Ohio has some of the most restrictive regulations on abortions in the country. Recently, clinics have had to comply with stringent and medically unnecessary provisions and many providers have been forced to close. The overall number of abortions in Ohio decreased from 2009 to 2014. Recently, anti-choice organizations and legislators have tried to argue that this decrease is due to the effectiveness of restrictive abortion legislation. However, the decrease in the number of abortions needs to be placed in the context of the accessibility of these procedures as well as the overall birth rate in Ohio. The number of births has decreased from 2005 to 2014. The birthrate also decreased by 7.6% from 2007 to 2010. Similarly, the fertility rate in Ohio has decreased by 4.2% from 2005 to 2010. The number of abortions in Ohio dropped around 26% from 2009 to 2014 (Ohio Department of Health, 2014).
While it is impossible to completely explain the decrease in abortion through decreases in birth and fertility rates in Ohio, it is critical to examine these two figures, abortion and birth/fertility, in relationship with one another.
The Ohio Abortion Report, annually published by the Ohio Department of Health, tracks different demographic information as well as important characteristics about the abortions performed. The report records gestational age, which refers to how many weeks into the pregnancy the woman is at the time of the procedure. Between 2013 and 2014, the Ohio Abortion Report showed an emerging trend. The percentage of abortions that take place under nine weeks of gestation decreased while the percentage of abortions that take place between nine and 12 weeks as well as between 13 and 19 weeks increased. Some fluctuations in this rate have occurred previously, but none have been as prominent as the change from 2013 to 2014. The 2014 statistics could indicate that women are delaying abortions to later stages in their pregnancy. Delaying abortion care often means the procedure will be more expensive and increases the risk of complications.
Age of the Woman
The majority of women who have abortions in Ohio are between the ages of 25 and 55 years old, with the second largest age group being 20 to 24 years. This data challenges the notion that the majority of women seeking abortion care are in their teens and early twenties. The percentage of abortions accessed by women in the under nineteen-age group consistently decreased between 2010 and 2014. This number indicates that fewer teenage women are having abortions. In order to understand the decrease in the teenage demographic it is important to look at teen pregnancy rates. Unfortunately, the most recent data on teen pregnancy rates in Ohio are from 2010. Teen pregnancy rates, pregnancy per 1,000 women, dropped between 2006 and 2010.
There are more recent figures on teen birth rates, as current as 2014. The teen birth rates also largely declined from 2008 to 2014 (The National Campaign, 2016 and National Kids Count, 2014). According to the annual Youth Risk Behavioral Study, the rate of teens having sex remained steady between 2003 and 2013. Because the rate of sexual activity has remained constant, both the drop in the numbers of teens having an abortion and the drop in giving birth cannot be explained by fewer teens having sex. Instead, this drop is most likely attributable to more teens using effective forms of birth control and condoms (Ohio Department of Health, 2013).
Race and Ethnicity
The reports on abortion care from 2010 and 2014 show clear racial differences in abortion care demographics. Black women in Ohio made up around 38% of the patients receiving abortion care, while Black people are only about 13% of the overall Ohio population. White women made up around 53% of the patients receiving abortion care during the same period, despite constituting about 80% of the Ohio population. The percentages of American Indian, Asian or Pacific Islander, Hispanic, and women who identify as more than one race who terminated their pregnancies between 2010 and 2014 are largely proportional to Ohio population demographics at large. Systemic racial inequality contributes to the demographic difference in abortion rates that is most prominently seen between white and Black women. Racial differences in access to contraception, comprehensive sexual education, other health services, and socio-economic status pose different reproductive obstacles for Black women than white women. Hispanic and Black women have higher rates of unintended pregnancy in Ohio. Between 2009 and 2010 around 40% of white women’s pregnancies were unintended, compared to around 60% of Hispanic women’s pregnancies and around 70% of black women’s pregnancies (Ohio Department of Health, 2014). These differences in unintended pregnancy rates illustrate the disparity in access to reproductive choice and also contribute to their higher rates of abortion (Ohio Department of Health, 2014).
Level of education is another important factor in analyzing abortion demographics. Data from the Ohio Abortion Reports from 2010 to 2014 show that women who graduated high school or received a GED made up the largest percentage of the total abortions in Ohio (Ohio Department of Health, 2011, 2012, 2013, 2014, 2015). However, since 2012 the percent of abortions for the high school graduate group has decreased by 4% (Ohio Department of Health, 2013, 2014, 2015). The Ohio Abortion Report does not track economic indicators but education level often correlates with income level (Bureau of Labor Statics, 2016). The level of education figures may suggest an emerging trend that women with a lower educational attainment are having more difficulty accessing abortion care.
The percentage of total abortions performed in Ohio for out of state residents decreased from 2003 to 2014. The number of abortions for Ohio residents has decreased by 37.8% since 2003, while the number of abortions for non-residents has decreased by 62.8% in the same timeframe (Ohio Department of Health, 2007-2015). These percentages suggest that women from other states who once turned to Ohio for abortion care no longer seek services in the state.
Solely focusing on residency and abortion rates in Ohio creates a partial picture of what is actually happening to women in the state. Clinic shutdown, TRAP laws , mandatory wait times, parental consent requirements, and increased medical costs are forcing women to travel outside of Ohio to receive reproductive care. In fact, while Ohio’s total number of induced abortions decreased in recent years, Michigan’s abortion numbers have increased within the same timeframe. From 2012 to 2014, the number of abortions in Michigan spiked 18.2% (Michigan Department of Community Health, 2014 and 2015). The number of out-of-state residents receiving abortion care in Michigan also increased from 708 in 2013 to 1,300 in 2014 (Gross, 2015). The rise in both the total number of abortions and the number of out-of-state residents having abortions in Michigan suggests that women who cannot access care in Ohio are traveling to Michigan for abortion care. Furthermore, the number of abortions in Lucas County, where one of Ohio’s larger cities, Toledo, is located, decreased from 2,563 in 2010 to only 733 in 2014 (ODH, 2015). Lucas County is located on the border with Michigan. Although the drastic decrease in abortions in Lucas County cannot completely account for the increase in Michigan’s non-resident or total abortion numbers, it is clear that there is a connection between these statistics. This bigger picture reveals that Ohio anti-choice legislation is only reducing the accessibility of abortion, and not the need for safe and legal procedures.
Marriage and Family Status
There are many stereotypes about women who need abortions, particularly that they are unmarried, young, and have not had children prior to the abortion. In 2014, 35.7% of women receiving abortion care already had two or more children, 35.2% of women had no children and 26.8% of women had one child (ODH, 2015). In 2014, 68.7% of women who had an abortion had never been married, 10.1% were married, 2.6% were separated, 5.4% were divorced and 0.3% were widowed (ODH, 2015). These statistics, which have remained fairly consistent over the past decade, indicate that Ohio women who have abortions have a variety of different family backgrounds and situations with different considerations that inform their decisions (ODH, 2015).
Method of Termination
There are many different safe and legal methods for terminating a pregnancy in the United States. Curettage suction is the most frequently used method of termination in Ohio. In 2014 this method accounted for almost 83%, or 17,529 out of the total 21,186 abortions in Ohio (Ohio Department of Health, 2015).
Medication abortion, or the “abortion pill,” accounted for around 21% of the total abortions performed in Ohio in 2009 and 2010. Between 2010 and 2011, the medication abortion method use dropped to only 5% of the total abortions (Ohio Department of Health, 2012, 2011). In 2004, the Ohio legislature passed a regulation that restricted the use of the RU-486 medication abortion protocol unless the provider used it in strict accordance with FDA regulations, instead of the evidence-based regimen supported by American College of Obstetricians and Gynecologists, National Abortion Federation, and Planned Parenthood Federation of America. The evidence-based regimen allowed for a lower dose of mifepristone, fewer clinic visits, and can be used up to 63 days after the woman’s last menstrual period versus the 49 days limit required by the FDA (Guttmacher Institute, 2016). The evidence-based protocol is less expensive, allows for more options, and results in fewer side effects, less travel time, and fewer missed work hours. Furthermore, several studies indicate that the evidence-based protocol is 95-99% effective, while the FDA regimen is 92% effective (Guttmacher Institute, 2016). In 2011 an Ohio court upheld the 2004 law, thus requiring compliance with the outdated FDA regulations on medication abortions. This court decision could be one of the reasons that there was such a substantial decrease in medication abortions between 2010 and 2011 numbers.
On March 30, 2016 the FDA changed protocol for RU-486, which greatly impacts access to this method of termination in Ohio. The new FDA regulations now allow use of medication abortions through 70 days of gestation (instead of 49 days), allow fewer clinic visits, and recommend a significantly lower dose of mifepristone, 200mg instead of 600mg (FDA, 2016). These changes in FDA policy will make medication abortions much more accessible by lowering cost, travel time, side effects, and permitting the use longer in pregnancy. The new protocol will give Ohio women more options and control over their reproductive destiny. Future reports will follow how this impacts on the number of women that choose medication abortion to terminate their pregnancies.
When performed in a medical office by trained medical providers, abortions are an incredibly safe procedure with a very low risk of complication. Abortions are considerably safer than both carrying a pregnancy to term and childbirth. In Ohio there are two forms that record abortion complications: the Confidential Abortion Report (completed at the time the abortion is performed) and the Post Abortion Care Report for Complications (completed by the medical professional who treated the complication). The data on complications can vary between these two sources. According to the Confidential Abortion Report, in 2014 a total of 0.17% of abortions had complications (Ohio Department of Health, 2015). Because some complications do not occur immediately following the procedure, the Post Abortion Care Report for Complications had a slightly higher number: 0.27% of abortions had complications (Ohio Department of Health, 2015). Table 3 outlines the very low numbers of specific complications since 2010 recorded by both forms.
Following the abortion procedure, medical providers recommend and provide information about contraception options to patients. In 2014, 98.8% of women who had abortions received a recommendation for or information on contraception (Ohio Department of Health, 2015). Oral contraception or birth control pills were the number one recommended form of contraception, followed by male condoms. In 2014 three types of contraception, the hormone implant, hormone patch, and Depo-Provera (hormone shot), were recommended at higher numbers than compared to 2013 (Ohio Department of Health, 2015, 2014). The implant was recommended to 730 patients in 2014 versus 293 in 2013. The patch was recommended to 364 patients in 2014 versus 122 in 2013. Depo-Provera was recommended to 1,663 patients in 2014 versus 1,573 in 2013. Furthermore the total number of abortions decreased from 23,216 in 2013 to 21,186 in 2014, meaning that the increase in recommendations for these types of contraception are even more noteworthy (Ohio Department of Health, 2015, 2014).
The Ohio Abortion Report also tracks the number of women having abortions who used some type of contraception at the time of conception. Data from 2014 indicates that nearly a quarter of the women terminating their pregnancies were using some type of contraception at the time of conception (Ohio Department of Health, 2015). These forms of contraception include the withdrawal and ovulation rhythm methods, which are considered to be the least effective forms of birth control, through more effective methods like birth control pills and implants (CDC, 2011). These numbers demonstrate the need for both comprehensive sexual education, to ensure people know how to effectively use birth control, and accessible, safe and legal abortion care even when contraception is used. These statistics challenge the myth that women receiving abortions are irresponsible, do not want to use birth control, or use abortion as a primary form of contraception. Women become pregnant from a variety of situations with various reasons for using or not using contraception methods.
Cost of Procedure
Financial barriers pose some of the biggest obstacles to women’s access to abortion care. The cost of an abortion generally depends on how far along the pregnancy is, the general health of the mother, the body mass index (BMI) of the mother, the method of abortion, and the location where the abortion is performed. The Ohio Abortion Report that tracks and compiles the majority of the data on abortions in Ohio does not gather data on socio-economic status or income level. There are no reports that correlate income level and abortion access that are specific to Ohio data; therefore it is difficult to accurately evaluate abortion access.
Ohio and federal law forbids Medicaid coverage for abortion unless the pregnancy was the result of rape or incest, or the woman’s life is at risk. Abortion coverage is also forbidden in the insurance plans of state and local government employees. Ohio law also forbids qualified health insurance plans from covering abortion procedures (LAWriter, 2012) . This leaves many women in the position of not being able to afford the abortion they need. Some women can qualify for financial assistance from the clinic, which is generally funded by private non-profit organizations, such as Women Have Options Ohio Abortion Fund (WHO/O). These funds are essential for the accessibility of abortion services. The right to have an abortion is hollow if the woman does not have access because they cannot pay for the procedure.
Abortions can be financially out of reach for many women. The base cost for a medication abortion or the abortion pill ranges from $400 to $800 depending on the clinic. The base price for an abortion through 12 weeks’ gestation is around $400 to $500. The starting price through 13 and 14 weeks’ gestation is around $500 to almost $700. The price through 15 and 16 weeks’ gestation is around $450 to $800. The cost through 17 and 18 weeks’ gestation is around $800. Any abortion past 19 weeks’ gestation will most likely be over $1,000. Differential pricing at clinics is most likely due to the prohibition on Medicaid and insurance funding as well as Ohio’s demanding regulations on abortion providers that require expensive and unnecessary accommodations.
Provider Shut Down
As previously stated in the Executive Summary, there were 16 clinics open in Ohio in January 2011. As of April 2016 there are only nine clinics left in the state. Many of these closures can be attributed to the numerous TRAP laws passed since 2011, lack of funding, anti-choice smear campaigns, and other legislation aimed at restricting access to abortion care. Another emerging trend is that private hospitals that formerly performed abortions, particularly in the case of severe fetal anomalies, are now refusing to provide those services. For example, in November 2015 The Christ Hospital, a private hospital in the greater Cincinnati area, instituted a new policy that bans physicians from providing abortions except “in situations deemed to be a threat to the life of the mother” (Balmert and Thompson, 2016). The Christ Hospital was one of the last options for women seeking abortion care in that region of Ohio. Most of the abortions performed at the hospital were cases in which there were severe fetal anomalies that made it unlikely that the fetus would survive birth, but that did not threaten the life of the mother. Policies such as these prevent doctors from being able to provide the medical services that they believe are best for their patients, and forces them to send their patients elsewhere for the care they need.