The Association Between Intimate Partner Violence and Distance Traveled to Access Abortion in a Nationally Representative Sample of Abortion Patients

Abstract

The objective of this article is to describe a secondary data analysis of the 2008 Abortion Patient Survey (APS 2008) data exploring the association between intimate partner violence (IPV) and travel distances in a national sample of patients seeking abortion services in the United States. The researchers used the 2008 APS, which is the most recent publicly available version of this dataset, to conduct chi-square tests to examine the bivariate associations between all independent and dependent variables. Prevalence ratios were calculated to determine the association between physical and sexual violence and distance traveled to get an abortion, controlling for length of pregnancy, age, education, income, poverty category, race, relationship status, insurance type, whether women went to the closest clinic, whether the pregnancy was wanted, and number of previous abortions. Results indicate that approximately 83% of the women traveled between 1 and 50 miles, 11% traveled between 51 and 100 miles, 4% traveled between 101 and 150 miles, and 3% traveled more than 151 miles to get an abortion. Prevalence ratios (PR) reveal that physical violence was significantly associated with distance traveled to get an abortion (PR = 1.15, p < .05) when all control variables were accounted for. Patients in abusive relationships that involve physical violence may have to travel longer distances to access abortion. Repeal of policy that impedes access to abortion is recommended.

Keywords

abortion intimate partner violence travel distance physical violence

Introduction

It is well known that intimate partner violence (IPV) negatively affects women’s reproductive health (Silverman & Raj, 2014), as evidenced by reports that approximately 3% to 13% of pregnancies are somehow affected by IPV (Campbell, 2002), and women with a history of IPV are at increased risk for unintended pregnancy, problems with contraception, and a history of having a miscarriage (Colarossi & Dean, 2014; Pallitto et al., 2013). Partner violence puts women at risk for negative health outcomes in general and creates an environment where negotiating family planning may be tenuous or impossible. Abusive partners are known to sabotage family planning efforts and to express the desire to impregnate their partners without concern for the partner’s desire for pregnancy (Moore, Frohwirth, & Miller, 2010). This kind of home environment can create a need for a range of reproductive health services, and abortion is often among the services that may be needed.

Patients in need of abortion also experience various burdens when attempting to access the procedure. These burdens often include the necessity of travel to access abortion services that are widely inaccessible (Jones & Jerman, 2013). The distance from one’s community to an abortion provider is a burden in and of itself, which is often compounded by other factors such as a lack of resources to pay for procedural and travel costs, or prohibitions on Medicaid or private insurance coverage of abortion (Ely, Hales, Jackson, Maguin, & Hamilton, 2017b; Jones & Jerman, 2013). Various studies have explored the burdens that may affect travel in relation to abortion, and these include, but are not limited to, living in states with waiting period requirements, living in rural areas, and having limited access to insurance coverage (Jones & Jerman, 2013).

Despite the existence of studies examining various barriers related to abortion travel, to our knowledge, the relationship between IPV and abortion travel has not been explored in the literature, even in light of evidence suggesting that patients in need of abortions may also be involved in IPV. For example, in one study, both physical and sexual IPV were found to increase the risk of having an induced abortion (Alio et al., 2010). Given this dearth of information, the current study was designed to examine the association between distance traveled and two forms of IPV, physical and sexual, in a national sample of abortion patients.

Background

Definitions of Terms

IPV can be defined as physical, emotional, or sexual abuse; stalking; or coercive tactics perpetrated by an intimate partner (Breiding, Basile, Smith, Black, & Mahendra, 2015). An intimate partner can be defined as someone in a close, personal relationship with a person in which emotional connectedness, physical contact, and identity as a couple are shared (Breiding et al., 2015). Physical violence can be defined as the use of physical force for the purpose of inflicting physical harm, injury, or death (Breiding et al., 2015). Sexual violence is defined as a sexual act that is attempted or perpetrated without consent (Breiding et al., 2015).

Abortion is defined as the deliberate termination of a human pregnancy by means of removing the fetus and placenta from the uterus of the pregnant person (U.S. National Library of Medicine, n.d.-b). Deliberate termination of pregnancy can occur through surgical or medical abortion. Surgical abortion refers to the removal of the pregnancy from the uterus through surgical means, and medical abortion refers to the use of medication to induce the uterus to expel its contents to end the pregnancy (U.S. National Library of Medicine, n.d.-a).

For the purposes of this article, the term abortion is used to refer to all types of abortion and the term intimate partner violence is used to refer to both physical violence and sexual violence that are perpetrated upon an intimate partner.

IPV and abortion

The impacts of IPV have been documented in relation to abortion. Women with abusive partners often report becoming pregnant as a result of contraceptive refusal (Gee, Mitra, Wan, Chavkin, & Long, 2009; Moore et al., 2010). In many instances, women report that abusive partners verbally indicated their intention to impregnate them, and then once the pregnancy occurred, it was deemed unwanted or declared to be mistimed, and thus terminated (Moore et al., 2010). In one study, qualitative accounts of abuse describe situations where partners acquiesced to demands for unprotected sexual intercourse to avoid abuse, yet when pregnancy occurred, the partner refused to pay for the abortion, and some women experienced this scenario multiple times (Moore et al., 2010). In this same study, it was reported that abusive partners used tactics such as begging, badgering, and promising to support the child, to try to coerce women to carry to term when they expressed the desire to terminate the pregnancy, which often put the woman at risk of not being able to access the abortion via means such as resource withholding and appointment sabotage (Moore et al., 2010).

In terms of lifetime exposure to IPV, collective exposure increases the odds of having an abortion over the life course, and abortion patients often report a history of IPV and higher rates of unintended pregnancy (Coyle, Shuping, Speckard, & Brightup, 2015; McCloskey, 2016; Pallitto et al., 2013; Roberts et al., 2014). Moreover, women with reproductive health histories that include abortion are more likely to have sexual abuse, rape, and violent partnerships in their histories (Russo & Denious, 2001). In one study, 8% of women report abusive partners as a reason for seeking an abortion (Chibber, Biggs, Roberts, & Foster, 2014). In another study describing in-depth interviews with abortion patients, women report that IPV increased after pregnancy and that the violence played a role in the decision to terminate (Williams & Brackley, 2009). Fifteen percent of abortion patients in one study report abuse by the co-conceiving partner (Ely & Otis, 2011). IPV is also associated with repeat abortions in the United States (Colarossi & Dean, 2014; Ely & Otis, 2011). Taken together, this body of literature demonstrates a complicated relationship between various aspects of IPV and abortion. While the existence of the relationship is known, some of the burdens related to abortion that take place in the context of IPV remain underexplored.

Perpetrator-focused studies also suggest a relationship between IPV and abortion. For example, men with IPV perpetration histories are more likely to report a history of partner conflict over abortion and involvement with a partner who had a pregnancy that ended in abortion, and this effect was multiplied for men with a history of involvement in three or more abortions (Silverman et al., 2010). Moreover, male IPV perpetrators were more likely to report conflicts with pregnant partners over abortion-related decision making. Other studies also suggest that male perpetrators have a greater likelihood of a history of involvement with unintended pregnancy (Cripe, Sanchez, Perales, Lam, & Garcia, 2008; Silverman, Gupta, Decker, Kapur & Raj, 2007).

There is also information suggesting that IPV may affect the timing of abortion. Women reporting both IPV and male partner conflict histories were also more likely to seek abortions in the second trimester or later than 20 weeks (Colarossi & Dean, 2014; Foster & Kimport, 2013). Delays in accessing the procedure may also be exacerbated by problems with accessing health services overall, which is also associated with a history of IPV (Pilchta, 2004). The delay in abortion seeking suggests that barriers to getting the abortion exist, which would not be unexpected, given the complex environment created by pregnancies occurring in the context of IPV. These barriers may include having to navigate the violence to sneak away from a partner to obtain an abortion, for example. Such barriers are underexplored, and the need for additional research in this area exists.

Women may seek abortion to break away from partnerships that involve IPV. One qualitative study documents the experience of an abortion patient who left college in the middle of the semester to flee an abusive partner (Fuentes et al., 2016). In another study, 8% of respondents who were seeking abortion and who identified the partner as the one reason for wanting to terminate the pregnancy reported that the abuse was a primary factor in the desire for an abortion (Chibber et al., 2014). From this 8% subgroup, one respondent reported attempts by her partner to force an abortion, while the others reported terminating to break ties with an abusive partner (Chibber et al., 2014). Overall, women in this study reported that their own motivation for seeking the abortion, in the context of IPV, was to end the abusive relationship, rather than any coercion to get the abortion (Chibber et al., 2014). In other words, they are seeking abortions because they want them, not because a partner wants them to.

In light of the findings presented above that suggest a relationship between abortion and IPV, it is important to highlight that reproductive coercion (RC) is identified as a specific category of controlling behavior that may play a role in unintended pregnancy, thus resulting abortions in the context of IPV. RC is a tactic that interferes with autonomous reproductive health decision making, and it can include contraceptive sabotage, coercion around pregnancy decision making, and attempts to control pregnancy outcomes (Grace & Anderson, 2016; Thaller & Messing, 2016). A comprehensive review of the RC literature suggests that it frequently intersects with IPV, and it disproportionately affects those who are concurrently experiencing IPV (Grace & Anderson, 2016). Elective and forced abortion may be a consequence of the inability to negotiate sexual activity and contraception (Park, Nordstrom, Webber, & Irwin, 2016), which can thus result in RC being a potential barrier to abortion access, depending on the goals of the abusive partner. On one hand, RC could include attempts to force pregnancy and abortion. On the other hand, abortion may be sought to escape this behavior.

Socioeconomic Disadvantage

Socioeconomically disadvantaged women experience more barriers when seeking abortion and they report struggling to arrange travel and secure adequate resources to cover procedural costs (Ostrach & Cheyney, 2014). For example, a lack of resources and an inability to afford abortion-related costs have been cited as reasons for delaying an abortion (Ostrach & Cheyney, 2014; Upadhyay, Koregol, Bulusu, Dubey, & Shah, 2013). Moreover, economically vulnerable patients who received financial assistance from an abortion fund were found to have a mere one fifth of the resources needed to pay for their abortions, which cost an average of over US$2,000 (Ely, Hales, Jackson, Maguin, & Hamilton, 2017a). In addition, in this same study, patients who received financial aid for an abortion were more likely to be single and African American, when compared with general abortion patients at the national level (Ely et al., 2017a). In instances where women cannot afford to cover abortion expenses, even when an abortion is wanted, forced pregnancy can occur, which may result in problems such as postpartum depression (Medoff, 2014).

Policy Barriers

In the United States, abortion policy restricts access to the procedure and creates barriers to abortion seeking that may be difficult to navigate (Aiken & Scott, 2016; Medoff, 2016). At the federal level, the Hyde Amendment, which has been in place since 1977, bans funding of abortion except in rare cases of rape, incest, or life endangerment (Arnold, 2014). The Hyde Amendment affects a variety of patients, including those on Medicaid, indigenous populations served by the Indian Health Services Program, federal prisoners, volunteers in the Peace Corps, veterans, military personnel, and adolescents covered under the Child Health Insurance Program (Arnold, 2014; Donovan, 2017). This restriction also affects individuals who receive health coverage through the Affordable Care Act (ACA) health insurance exchange (Salganicoff, Beamesderfer, Kurani, & Sobel, 2014).

State-level policy barriers can include parental notification and consent laws, waiting periods, mandatory counseling, and targeted regulation of abortion providers (TRAP; Conti, Brant, Shumaker, & Reeves, 2016; Medoff, 2012, 2016; Medoff & Dennis, 2011). Parental notification laws require a parent or both parents of a minor to be notified and/or provide consent for a minor who intends to obtain an abortion (Medoff, 2016). Mandatory waiting periods require patients to wait a certain amount of time between the abortion appointment and the abortion procedure (Guttmacher Institute, 2017; Medoff, 2016). Other policies include mandatory and state-scripted counseling requirements (Medoff, 2016), which are often paired with mandatory waiting periods. Policies known as TRAP laws (Jones & Jerman, 2014; Medoff, 2012; Medoff & Dennis, 2011) impose stringent regulations on abortion clinics, which are not necessary for safety, and often result in clinic closures when providers cannot meet the requirements (Jones & Jerman, 2014; Medoff & Dennis, 2011; Rosen, 2012). Although TRAP laws vary, some have strict requirements on physical spaces, such as hallway width or air flow rates, or personnel requirements (Medoff, 2012; Medoff & Dennis, 2011). TRAP laws restrict access to abortion services and make the procedure costlier (Medoff & Dennis, 2011). In sum, since 2011, over 334 laws designed to restrict abortion have been passed at the state level (Conti et al., 2016; Nash & Gold, 2015). Policies vary widely by state, yet any patient seeking abortion must navigate some policy-based requirements. These examples are not exhaustive and demonstrate the regressive approach to abortion policy in the United States, which result in multiple burdens for abortion seekers. These policies are often framed as protective, and yet their consequences are harmful to patients seeking an abortion (Biggs, Upadhyay, McCulloch, & Foster, 2017).

Travel as a Barrier to Abortion

The barriers identified above can exacerbate problems for abortion seekers. For example, these barriers can delay abortion seeking and force patients to travel out of their communities to avoid policy restrictions or to seek providers who offer later abortion services that are needed due to delays. For abortion patients in general, traveling to access a provider can be a significant barrier to obtaining abortion services, given that almost 90% of U.S. counties lack abortion providers (Jones & Jerman, 2014). Extensive-travel distance to access an abortion provider has long been established as a barrier to abortion (Shelton, Brann, & Schultz, 1976), and longer travel distances are associated with delays in accessing abortion (Harper, Henderson, & Darney, 2005). It follows, then, that counties without abortion providers are known to have the lowest abortion rates (Jewell & Brown, 2000), suggesting that lack of providers may result in lack of being able to get an abortion. This is evident in states such as Texas, where abortion services are available in a mere 19 of their 254 counties (Jewell & Brown, 2000), translating into the need for many abortion patients to travel outside of their community to receive services. Providers estimate that approximately 25% of patients traveled more than 50 miles to obtain abortions (Henshaw & Finer, 2003), while patients themselves report traveling 30 miles on average (Jones & Jerman, 2013). Travel for economically vulnerable women can be particularly burdensome. This is evidenced by results from a study of recipients of financial assistance from an abortion fund indicating that respondents expect to travel an average distance of 140 miles, with those in the second trimester expecting to travel over 3 times farther than those in the first trimester (Ely et al., 2017b).

However, despite the existing knowledge base noted above around the complex relationship between IPV and abortion, which includes the need to seek an abortion to exit an abusive relationship, the relationship between IPV and the distance traveled to access an abortion has not yet been explored, to our knowledge. This is a notable dearth of information in light of studies that do exist on the topic of travel burdens and abortion. Given this lack of information, the purpose of the current study was to explore the relationship between IPV and travel distances in a national sample of patients seeking abortion services in the United States. To expand the knowledge base, we explore the hypothesis that respondents who report experiencing physical violence and sexual violence are more likely to travel longer distances to get an abortion.

The current study uses data from the Guttmacher Institute’s nationally representative, de-identified Abortion Patient Survey from 2008 (APS 2008). This is the most recent publicly available version of the survey, which was released for general public use in 2015 (Guttmacher Institute, 2015). While Guttmacher has collected information for the 2014 APS, these data are not available for public use at this time, which is the reason the authors have used the 2008 APS for the current study.

Method

Data

The Guttmacher Institute (2015) administered the original 2008 APS survey in 95 hospital and clinic settings where patients received abortions. According to Guttmacher Institute (2015), “The questionnaire included an introduction explaining the purpose of the survey and informing women that participation was voluntary and anonymous” (p. 63). The authors of the current study were not involved in the collection of the original dataset, which is freely available on the Internet and completely devoid of identifying information, and therefore not considered research with human subjects that requires additional informed consent. Institutional Review Board (IRB) permission to conduct research with existing, de-identified data was obtained.

The inclusion criteria of the current study were patients who responded to questions on distance traveled to get an abortion, IPV including physical and sexual violence, length of pregnancy, whether they wanted the pregnancy, number of previous abortions, whether they went to the nearest clinic (i.e., accounting for whether the distance traveled was because of unavailability of services or because they needed distance from their partners), and demographic variables (age, education, race, marital status, insurance, income, and poverty status).

The original dataset contains data from 9,493 women, but after accounting for missing data for the specific variables of interest, the current study has a sample size of 7,290 women. This was because we did a listwise deletion to account for missing data. The missing data were at random, not systematic, which is why we do not expect this to affect the results. In addition, the demographic characteristics of the sample of 7,290 women are comparable with that of the sample of 9,493 women.

The survey was conducted at medical facilities; clinics with large caseloads (of abortion) were oversampled. Women at these medical facilities filled out the questionnaire pertaining to this study along with other paperwork while waiting to be seen. Questionnaires that were not completed were filled out by staff using existing intake information. Because the information on the patients were available to staff as a result of them seeking medical services at the medical institution, the data provided by the staff were deemed trustworthy. Individual weights, facility weights, and stratum weights were constructed to create a final weight to allow use of survey techniques to account for complex sampling design of the study (Guttmacher Institute, 2015).

Measures

The APS 2008, which was the fourth survey in a series, employing a design similar to data collected in the previous years (1987, 1994-1995, and 2000-2001), used indicators, not standardized scales, to elicit information from the nationally representative sample of abortion patients (Guttmacher Institute, 2015). The key dependent variable was distance traveled to get an abortion. This was conceptualized as a categorical variable which identified whether respondents traveled between 0 and 50 miles, 51 and 100 miles, 101 and 150 miles, or more than 151 miles.

The key independent variables were experiences of physical violence and sexual violence. Respondents answered two questions about their current or most recent relationship: “Has a man physically abused you?” and “Has a man sexually abused you?” Respondents responded either yes or no.

The study controlled for length of pregnancy measured in weeks; age measured in years; education categorized into 0 to 11th grade, high school or Graduate Equivalent Diploma (GED), some college or associates degree, college graduate and higher; income categorized as under US$9,999, US$10,000 to US$19,999, US$20,000 to US$29,999; US$30,000 to US$39,999, US$40,000 to US$49,999, and US$50,000 and over; poverty status based on the number of household members and reported family income at the time of abortion measured as percentage of the federal poverty threshold; race categorized into American Indian, Asian or South Asian, Native Hawaiian or Pacific Islander, Black or African American, White and Other; relationship status categorized as married, cohabiting but not married, never married, and previously married; insurance type: Medicaid, private insurance, other, or uninsured; whether women went to the closest clinic to which women responded yes or no; whether the pregnancy was wanted categorized into intended, indifferent, mistimed, and unwanted; and number of previous abortions categorized into 1, 2, 3, 4+.

Analysis

Sample characteristics were calculated based on population estimates. Chi-square tests were conducted to examine the bivariate associations between all independent and dependent variables. Prevalence ratios were calculated to determine the association between IPV, physical and sexual, and distance traveled to get an abortion, controlling for length of pregnancy, age, education, income, poverty category, race, relationship status, insurance type, whether women went to the closest clinic, whether the pregnancy was wanted, and number of previous abortions. This was done using log-binomial method that uses the binomial distribution to obtain maximum likelihood estimates. This method is often preferred over computing odds ratios because odds ratios often overestimate the strength of association between variables (Tamhane, Westfall, Burkholder, & Cutter, 2016).

Results

Sample Characteristics

Sample characteristics (Table 1) indicated that a majority of the women (83%) traveled between 1 and 50 miles, while 11% traveled between 51 and 100 miles, 4% traveled between 101 and 150 miles, and 3% traveled more than 151 miles to get an abortion.

Table 1.

The Study Population and the Sample.

	Sample Size	Population Distribution
All	7,290	100.0
Key dependent variable
Distance traveled to get an abortion (in miles)
0-50	5,748	82.7
51-100	763	10.8
101-150	281	3.9
151+	205	2.7
Independent variables
Physical violence	439	6.0
Sexual violence	195	2.7
Length of pregnancy (in weeks)
0-4	522	7.4
5-9	4,835	65.9
10-14	1,557	21.5
15+	375	5.1
Age
13-17	492	6.7
18-22	2,332	31.9
23-27	2,095	28.4
28-32	1,291	17.4
33-37	721	10.0
38+	398	5.5
Education
0-11th grade	1,236	17.1
High school graduate or GED	2,108	29.2
Some college or associate degree	2,730	37.2
College graduate or more	1,216	16.5
Income
Under US$9,999	1,552	21.2
US$10,000-US$19,999	1,716	23.5
US$20,000-US$29,999	1,248	17.1
US$30,000-US$39,999	840	11.6
US$40,000-US$49,999	541	7.4
US$50,000+	1,393	19.2
Poverty category (% of federal poverty threshold)
Under 100%	2,961	40.8
100%-199%	1,980	27.1
200+%	2,349	32.1
Race
American Indian	130	1.7
Asian or South Asian	374	5.3
Native Hawaiian or Other Pacific	126	17.4
Black or African American	2,249	30.8
White	3,284	44.1
Other	1,127	16.4
Union
Married	1,036	14.3
Cohabiting, not married	2,101	29.0
Never married	3,351	45.8
Previously married	802	10.9
Insurance
Medicaid	2,182	30.4
Private	2,356	31.5
Other	365	4.8
Uninsured	2,387	33.3
Traveled to closest clinic
No	1,377	18.6
Yes	5,913	81.4
Pregnancy wantedness
Intended	349	4.6
Indifferent	54	0.1
Mistimed	3,795	52.3
Unwanted	3,092	42.3
Number of abortions
0	3,772	51.3
1	2,060	28.2
2	880	12.3
3	336	4.8
4+	242	3.4

In terms of the violence predictors, 6% of the women reported physical violence while about 3% reported sexual violence. In terms of length of pregnancy, the majority (66%) were between 5 and 9 weeks pregnant.

In terms of demographic characteristics of the study population, we examined age, education, income, poverty category, and race.

In terms of age, the majority were between 18 and 32 years. In terms of education, most of the patients were high school graduates or had some college education. In terms of income, the patients were overrepresented in the low- and high-income groups. As such, in terms of poverty category estimated as percentage of family income to federal poverty line, 40.8% were under 100%, 27.1% were between 100% and 199%, and 32.1% were 200+% of the federal poverty threshold. In terms of race, most were either African American/Black or White. In terms of union or marital status, 14.3% were married, 29% were cohabiting but not married, 45.8% were never married, and 10.9% were previously married.

We had controlled for potential confounders: type of insurance, whether women traveled to the nearest clinic (to ensure that the distance traveled was not a function of availability of services in their locality), pregnancy wantedness, and number of previous abortions.

In terms of insurance, 30.4% had Medicaid, 31.5% had private insurance, 4.8% had some other form of insurance, while 33.3% were uninsured. Approximately 81% of the respondents traveled to the nearest clinic to get an abortion. In terms of pregnancy wantedness, a majority said the pregnancy was mistimed. Of all the women who were part of the study population, 51.3% had never had an abortion before.

Bivariate Associations

Chi-square tests (Table 2) revealed that most of the independent variables were significantly associated with distance traveled to get an abortion: physical violence, length of pregnancy, income, race, union or marital status, insurance, whether women traveled to closest clinic, pregnancy wantedness, and number of abortions. Poverty category was found to be marginally associated with distance traveled to get an abortion. Sexual violence, age, and education were not found to be significantly associated with distance traveled to get an abortion.

Table 2.

Bivariate Associations Between the Dependent and Independent Variable (Based on Population Estimates).

	Distance Traveled to Get an Abortion(N = 7,290)
	0-50 Miles	51-100 Miles	101-150 Miles	151+ Miles
Independent variables
Physical violence	5.6	5.8	9.3	8.1*
Sexual violence	2.5	2.4	3.2	3.7
Length of pregnancy (weeks)
0-4	86.8	9.6	1.6	1.9*
5-9	82.8	10.6	3.9	2.7
10-14	81.7	11.4	4.5	2.4
15+	79.7	11.0	4.4	4.9
Age
13-17	85.6	9.7	3.4	1.3
18-22	82.3	10.8	3.9	3.0
23-27	81.9	11.4	4.0	2.7
28-32	83.2	10.6	3.6	2.6
33-37	82.8	9.6	4.7	3.0
38+	83.4	10.9	3.4	2.3
Education
0-11th grade	84.8	9.2	3.3	2.7
High school graduate or GED	82.9	10.9	3.5	2.6
Some college or associate degree	81.4	11.5	4.4	2.7
College graduate or more	82.9	10.3	3.8	2.9
Income
Under US$9,000	82.5	10.1	4.6	2.8*
US$10,000-US$19,999	79.1	12.9	4.6	3.4
US$20,000-US$29,999	83.0	11.7	3.1	2.1
US$30,000-US$39,999	84.1	9.3	4.6	1.9
US$40,000-US$49,999	85.6	8.8	2.9	2.7
US$50,000+	85.0	9.7	2.7	2.7
Poverty category (% of federal poverty threshold)
Under 100%	81.6	10.9	4.5	3.0^†^
100%-199%	82.2	11.5	3.8	2.5
200+%	84.5	9.9	3.1	2.5
Race
American Indian	77.6	9.7	4.2	8.4*
Asian or South Asian	91.9	5.0	1.2	1.9
Native Hawaiian or Other Pacific	96.2	2.5	1.3	0
Black or African American	83.3	10.7	3.7	2.2
White	77.7	13.8	5.1	3.5
Other	91.2	5.2	2.0	1.5
Union
Married	8.3	10.5	3.3	3.6*
Cohabiting, not married	82.6	11.2	3.7	2.4
Never married	83.6	10.2	3.6	2.6
Previously married	79.2	12.3	6.0	2.6
Insurance
Medicaid	84.3	9.8	3.5	2.4*
Private	82.1	11.3	3.6	2.0
Other	86.3	6.9	2.9	3.9
Uninsured	81.3	11.6	4.6	2.5
Traveled to closest clinic
No	47.4	27.6	13.8	11.2*
Yes	91.1	6.7	1.5	0.7
Pregnancy wantedness
Intended	79.5	10.7	3.4	6.4*
Indifferent	86.3	8.1	3.6	1.9
Mistimed	84.3	10.1	3.2	2.4
Unwanted	80.9	11.6	4.7	2.7
Number of abortions
0	80.3	11.6	4.6	3.5*
1	83.9	10.4	3.5	2.2
2	84.6	10.5	2.9	2.1
3	89.8	7.3	2.1	0.7
4+	92.1	6.0	1.3	0.6

†

p < .09. *p < .05.

Multivariate Model

Prevalence ratios for the sample of 7,290 women revealed an overall significant design degrees of freedom of 9486 (p < .05). Prevalence ratios revealed that physical violence was significantly associated with distance traveled to get an abortion (PR = 1.15, p < .05) when all control variables were accounted for. Sexual violence, however, was not found to be significantly associated with distance traveled to get an abortion.

The control variables that were significantly associated with distance traveled to get an abortion in the multivariate model, as shown in Table 3, were length of pregnancy (PR = 1.15, p < .05); some college or associate degree (PR = 1.09, p < .05); income level US$$10,000 to US$19,000 (PR = 1.12, p < .05); poverty rate (PR = 0.99, p < .05); race with reference group being American Indian: Asian or South Asian (PR = 1.15, p < .05), Native Hawaiian or Other Pacific (PR = 0.50. p < .05), Black or African American (PR = 0.65, p < .05), and Other (PR = 0.55, p < .05); union or marital status with reference group being “married”: cohabiting couples (PR = 0.88, p < .05), never married (PR = 0.87, p < .05); insurance type with Medicaid as reference group, private insurance (PR = 1.11, p < .05); whether women traveled to closest clinic (PR = 0.27, p < .05); pregnancy wantedness (by the woman) with intended pregnancy as reference group: indifferent (PR = 0.70, p < .05), mistimed pregnancy (PR = 0.75, p < .05), and unwanted pregnancy (PR = 0.81, p < .05); and number of previous abortions with zero abortions as reference group: one abortion (PR = 0.84, p < .05), two abortions (PR = 0.88, p < .05), three abortions (PR = 0.66, p < .05), and four or more abortions (PR = 0.63, p < .05) (see Table 3).

Table 3.

Prevalence Ratios Estimating Association Between IPV and Distance Traveled to Get Abortion.

Prevalence Ratios	Distance Traveled to Get AbortionN = 7,290, Design df = 9486 p < .001
	Prevalence Ratio
Physical violence	1.15*
Sexual violence	0.97
Length of pregnancy	1.01*
Age	0.99
Education
0-11th grade (Ref.)	—
High school graduate or GED	1.07
Some college or associate degree	1.09*
College graduate or more	1.08
Income
Under US$9,999 (Ref.)	—
US$10,000-US$19,000	1.12*
US$20,000-US$29,999	0.97
US$30,000-US$39,999	0.98
US$40,000-US$49,999	0.99
US$50,000+	1.06
Poverty rate	0.99*
Race
American Indian (Ref.)	—
Asian or South Asian	0.50*
Native Hawaiian or Other Pacific	0.50*
Black or African American	0.65*
White	0.82
Other	0.55*
Union
Married (Ref.)	—
Cohabiting, not married	0.88*
Never married	0.87*
Previously married	1.01
Insurance
Medicaid (Ref.)	—
Private	1.11*
Other	1.03
Uninsured	1.04
Traveled to closest clinic	0.27*
Pregnancy wantedness
Intended (Ref.)	—
Indifferent	0.70*
Mistimed	0.75*
Unwanted	0.81*
Number of abortions
0 (Ref.)	—
1	0.84*
2	0.88*
3	0.66*
4+	0.63*
Constant	159.63*

Note. IPV = intimate partner violence.

p < .05.

Discussion

In this study, we examined whether experiencing physical violence or sexual violence was associated with distance traveled to get an abortion among a nationally representative sample of women who received abortion services in 2008. We found that patients who experienced physical violence traveled longer distances to get an abortion.

To our knowledge, this is the only study to specifically examine the relationship between IPV and distance traveled for abortion services. The results of the analysis support the hypotheses that there is a positive relationship between physical IPV and distance traveled to get an abortion, but the hypothesis about the relationship between sexual IPV and distance traveled to get an abortion in this nationally representative sample of U.S. abortion patients is not supported. Explanations for this include the possibility that navigating violence delays a woman’s ability to access the procedure in a timely manner, given that IPV is also associated with fertility control (Liu et al., 2013). This may increase the need for later abortion services that are offered by fewer clinics so more extensive travel to access those limited services is required. It is also possible that navigating violence impedes problem solving and self-awareness in such a way that pregnancies are not quickly confirmed and signs of pregnancy are not easily recognized, thus delaying the abortion. Such an explanation would be consistent with another study suggesting that delayed abortions are associated with various logistical factors such as problems accessing pregnancy tests and lack of knowledge of missed menstrual periods (Drey et al., 2006). Other related findings suggest that abortion patients who experienced violence from the co-conceiving partner were less likely to inform the partner of the abortion (Ely & Otis, 2011), which indicates that patients might be navigating the violence to seek the abortion without the partner’s knowledge for the purposes of self-protection. Delays caused by navigating the violence could result in a delay in being able to get the abortion, because those seeking abortion must wait until there is a safe time to go for services. This need for self-protection may also prompt women involved in IPV to purposely seek abortion services outside the community of residence to avoid detection by a violent partner, which may be another explanation for the relationship between violence and longer travel distances. This is possible in light of the findings from one study suggesting that pregnancy increases IPV and that the IPV plays a role in the decision to terminate (Williams & Brackley, 2009).

Political factors and state policy regarding abortion may necessitate traveling long distances for patients residing in certain areas, in comparison with those residing in areas where services are more accessible, which means those with more limited provider access could be more likely to travel across state lines. However, as Table 4 indicates, barring a few states like Nebraska, Oklahoma, Utah, and New Mexico, most of the women in the study sample accessed abortion services in their own states. The distance traveled, therefore, was not primarily because of traveling out of state, yet it was related to having to travel to another city or community to access the procedure. This is consistent with information indicating that almost 90% of counties in the United States have no abortion provider (Jones & Jerman, 2017).

Table 4.

State Residence and States Where Abortion Facilities Were Located.

	Frequency	%	Cumulative
State ID
Alabama	96	2.21	2.21
Arizona	55	1.27	3.48
California	619	14.27	17.75
Colorado	12	0.28	18.03
Connecticut	14	0.32	18.35
Delaware	42	0.97	19.32
District of Columbia	10	0.23	19.55
Florida	260	5.99	25.55
Georgia	85	1.96	27.51
Hawaii	57	1.31	28.82
Illinois	189	4.36	33.18
Indiana	145	3.34	36.52
Iowa	95	2.19	38.71
Kentucky	65	1.50	40.21
Louisiana	46	1.06	41.27
Maine	14	0.32	41.60
Maryland	149	3.44	45.03
Massachusetts	81	1.87	46.90
Michigan	123	2.84	49.73
Minnesota	20	0.46	50.20
Mississippi	58	1.34	51.53
Missouri	39	0.90	52.43
Nebraska	9	0.21	52.64
Nevada	69	1.59	54.23
New Hampshire	3	0.07	54.30
New Jersey	171	3.94	58.24
New York	444	10.24	68.48
North Carolina	44	1.01	69.50
North Dakota	52	1.20	70.69
Ohio	106	2.44	73.14
Oklahoma	2	0.05	73.18
Oregon	112	2.58	75.77
Pennsylvania	224	5.16	80.93
South Carolina	33	0.76	81.69
South Dakota	10	0.23	81.92
Tennessee	14	0.32	82.25
Texas	409	9.43	91.68
Utah	1	0.02	91.70
Virginia	180	4.15	95.85
Washington	88	2.03	97.88
West Virginia	35	0.81	98.69
Wisconsin	46	1.06	99.75
Wyoming	1	0.02	99.77
Mexico	6	0.14	99.91
Other	3	0.07	99.98
Other foreign country	1	0.02	100.00
Total	4,337	100.00
Abortion facility location
Alabama	170	3.71	3.71
Arizona	53	1.16	4.86
California	659	14.37	19.23
Colorado	13	0.28	19.52
Connecticut	15	0.33	19.84
Delaware	58	1.26	21.11
Florida	274	5.97	27.08
Georgia	125	2.73	29.81
Hawaii	61	1.33	31.14
Illinois	208	4.54	35.67
Indiana	138	3.01	38.68
Iowa	110	2.40	41.08
Kentucky	74	1.61	42.70
Louisiana	48	1.05	43.74
Maine	19	0.41	44.16
Maryland	182	3.97	48.12
Massachusetts	84	1.83	49.96
Michigan	128	2.79	52.75
Missouri	38	0.83	53.58
Nevada	77	1.68	55.26
New Jersey	199	4.34	59.59
New York	475	10.36	69.95
North Carolina	50	1.09	71.04
North Dakota	81	1.77	72.81
Ohio	115	2.51	75.32
Oregon	148	3.23	78.54
Pennsylvania	222	4.84	83.38
Tennessee	15	0.33	83.71
Texas	436	9.51	93.22
Virginia	178	3.88	97.10
Washington	60	1.31	98.41
West Virginia	31	0.68	99.08
Wisconsin	41	0.89	99.98
Wyoming	1	0.02	100.00
Total	4,586	100.00

Recommendations for Practice

In light of the evidence presented here, it is recommended that practitioners working with patients who are experiencing IPV be assessed for pregnancy status, and those working with pregnant patients and abortion patients screen for IPV and provide assessments to identify problems that may affect a continuing pregnancy or impede control over reproductive health, via rapid assessments designed to detect specific behaviors, and then offer referrals to any patients identifying violent relationships. Patients who wish to seek pregnancy termination services should be provided information about how to access services, including the closest abortion provider, and information about abortion fund services that include financial aid, if needed (Ely et al., 2017a). Such recommendations are supported by others (Coyle et al., 2015; Ely, Flaherty, & Cuddeback, 2010; Grace & Anderson, 2016; Kramer, 2014; Silverman & Raj, 2014) who recommend screening for partner violence and RC, which may serve to help interrupt subsequent unwanted pregnancies as a result of continued violence. Probing for IPV may be helpful very early in the process, such as during the initial call with the patients when making abortion appointments or during early appointments for pregnant patients. Some suggest that adopting a patient-centered approach that begins by simply asking pregnant patients about IPV is an important step in the screening process (Kramer, 2014). This can allow practitioners the time to suggest resources, make referrals, and help patients strategize and plan around navigating IPV.

The timely need for assessment and referrals by nonmedical practitioners, such as social workers and other behavioral health professionals, who interact with clients requesting information or referrals for reproductive health services on the front lines, in settings that are not necessarily related to reproductive health, is also critical. Given that in one study, 49% of social work students perceived an inability to provide referrals for abortion services (Ely, Flaherty, Akers, & Noland, 2012), and in another study 22% of social work students reported antichoice abortion stances (Begun, Bird, Winter, Combs, & McKay, 2016), it is essential that frontline practitioners in all settings prepare for potential reproductive health requests, and make a plan for how they will refer patients for abortion, even in cases where the requests are not expected in the existing setting. This is critical for promoting unintended pregnancy prevention, providing adequate prenatal care for those seeking to continue a pregnancy, and facilitating early, less costly access to abortion for those who choose to terminate but who may already be striving to overcome barriers to abortion, which can include IPV. This would also allow any patient who is experiencing partner violence additional time to navigate the violence to arrange for the reproductive health care options of their choice, which could include traveling to access an abortion.

This attention to referrals is especially important for patients seeking abortion in light of building state-level policy restrictions, such as mandatory waiting periods, that can further delay the procedure (Zurek, O’Donnell, Hart, & Rogow, 2015). From the years 2011-2015, states enacted 288 new policies designed to restrict abortion access (Guttmacher Institute, 2016). These restrictions can combine with problems around IPV to impede travel for women seeking abortion who are also navigating the effects of violent relationships. These policy-based restrictions have also affected reproductive health services overall, making preventing pregnancy even more difficult (Hasstedt, 2014), which is especially problematic for women navigating violent relationships. Advocates from various disciplines are encouraged to oppose abortion restrictions in favor of evidence-based abortion policy to eliminate as many barriers as possible for those who may be navigating IPV to access an abortion.

The results of the current study contribute to the knowledge base on IPV and abortion, yet more research in this area is needed. Future research should be designed that examines the relationship between IPV and abortion in more detail, including the impact of IPV on delays in accessing the procedure and travel distances for the purpose of informing intervention, especially policy advocacy in this area. Given that the data used for the current study were from 2008, additional research should examine whether or not travel distances for those experiencing violence have been increasing over time since then, in light of building state-level policy restrictions that are increasing wait times and often resulting in clinic closures.

Diversity statement

The dataset used to conduct this secondary data analysis represents a national, diverse sample of respondents. The majority of respondents identified as White, followed by those who identify as Black or African American, and then followed by those who identify with a racial group that was not provided as a category (Other). In our study, we found a significant difference between racial groups and distance traveled. While it is beyond the scope of the article to discuss why that may be, it is common to account for demographic differences when reporting study results which is why we controlled for race when we controlled for potential confounders.

Limitations

This study has several limitations. First, the cross-sectional nature of the study disallows causal inference. Second, the measures used in the study are indicators, not validated scales, which introduces issues of construct validity. For example, the measurement of variables like IPV is in yes/no format, which research suggests can reduce the reports of violence by respondents, and, therefore, when possible, IPV should be measured using multiple strategies (Bonomi et al., 2006). Future studies would do well to assess severity of violence, which we have been unable to do. Finally, questions on sensitive topics such as IPV are often misrepresented in self-reported surveys due to social desirability bias. This study, like all studies that focus on IPV, needs to be in light of the issue of social desirability bias as well.

Conclusion

The results of the current study uniquely contribute to the knowledge base in the area of IPV and abortion by demonstrating a relationship between IPV and travel distance in abortion patients that, to our knowledge, has not been previously examined. While the nature of this relationship could not be determined here, the results of the current study offer evidence of a relationship between IPV and travel for abortion that adds to the existing knowledge base and serves as a foundation for the development of more research in this area. Patients who are involved in violent relationships may be at risk of delays in accessing the procedure that push the need for abortion up into the second trimester and put patients at risk of not being able to exercise autonomy in terms of their reproductive health.

Footnotes

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) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Gretchen Ely, PhD, is an associate professor at the University at Buffalo, School of Social Work.

Nadine Murshid, PhD, is an assistant professor at the University at Buffalo School of Social Work.

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