In the first post of this two-part series, I reflected on foundational research on abortion care that centers patient experiences and how using survey or administrative data alone can result in incomplete conclusions about patient preferences about abortion care methods. This is especially true because people make choices about abortion care method in the context of tradeoffs, such as wait time and cost.
Discrete choice experiments
To address these limitations, health services researchers are also using experimental methods such as the discrete choice experiment (DCE) to examine how people place (relative) value on different characteristics of the abortion experience. DCEs require respondents to choose between various options for a form of health care or service. In turn, these choices “reveal” the attributes (i.e., features) of that service or good that are the most consequential to their care decision-making. Scholars have used discrete choice experiments to understand a wide variety of policy-relevant phenomena, including preferences for prenatal testing and follow-up treatment for breast cancer.
My UW-Madison colleague, Dr. Jane Seymour (Collaborative for Reproductive Equity), was the first researcher to apply the DCE approach to study abortion preferences. While she and her coauthors found that study participants had a slight preference for medication (vs. procedural) abortion, the larger story here is that wait time and the cost of the abortion mattered more than the abortion method. Another recent study led by Dr. Gracia Sierra at Resound Research for Reproductive Health also found that pregnant Texan abortion seekers valued decreased wait time over distance and cost when making decisions about where to go for care. Other researchers recently funded by the Society of Family Planning are conducting mixed-methods DCEs in a variety of geographic contexts (Mississippi, Texas, and Ohio, Kentucky, Tennessee, and West Virginia) to understand people’s preferences for abortion within and outside of formal health care settings. These findings can inform strategies around expanding access to care by accounting for abortion seekers’ preferences that most heavily influence decision-making.
Black People’s Pregnancy Preferences Study (BoPPs)
My personal interest in DCEs stemmed from my frustration with a seemingly pervasive post-Dobbs narrative (i.e., medication abortion would ‘save the day’) that seemingly ignored racial differences in abortion method preferences, particularly when it came to Black people. One study that has been incredibly influential in my thinking was written by Dr. Elizabeth Mosley and colleagues. This qualitative study of non-Hispanic Black and Hispanic/Latinx cisgender women living in Georgia found that some Black women feared that medication abortion could have undocumented adverse effects on fertility and increase risk of cancer. Others reported that health care providers failed to educate them about medication abortion due to provider biases about Black patients’ health literacy and/or ability to adhere to follow-up requirements. I wondered how we could use these insights to systematically understand Black people’s preferences and desires around abortion care, particularly in the context of varying state levels of abortion restrictions.
To answer these questions, our team at the Reproductive Equity Action Lab (myself, Dr. Laura Swan, Klaira Lerma) is partnering with Dr. Jane Seymour, Dr. Jessica Cao (UW-Madison Population Health Sciences), and Adrienne Ghorashi (legal epidemiologist at Temple University’s Center for Public Health Law Research) on a funded sequential mixed-methods study through the Collaborative for Reproductive Equity at UW-Madison (CORE). The Black People’s Pregnancy Preferences Study (BoPPs) is a mixed method study designed to examine preferences surrounding the abortion experience among Black people who can get pregnant and how legal and structural barriers can shape these preferences.
An important first step was to let the participants lead the conversation about which attributes of abortion care were most important, rather than making assumptions ourselves. That is, rather than relying solely on existing literature, it was important to us to understand what people closest to this issue thought about the abortion experience. Specifically, we conducted fifteen individual interviews with abortion ‘facilitators’ that focus on Black populations, including researchers, doulas, support staff, and clinicians to understand their perspectives on Black patients’ desires around abortion. We recruited another 15 self-identified Black individuals ages 18-44 who had recently had an abortion. We’re currently in the process of analyzing our qualitative interviews to help us explore this issue and help to pick key attributes for our discrete choice experiment. We’ll be fielding the experiment among 1,000 Black participants by summer 2025 and are eager to share the results with this research community, policymakers, and other relevant stakeholders.
Lessons learned thus far
- Mixed methods research is hard. Beyond the normal challenges that occur in every research project, qualitative research is incredibly emotionally taxing. Even though I’m fortunate to have an expert qualitative researcher in our group (Dr. Swan), it was important to me to get my feet wet as an interviewer (just a little!). Not only are economists like me NOT trained to do this, but qualitative interviewing can be incredibly emotionally taxing in ways that quantitative research is not. Hearing stories about the long distances that patients had to travel to receive essential health care was sobering and a good reminder of the importance of abortion research. I’m grateful for this experience of becoming a ‘student’ again, as it reminded me that every data point in our samples represents a human being with a life and experiences that have value.
- Community is vital. I’ve been so grateful to the other researchers in this space who have been willing to talk to us about lessons learned in doing their own DCEs related to abortion preferences. This kind of generosity has always been critical for improving our field but has taken on heightened importance in the current era where science is under attack. In another example, abortion clinics and funds were critical sites of participant recruitment. Engaging with these valuable partners has improved the significance of our work and given us new ideas for effective dissemination practices; it has also helped to drastically reduce the kinds of participant fraud that is pervasive in online research.
- Imagination and rigor aren’t mutually exclusive. It’s important to do research that is grounded in what has come before. Yet, I believe that our job as researchers is not merely to document what is, but what is possible. We envisioned a study that emphasized the diversity of Black people and have made a concerted effort through our visual branding and recruitment to shed light on the experiences of disabled, LGBTQIA+, larger-bodied, and non-US born participants. Working with participants to co-create new possibilities for desired abortion care is part of what makes this work so special and fills me with endless gratitude.
For those attending the Annual Research Meeting and interested in continuing this conversation, mark your calendars for a related session on Sunday, April 8, 3:45–5:00 p.m. CT, Partnering with Community and Applying Evidence to Advance Reproductive Health. I’ll be giving attendees a sneak preview of our BoPPs qualitative findings there.
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.