This study evaluates the association between distance to care and the abortion rate, adjusting for abortion demand. METHODS : Two analyses were conducted using a data set linking provider locations and 2000-2014 county-level abortion data for 18 states; data sources included the Census Bureau, state vital statistics offi ces and the Guttmacher Institute. First, a series of linear regression models were run, with and without adjustment for demographic covariates, modeling distance as both a continuous and a categorical variable. Then, an instrumental variable analysis was conducted in which being 30 or more miles from a large college-enrolled female population younger than age 25 was used as an instrument for distance to a provider. The outcome variable for all models was abortions per 1,000 women aged 25 or older. All models were adjusted for state, year and state-year interaction fi xed eff ects. RESULTS : Increased distance to a provider was associated with a decreased abortion rate. Each additional mile to a provider was associated with a decrease of 0.011 in the abortion rate. Compared with being within 30 miles of a provider, being between 30 and 90 miles from a provider was associated with 0.80-1.46 fewer abortions per 1,000 women. In the instrumental variable analysis, being 30 or more miles from a provider was associated with 5.26 fewer abortions per 1,000 women.

IMPORTANCEAlthough abortion is common in the United States, patients face substantial barriers to obtaining an abortion. Recently enacted abortion restrictions pose such barriers.OBJECTIVES To assess the association between a state legislative climate that is highly restrictive toward abortion provision and the abortion rate and to evaluate whether distance to a facility providing abortion care mediates the association between legislative climate and the abortion rate. DESIGN, SETTING, AND PARTICIPANTSThis cohort study examined county-of-residence abortion rates from all states that publicly provided them and used data on abortion restrictions, facility locations, and county demographic characteristics for the years 2000 to 2014. The association between legislative climate and abortion rates was evaluated using propensity score-weighted, linear regression difference-in-difference analysis. All models included state and year fixed effects and standard errors adjusted for state-level clustering.EXPOSURES Highly restrictive legislative climate, defined as having at least 3 of 4 types of abortion restrictions; distance to a high-volume facility providing abortion care (ie, performing Ն395 abortions per year) in miles. MAIN OUTCOMES AND MEASURESCounty-level abortion rate, defined as abortions per 1000 women per year. RESULTSAbortion rate data were obtained from 1178 counties in 18 states for a median of 12.5 years (range, 5-14). The median abortion rate was 2.89 per 1000 women (interquartile range, 1.71-4.46 per 1000 women). A highly restrictive legislative climate, when compared with a less restrictive one, was associated with 0.48 fewer abortions per 1000 women (95% CI, −0.92 to −0.04 abortions per 1000 women; P = .03). Adjusted for distance to a facility providing abortion care, a highly restrictive legislative climate was associated with 0.44 fewer abortions per 1000 women (95% CI, −0.85 to −0.03; P = .04). Each mile to a facility was associated with 0.02 fewer abortions per 1000 women (95% CI, −0.03 to −0.01 abortions per 1000 women; P = .003). Legislative climate was not significantly associated with distance to a facility providing abortion care (change in distance associated with highly restrictive climate, −2.73 [95% CI, −6.02 to 0.57] miles; P = .10). CONCLUSIONS AND RELEVANCEThis study provides evidence that a state legislative climate that is highly restrictive toward abortion provision is associated with a lower abortion rate. The cumulative effect of restrictive policies may pose a barrier to abortion access.

About 6% of women in the world live in countries that ban all abortions, and 34% in countries that only allow abortion to preserve maternal life or health. In the USA, over the last decades—even before Dobbs v. Jackson Women’s Health Organization overturned the federal right to abortion—various states have sought to restrict abortion access. Often times, this legislation has been advanced based on legislators’ personal moral values. At the bedside, in contrast, provision of abortion care should adhere to the normative principles of medical ethics and reproductive justice, centreing patients and their individual reproductive intentions and desires. Abortion regulations, through their influence on patients and providers, may facilitate or impede such ethical care at the bedside. In this paper, we present a framework to model how abortion legislation should fit into the patient–provider relationship and to clarify the dynamics by which legislation may affect healthcare encounters. Our proposed framework serves as a tool to analyse the ethical impact of abortion regulations. We propose a model for assessing abortion policies based not on legislators’ or advocates’ individual moral claims, but on the shared, normative framework of clinical medical ethics. Through contrasting case studies, we demonstrate how a robust normative ethical framework can recentre patients and their reproductive needs. Our model is one way to account for—and safeguard—patients’ diverse viewpoints and needs in the development of abortion policy, and it can serve to ground narratives for advocacy by healthcare workers and their professional organisations.