.2022.20423363181979627516)
Beasley AD, Nagle A, Lerma K, Sierra G, Alvarez Peréz G, White K. Pregnant Texans’ interest in other models of abortion care after the fall of Roe. Austin, TX: Texas Policy Evaluation Project; 2023 [cited 2024 Aug 29]. Available from: https://resoundrh.org/wp-content/uploads/2024/06/txpep-2023-interest-in-abortion-models-brief.pdf.
Lerma K, Nagle A, McCuaig KD, Beasley AD, Ogburn T, Potter JE, et al. Recruiting people considering abortion with Google Ads for research in a restrictive setting. Contraception. 2023 Nov 1 [cited 2024 Aug 1];127. Available from: https://www.contraceptionjournal.org/article/S0010-7824(23)00353-0/abstract.
Traets F, Sanchez D, Vandebroek M. Generating optimal designs for discrete choice experiments in R: the idefix package. J Stat Softw. 2020;96(3):1–41. (PMID: 10.18637/jss.v096.i03)
Croissant Y. Estimation of random utility models in R: the mlogit package. J Stat Softw. 2020;95(11):1–41. (PMID: 10.18637/jss.v095.i11)
Louviere J, Flynn T, Carson R. Discrete choice experiments are not conjoint analysis. J Choice Model. 2010;3(3):57–72. (PMID: 10.1016/S1755-5345(13)70014-9)
Lancaster K. A new approach to consumer theory. J Polit Econ. 1966;74(2):132–57. (PMID: 10.1086/259131)
Smitz M, Witter S, Lemiere C, Eozenou P, Lievens T, Zaman R, et al. Understanding health workers’ job preferences to improve rural retention in Timor-Leste: Findings from a discrete choice experiment. PLoS ONE. 2016;11(11):e0165940. (PMID: 10.1371/journal.pone.0165940278462425112867)
Hanson K, McPake B, Nakamba P, Archard L. Preferences for hospital quality in Zambia: results from a discrete choice experiment. Health Econ. 2005;14(7):687–701.
Coast J, Al-Janabi H, Sutton EJ, Horrocks SA, Vosper AJ, Swancutt DR, et al. Using qualitative methods for attribute development for discrete choice experiments: Issues and recommendations. Health Econ. 2012;21:730–41. (PMID: 10.1002/hec.173921557381)
Caussade S, de Dios OJ, Rizzi L, Hensher D. Assessing the influence of design dimensions on stated choice experiment estimates. Transp Res Part B Methodol. 2005;39(7):621–40. (PMID: 10.1016/j.trb.2004.07.006)
DeShazo J, Fermo G. Designing choice sets for stated preference methods: the effects of complexity on choice consistency. J Environ Econ Management. 2002;44(1):123–43. (PMID: 10.1006/jeem.2001.1199)
Guttmacher Institute. Six months Post-Roe, 24 US states have banned abortion or are likely to do so: A Roundup. New York, NY: Guttmacher Institute; 2023 [cited 2024 Feb 18]. Available from: https://www.guttmacher.org/2023/01/six-months-post-roe-24-us-states-have-banned-abortion-or-are-likely-do-so-roundup.
Sepper E, Moayedi G, Thaxton L, Beasley A, Dixon L, White K. After Roe: Criminal abortion bans in Texas. 2022. Available from: https://sites.utexas.edu/txpep/files/2022/06/TexasPostRoeCriminalAbortionBans-TxPEP-PolicyBrief_27June22.pdf.
AAA. AAA Gas Prices. 2022 [cited 2024 Feb 18]. Available from: https://gasprices.aaa.com/?state=TX.
Johnson RM, Orme BK. How many questions should you ask in choice-based conjoint studies. InArt Forum, Beaver Creek. 1996. pp. 1–23.
Páez A, Biosjoly G. Discrete Choice Analysis with R. Springer; 2022.
Oehlert G. A note on the delta method. Am Stat. 1992;46(1):27–9. (PMID: 10.1080/00031305.1992.10475842)
Biggs MA, Neilands T, Kaller S, Wingo E, Ralph LJ. Developing and validating the psychosocial burden among people seeking abortion scale (PB-SAS). PLoS ONE. 2020;15(12):e0242463. (PMID: 10.1371/journal.pone.0242463333014807728247)
Dickman SL, White K, Sierra G, Grossman D. Financial hardships caused by out-of-pocket abortion costs in Texas, 2018. Am J Public Health. 2018;112(5):758–61. (PMID: 10.2105/AJPH.2021.306701)
Greene FD. The Turnaway Study: Ten years, a thousand women, and the consequences of having–or being denied–an abortion. New York: Scribner; 2020.
Jones RK, Friedrich. Medication abortions accounted for more than 60% of all abortions in the formal US health care system in 2023. New York, NY: Guttmacher Institute; 2023 [cited 2024 Apr 1]. Available from: https://www.guttmacher.org/2024/03/medication-abortion-accounted-63-all-us-abortions-2023-increase-53-2020.
Kimport K. No real choice: How culture and politics matter for reproductive autonomy. Rutgers University Press; 2021.
Jones RK, Upadhyay UD, Weitz TA. At what cost? Payment for abortion care by US women. Womens Health Issues. 2013;23(3):e173–178. (PMID: 10.1016/j.whi.2013.03.00123660430)
Covert B. As Costs and Demand Skyrocket, Abortion Funds Struggle to Keep Up. The Nation. 2023 [cited 2024 Feb 18]; Available from: https://www.thenation.com/article/society/abortion-funds-dobbs/.
Klibanoff E. Some Texas groups resume funding out-of-state abortions after court ruling. Tex Trib. 2023 [cited 2024 Feb 18]; Available from: https://www.texastribune.org/2023/03/24/texas-court-abortion-funds/.
Society of Family Planning. #WeCount Report: April 2022 to June 2023. 2023 [cited 2024 Feb 18]. Available from: https://doi.org/10.46621/218569qkgmbl.

Keywords: Abortion; Abortion decision-making; Discrete-choice experiment; Out-of-state facility-based abortion care; Preferences; Texas; Trade-offs; United States

Date Created: 20241219 Date Completed: 20241219 Latest Revision: 20241219

20241219

10.1186/s12913-024-12005-9

39695667