Access to Abortion: The Intersection of 'Who You Are' and 'Where You Live'

Abstract

Access to reproductive health services, including abortion services, is essential to the health of women and families. While existing literature has documented the influence of demographic factors (‘who you are’) on access to abortion in the United States, exploration of the influence of place of residence (‘where you live’) is limited. Evidence on the relationship between rurality and access to abortion is notably incomplete, despite the assertions in the public discourse that women living in rural communities have worse access to care than their urban peers. This dissertation addresses this gap via qualitative and quantitative research in the Central Appalachian region. The qualitative study explores rural women’s reproductive health needs and experiences via in-depth interviews. Paper 1 analyzes the variability of experiences related to accessing a range of reproductive health needs, including abortion. This critical formative research is needed not only to replace assumptions with evidence, but also to contextualize access to abortion within reproductive health access broadly. Paper 2 focuses on rural women’s experiences related to abortion services. It explores how perceived feasibility of obtaining abortion care influences pregnancy decision-making. Paper 3 explores the relationship between gestational age at time of abortion and county-level factors, adjusting for individual characteristics and distance traveled to care, using a three-level hierarchical model. The dissertation results suggest that reproductive health services are not uniformly difficult for women in rural communities to access. Instead, experiences accessing services vary as a result of the nature of the health need, with barriers to obtaining highly specialized and/or stigmatized services. Abortion services are both specialized and stigmatized, thus these services are uniquely challenging to access for women in rural communities, which influences women’s pregnancy decision-making. When women assess pregnancy as unacceptable but abortion services as unfeasible, they adjust their emotional orientation towards continuing pregnancy, casting ongoing pregnancy as acceptable. Finally, place of residence, specifically county of residence, is relevant to gestational age at time of abortion. Residing in a nonmetropolitan county is associated seeking abortion later, even after controlling for miles traveled and county-level poverty.