How State and Local Policies Affect Abortion Care

The implementation of Senate Bill 20 in July 2023 limited abortion to 12 weeks and 6 days, with exceptions to the gestational limit for cases of rape, incest, or medical emergency. Along with reducing the gestational limit, this bill introduced an in-person consent requirement on top of the existing 72-hour waiting period for both procedural and medication abortions. The bill also modified consent language to include information unrelated to the procedure and added numerous signature requirements. In addition, the bill required specific medical tests (e.g., Rh factor) before procedural abortions and that pregnancy verification results be reported to the state health department. Finally, for medication abortions, provisions noted that clinicians are obligated to notify patients that an additional appointment seven to ten days after the abortion is required. Other provisions of note include requiring a registered nurse to be in the building at all times patients are in the clinic and specifying that abortions cannot be performed for reasons related to race or the presence (or assumed presence) of Down syndrome.

Study participants reported noise ordinances as the only local policies that affected abortion access. They noted that the allowance of amplified sound by protestors outside clinics negatively affected the experiences of both providers and patients.

Facility-level policies affecting access to care included implementing earlier gestational limits, given the 72-hour in-person consent requirement; requiring more than one provider to sign off before performing an abortion procedure in more-complex cases; developing definitions and guidance around medical emergencies; and revisiting sedation policies, particularly those relating to when patients are required to have someone give them a ride home following the procedure.

The fact that it ties up a nurse to complete that 72-hour consent also means that in the sites where we offer higher levels of sedation, we have to minimize that, and we can only offer that to a certain number of patients, instead of anybody who needs or wants it.

Facilities had to adapt their operations, personnel, and physical infrastructure in some cases to meet the requirements of Senate Bill 20. Given national clinician shortages, facilities, especially independent clinics, noted that they had to navigate these increased demands while also struggling to find enough physicians to provide care. Facilities with supportive administrators, more personnel and financial resources, or practices not solely devoted to abortion care were able to adapt more easily to changing state laws.

Clinicians reported spending a significant amount of time on administrative tasks, such as reading and signing consent documents, because of new burdensome consenting requirements and spending less time on direct patient care, which affected services offered. Clinicians also expressed anxiety about filling out the consent forms incorrectly and frustration with the amount of misinformation (intended to dissuade patients from completing the abortion process) included in the consent forms. Some participants expressed concerns about the potential impact of abortion policies on educational opportunities for residents and fellows and long-term consequences on health care provider training, burnout, and availability.

Interview participants emphasized the disproportionate impact that Senate Bill 20 has had on low-income patients, immigrants, persons of color, adolescents, and rural patients. The 72-hour in-person consent requirement was particularly noteworthy, given the additional resources that it requires to seek abortion care. Even though clinicians reported that getting care was more challenging for patients, clinicians also mentioned partnerships with other abortion facilities and funds to ultimately help patients make appointments, travel to a facility, and receive timely care.