Understanding the State and Local Policies Affecting Abortion Care Administration, Access, and Delivery

In Roe v. Wade, the U.S. Supreme Court held that the Constitution protects the right to previability abortion throughout the United States, but states could regulate abortion to some extent during the second trimester.¹ Until the 2022 Supreme Court decision in Dobbs v. Jackson Women's Health Organization, states retained the power to enact and enforce such policies as mandatory waiting periods and targeted building code requirements.² These restrictive laws meant that, in many states, abortion was technically legal but feasibly challenging for both patients and providers.³ By the middle of June 2022, right before the Dobbs decision, a total of 1,381 statewide abortion restriction laws had been enacted. Almost half (46 percent) of these policies had been implemented since 2012, and many involved gestational limits or medication abortion restrictions.⁴

In Dobbs, the Supreme Court overturned Roe v. Wade, holding that there is no constitutionally protected right to an abortion in the United States. As a result, abortion access is now determined state by state, and states were granted the authority to ban abortion at any point in pregnancy, exacerbating the significant variation between states in terms of laws and policies affecting abortion care that already existed prior to Dobbs. Total or near-total abortion bans have been implemented primarily in the Southeast and South Central United States; 14 states implemented full (or nearly full) restrictions on abortion, with Texas, Georgia, Tennessee, Louisiana, and Alabama experiencing the steepest declines in abortion volume over the first 15 months post-Dobbs.⁵ Other states protect abortion as a right in their statutes, prohibit cooperation with out-of-state investigations related to abortion, and require private insurance to cover abortion care.⁶

Examining abortion access and law and policy implementation at the level of the county, city, or individual health facility can reveal significant within-state variation. Research has highlighted how bureaucratic discretion can lead to variation (and, oftentimes, additional restrictiveness) in implementing state abortion regulations.⁷ For example, abortion clinics in Ohio are required to obtain written transfer agreements with nearby hospitals or obtain approval for an exemption from the state Department of Health. State employees are responsible for county-level implementation and have full discretion to determine whether a clinic meets the exemption requirements. In other words, despite clinics meeting written state requirements, individuals can determine that a component of a clinic's application is insufficient and reject the exemption.

However, other local leaders have implemented more-supportive measures for abortion, such as the district attorney in Travis County, Texas, refusing to prosecute criminal cases involving abortion or the mayor of St. Louis, Missouri, signing a bill that directs $1.5 million to cover “logistical support,” such as travel costs and lodging, for residents who must leave the area to get an abortion.⁸ Still, it is unclear how local providers may change their practices as a result of these promised protections.

Finally, some facilities might restrict abortions further than the state or local municipalities. For example, some facilities might have policy restrictions beyond what the state requires to garner a positive image in the surrounding community or avoid any potential room for accusation.⁹ Furthermore, religiously affiliated hospitals often require an ethics board to review all abortion requests (medically necessary or otherwise), which can further delay or impede care,¹⁰ and some hospital staff have discouraged referrals for abortion care, kept them hidden, or generally offered minimal support.¹¹ At the same time, some facilities may explicitly support providers and patients by outwardly backing increased access. For example, the CEO of Planned Parenthood League of Massachusetts stated her intent to increase protections and access by expanding telehealth services, training more providers, and reducing the minimum age required for parental consent.¹²

Given this variation in both policies and potential enforcement, we set out to better understand experiences with these policies, particularly in states that have or are likely to have significant abortion policy changes in the next few years. We selected North Carolina as the first state to examine, given the recent passage of Senate Bill (S.B.) 20, which reduced the state's gestational limit for legal abortions to 12 weeks and 6 days.¹³ North Carolina is important to examine because of its location in the United States as one of the only states in the South providing abortion care beyond 6 weeks. We sought to answer two research questions:

1. What policies further restrict abortion provision in addition to this gestational limit, and how are these policies enforced?
2. What are the potential impacts of these different types of policies?

Key Takeaways

The implementation and enforcement of state and local abortion policy can vary significantly between medical clinics and depend on the context and the individual decisionmakers involved. Research conducted prior to the U.S. Supreme Court decision in Dobbs v. Jackson Women's Health Organization showed that, when providers are unclear about potentially conflicting or changing local and state policies (formal and informal) or enforcement, many err on the side of caution and become more restrictive in their practices.¹⁴ However, it is unknown whether and to what extent state and local policies and practices in the wake of Dobbs have influenced practices at facilities.

We conducted an initial study of laws and policies post-Dobbs in one state, North Carolina, to better understand the policy landscape and gather perspectives from staff working in facilities or for organizations providing or supporting abortion care. This study served as a unique opportunity to explore laws and policies, as well as implementation experiences, given North Carolina's Senate Bill 20, which instituted a gestational limit of 12 weeks and 6 days, among other provisions. We found the following:

• Of the provisions in Senate Bill 20, the reduced gestational limit and the 72-hour in-person consent requirement were the most-restrictive components.
• Local laws did not appear to play a large role in abortion provision, although noise ordinances influenced access at clinics with protesters.
• Individual facilities adapted policies and workflows to align with their organizations' interpretations of Senate Bill 20 and its provisions, such as stipulating that two providers must agree on medical exceptions or implementing a referral system for people who are 12 weeks and 3 days pregnant or later at the time of their ultrasounds because of the in-person consent requirement.
• The impacts of laws and policies were reported at three levels (i.e., facilities, providers, patients):
  • Facilities reported reorganizing or changing clinical workflows, adjusting staffing, facing increased costs for providing abortion care, losing patients, and physically relocating some of clinics to adapt to Senate Bill 20 provisions.
  • Providers reported increased time on administrative tasks, frustration with new required consent forms, feelings of anxiety and burnout, and fears for the provider pipeline in the state.
  • Providers reported that patients faced increased resource and time burdens, particularly with the in-person consent requirement, with a disproportionate impact for more historically marginalized populations. Additionally, providers reported that individuals seeking care faced limitations on decisionmaking inputs, combined with high levels of confusion and misinformation.