摘要：Objectives. To evaluate the additional burdens experienced by Texas abortion patients whose nearest in-state clinic was one of more than half of facilities providing abortion that had closed after the introduction of House Bill 2 in 2013. Methods. In mid-2014, we surveyed Texas-resident women seeking abortions in 10 Texas facilities (n = 398), including both Planned Parenthood–affiliated clinics and independent providers that performed more than 1500 abortions in 2013 and provided procedures up to a gestational age of at least 14 weeks from last menstrual period. We compared indicators of burden for women whose nearest clinic in 2013 closed and those whose nearest clinic remained open. Results. For women whose nearest clinic closed (38%), the mean one-way distance traveled was 85 miles, compared with 22 miles for women whose nearest clinic remained open ( P ≤ .001). After adjustment, more women whose nearest clinic closed traveled more than 50 miles (44% vs 10%), had out-of-pocket expenses greater than $100 (32% vs 20%), had a frustrated demand for medication abortion (37% vs 22%), and reported that it was somewhat or very hard to get to the clinic (36% vs 18%; P < .05). Conclusions. Clinic closures after House Bill 2 resulted in significant burdens for women able to obtain care. Since 2010, US states have enacted nearly 300 abortion restrictions, with 51 new restrictions passed in the first half of 2015 alone. 1 Of note is the increase in laws that make it more difficult to provide abortion services by imposing expensive or logistically difficult requirements on facilities and clinicians, which are often referred to as Targeted Regulation of Abortion Provider (TRAP) laws. In the summer of 2013, Texas passed House Bill 2 (HB2), a TRAP law that restricted abortion services in 4 ways: (1) physicians performing abortions must have admitting privileges at a hospital within 30 miles of the facility, (2) medication abortion must be administered according to the mifepristone label approved by the Food and Drug Administration (with some dosage exceptions), (3) most abortions at or after 20 weeks “postfertilization” are banned, and (4) all abortions must be performed in facilities meeting the requirements of an ambulatory surgical center (ASC). 2 The first 3 provisions of HB2 were enforced by November 1, 2013; the ASC requirement is currently enjoined pending a US Supreme Court decision, as is the admitting privileges requirement as it applies to 2 Texas facilities. Eight of the 41 Texas facilities providing abortion care in April 2013 closed or stopped providing abortion services after the introduction of the HB2 bill. 3 Eleven more facilities closed or stopped providing abortions when HB2 was enforced, primarily because physicians experienced barriers to obtaining hospital admitting privileges. 3 Although some clinics were able to reopen once physicians successfully obtained admitting privileges, still others closed, resulting in 19 licensed facilities providing abortions in Texas by July 2014—a 54% reduction in the number of facilities since April 2013. 4 Recent studies have reported the effects of state-level abortion restrictions on abortion rates, out-of-state travel for abortion, and the consequences for women of being denied a wanted abortion because of clinic gestational age limits, but less is known about the burdens that women experience as a result of clinic closures. 5–9 Evaluating the impact of a substantially reduced number of abortion clinics in Texas on hardships experienced by women who are in need of abortion services is essential to determining the constitutionality of HB2, as the legal thresholds for abortion restrictions center upon the magnitude and nature of these burdens on women. 10 However, such an evaluation presents a number of methodological challenges. Documenting the experiences of women who were unable to obtain a wanted abortion because of insurmountable hardship is difficult, primarily because those are the very women who were unable to reach an abortion clinic where they might be enrolled in a study. 11,12 Indeed, the 13% decline in abortions performed in Texas during the first 6 months after HB2 went into effect gives an indication of the law’s impact. 3 In addition, HB2 affected women who were able to obtain an abortion. These women include those who were directly affected by the closure of the clinic they would have used, as well as women whose nearest or preferred clinic did not close, but who nevertheless were burdened by the law through discontinued offering of medication abortion, longer wait times for appointment availability, or higher costs of the procedure at one of the remaining facilities. In this study, we assess the impact of HB2 on women who obtained an abortion after the law was implemented. With survey data collected from a sample of women who obtained an abortion in Texas in 2014, we compared the experiences of women whose nearest clinic closed with those of women whose nearest clinic remained open. Through this comparison, we sought to assess the additional burdens experienced by women whose nearest clinic closed.
