Limitations of Clinic-Based Research Regarding Abortion Cost Barriers
2. Materials and Methods
2.1. Reddit as an Emerging Qualitative Data Source
2.2. Data Collection
3.1. Inability to Secure Funds for Abortion Services and Transportation
(The clinic) said it would be $550. I haven’t been able to come up with that due to bills and finding out so late. I’ve been applying for loans but my credit score is 500. By my appointment time I will be 8 weeks along. What have you done when you need money quick?
(The clinic) was no help. I was essentially turned away because I hadn’t heard back from the funding assistance places they’d told me about, and I was too broke to be able to afford any of the procedures. I felt stuck, powerless, and defeated.
I don’t have a car and the nearest abortion clinic is six hours away. I just began my new job and I couldn’t afford to pay someone to drive me or the $500 fee.
3.2. Insufficient Funds to Select Desired Aspects of Abortion Services
Tomorrow I go to the clinic to take my first pill for medical abortion. As of Saturday when I take the second set of pills, I will be 10 weeks along. I am very nervous about having the procedure this late, but the surgical option was not financially viable for me. I can hardly afford the medical termination.
It’s been three weeks since I had the abortion, all pregnancy symptoms are gone but I haven’t had money for an ultrasound so I took a urine pregnancy test and this test has a very very faint second line. Could it be because my HGC is dropping low? Is it normal?
I don’t qualify for financial assistance at (the clinic). I’ll have to postpone another week—I have a second appointment the following week through my insurance. The surgical (procedure) will cost me $400 and does not include sedation of any kind (I would not be able to afford it). But, worse than the cost and lack of sedation is the fact that I’ll have to endure this pregnancy for an entire week longer…and I’m literally at my breaking point.
3.3. Insurance and Administrative Hurdles Create Unique Barriers
My appointment is tomorrow, and I found out Friday afternoon that my insurance won’t cover the abortion (pills). I read somewhere that I could apply for a temporary Medical-Cal (sic) but I can’t find much info on how to get it and how quickly I can receive it. As a pregnant woman, will I automatically qualify for it? (Authors’ note: California Medicaid is called MediCal.)
I’m going to have the aspiration procedure done on Saturday morning. I had Medicaid approved here in Florida because of pregnancy. Now I’m confused. I previously posted that I’m having to terminate due to my baby having anencephaly.
Has anyone been through this? Do you call them and tell them what happened? How long after do they cancel your Medicaid? And if you ever get pregnant again are you blacklisted or something? I’m just scared and nervous and want to make sure I can go to my follow-up appointment after the procedure.
I do have health insurance. It’s just that I’m under my parents’ plan and there is absolutely no way I can let them know about this. If anyone could help me it would be greatly appreciated. I’m terrified. My boyfriend and I are living paycheck to paycheck, so I can’t afford anything over $500. I don’t know what to do.
3.4. Relying on Self-Managed Abortion Options Due to Cost Barriers
I used Aid Access to terminate my pregnancy because I couldn’t afford $500+ for the abortion counseling appointment and medical abortion. I didn’t qualify for aid because my finances look good on paper. But they don’t take into account your rent, health insurance, car payment, student loans, etc.
I decided to hide (my pregnancy) from my parents and sister–basically, everyone except my boyfriend. Because I had only him, and he didn’t have a job at this time (rare for him) or a car, I knew my options were limited. I had enough savings to go to Planned Parenthood, but it would have depleted my bank account, and we probably wouldn’t be able to get to appointments. So I took the cheaper and easier way, and I ordered mifepristone and misoprostol from overseas.
I’m not financially fit, mentally ready... but I can’t afford abortion pills. And the closest Planned Parenthood is over 4 hours away... I’m scared about this whole thing. Also someone told me they have animal misoprostol that might work but I don’t think it would?
I’ve been using birth control however I didn’t realize one of my medications may make it ineffective. My insurance doesn’t cover abortions unless a physician says I was raped and my bank account is joint with my husband who I’m pretty sure would try to talk me out of aborting. Could I use diclofenac (voltaren) (a medication used to relieve pain and swelling from arthritis)? Someone told me it’s basically misoprostol.
4.1. Public Health Implications: The Potential Impact of, and Building Momentum for, Overturning Hyde
Institutional Review Board Statement
Informed Consent Statement
Conflicts of Interest
- Cohen, D.; Joffe, C. Obstacle Course: The Everyday Struggle to Get an Abortion in America; University of California Press: Berkeley, CA, USA, 2020. [Google Scholar]
- Henshaw, S.K.; Finer, L.B. The Accessibility of Abortion Services in the United States, 2001. Perspect. Sex. Reprod. Health 2003, 35, 16–24. [Google Scholar] [CrossRef] [PubMed]
- Dickman, S.L.; White, K.; Grossman, D. Affordability and Access to Abortion Care in the United States. JAMA Intern. Med. 2021. [Google Scholar] [CrossRef] [PubMed]
- Bessett, D.; Gorski, K.; Jinadasa, D.; Ostrow, M.; Peterson, M.J. Out of Time and Out of Pocket: Experiences of Women Seeking State-Subsidized Insurance for Abortion Care in Massachusetts. Women’s Health Issue 2011, 21, S21–S25. [Google Scholar] [CrossRef]
- Finer, L.B.; Zolna, M.R. Declines in Unintended Pregnancy in the United States, 2008–2011. N. Engl. J. Med. 2016, 374, 843–852. [Google Scholar] [CrossRef]
- Donovan, M.K. In Real Life: Federal Restrictions on Abortion Coverage and the Women They Impact. Available online: https://www.guttmacher.org/gpr/2017/01/real-life-federal-restrictions-abortion-coverage-and-women-they-impact (accessed on 22 March 2021).
- Upadhyay, U.D.; McCook, A.A.; Bennett, A.H.; Cartwright, A.F.; Roberts, S.C.M. State abortion policies and Medicaid coverage of abortion are associated with pregnancy outcomes among individuals seeking abortion recruited using Google Ads: A national cohort study. Soc. Sci. Med. 2021, 274, 113747. [Google Scholar] [CrossRef]
- Roberts, S.C.M.; Gould, H.; Kimport, K.; Weitz, T.A.; Foster, D.G. Out-of-Pocket Costs and Insurance Coverage for Abortion in the United States. Women’s Health Issue 2014, 24, e211–e218. [Google Scholar] [CrossRef] [PubMed]
- Upadhyay, U.; Ahlbach, C.; Kaller, S.; Cook, C.; Munoz, I. Trends in self-pay costs and insurance acceptance for abortion across the United States, 2017 to 2020. Contraception 2021, 103, 375. [Google Scholar] [CrossRef]
- Witwer, E.; Jones, R.K.; Fuentes, L.; Castle, S.K. Abortion service delivery in clinics by state policy climate in 2017. Contraception 2020, 2, 100043. [Google Scholar] [CrossRef] [PubMed]
- Bearak, J.M.; Burke, K.L.; Jones, R.K. Disparities and change over time in distance women would need to travel to have an abortion in the USA: A spatial analysis. Lancet Public Health 2017, 2, e493–e500. [Google Scholar] [CrossRef]
- Guttmacher Institute. Counseling and Waiting Periods for Abortion. Available online: https://www.guttmacher.org/state-policy/explore/counseling-and-waiting-periods-abortion (accessed on 26 April 2021).
- Board of Governors of the Federal Reserve System. Report on the Economic Well-Being of U.S. Households. Available online: https://www.federalreserve.gov/publications/2020-economic-well-being-of-us-households-in-2019-dealing-with-unexpected-expenses.htm (accessed on 26 April 2021).
- Biggs, M.A.; Gould, H.; Foster, D.G. Understanding why women seek abortions in the U.S. BMC Women’s Health 2013, 13, 29. [Google Scholar] [CrossRef] [PubMed]
- Jones, R.K.; Upadhyay, U.D.; Weitz, T.A. At What Cost? Payment for Abortion Care by U.S. Women. Women’s Health Issue. 2013, 23, e173–e178. [Google Scholar] [CrossRef] [PubMed]
- O’Donnell, J.; Goldberg, A.; Lieberman, E.; Betancourt, T. “I wouldn’t even know where to start”: Unwanted pregnancy and abortion decision-making in Central Appalachia. Reprod. Health Matters 2018, 26, 98–113. [Google Scholar] [CrossRef] [PubMed]
- Jerman, J.; Frohwirth, L.; Kavanaugh, M.L.; Blades, N. Barriers to Abortion Care and Their Consequences for Patients Traveling for Services: Qualitative Findings from Two States. Perspect. Sex. Reprod. Health 2017, 49, 95–102. [Google Scholar] [CrossRef] [PubMed]
- Benson, G.R.; Nash, E. TRAP Laws Gain Political Traction While Abortion Clinics—and the Women They Serve—Pay the Price. Available online: https://www.guttmacher.org/gpr/2013/06/trap-laws-gain-political-traction-while-abortion-clinics-and-women-they-serve-pay-price (accessed on 19 August 2021).
- Upadhyay, U.D.; Weitz, T.A.; Jones, R.K.; Barar, R.E.; Foster, D.G. Denial of Abortion Because of Provider Gestational Age Limits in the United States. Amer. J. Public Health 2014, 104, 1687–1694. [Google Scholar] [CrossRef]
- Venator, J.; Fletcher, J. Undue Burden Beyond Texas: An Analysis of Abortion Clinic Closures, Births, and Abortions in Wisconsin. J. Policy Anal. Manag. 2021. [Google Scholar] [CrossRef]
- Roberts, S.C.M.; Kimport, K.; Kriz, R.; Holl, J.; Mark, K.; Williams, V. Consideration of and Reasons for Not Obtaining Abortion Among Women Entering Prenatal Care in Southern Louisiana and Baltimore, Maryland. Sex. Res. Soc. Policy 2019, 16, 476–487. [Google Scholar] [CrossRef]
- Zhao, Y.; Zhang, J. Consumer health information seeking in social media: A literature review. Health Infor. Libr. J. 2017, 34, 268–283. [Google Scholar] [CrossRef]
- Altshuler, A.L.; Gerns, S.H.L.; Prager, S.W. Exploring abortion attitudes of U.S. adolescents and young adults using social media. Contraception 2015, 91, 226–233. [Google Scholar] [CrossRef]
- Pew Research Center. Who uses YouTube, WhatsApp and Reddit. Available online: https://www.pewresearch.org/internet/chart/who-uses-youtube-whatsapp-and-reddit/ (accessed on 12 March 2021).
- reddit.com Competitive Analysis, Marketing Mix and Traffic-Alexa. Available online: https://www.alexa.com/siteinfo/reddit.com (accessed on 12 March 2021).
- Caplan, M.A.; Purser, G. Qualitative inquiry using social media: A field-tested example. Qual. Soc. Work 2019, 18, 417–435. [Google Scholar] [CrossRef]
- Sowles, S.J.; McLeary, M.; Optican, A.; Cahn, E.; Krauss, M.J.; Fitzsimmons-Craft, E.E.; Wilfley, D.E.; Cavazos-Rehg, P.A. A content analysis of an online pro-eating disorder community on Reddit. Body Image 2018, 24, 137–144. [Google Scholar] [CrossRef]
- Delnevo, G.; Mirri, S.; Monti, L.; Prandi, C.; Putra, M.; Roccetti, M.; Salomoni, P.; Sokol, R.J. Patients Reactions to Non-Invasive and Invasive Prenatal Tests: A Machine-Based Analysis from Reddit Posts. In Proceedings of the 2018 IEEE/ACM International Conference on Advances in Social Networks Analysis and Mining (ASONAM), Barcelona, Spain, 28–31 August 2018; pp. 980–987. [Google Scholar] [CrossRef]
- Brett, E.I.; Stevens, E.M.; Wagener, T.L.; Leavens, E.L.S.; Morgan, T.L.; Cotton, W.D.; Hébert, E.T. A content analysis of JUUL discussions on social media: Using Reddit to understand patterns and perceptions of JUUL use. Drug Alcohol Depend. 2019, 194, 358–362. [Google Scholar] [CrossRef]
- Sandelowski, M. Whatever happened to qualitative description? Res. Nurs. Health 2000, 23, 334–340. [Google Scholar] [CrossRef]
- Creswell, J.W. Qualitative Inquiry and Research Design: Choosing among Five Approaches, 3rd ed.; SAGE Publications: Los Angeles, CA, USA, 2013. [Google Scholar]
- Ely, G.E.; Hales, T.; Jackson, D.L.; Bowen, E.A.; Maguin, E.; Hamilton, G. A trauma-informed examination of the hardships experienced by abortion fund patients in the United States. Health Care Women Int. 2017, 38, 1133–1151. [Google Scholar] [CrossRef]
- Gambir, K.; Garnsey, C.; Necastro, K.A.; Ngo, T.D. Effectiveness, safety and acceptability of medical abortion at home versus in the clinic: A systematic review and meta-analysis in response to COVID-19. BMJ Glob. Health 2020, 5, e003934. [Google Scholar] [CrossRef]
- Ngo, T.D.; Park, M.H.; Shakur, H.; Free, C. Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: A systematic review. Bull. World Health Organ. 2011, 89, 360–370. [Google Scholar] [CrossRef]
- Foster, D.G. The Turnaway Study; Scribner: New York, NY, USA, 2020. [Google Scholar]
- Roberts, S.C.M.; Berglas, N.F.; Kimport, K. Complex situations: Economic insecurity, mental health, and substance use among pregnant women who consider—but do not have—abortions. PLoS ONE 2020, 15, e0226004. [Google Scholar] [CrossRef] [PubMed]
- Jones, R.K.; Jerman, J. Characteristics and Circumstances of U.S. Women Who Obtain Very Early and Second-Trimester Abortions. PLoS ONE 2017, 12, e0169969. [Google Scholar] [CrossRef]
- Guttmacher Institute. Targeted Regulation of Abortion Providers (TRAP) Laws. Available online: https://www.guttmacher.org/evidence-you-can-use/targeted-regulation-abortion-providers-trap-laws (accessed on 22 March 2021).
- Roberts, S.C.M.; Johns, N.E.; Williams, V.; Wingo, E.; Upadhyay, U.D. Estimating the proportion of Medicaid-eligible pregnant women in Louisiana who do not get abortions when Medicaid does not cover abortion. BMC Women’s Health 2019, 19, 78. [Google Scholar] [CrossRef]
- Donovan, M.K. EACH Woman Act Offers Bold Path toward Equitable Abortion Coverage. Available online: https://www.guttmacher.org/article/2019/03/each-woman-act-offers-bold-path-toward-equitable-abortion-coverage (accessed on 19 August 2021).
- Glueck, K. Joe Biden Denounces Hyde Amendment, Reversing His Position. Available online: https://www.nytimes.com/2019/06/06/us/politics/joe-biden-hyde-amendment.html (accessed on 22 March 2021).
- Office of Ayanna Pressley. Reps. Pressley, Lee, Schakowsky and Ocasio-Cortez Introduce Amendment to Strip Discriminatory Hyde Amendment from Labor-HHS Appropriations Bill. Representative Ayanna Pressley. Available online: https://pressley.house.gov/media/press-releases/reps-pressley-lee-schakowsky-and-ocasio-cortez-introduce-amendment-strip (accessed on 22 March 2021).
- Office of Lois Frankel. DeLauro, Health Appropriations Subcommittee Examine Hyde Amendment’s Impact on Women’s Rights and Economic Security. Congresswoman Lois Frankel. Available online: https://frankel.house.gov/news/documentsingle.aspx?DocumentID=3184 (accessed on 22 March 2021).
- Banks, J. Why We Will Oppose Spending Bills That Repeal or Weaken the Hyde Amendment. Available online: https://thehill.com/blogs/congress-blog/healthcare/537256-why-we-will-oppose-spending-bills-that-repeal-or-weaken-the (accessed on 22 March 2021).
- Brufke, J.G. House Republicans Vow Not to Support Spending Bills That Repeal Hyde Amendment. Available online: https://thehill.com/homenews/house/535863-house-republicans-vow-not-to-support-spending-bills-that-repeal-hyde-amendment. (accessed on 22 March 2021).
- McCammon, S. Biden’s Budget Proposal Reverses A Decades-Long Ban on Abortion Funding. Available online: https://www.npr.org/2021/05/31/1001881788/bidens-budget-proposal-reverses-a-decades-long-ban-on-abortion-funding (accessed on 19 August 2021).
- Abrams, A. The House Just Passed Federal Spending Bills Without Abortion Restrictions for the First Time in Decades. Available online: https://time.com/6085444/hyde-amendment-spending-bills-congress/ (accessed on 19 August 2021).
- Thompson, T.A.; Price, J.; Carrión, F. Changes needed in Medicaid coverage and reimbursement to meet an evolving abortion care landscape. Contraception 2021, 104, 20–23. [Google Scholar] [CrossRef] [PubMed]
- Upadhyay, U.D.; Jovel, I.J.; McCuaig, K.D.; Cartwright, A.F. Using Google Ads to recruit and retain a cohort considering abortion in the United States. Contraception 2020, 2, 100017. [Google Scholar] [CrossRef] [PubMed]
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.
© 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).