Do Restrictions Beget Responsibility? The Case of U.S. Abortion Legislation

Abstract

Over the past decade, more than 25 U.S. states enacted legislation surrounding abortions. By analyzing state abortion legislation and proxying how the cost of obtaining an abortion varies across states, this study assesses the implications of legislative changes on women’s contraceptive choices. Examining women by race/ethnicity, income, age, and religious affiliation, the results show that women respond to increased restrictions on abortion availability and cost but that the effects are very small. This study demonstrates that legislation restricting women’s access to abortions fails to promote greater use of more effective contraceptive methods, increasing the likelihood of unwanted births and illegal abortion procedures.

JEL Classifications: D1, D81, I18, J13

Keywords

birth control contraception abortion legislation unwanted births contraceptive choice

Introduction

Over the past decade, more than 25 U.S. states enacted legislation changing the rules surrounding abortions. Many of these changes test the limits of Roe v. Wade and Planned Parenthood v. Casey, making abortions harder to obtain. In June 2016, the Supreme Court issued its first major abortion ruling in nearly a decade. With a 5-3 vote, the court decided that 2013 Texas legislation stipulating provisions for abortion providers placed an undue burden on the reproductive rights of women. This legislation, which required physicians performing abortions have admitting privileges at a hospital with 30 miles and that abortion clinics comply with standards for ambulatory surgical centers, cut the number of abortion providers in Texas by half and had the potential to do so again if the law had gone into full effect. Although the Supreme Court determined this particular regulation was unconstitutional, there is a national trend of growing hostility toward abortion as many states have expanded the number of onerous restrictions on abortions (Daniels, Ferguson, Howard, & Roberti, 2016; “Federal Appellate Review,” 2016; Gold & Nash, 2012). Amid this wave of antiabortion legislation, understanding how restricting access to abortions affects individual behavior is critical.

This article provides evidence on whether paternalism is effective in enhancing individual responsibility and specifically looks at how restrictions on abortion legislation change preferences over contraceptive use. Although enhanced responsibility is not the intention of these laws, rather they are simply meant to decrease the number of abortions, without the unintended side effect of greater reproductive responsibility abortion restrictions will simply increase unwanted births. So, this study explores whether women seek more reliable contraception when abortions become more costly. If contraceptives and abortions are substitutes, then as abortions become more costly one would expect more individuals to seek other methods of family planning, that is, conception control. Alternatively, if added abortion restrictions have no effect on the utilization of contraceptives, the result will be an increase in illegal abortions and unwanted pregnancies. This analysis provides evidence on whether more restrictive abortion legislation has the unintended consequence of enhancing responsibility in family planning. It measures how legislative hostility toward abortions and abortion provider availability affect women’s contraceptive decisions. This study is unique in two important ways: (a) examining the largely unexplored relationship between legalized abortion and contraception use and (b) considering choices across the whole spectrum of contraceptives through multinomial logit analysis.

Literature and Theoretical Framework

Studies show provider availability increases the demand for abortions (Brown, Jewell, & Rous, 2001), and the number of abortion providers is affected by state abortion legislation (Medoff, 2015). Previous work also reveals that abortions and contraceptives are substitutes, and the abortion rate declines as contraceptive use increases (Marston & Cleland, 2003; Miller & Valente, 2016). For instance, enhancing the ease with which women could access long-acting reversible contraceptive methods resulted in fewer unintended pregnancies and abortions (Birgisson, Zhao, Secura, Madden, & Peipert, 2015). Although these relationships make sense, and suggest expanding contraceptive availability may be an effective way to decrease the utilization of abortion, one cannot assume that the opposite is true—that restricting abortion will increase contraceptive use. Moreover, there is a risk of a rise in illegal abortions and/or unwanted births as abortion restrictions grow.

Indeed, evidence about how women alter their contraceptive choices in reaction to changes in the rules surrounding the termination of unwanted pregnancies is scarce. A small number of studies look at whether young women increase contraceptive use in response to parental consent restrictions and find a positive association (Levine, 2003) as well as no effect (Averett, Rees, & Argys, 2002; Sabia & Anderson, 2016; Sen, 2006). Earlier studies found that women are more likely to use oral contraceptives when faced with more stringent abortion regulations (Felkey & Lybecker, 2014; Felkey & Lybecker, 2015). To date, however, there is no evidence about how women’s preferences between methods shift and the potential shift to more effective methods can be important in the prevention of unwanted births and abortions.

The economic rationale for how women make a contraceptive decision would include all direct and indirect costs as well as known probabilities over potential outcomes. That is, if a woman is not seeking pregnancy, she will weigh the costs associated with purchasing and using her preferred method of contraception against those of potentially getting pregnant. If women are forward thinking in making their birth control decisions, the costs associated with getting pregnant include those associated with the ease or difficulty of terminating that unintended pregnancy. Important in this analysis are the changes in costs associated with the legislation surrounding abortion. Specifically, this study seeks to identify whether women become more responsible and use more effective methods of birth control in the face of these higher costs or whether the incidence of unwanted births simply rise as a result of antiabortion legislation.

Data

This analysis uses individual-level data from the most recent cycle of the National Survey of Family Growth (NSFG) 2006-2010, collected by the Centers for Disease Control and Prevention. The NSFG is designed to be nationally representative of noninstitutionalized, civilian women aged 15 to 44 years. This study utilizes sampling weights to correct our results for oversampling, nonresponse, and lack of coverage in the data. So, although the means presented in Table 1 are not nationally representative, the effects measured in all the following tables are indeed representative of contraceptive choices of women in the United States.

Table 1.

Descriptive Statistics for the NSFG Sample (N = 7,070).

Variable	M	SD
Legislative variables
Hostility	88.50	82.71
Women without a provider	35.11	23.96
Control variables
Married	0.29	0.45
At least some college	0.25	0.43
Urban	0.86	0.34
Age	28.06	7.65
Employed fulltime	0.44	0.50
Private health insurance	0.56	0.50
Public health insurance	0.21	0.41
Religion
Catholic	0.25	0.44
Fundamentalist Protestant	0.19	0.39
Protestant	0.25	0.44
Other religion	0.08	0.28
No religion	0.22	0.41
Income
Less than US$20,000	0.30	0.46
US$20,000-US$39,999	0.28	0.45
US$40,000-US$59,999	0.18	0.38
US$60,000-US$74,999	0.08	0.27
US$75,000 or more	0.16	0.36
Race/ethnicity
Black	0.21	0.41
Hispanic	0.22	0.41
White	0.51	0.50
Other	0.06	0.24

Note. NSFG = National Survey of Family Growth.

The sample is restricted to women who are actively making an observable contraceptive choice (N = 7,070), controlling for individual characteristics including marital status, religious affiliation, employment, income, education, age, race/ethnicity, and residency. Table 1 describes the sample. In the survey, women report their primary method of birth control, and this study considers five contraceptive categories based on effectiveness as defined by Planned Parenthood (2009). From least to most effective, the categories are as follows:

Nonusers—no contraception (30% of the sample)

Withdrawal—spermicide alone or the withdrawal method (5.6%)

Barriers—diaphragm, the male condom, the sponge, or fertility awareness based methods including the rhythm method (20%)

Hormone—injectable hormones, the pill, the patch, the ring, or the morning after pill (37%)

Surgical—intrauterine device or implantation (7.1%)

The two variables of interest measure state abortion legislation and capture how the cost of obtaining an abortion varies across states. First, Hostility is an index of the myriad state regulation pertaining to abortion availability and provision. Based on the measure compiled by NARAL Pro-Choice America in their publication “Who Decides?” (NARAL Pro-Choice America, 2006), the index is larger when a state has and enforces legislation that makes it more difficult to obtain an abortion and smaller when legislation protects a woman’s right to choose. Hostility includes bans on abortions, biased counseling, mandatory delays, TRAP (Targeted Regulation of Abortion Providers) laws, refusal to provide medical services, restrictions for low income and young women, gag rules, insurance coverage and prohibition, availability of emergency contraception, protection against clinic violence, constitutional protection, and the Freedom of Choice Act. Second, as a proxy for the time and travel costs associated with obtaining an abortion, the 2005 abortion provider availability data from the Guttmacher Institute (2010) are used. Women Without a Provider (WWP) indicates the proportion of women in a state that live in a county without an abortion provider. In light of the recent closures of many family planning clinics through legislated means, this is an increasing concern for many women. Beyond the impact on abortion services, many other medical and educational services are also no longer provided. This is the proportion of women residing a great distance from an abortion provider, thus facing relatively higher costs when pursuing the abortion option. It is worth noting that the impact of greater distances and the associated costs will probably have a greater impact on poorer women who likely have fewer choices than wealthier women. WWP is as low as 4% (California) and as high as 96% (Wyoming). Figure 1 depicts the 2005 distribution across states.

Figure 1.

State distribution of women without a provider in 2005.

Method

A multinomial logit model is used to determine how abortion legislation and provider availability affect women’s contraceptive decisions. The probability of any decision with respect to some base decision is described by the following equation:

\Pr (M e t h o d = m | x) = \frac{\exp (x β_{m | b})}{\sum_{j = 1}^{J} \exp (x β_{j | b})},

where Method is the woman’s observed contraceptive choice. This model estimates how x, a vector, including Hostility, WWP, and individual control variables, affects the probability that she chooses a particular contraceptive method, m. Table 2 reports the estimated coefficients from vector β that determines how Hostility and WWP affect the probabilities of each choice relative to each type of contraceptive as the base category. This provides all pairwise comparisons, indicating how the probability of choosing each method changes relative to each other contraceptive method, given abortion legislation differences.

Table 2.

Effects on the Likelihood of Switching Contraceptive Choice—All Women (N = 7,070).

Note. Standard errors are in parentheses. Results control for marital status, religious affiliation, employment, income, health insurance, education, age, age squared, race, and residency.

and ** indicate significance at the 5% and 1% levels, respectively.

If regulating abortions makes women more responsible in pursuing more reliable contraception, the result should be positive effects on the probability of switching from less effective to more effective methods. The analysis should also show exclusively positive signs if women are using more effective contraception due to more restrictions on abortions. If the opposite presents, or if there is no significant effect, then there is a reason to believe that these restrictions will have the unintended consequence of more unwanted births and illegal abortions.

Results and Discussion

The estimates are weighted according to survey design to be representative of the population. The tables are abbreviated to exclude redundant information, as the effects are symmetric for each pairwise comparison, reporting how a women’s choice of contraceptive is affected by Hostility and WWP. To understand whether women are asymmetrically affected by abortion legislation and availability, the significant effects for specific groups of women are summarized, differentiated by income, religious designation, race/ethnicity, and age. To ensure these results are robust, the analysis considered Hostility and WWP separately, used different specifications for provider availability, and used several measures of legislative hostility.

All Women

Table 2 shows many of the effects are insignificant, indicating women are not systematically switching to more effective forms of contraception as abortions become harder to obtain, meaning there may be more unwanted births and illegal procedures.

The only significant effects for all women include the surgical category of contraceptives. Increases in Hostility negatively and significantly affect the relative probability women select surgical methods rather than other methods. Perhaps the laws measured in this index both make it harder to get an abortion and increase the cost of obtaining surgical contraceptives.

As WWP increases, the probability women prefer a surgical method of birth control relative to each other method grows. These positive effects are significant but of tiny magnitude. Using the estimated odds ratio (approximately 1.02), the probability that a woman chooses a surgical method when no contraception (withdrawal, a barrier method, and hormonal contraception) is the base category grows from 7.1% to 7.24% (7.26%, 7.24%, and 7.22%, respectively) for every 1% increase in WWP, holding Hostility and all individual characteristics constant. Although the effect is significant, it is not meaningful in terms of how many women it affects. These tiny effects may indicate that personal characteristics rather than abortion legislation and availability are driving contraceptive choices. It is also possible that this model omits information about women that is important to the contraceptive decision. For instance, given the data available, it is impossible to control for a woman’s insurance status, and it is easy to make an argument that this key cost reducing element may drive a woman’s contraceptive choice.

Women by Income, Race/Ethnicity, Religion, and Age

To better understand the effects of abortion restriction on different types of women, this study replicates the above analysis for subgroups of women by income, race/ethnicity, religion, and age. Rather than reporting the 17 tables of actual estimated coefficients, only the significant effects are presented. Tables 3 to 6 indicate for which groups of women there is a significant effect on the probability of choosing a particular type of contraceptive relative to another. The tables display each unique pairwise comparison and list the groups of women that exhibit significant changes in preferences (at the 5% level). For example, in Table 3, only women with incomes of US$60,000 to US$74,999 have a significant change in the probability of choosing a barrier method relative to no contraception. This effect is negative (indicated in parentheses), meaning they are less likely to prefer a barrier method to no birth control as Hostility increases.

Table 3.

Income Groups Significantly Affected.

Note. Results are significant at the 5% level and control for marital status, religious affiliation, employment, health insurance, education, age, age squared, race, and residency.

Table 4.

Racial Groups Significantly Affected.

Note. Results are significant at the 5% level and control for marital status, religious affiliation, employment, health insurance, education, age, age squared, income, and residency.

Table 5.

Religious Groups Significantly Affected.

Note. Results are significant at the 5% (and 10% in italics) level and control for marital status, income, employment, health insurance, education, age, age squared, race, and residency.

Table 6.

Age Groups Significantly Affected.

Note. Results are significant at the 5% level and control for marital status, religious affiliation, employment, education, income, health insurance, race, and residency.

Table 3 summarizes these effects across five income categories. Women making US$20,000 to US$59,999 a year are unaffected by both abortion restriction measures. That is, their contraceptive behavior does not change as abortions become harder to obtain. This is worrisome because these women may not be able to afford the additional travel costs associated with seeking an abortion, potentially resulting in an increase in unwanted births or illegal abortions. The poorest women (income < US$20,000/year) are affected in almost the same way as the total population of women. There are similar results for women making US$60,000 to US$74,999 a year. In addition, they are relatively less likely to use barrier and hormonal methods relative to no contraception. This means as abortion restrictions grow, there are some cases where they move toward less reliable forms of birth control. Finally, the richest women are rarely affected significantly. Increases in Hostility make them more likely to use hormonal methods relative to nothing and less likely to use surgical methods relative to hormonal methods. Finally, increases in WWP increase the likelihood of using surgical methods over hormonal methods.

This analysis also considers four racial/ethnic categories: Hispanic, Black, White, and Other. Table 4 summarizes these effects. Women self-identifying as Hispanic are unaffected by changes in abortion legislation and availability, indicating that additional restrictions may increase unwanted births and illegal abortions. Among Whites, the effects mimic those for all women. For Blacks, there is a slight increase in the use of more effective contraception as provider availability falls. Specifically, an increase in WWP increases the probability that Black women choose either barrier, hormonal, or surgical over withdrawal. These changes in preference are toward more reliable forms of contraception which one would expect to yield fewer unwanted pregnancies and decrease the need for abortions.

Table 5 summarizes the effects across five different religious categories. Many of the significant effects mimic those found in the entire sample of women. There are a few additional significant effects. For instance, women in the Other Religion category shift from nonuse to withdrawal and barrier methods as Hostility grows but are less likely to pursue those more reliable forms of contraception over nonuse as WWP increases. The latter means women are not becoming more responsible with additional restrictions on abortion. Interestingly, but only significant at the 10% level, the relative probability that Catholics will use withdrawal instead of nothing increases as Hostility grows, and as WWP increases, women who identify as Fundamentalist Protestant are more likely to use barrier methods relative to no contraception or the withdrawal method. There are also several cases where restrictions have a negative and significant effect, meaning women are shifting away from reliable forms of contraception.

Table 6 shows where there is significant movement from one category of contraception to another by age group: women aged 15 to 25 years, 26 to 35 years, and 36 to 45 years. Notably, women aged 26 to 35 years are completely unaffected by increased restrictions on abortion. This makes sense as they are more likely to be forming their families and not as actively preventing pregnancy. Younger and older women are affected in the surgical category in much the same way the entire sample was affected. In addition, the relative probability that women aged 36 to 45 years prefer hormonal methods to the withdrawal method increases when WWP increases.

This analysis provides statistically significant results, but of very small magnitude. Nevertheless, these results are important from a policy perspective for several reasons. First, the vitriolic debate over abortion rights is most frequently based on emotional and moral arguments, pointing to the importance of empirical evidence for understanding the full impact of legislative changes on women and their choices. Second, restricted access to abortions has significant consequences for individual women, especially women living in poverty and those with lower incomes. It is critical to fully examine the effects of these restrictions on women’s behavior and choices to ensure that these restrictions are having the desired effect and incentivizing women in ways that correspond to their intent. Finally, this article provides evidence that restrictive legislation has differential impacts on different groups of women. Policy makers should account for these differential effects, considering complementary policies to remedy the potential harm done to particularly vulnerable groups of women.

Research Limitations and Avenues for Future Research

Although this study provides evidence that abortion availability and legislation affects women’s propensity to take precautions against unwanted pregnancy, it is limited in scope as it does not consider (a) different types of abortion legislation separately and (b) changes in abortion legislation over time. The Hostility measure in this analysis indexes the overall restrictive nature of a woman’s abortion environment and does not distinguish between different types of legislation, which may matter to a woman’s contraceptive decision in different ways. For instance, mandatory waiting periods increase the time cost associated with abortion so the magnitude of their effect could be directly related to a woman’s earnings. As wealthy working women will likely be affected by changes in waiting periods, public funding restrictions will disproportionately affect women of modest means. As there is a wide array of abortion restrictions and their effects are potentially disproportionate among women, future research should parse out these effects by considering abortion restrictions individually or in related subgroups. Such an analysis could determine what types of women respond more favorably to particular restrictions and provide policy makers with more avenues by which to combat increases in unwanted births while restricting the use of abortion.

In addition, the present analysis utilizes cross-section data about variations in abortion legislation, and future research should consider more closely changes in legislation over time. Considering the upcoming changes in the composition of the Supreme Court and the fact that states continue to pass legislation restricting the availability of abortion, more data about how a particular woman behaves with and without abortion legislation will become available. With panel data, research could examine the effect of restrictions more precisely and over the lifetime of the policy change—from drafting of the bill and consideration by legislators to several years after the law is passed. This type of analysis will provide policy makers with even more detail with which they can hone effective family planning legislation.

Conclusion

Beyond the fervor surrounding abortion politics, the legislation restricting women’s access to abortion has very real consequences for individual women. Moreover, increasing numbers of unwanted births has implications for poverty, inequality, and even crime. As the U.S. Supreme Court has recently ruled in its first abortion case in more than a decade, considering how the ruling may affect behavior is essential. By analyzing Hostility and WWP, this study assesses the implications of more costly abortions on women’s contraceptive choices. Through an examination of women by race/ethnicity, income, age, and religious affiliation, this analysis demonstrates that women do respond to increased restrictions on abortion availability and cost, but that the effects are very small if not negligible. This study demonstrates that legislation aimed at restricting women’s access to abortions fails to promote greater use of more effective contractive methods. Consequently, the increased cost and difficulty in attaining abortions are likely to pose a disproportionate burden on poor and disadvantaged women, increasing the likelihood of unwanted births and illegal abortion procedures.

Footnotes

Acknowledgements

We are grateful to Alexandra Ehrlich, Nataliya Kravets, Jo Jones, and Peter Meyer of the U.S. Centers for Disease Control and Prevention; Frank Limehouse of the Census Bureau; and Bhash Mazumder at the Federal Reserve Bank of Chicago for facilitating our access to the data. We are also grateful for research assistance provided by Lucy-George Cooper, M. Casey Hartfiel, Margaret Hennessy, Benjamin Munyao, Marcel Tatum, Dragan Trivanovic, and Ned Yonkers. We appreciate the comments that we received from discussants and participants at the 2015 Western Social Science Association annual meeting and the 2015 International Health Economics Association meeting.

Authors’ Note

The findings and conclusions in this article are those of the author(s) and do not necessarily represent the views of the Research Data Center, the National Center for Health Statistics, or the Centers for Disease Control and Prevention.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Lybecker received financial support from the Chapman Fund and The Colorado College, and Felkey received financial support from the Kemper Fund, the Charles Koch Foundation, and Lake Forest College.

Author Biographies

Amanda J. Felkey is Associate Professor of Economics and business at Lake Forest College in Lake Forest, Illinois. She received her PhD in economics from Cornell University. Her research focuses on household economics and issues of poverty and inequality.

Kristina M. Lybecker is Associate Professor of Economics in the Department of Economics and Business at Colorado College in Colorado Springs, CO. She received her PhD in economics from the University of California, Berkeley. Her research analyzes the challenges surrounding pharmaceutical innovation and the difficulties of strengthening intellectual property rights protection in developing countries.

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