ACCESS: Assessment of costs and coverage of ending pregnancy in the southeastern states
Awarded 2019
Complex Family Planning Fellowship Research
Elizabeth Clark, MD, MPH
Emory University

Background: People in the United States (US) face numerous challenges when accessing abortion, including an increasingly restricted legal environment and economic costs. Previous research has demonstrated that people with low income have more abortions than people with higher income. Our study aims were two-fold: first, we examined costs of obtaining abortion care in terms of both economic expenses and social capital. Second, we sought to understand what people seeking abortion in Georgia might do if abortion were made illegal in the state (with exceptions for rape, incest and endangerment of life of the mother).
Methodology: We conducted a cross sectional, self-administered survey. We recruited people seeking abortion from three high-volume outpatient abortion clinics in Atlanta, Georgia from April 2019 through August 2019. English and Spanish speaking patients were eligible for the study. Study data were collected and managed using REDCap electronic data capture tools hosted at Emory University. Participants received a $20 gift card incentive for answering any of the survey questions. The medical chart was used to confirm gestational age and payment information. IRB approval was obtained from the Emory University Institutional Review Board.
We created two scales to measure social capital: one that measured general social capital and a second that measured abortion-related social capital. We used statistical tests to see if there were differences between the two. We also used statistical tests to see if there were certain characteristics associated with higher abortion costs, social capital scores, or how people would manage an unwanted pregnancy if abortion were outlawed in Georgia.
Results: Our study found that people seeking abortion face significant financial challenges in accessing abortion care. For people with incomes below the federal poverty line, the mean total cost was nearly 80% of their monthly income. People who were unemployed, traveling from other states and with more advanced pregnancies also encountered higher costs relative to their monthly income. Participants with lower income more frequently reported forgoing or delaying basic necessities such as food, rent, and utilities. People with lower incomes tended to have lower social capital scores. Abortion-related social capital scores were lower than general social capital scores, because people were less willing to ask their social networks for support in the context of abortion.
When asked how participants would manage their pregnancy if abortion were illegal in Georgia, the majority (81.9%) would continue to pursue abortion: by traveling to another state, self-management with medications and/or herbs, and self-harm behaviors. When asked how they would feel about not being able to have a desired abortion, 94% reported negative emotions, ranging from “scared” to “enslaved.”
Conclusions: The impact of this work is that we now have a clearer idea of the burdens facing people seeking abortion in Georgia: both in terms of money, as well as difficulty accessing support for abortion within social networks. Our study also demonstrates that access to social capital may be impacted by poverty within social networks, and stigma against abortion may deter people from asking their social networks for support.
We also found that limiting access to legal abortion in Georgia would negatively impact the lives of people seeking abortion and has the potential to drive individuals to seek more costly alternatives to end their pregnancy. Restricting abortion in Georgia may increase risk of negative impact on the well-being of Georgians.

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