Abortion, the termination of pregnancy, is safe when provided as a surgical procedure by a trained provider or when the correct dosage of the drugs mifepristone and/or misoprostol are used. Despite this, many barriers to abortion care exist. In the United States (US), targeted state-level abortion restrictions create barriers to care, which make it so that people who wish to utilize abortion care face difficulty or are unable to do so. Such barriers to care have important public health implications, as studies have shown that individuals who cannot access wanted abortion care have poorer psychological, physical, social, and economic outcomes than those who obtained care. This dissertation aims to examine one component of abortion access, accessibility, operationalized as the drive time from a woman’s home to the nearest abortion-providing facility. We employ a novel measure of abortion accessibility constructed from three data sources: (1) the Advancing New Standards in Reproductive Health facility database; (2) US Census estimates and shapefiles; and (3) OpenStreetMap data. In the first study, we used geographic information systems (GIS) to explore the effect of programmatic and policy changes related to telemedicine for medication abortion services (TMAB) on population-level measures of abortion accessibility, or drive time to the nearest abortion-providing facility. We found that either expansions in TMAB services or removal of TMAB bans could improve abortion accessibility in the US. For these two exposure scenarios, compared to the current abortion provision scenario, increases in the proportion of women within a 30-, 60-, and 90-minute drive time of an abortion-providing facility ranged from 1.25 percentage points, or an additional 781,556 US women aged 15-44 years with accessibility, to 5.66 percentage points, or an additional 3,530,423 US women aged 15-44 years with accessibility. In the second study, we used GIS to assess the potential effect of the geographic unit of analysis (i.e., block group, ZIP code tabulation area [ZCTA], or county) on misclassification of the proportion of US women of reproductive age within a 30-minute drive time of an abortion-providing facility relative to a measure calculated using Census blocks. We found that block group- or ZCTA-based estimates of abortion accessibility were an underestimate, but resulted in little misclassification relative to measures constructed using Census blocks at the national level; however, county-based measures substantially underestimated abortion accessibility compared with Census block-based measures. Nationwide, the Census block-based abortion accessibility estimate was 0.35 percentage points greater than the block group-based estimate, 2.72 percentage points greater than the ZCTA-based estimate, and 24.21 percentage points greater than the county-based estimate. By state, the Census block-based abortion accessibility estimate ranged from 0 to 8.51 percentage points greater than the block group-based estimate, from 0 to 27.86 percentage points greater than the ZCTA-based estimate, and from 0 to 79.49 percentage points greater than the county-based estimate. Given that state-level ZCTA-based estimates could be substantially different from the Census block-based estimate, ZCTA-based estimates are likely not appropriate for state-level analyses or US analyses stratified by state. Finally, in the third study, we assessed the relationship between level of accessibility in an abortion client’s home ZCTA and the gestational age at which the client obtained abortion care, using fine stratification by propensity score to control confounding. We found that compared with living in a ZCTA with >0% accessibility, living in a ZCTA with 0% accessibility was associated with a decreased risk of being at or beyond 14 weeks’ gestation at abortion visit. These unexpected findings could be due to a selection bias induced by limiting the sample to those who obtained abortion care, uncontrolled or poorly controlled confounding, misclassification of exposure and/or outcome, and/or unidentified effect measure modification by state abortion provision landscape. Through these three dissertation studies, we highlighted the potential impact on abortion accessibility in the US with different changes in programming and policy, quantified misclassification of abortion accessibility, and examined how misclassification varied by geographic measure and location. The third study in this dissertation suggests a need for more research to identify how selection bias may affect studies of abortion access in the US that rely on data only from those who are able to access care.

Unintended pregnancies resulted in $21 billion in avoidable health care costs in the United States as of the most recently available data in 2010 and are associated with myriad negative health effects for mothers and children. They disparately impact vulnerable groups of women, such as those 18-29 years old, Black women, low-income women, single women, and less educated women. A medication abortion is one method of terminating a pregnancy which is over 95% effective, safe (with major adverse events in less than 0.5% of cases), has minor side effects, and costs less than 20% of a live birth.However, states have different levels of medication abortion utilization: in 2020, percentages ranged from 13.7% in Missouri to 96.6% in Wyoming in 2020. The FDA’s abortifacient protocol is more restrictive than medically necessary to ensure women’s safety. For example, although the FDA expanded medication abortions for use up to ten weeks of gestation in 2016 from the previous seven-week limit, studies show safety and efficacy beyond ten weeks of gestation. Many states have laws which restrict access to medication abortions beyond their laws that restrict access to all abortions. Additionally, many states have laws that regulate access to medication abortions more strictly than the FDA. These laws can result in a delay in obtaining abortion care, possibly past the FDA’s ten-week limit for medication abortions, which could make the patient ineligible for a medication abortion in some states. A state’s percentage of medication abortion utilization may depend upon which law(s) that state has in place restricting access. This is the first study to examine that relationship. There is a gap in the literature as to why medication abortion is underutilized given that a majority of abortions occur within the FDA’s ten-week time limit and that the majority of women who received an abortion would have preferred to receive it earlier than they did. The goal of this dissertation is to examine the impact of certain laws restricting medication abortion access on medication abortion utilization in states with such laws in place as compared to states without such laws in place. The aims of the proposed dissertation were threefold. Study one examined medication abortion utilization among women who obtained abortions in states with laws that restrict public and/or private insurance coverage of abortion as compared to states with no insurance coverage restrictions from 2010 to 2019. It was expected that restricting public and/or private insurance coverage of abortion would be statistically significantly associated with lower state medication abortion utilization as compared to states without public and/or private insurance coverage restrictions. Study two examined medication abortion utilization among women who obtained abortions in states that required both in-person physician involvement prior to the abortion and that the first dose be administered in person in the presence of a physician and states with only one physician involvement requirement as compared to states with neither physician involvement requirement from 2010 to 2019. It was expected that state laws requiring either or both in-person physician involvement prior to the abortion and/or that the first dose be administered in the presence of a physician will be statistically significantly associated with lower medication abortion utilization as compared to states requiring no in-person physician involvement. Study three examined medication abortion utilization among women who obtained abortions in states that require both in-person physician involvement prior to the abortion and that the first dose be administered in person in the presence of a physician and states with only one physician involvement requirement as compared to states with neither physician involvement requirement, adjusting for the percentage of women aged 15-44 living in counties without an abortion provider in 2017. It was expected that state laws requiring either or both in-person physician involvement prior to the abortion and/or that the first dose be administered in the presence of a physician would be statistically significantly associated with lower medication abortion utilization as compared to states requiring no in-person physician involvement, adjusting for the percentage of women aged 15-44 living in counties without an abortion provider in 2017. We used multiple imputation of data in all three of our studies, linear mixed model analyses in the first two, and a regression analysis in the third. While our studies did not uncover any statistically significant associations between the laws examined alone and medication abortion utilization, there were some statistically significant secondary findings. All three of our studies found states with higher percentages of patients who were at least ten weeks pregnant at the time of their abortions to be associated with lower percentages of medication abortion utilization. Our first study found that having had no previous live births was associated with a higher percentage of medication abortion utilization in states with laws restricting Health Exchange insurance plans from covering abortions, regardless of whether there were other laws restricting insurance coverage of abortion in place. Both our first and second studies found that being over thirty years of age at the time of obtaining an abortion was associated with a higher percentage of medication abortion utilization in states with at least one form of abortion insurance coverage restriction law and regardless of how many in-person physician interactions were required, respectively. These findings should guide both future research aimed at taking further steps toward understanding states’ disparate levels of medication abortion utilization as well as policymakers’ efforts at improving access to medication abortion services. / Public Health

Despite legal and technological advances, women still face barriers to abortion care in legally restricted or low-resource settings. The advent of medication abortion using misoprostol with or without mifepristone, has enabled women to self-manage their abortions outside of the formal healthcare system. Self-managed abortions are often assisted by telemedicine services, which provide women with evidence-based guidance on managing the abortion process on their own. This thesis explores two separate abortion telemedicine services operating in legally restricted and/or low resource settings – a global online telemedicine service and an abortion support hotline in Venezuela – and evaluates the outcomes associated with each. By interviewing counsellors at a Venezuelan abortion support hotline and the women who used the service, we gained a stronger understanding of the hotline’s successes, barriers, and areas for improvement. We conclude that abortion telemedicine services provide effective and acceptable care, in general, and we recommend greater access to misoprostol in Venezuela.

Improving the quality of abortion care can reduce stigma, increase access, and enhance knowledge about pregnancy prevention and reproductive health. Midwifery-led medication abortion is considered effective, efficient, accessible, person-centred, equitable, and safe in alignment with the World Health Organization’s framework on quality abortion care. As research on client-centred access to healthcare recommends, Ontario’s expanded midwifery care models are improving the ease with which people can find and use sexual and reproductive services most appropriate to their unique needs. The expanded midwifery care presented in this study demonstrates how midwifery-led medication abortion provides high-quality services, decreases stigma, and improves access to safe, acceptable, and client-centred abortion care, particularly for commonly underserved populations deserving of health equity and Reproductive Justice. / The World Health Organization, the International Confederation of Midwives, and the Canadian Association of Midwives advocate for the inclusion of comprehensive abortion care within midwifery practice. International evidence shows positive outcomes in terms of efficacy, safety, acceptability, and post-abortion contraception uptake when midwives provide abortion services. In Canada, midwifery services are available across various populations, including urban, rural, remote, and Northern areas, suggesting a potential to enhance access and quality of abortion care, particularly for underserved people. Expanding the role of Canadian midwives to include comprehensive abortion care could improve accessibility, address gaps in service provision, support community needs, ensure professional sustainability, foster interprofessional collaboration, and offer continuity of care. Since 2017, the Ontario Ministry of Health has funded Expanded Midwifery Care Models to support midwifery integration, interprofessional collaboration, and delivery of midwifery-led sexual and reproductive care that is not funded under the current payment model. This research explores the individual and shared experiences of midwifery-led medication abortion delivered through Expanded Midwifery Care Models across three distinct regions in Ontario. The study employs interpretive description methodology to understand how midwifery influences the experiences of medication abortion for midwives, collaborating healthcare professionals, and clients. The methodology focuses on exploring how integrating a midwifery model of abortion care supports medication abortion services and promotes Reproductive Justice within primary care settings. By gathering insights from multiple perspectives, the findings hope to inform clinical practice, interest policymakers, and identify outcomes valued by midwives, clients, and healthcare professionals for future research on midwifery-led abortion care. / Thesis / Master of Science (MSc) / Quality abortion care improves the lives, health, and wellness of reproductive-aged people. Abortion is time-sensitive and people face barriers to this care. Reproductive-aged people benefit from healthcare systems that make abortion simple, safe, and effective. Internationally, midwives play a significant role in abortion care by delivering comprehensive services within sexual and reproductive healthcare. In Canada, however, the potential of midwifery in providing abortion care has not been fully realized. As an exception, Ontario’s Expanded Midwifery Care Models (EMCMs) - innovative sexual and reproductive healthcare delivery programs - have made it possible for midwives to provide abortion services. Midwifery-led abortion care in EMCMs includes providing early abortion care in ways that make it easier for people who find it difficult to access care. This research explores and compares the personal and professional experiences of medication abortion care delivered by midwives across three regions in Ontario.