Understanding the State and Local Policies Affecting Abortion Care Administration, Access, and Delivery: A Case Study in Virginia

The patchwork of laws and regulations that affect abortion access in the United States has become increasingly complex since the 2022 Dobbs v. Jackson Women's Health Organization U.S. Supreme Court decision that gave states the right to enact and enforce policies facilitating or restricting abortion access.¹ In addition, local and institutional-level policies can create further complexities and challenges. Local governments often vary in how they implement state regulations, which contributes to differences in abortion provision and access.² Finally, facilities can introduce another policy layer, ranging from additional restrictions on gestational age limits to implementing policies that may ease access (e.g., telehealth options).

Although previous research has explored how state, local, and institutional policies affect abortion provision, much of this work was performed prior to Dobbs.³ Since Dobbs, many researchers have shifted focus to comparing state policies, often focused on gestational age limits. However, other provisions and policies might differentially affect access. In our initial study examining the policy landscape within North Carolina, we found that North Carolina Senate Bill 20 significantly influenced how facilities and clinicians provided abortion care and greatly affected patients' access.⁴ This was perhaps not surprising given the changes introduced through that bill and the timing of our study, which was within a year of the bill's implementation.

To further identify how state, local, and institutional policies intersect to affect access to abortion care, we identified a second state, Virginia, with no recent legislative changes at the state level around abortion access. Virginia offers a unique case study given that it is one of the only remaining states in the South post-Dobbs with legal access to abortion care past 13 weeks gestational age.

The state has seen significant increases in the number of abortions post-Dobbs. In June 2022, the estimated number of abortions was 2,310; as of March 2024, this number had increased to 3,530. In comparing the first quarter of 2024 with the first quarter of 2023, Virginia had the third highest increase in the average number of abortions per month (after New York and California); the average number of in-person abortions increased by 13 percent, and the average number of telehealth abortions increased 53 percent.⁵ Clinics and supporting organizations reported increased working hours, expansion of telemedicine use, and a significant increase in wait times.⁶ Virginia abortion funds (i.e., nonprofit organizations that provide both in- and out-of-state patients reimbursement for common abortion-related costs, such as for the procedure and medication, the hotel, and transportation) reported an increase in demand for funding yet a decrease in donations.⁷

To better understand the policies in this shifting landscape, our team sought to answer two research questions:

• What are the current laws and policies on abortion in Virginia?
• What are the potential impacts of these different types of policies?

Key Takeaways

We examined state, local, and institutional policies in Virginia—which is one of the only remaining states in the South post-Dobbs with legal access to abortion care past 13 weeks gestational age—to better understand how the policy landscape is influencing provision of care in the state. For this qualitative study, we analyzed laws, policies, and implementation experiences in what is largely seen as a moderate state for abortion access—and one of the most permissive states for abortion access in the South. We reviewed existing legislation, bills, and sources detailing the policy landscape and interviewed a sample of clinicians and nonclinicians working at organizations providing or supporting abortion care. The study principally focused on state laws, local policies and actions, institutional policies, and reported implementation experiences affecting access to abortion care. We found the following:

• Although Virginia's laws surrounding reproductive care became more permissive in 2020, abortion remains in the criminal code. Some state provisions on abortion care before the third trimester were noted as affecting access, including a lack of clarity on some provisions and how to interpret them:
  • Advanced practice registered nurses are allowed to provide abortion care in the first trimester.
  • The ability to provide second-trimester abortions in nonhospital settings was not apparent to all respondents.
  • An abortion occurring in the third trimester must be certified by three physicians as necessary for the patient's health and performed in a licensed hospital.
  • Unemancipated minors must obtain parental or guardian consent or receive a judicial bypass of the parental-consent requirement.
  • State-based Medicaid funding is available only in limited circumstances.
• Zoning practices and other local actions created more-restrictive or more-favorable environments for clinics looking to establish or extend leases.
• Institutional-level policies on gestational age limits were often based on institution-specific definitions of viability, the ability to transfer patients to a trusted nearby hospital, and the skill set and comfort level of the clinicians providing care.
• The impacts of laws and policies were examined at three levels (facilities, providers, and patients):
  • Respondents reported that local zoning restrictions or permissions influenced their facility's ability to establish and maintain leases and exist in a stable and safe environment.
  • Respondents reported minimal impact of policies on providers but noted other nonpolicy barriers and challenges.
  • Respondents reported that marginalized populations, often including youth populations, were most affected by such regulations as minor consent requirements, and the lack of Medicaid coverage made accessing care more challenging.