Cover: How State and Local Policies Affect Abortion Care

How State and Local Policies Affect Abortion Care

A Case Study in North Carolina

Published Jul 3, 2024

by Julia Rollison, Skye Miner, Maya Buenaventura, Maya Rabinowitz

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Research Brief

Key Findings

  • The gestational limit and the 72-hour in-person consent requirement were the most- restrictive components of Senate Bill 20.
  • Local laws did not appear to play a large role in abortion provision.
  • Facilities reported reorganizing or changing clinical workflows, adjusting staffing, and facing increased costs for providing abortion care 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 burdens and misinformation when seeking care, with a disproportionate impact for marginalized populations.

In the landmark Dobbs v. Jackson Women's Health Organization decision in 2022, the U.S. Supreme Court overturned Roe v. Wade, holding that there is no constitutionally protected right to abortion in the United States and that policies about abortion access will fall to states. It is unknown how the policies and practices that states and local governments adopted in the wake of Dobbs have influenced experiences for those providing and seeking care.

A RAND team conducted a case study of laws and policies post-Dobbs in North Carolina to better understand the policy landscape and gather perspectives from staff working in abortion facilities and support organizations. North Carolina is important to examine because it is one of the only states in the South where abortion care is still provided beyond 6 weeks. At the same time, Senate Bill 20 recently instituted numerous provisions that affect abortion access, including a gestational limit of 12 weeks and 6 days and a 72-hour in-person consent requirement. The RAND team sought to better understand two key questions: (1) What state and local policies further restrict abortion provision in addition to the gestational limits, and how are these policies enforced? (2) What are the potential impacts of different types of restrictive policies?

The team used a mixed-methods approach, drawing from a landscape review of laws and policies in North Carolina and interviews with more than a dozen stakeholders involved in providing or supporting abortion care in the state. The team conducted a rapid analysis of interview findings to triangulate with findings from the landscape review.

Laws and Policies Further Restricting Abortion Provision

State

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.

Magenta icon representing North Carolina

Local

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.

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Facility

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.

Magenta icon representing a clinic

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.

Clinician

Potential Impacts on Those Providing and Seeking Care

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.

Light blue icon representing a clinic

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.

Light blue icon representing a clinician

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.

Light blue icon representing a group of people of mixed genders

Ninety-one of our state's 100 counties don't have an abortion provider. Generally, you're traveling anyway, depending on where you are. Now, not only do you have to travel, you have to travel and do this 72-hour wait period that has no clinical benefit. And to put a point on it, if I'm an hourly worker, and remember our minimum wage in [North Carolina] is $7.25 an hour, a day away from wages. . . . That is a crushing experience for someone who is on the margins.

Nonclinician

Conclusion

Beyond gestational limits, provisions around in-person consent created new barriers to abortion access, added an extra burden on providers, and may negatively affect the decision process for patients seeking an abortion, especially those who are members of marginalized communities.

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