Population Research Center, University of Texas at Austin, Austin, TX.
Population Research Center, University of Texas at Austin, Austin, TX.
Am J Obstet Gynecol. 2020 Aug;223(2):236.e1-236.e8. doi: 10.1016/j.ajog.2020.02.028. Epub 2020 Feb 25.
In 2013, the Texas legislature passed House Bill 2, restricting use of medication abortion to comply with Food and Drug Administration labeling from 2000. The Food and Drug Administration updated its labeling for medication abortion in 2016, alleviating some of the burdens imposed by House Bill 2.
Our objective was to identify the impact of House Bill 2 on medication abortion use by patient travel distance to an open clinic and income status.
In this retrospective study, we collected patient zip code, county of residence, type of abortion, family size, and income data on all patients who received an abortion (medication or aspiration) from 7 Texas abortion clinics in 3 time periods: pre-House Bill 2 (July 1, 2012-June 30, 2013), during House Bill 2 (April 1, 2015-March 30, 2016), and post-Food and Drug Administration labeling update (April 1, 2016-March 30, 2017). Patient driving distance to the clinic where care was obtained was categorized as 1-24, 25-49, 50-99, or 100+ miles. Patient county of residence was categorized by availability of a clinic during House Bill 2 (open clinic), county with a House Bill 2-related clinic closure (closed clinic), or no clinic any time period. Patient income was categorized as ≤110% federal poverty level (low-income) and >110% federal poverty level. Change in medication abortion use in the 3 time periods by patient driving distance, residence in a county with an open clinic, and income status were evaluated using χ tests and logistic regression. We used geospatial mapping to depict the spatial distribution of patients who obtained a medication abortion in each time period.
Among 70,578 abortion procedures, medication abortion comprised 26%, 7%, and 29% of cases pre-House Bill 2, during House Bill 2, and post-Food and Drug Administration labeling update, respectively. During House Bill 2, patients traveling 100+ miles compared to 1- 24 miles were less likely to use medication abortion (odds ratio, 0.21; 95% confidence interval, 0.15, 0.30), as were low-income compared to higher-income patients (odds ratio, 0.76; 95% confidence interval, 0.68, 0.85), and low-income, distant patients (adjusted odds ratio, 0.14; 95% confidence interval, 0.08, 0.25). Similarly, post-Food and Drug Administration labeling update, rebound in medication abortion use was less pronounced for patients traveling 100+ miles compared to 1-24 miles (odds ratio, 0.82; 95% confidence interval, 0.74, 0.91), low-income compared to higher-income patients (odds ratio, 0.77; 95% confidence interval, 0.72, 0.81), and low-income, distant patients (adjusted odds ratio, 0.80; 95% confidence interval, 0.68, 0.94). Post-Food and Drug Administration labeling update, patients residing in counties with House Bill 2-related clinic closures were less likely to receive medication abortion as driving distance increased (52% traveling 25-49 miles, 41% traveling 50-99 miles, and 26% traveling 100+ miles, P < .05). Geospatial mapping demonstrated that patients traveled from all over the state to receive medication abortion pre-House Bill 2 and post-Food and Drug Administration labeling update, whereas during House Bill 2, only those living in or near a county with an open clinic obtained medication abortion.
Texas state law drastically restricted access to medication abortion and had a disproportionate impact on low-income patients and those living farther from an open clinic. After the Food and Drug Administration labeling update, medication abortion use rebounded, but disparities in use remained.
2013 年，德克萨斯州立法机构通过了众议院法案 2，要求药物流产必须符合 2000 年食品和药物管理局的标签规定。2016 年，食品和药物管理局更新了药物流产的标签，缓解了众议院法案 2 带来的部分负担。
我们的目的是确定众议院法案 2 对药物流产使用的影响，以患者前往开放诊所的距离和收入状况为依据。
在这项回顾性研究中，我们收集了所有在德克萨斯州 7 家堕胎诊所接受堕胎（药物或抽吸）的患者的邮政编码、居住地县、堕胎类型、家庭规模和收入数据，时间分为三个阶段：众议院法案 2 之前（2012 年 7 月 1 日至 2013 年 6 月 30 日）、众议院法案 2 期间（2015 年 4 月 1 日至 2016 年 3 月 30 日）和食品和药物管理局标签更新后（2016 年 4 月 1 日至 2017 年 3 月 30 日）。患者前往诊所的驾车距离分为 1-24 英里、25-49 英里、50-99 英里和 100 英里以上。患者居住地县根据众议院法案 2 期间的诊所可用性（开放诊所）、诊所关闭的县（关闭诊所）或任何时期都没有诊所的情况进行分类。患者收入分为≤110%联邦贫困线（低收入）和>110%联邦贫困线。通过 χ 检验和逻辑回归评估三个时期内药物流产使用情况的变化，依据患者的驾车距离、居住地是否有开放诊所以及收入状况。我们使用地理空间映射来描绘每个时期接受药物流产的患者的空间分布。
在 70578 例堕胎手术中，药物流产分别占众议院法案 2 之前、期间和食品和药物管理局标签更新后的 26%、7%和 29%。在众议院法案 2 期间，与 1-24 英里相比，行驶 100 英里以上的患者使用药物流产的可能性较小（比值比，0.21；95%置信区间，0.15，0.30），与高收入患者相比，低收入患者也是如此（比值比，0.76；95%置信区间，0.68，0.85），而低收入、远距离患者（调整后的比值比，0.14；95%置信区间，0.08，0.25）也是如此。同样，食品和药物管理局标签更新后，与 1-24 英里相比，行驶 100 英里以上的患者使用药物流产的反弹幅度较小（比值比，0.82；95%置信区间，0.74，0.91），与高收入患者相比，低收入患者也是如此（比值比，0.77；95%置信区间，0.72，0.81），而低收入、远距离患者（调整后的比值比，0.80；95%置信区间，0.68，0.94）也是如此。食品和药物管理局标签更新后，与开车距离增加相关，与众议院法案 2 相关的诊所关闭的县的患者更有可能接受药物流产（52%的患者行驶 25-49 英里，41%的患者行驶 50-99 英里，26%的患者行驶 100 英里以上，P<.05）。地理空间映射显示，在众议院法案 2 之前和食品和药物管理局标签更新后，患者从全州各地前往接受药物流产，而在众议院法案 2 期间，只有那些居住在或靠近开放诊所的县的患者才能获得药物流产。
德克萨斯州法律严重限制了药物流产的获得途径，对低收入患者和距离开放诊所较远的患者产生了不成比例的影响。食品和药物管理局标签更新后，药物流产的使用量有所反弹，但使用差异仍然存在。
