Health services researchers—including economists, sociologists, public health scholars, and more—have been working tirelessly to document the harms of restricting access to abortion. This work has taken on even greater urgency since the 2022 Supreme Court decision in Dobbs v. Jackson Women’s Health Organization, which dismantled Roe v. Wade and Planned Parenthood v. Casey. We know from the groundbreaking pre-Dobbs Turnaway Study that women who were denied a wanted abortion experienced increases in poverty and had worsened health and wellbeing compared to those who were not denied an abortion. Advances in empirical estimation have allowed us to produce critical evidence about the causal effects of abortion restrictions on population-level outcomes. This body of work demonstrates that pre-Dobbs abortion restrictions decreased abortion rates, increased the number of unintended births and have had negative impacts on health, educational, and labor market outcomes. Given the short-, medium-, and long-term effects of abortion restrictions and the relative ease of accessing some (not all!) relevant forms of administrative data, it can be tempting for health services researchers to focus almost exclusively on abortion access.
However, I argue that one critical area that we as a field have largely overlooked is understanding people’s preferences about the abortion care experience itself, including method, provider characteristics, setting, pain treatment, and more. The reasons for this lack of attention are not certain but are likely related to abortion stigma in research spaces as well as society at large. Yet, what is clear is that as health services researchers, we are trained to creatively identify, combine, and analyze large administrative and survey datasets. Unfortunately, the kinds of preexisting data that comprise the bedrock of health services research rarely if ever contain information on people’s preferences and desires around abortion. And, because our field tends to focus on quantitative work alone, health services researchers who are new to abortion scholarship may not be aware of or appreciate the existing qualitative work in this area (for example, see here and here). This qualitative scholarship is not only valuable in its own right, but is essential for hypothesis generation and developing survey instruments that can improve care experiences at the population level.
Fortunately, things are changing and health services researchers studying abortion are using mixed-methods approaches to better understand people’s desires around the abortion experience. In Part II of this blog, I’ll highlight one such approach, the discrete choice experiment. (Note: While this two-part blog is focused on discrete choice experiments, I would be remiss if I failed to point out recent work on measuring abortion quality fielded in both the Global South and United States.) My hope is that we as a field will continue to use these experimental approaches (and other methods) in service of highlighting the care experiences that abortion seekers desire.
Foundational work on patient-centered abortion care
While qualitative studies on abortion experiences that meet patients’ needs and desires are relatively sparse, existing work in U.S. settings suggests that patients value personal autonomy and desire empathy from clinicians. That is, patients who report positive abortion experiences tend to have positive experiences with clinic staff, report that medical personnel affirmed their decision as moral, and have the ability to choose the abortion method (i.e., procedural or medication), manage their pain (i.e., anesthesia or not), and exercise discretion around their procedure. More recent work has emphasized patients’ desire to have a support person accompanying them during their abortion.
Researchers have paid increasing attention to quantitatively capturing people’s preferences around abortion methods, particularly in the post-Dobbs era. For example, recent data from Guttmacher’s Monthly Abortion Provision Study show that medication (vs. procedural) abortion accounts for a rapidly increasing share of all US abortions; medication abortion comprised nearly 2/3 of all clinician-provided abortions in 2023.
On its face, this increase might suggest that more pregnant people seeking abortions ‘prefer’ to have medication abortions. However, this overlooks several key factors. First, there are significant demographic differences in abortion method across race, income, and education. Second, existing survey data tend to only capture individuals’ stated preferences without context. That is, individuals are asked directly which method of care they prefer without consideration of other attributes of care and the tradeoffs that are often necessary when seeking abortion care. Thus, merely stating that ‘X percent of people prefer medication abortion’ does not tell us how people value a particular abortion method compared to other care attributes such as cost, wait time, or distance to health care facilities.
In the second part of this two-part series, I will share what I am learning from discrete choice experiments, an experimental method useful for clarifying patient preferences and experiences in the post-Dobbs environment.
This post has been authored by one of AcademyHealth’s Reproductive Health Senior Scholars in Residence, Dr. Tiffany Green, who provides thought leadership on reproductive health issues within the health services research field and provides expert guidance to the Research Community on the Equity Impacts of Dobbs.
Supported by the Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The views presented here are those of the author and not necessarily those of the Commonwealth Fund, its directors, officers, or staff.