Association of Travel Distance to Nearest Abortion Facility With Rates of Abortion
Question Is there an association between median travel distance to an abortion facility and abortion rate?
Findings In this cross-sectional geographic analysis of US counties, increases in median travel distance to the nearest abortion care facility were associated with significant reductions in median abortion rate (21.1 per 1000 female residents of reproductive age for <5 miles; 3.9 per 1000 female residents of reproductive age for ≥120 miles). Reductions in travel distances were associated with significant increases in the median abortion rate (telemedicine simulation, 10.2 per 1000 female residents of reproductive age).
Meaning In this study, the abortion rates declined as travel distance to an abortion care facility increased, and modeling suggests the need for abortion care can be only partially met through service delivery innovations.
Importance Travel distance to abortion services varies widely in the US. Some evidence shows travel distance affects use of abortion care, but there is no national analysis of how abortion rate changes with travel distance.
Objective To examine the association between travel distance to the nearest abortion care facility and the abortion rate and to model the effect of reduced travel distance.
Design, Setting, and Participants This cross-sectional geographic analysis used 2015 data on abortions by county of residence from 1948 counties in 27 states. Abortion rates were modeled using a spatial Poisson model adjusted for age, race/ethnicity, marital status, educational attainment, household poverty, nativity, and state abortion policies. Abortion rates for 3107 counties in the 48 contiguous states that were home to 62.5 million female residents of reproductive age (15-44 years) and changes under travel distance scenarios, including integration into primary care (<30 miles) and availability of telemedicine care (<5 miles), were estimated. Data were collected from April 2018 to October 2019 and analyzed from December 2019 to July 2020.
Exposures Median travel distance by car to the nearest abortion facility.
Main Outcomes and Measures US county abortion rate per 1000 female residents of reproductive age.
Results Among the 1948 counties included in the analysis, greater travel distances were associated with lower abortion rates in a dose-response manner. Compared with a median travel distance of less than 5 miles (median rate, 21.1 [range, 1.2-63.6] per 1000 female residents of reproductive age), distances of 5 to 15 miles (median rate, 12.2 [range, 0.5-23.4] per 1000 female residents of reproductive age; adjusted coefficient, −0.05 [95% CI, −0.07 to −0.03]) and 120 miles or more (median rate, 3.9 [range, 0-12.9] per 1000 female residents of reproductive age; coefficient, −0.73 [95% CI, −0.80 to −0.65]) were associated with lower rates. In a model of 3107 counties with 62.5 million female residents of reproductive age, 696 760 abortions were estimated (mean rate, 11.1 [range, 1.0-45.5] per 1000 female residents of reproductive age). If abortion were integrated into primary care, an additional 18 190 abortions (mean rate, 11.4 [range, 1.1-45.5] per 1000 female residents of reproductive age) were estimated. If telemedicine were widely available, an additional 70 920 abortions were estimated (mean rate, 12.3 [range, 1.4-45.5] per 1000 female residents of reproductive age).
Conclusions and Relevance These findings suggest that greater travel distances to abortion services are associated with lower abortion rates. The results indicate which geographic areas have insufficient access to abortion care. Modeling suggests that integrating abortion into primary care or making medication abortion care available by telemedicine may decrease unmet need.
In the US, increasing travel distance or travel time to a health care clinician is associated with less use of preventive care and poorer health outcomes for women, including reduced use of mammography,1,2 later stage at diagnosis of breast cancer,3,4 and reduced use of risk-appropriate colonoscopy.5 County-level analyses of pregnancy-related outcomes have shown spatial relationships in rates of prenatal care use,6 and the closure of rural hospitals not adjacent to urban areas was associated with increased preterm births in the following year.7
Abortion is a common reproductive health care service, with 1 in 4 US women obtaining this care during their lifetime.8 However, many states have implemented policies restricting abortion care clinicians and facilities (hereinafter referred to as abortion providers).9 Studies of these policies have documented clinic closures and women unable to obtain abortion care, with disproportionate effects on low-income women and non-White women.10,11 Increased travel for an abortion is associated with delays in care, increased costs, and stress.10,12 Even when women are able to obtain abortion care, greater travel distance has been associated with decreased odds of returning to the abortion facility for follow-up care and increased odds of visiting an emergency department.13
Research in a variety of settings has indicated that the farther a woman lives from an abortion care facility, the less likely she is to obtain that care. These studies used distance or travel time to an abortion provider as a measure of potential rather than realized access.14 Regional research has focused on California, Texas, New York, and Wisconsin11,15-18; national analyses have focused on disparities in access.19-21 One longitudinal, econometric study in 18 states22 found an association between travel distance and abortion rate but did not generate interpretable abortion rates.
We conducted a national analysis to test the hypothesis that greater travel distance to the nearest abortion facility is associated with lower abortion rates and to provide estimated abortion rates under actual conditions and alternate assumptions of abortion access. We extend the literature by estimating changes in abortion rate under 2 travel distance scenarios: less than 30 miles (48 km), a common definition of network adequacy for primary care,23 and less than 5 miles (8 km), a simulation of medication abortion by telemedicine
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