Complex situations: Economic insecurity, mental health, and substance use among pregnant women who consider – but do not have – abortions

Abstract

We examine characteristics and experiences of women who considered, but did not have, an abortion for this pregnancy. Participants were recruited at prenatal care clinics in Louisiana and Maryland for a mixed-methods study (N = 589). On self-administered surveys and structured interviews, participants were asked if they had considered abortion for this pregnancy and, if so, reasons they did not obtain one. A subset (n = 83), including participants who considered abortion for this pregnancy, completed in-depth phone interviews. Multivariable logistic regression analyses examined characteristics associated with having considered abortion and experiencing a policy-related barrier to having an abortion; analyses focused on economic insecurity and of mental health/substance use as main predictors of interest. Louisiana interviews (n = 43) were analyzed using modified grounded theory to understand concrete experiences of policy-related factors. In regression analyses, women who reported greater economic insecurity (aOR 1.21 [95% CI 1.17, 1.26]) and more mental health diagnoses/substance use (aOR 1.29 [1.16, 1.45] had higher odds of having considered abortion. Those who reported greater economic insecurity (aOR 1.50 [1.09, 2.08]) and more mental health diagnoses/substance use (aOR 1.45 [95% CI 1.03, 2.05] had higher odds of reporting policy-related barriers. Interviewees who considered abortion and were subject to multiple restrictions on abortion identified material and instrumental impacts of policies that, collectively, contributed to them not having an abortion. Many described simultaneously navigating economic insecurity, mental health disorders, substance use, and interpersonal opposition to abortion from family and the man involved in the pregnancy. Current restrictive abortion policies appear to have more of an impact on women who report greater economic insecurity and more mental health diagnoses/substance use. These policies work in concert with each other, with people's individual complex situations-including economic insecurity, mental health, and substance use-and with anti-abortion attitudes of other people to make abortion care impossible for some pregnant women to access.

Health-related quality of life of hospitalized COVID-19 survivors: An initial exploration in Nanning city, China

“…In this study we found that living in a U.S. state with a restrictive abortion policy climate was associated with continuing pregnancy after considering abortion. This study is consistent with previous study findings that state-level abortion restrictions create numerous financial and logistical barriers to abortion ( Cohen and Joffe, 2020 ; Fuentes et al, 2016 ; Jerman et al, 2017 ; Roberts et al, 2020 , 2016 ; White et al, 2016 ). This study builds on the existing evidence using a large national sample of people considering or seeking abortion and shows that abortion restrictions are associated with some ultimately not having abortions at all.…”

“…People seeking abortions are already disproportionately economically disadvantaged compared to the general population ( Jerman et al, 2016 ) and previous research has shown that those who are economically disadvantaged are more likely to report that abortion policies have been barriers to abortion care ( Roberts et al, 2020 ). In addition, the longer people seeking abortion are delayed, the more expensive the abortion, leading to a perpetual cycle of fund-raising until the clinic or state gestational limit is reached and it is too late for an abortion ( Upadhyay et al, 2014 ).…”

“…To address this concern, a few studies have used innovative approaches to explore the experiences of women who considered abortion but may not have presented at an abortion clinic ( Fuentes et al, 2016 ; O’Donnell et al, 2018 ; Roberts et al, 2020 ). Fuentes et al (2016) interviewed people who were unable to access an abortion clinic (could not make appointments or had existing appointments canceled) after the passage of House Bill 2 closed many Texas abortion clinics ( Fuentes et al, 2016 ).…”

“…Those who experienced unwanted pregnancies did not always seek abortion, and described a complex decision-making process shaped by the options that were feasible. Roberts et al (2020) conducted a mixed methods study among women entering prenatal care in Louisiana and Maryland and found that 30% had considered abortion for their current pregnancy and that 6% of those in Louisiana and 1% in Maryland reported a policy-related barrier to obtaining an abortion, primarily lack of Medicaid coverage ( Roberts et al, 2020 , 2019 ). In this study, higher levels of economic insecurity were associated with experiencing a policy-related barrier to obtaining an abortion ( Roberts et al, 2020 ).…”

Real-Time Effects of Payer Restrictions on Reproductive Healthcare: A Qualitative Analysis of Cost-Related Barriers and Their Consequences among U.S. Abortion Seekers on Reddit

“…One major contextual factor is the intersection of structural disadvantage with abortion. People most likely to experience unwanted pregnancy and most in need of financial assistance for abortion services often face multiple structural hardships, including poverty, racism [5], homelessness [32], mental illness, and substance use [36]. Disruptive life events such as job loss and housing evictions also exacerbate the ability to secure funds and obtain abortion services quickly [37].…”