Texas Policy Evaluation Project

TxPEP Publications

*Contact Laura Dixon, TxPEP Media Liaison, to request a PDF of any of these articles.

American Journal of Public Health coverThe Impact of Reproductive Health Legislation on Family Planning Clinic Services in Texas

Kari White, Kristine Hopkins, Abigail R. A. Aiken, Amanda Stevenson, Celia Hubert, Daniel Grossman, Joseph E. Potter
American Journal of Public Health; published online ahead of print March 19, 2015; available online through American Journal of Public Health.

Abstract: We examined the impact of legislation in Texas that dramatically cut and restricted participation in the state’s family planning program in 2011 using surveys and interviews with leaders at organizations that received family planning funding. Overall, 25% of family planning clinics in Texas closed. In 2011, 71% of organizations widely offered long-acting reversible contraception; in 2012–2013, only 46% did so. Organizations served 54% fewer clients than they had in the previous period. Specialized family planning providers, which were the targets of the legislation, experienced the largest reductions in services, but other agencies were also adversely affected. The Texas experience provides valuable insight into the potential effects that legislation proposed in other states may have on low-income women’s access to family planning services.

Perspectives coverWomen's Experiences Seeking Publicly Funded Family Planning Services in Texas

Kristine Hopkins, Kari White, Fran Linkin, Celia Hubert, Daniel Grossman, Joseph E. Potter
Perspectives on Sexual and Reproductive Health 47(2) June 2015; available online through Wiley Online Library

Abstract: Little is known about low-income women's and teenagers’ experiences accessing publicly funded family planning services, particularly after policy changes are made that affect the cost of and access to such services. Eleven focus groups were conducted with 92 adult women and 15 teenagers in nine Texas metropolitan areas in July–October 2012, a year after legislation that reduced access to subsidized family planning was enacted. Although most women were not aware of the legislative changes, they reported that in the past year, they had had to pay more for previously free or low-cost services, use less effective contraceptive methods or forgo care. They also indicated that accessing affordable family planning services had long been difficult, that applying and qualifying for programs was a challenge and that obtaining family planning care was harder than obtaining pregnancy-related care. As a result of an inadequate reproductive health safety net, women experienced unplanned pregnancies and were unable to access screening services and follow-up care. Teenagers experienced an additional barrier, the need to obtain parental consent. Some women preferred to receive family planning services from specialized providers, while others preferred more comprehensive care. Women in Texas have long faced challenges in obtaining subsidized family planning services. Legislation that reduced access to family planning services for low-income women and teenagers appears to have added to those challenges.

Contraception Journal imageThe Public Health Threat of Anti-Abortion Legislation

Daniel Grossman, Kari White, Kristine Hopkins, Joseph E. Potter
Contraception 2014; 89(2):73–74; available online through ScienceDirect

Abstract: What happens when abortion access is severely restricted for 26 million Americans? Texas is about to find out. In July 2013, the Texas legislature passed one of the country’s most restrictive laws that not only bans most abortions after 22 weeks and limits the use of medical abortion but also contains several provisions that are likely to lead to the closure of most abortion clinics in the state. The law requires facilities to meet the standards of ambulatory surgery centers and mandates physicians to have admitting privileges at nearby hospitals. Proponents of the law claim it will improve safety, despite overwhelming evidence that abortions provided in outpatient clinics have a very low level of complications. This legislation comes on the heels of measures passed in 2011 that drastically reduced funding for family planning, effectively removed Planned Parenthood from all state-funded family planning programs and required women seeking abortion to make an extra visit at least 24 hours before the abortion in order to undergo an ultrasound and listen to a detailed description of its images.

Contraception Journal imageUnmet Demand for Highly Effective Postpartum Contraception in Texas

Joseph E. Potter, Kristine Hopkins, Abigail R.A. Aiken, Celia Hubert Lopez, Amanda J. Stevenson, Kari White, Daniel Grossman
Contraception 2014; 90(5): 488-495; available online through ScienceDirect

Abstract: We aimed to assess women's contraceptive preferences and use in the first 6 months after delivery. The postpartum period represents a key opportunity for women to learn about and obtain effective contraception, especially since 50% of unintended pregnancies to parous women occur within 2 years of a previous birth. Methods: We conducted a prospective cohort study of 800 postpartum women recruited from three hospitals in Austin and El Paso, TX. Women aged 18–44 who wanted to delay childbearing for at least 24 months were eligible for the study and completed interviews following delivery and at 3 and 6 months postpartum. Participants were asked about the contraceptive method they were currently using and the method they would prefer to use at 6 months after delivery. Results: At 6 months postpartum, 13% of women were using an IUD or implant, and 17% were sterilized or had a partner who had had a vasectomy. Twenty-four percent were using hormonal methods, and 45% relied on less effective methods, mainly condoms and withdrawal. Yet 44% reported that they would prefer to be using sterilization, and 34% would prefer to be using LARC. Conclusions: This study shows a considerable preference for LARC and permanent methods at six months postpartum. However, there is a marked discordance between women’s method preference and actual use, indicating substantial unmet demand for highly effective methods of contraception. Implications: In two Texas cities, many more women preferred long-acting and permanent contraceptive methods (LAPM) than were able to access these methods at six months postpartum. Women’s contraceptive needs could be better met by counseling about all methods, reducing cost barriers and by making LAPM available at more sites.

Contraception Journal image Finding the Twitter Users that Stood With Wendy

Amanda Jean Stevenson
Contraception 2014; (90)5: 502-507; available online through ScienceDirect

Abstract: I examine Twitter discussion regarding the Texas omnibus abortion restriction bill before, during, and after Wendy Davis’ filibuster in summer 2013. This critical moment precipitated wide public discussion of abortion. Digital records allow me to characterize the spatial distribution of participants in Texas and the United States and estimate the proportion of participants who were Texans. Study design: Building a dataset based on all hashtags associated with the bill between June 19th and July 14th, 2013, I use GPS locations and text descriptions of locations, to classify users by county of residence. Mapping tweets from accounts within the continental US by day, I describe the residential composition of the conversation in total and over time. Using indirect estimation, I compute an estimate of the number of Texans who participated. Results: About 1.66 million tweets were sent using hashtags associated with the bill from 399,081 user accounts. I estimate counties of residence for 160,954 participants (40.3%). An estimated 115,500 participants (29%) were Texans and Texans sent an estimated 48.8% of all tweets. Tweets were sent from users estimated to live in every region of Texas, including 189 of Texas’ 254 counties. Texans tweeted more than non-Texans on every day except the filibuster and the day after. Conclusion: The analysis measures real-life responses to proposed abortion restrictions from people across Texas and the US. It demonstrates that Twitter users from across Texas counties opposed HB2 by describing the geographical range of US and Texan abortion rights supporters on Twitter. Implications: The Twitter discussion surrounding Wendy Davis’ filibuster revealed a geographically diverse population of individuals who strongly oppose abortion restrictions. Texans from across the state were among those who actively voiced opposition. Identifying rights supporters through online behavior may present a new way of classifying individuals’ orientations regarding abortion rights.

Contraception Journal imageChange in Abortion Services After Implementation of a Restrictive Law in Texas

Daniel Grossman, Sarah Baum, Liza Fuentes, Kari White, Kristine Hopkins, Amanda Stevenson, Joseph E. Potter
Contraception 2014; 90(5): 496-501; available online through ScienceDirect

Abstract: In 2013, Texas passed omnibus legislation restricting abortion services. Provisions restricting medical abortion, banning most procedures after 20 weeks and requiring physicians to have hospital admitting privileges were enforced in November 2013; by September 2014, abortion facilities must meet the requirements of ambulatory surgical centers (ASCs). We aimed to rapidly assess the change in abortion services after the first three provisions went into effect. Study Design: We requested information from all licensed Texas abortion facilities on abortions performed between November 2012 and April 2014, including the abortion method and gestational age (<12 weeks versus >12 weeks). Results: In May 2013, there were 41 facilities providing abortion in Texas; this decreased to 22 in November 2013. Both clinics closed in the Rio Grande Valley, and all but one closed in West Texas. Comparing November 2012-April 2013 to November 2013-April 2014, there was a 13% decrease in the abortion rate (from 12.9 to 11.2 abortions/1000 women age 15-44). Medical abortion decreased by 70%, from 28.1% of all abortions in the earlier period to 9.7% after November 2013 (p<0.001). Second-trimester abortion increased from 13.5% to 13.9% of all abortions (p<0.001). Only 22% of abortions were performed in the state’s six ASCs. Conclusions: The closure of clinics and restrictions on medical abortion in Texas appear to be associated with a decline in the in-state abortion rate and a marked decrease in the number of medical abortions. Implications: Supply-side restrictions on abortion—especially restrictions on medical abortion—can have a profound impact on access to services. Access to abortion care will become even further restricted in Texas when the ASC requirement goes into effect in 2014.

NEJM cover imageCutting Family Planning in Texas

Kari White, Daniel Grossman, Kristine Hopkins, Joseph E. Potter
New England Journal of Medicine 2012; 367: 1179-1181; available online through New England Journal of Medicine

Abstract: Four fundamental principles drive public funding for family planning. First, unintended pregnancy is associated with negative health consequences, including reduced use of prenatal care, lower breast-feeding rates, and poor maternal and neonatal outcomes. Second, governments realize substantial cost savings by investing in family planning, which reduces the rate of unintended pregnancies and the costs of prenatal, delivery, postpartum, and infant care. Third, all Americans have the right to choose the timing and number of their children. And fourth, family planning enables women to attain their educational and career goals and families to provide for their children. These principles led to the bipartisan passage of Title X in 1970 and later to other federal- and state-funded programs supporting family planning services for low-income women.

Related Publications: 

Obstetrics and Gynecology, June 2015 issueContraception After Delivery and Short Interpregnancy Intervals AmongWomen in the United States

Kari White, Stephanie B. Teal, Joseph E. Potter
Obstetrics & Gynecology, published June 2015; available online through LWW Journals

Abstract: Our objective was to investigate women's patterns of contraceptive use after delivery and the association between method use and risk of pregnancy within 18 months. We used the 2006–2010 National Survey of Family Growth to examine women's contraceptive use after delivery and at 3, 6, 12, and 18 months after giving birth. The sample included 3,005 births that occurred within 3 years of the survey date and for which information on contraceptive use was available. We estimated multivariable-adjusted Cox regression models to assess the association between women's method use and risk of pregnancy within 18 months after delivery. We also examined the percentage of pregnancies occurring 18 months or less after the index birth that were unintended.

*Contact Laura Dixon, TxPEP Media Liaison, to request a PDF of any of these articles.

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