NARAL Pro-Choice Massachusetts
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Access to Abortion Care in Massachusetts (2011)

OVERVIEW

Massachusetts, like the rest of the nation, has experienced an overall decline in abortion providers in both clinics1 and hospitals in recent years. There are also significant – and growing – regional disparities in access to abortion care, with the majority of providers concentrated in the Metro-Boston area.

Beyond the numbers and geographic distribution, women face other obstacles to obtaining abortion care. The mere presence of a facility providing these services in a given region or community may be insufficient to ensure that women there have access to timely medical services. For instance, the majority of hospital-setting providers only offer abortion care in a very limited set of circumstances (such as for maternal or fetal health conditions).

Lower-income women and those in need of abortion care after the first trimester of pregnancy find their options further restricted. Out-of-pocket costs differ dramatically among providers, with the average hospital charging women over four times as much as the average clinic at the same gestational age.

Many women are forced to delay their care in order to save enough money to pay for their travel and for the procedure itself. National studies document that almost 60% of women who experience a delay cite these factors as contributing to their inability to obtain timely care.2 This not only affects their health,3 but further limits their options since most providers do not perform terminations throughout the entire second trimester. Although the vast majority (89%) of abortions occur in the first trimester,4   women in need of second-trimester procedures are particularly vulnerable due to the higher costs and their sometimes-special medical needs.

One important indicator of the future of abortion care is the degree of professional training available in the Commonwealth, which is known for its exceptional medical schools and residency programs. Not all programs offer training in core reproductive health services, including pregnancy terminations. Of those that do, all but one are located in Boston.

In this report, we document the current status of access to abortion care across the Commonwealth and note significant changes since 2002. Continue reading below or download the full report here.



TRENDS IN ABORTION CARE, 2002-2010


Licensed Clinics and Private Practices

The majority of women in need of abortion care rely on licensed clinics and physicians’ private practices specializing in women’s health. In 2010, these facilities accounted for nearly 9 in 10 abortions provided in the Commonwealth.5  According to a recent NARAL Pro-Choice Massachusetts survey, there are 11 clinics currently providing abortion care in Massachusetts. Additional research indicates that there may be 13 others – likely private physicians – providing a small number of abortions in certain restricted circumstances, such as for their established patients.6

Towns with Outpatient Abortion Care
 Black: Clinics practicing in 2008
Grey: Clinics lost since 2002

*Excludes two providers who requested that their locations not be disclosed due to privacy and safety concerns.



Despite the importance of clinics in providing abortion care, since 2002, Massachusetts has experienced a decline in the overall number of these providers as well as a significant change in regional distribution. The Southeast experienced the most dramatic shift, with the loss of two providers. The Central region also lost a provider, making access to care in this region even more limited. Historically, women living in the Western region – who live the farthest from the Metro-Boston area – have been particularly underserved. Today, they remain the worst-off geographically, with only a single clinic provider that offers generally accessible abortion care (two other providers, who don’t advertise their services, offer limited care to women living in a small portion of the region).

Hospitals

While only a small proportion of all abortions (14%7) occur in hospitals, access to these services is critical for some populations, particularly women with special medical needs. The distribution of hospitals providing abortion care largely exacerbates the geographic disparities seen in outpatient abortion services. For example, the Central, West, and Southeast regions have very few, if any, hospital providers while the Metro Boston area is home to a relatively large number of such providers.

Towns with Hospitals Providing Abortion Care, by Research Call Response (2011)

 Black: Abortion care available
Grey: Abortion care unavailable




In order to distinguish hospitals with abortion care available to the general public from those that provide abortions only in exceptional circumstances, in 2008, NARAL Pro-Choice Massachusetts conducted a study of all 55 hospitals with obstetrics and gynecology services in the Commonwealth. A researcher sent written surveys and also assumed the role of a pregnant woman inquiring via telephone about abortion services at the hospital. At the time, only seven (or 13%) of these 55 hospitals confirmed that their services include pregnancy terminations available to our mystery client. A follow-up set of "mystery client” calls in the summer of 2011 cast a wider net, contacting all 75 hospitals in the Commonwealth. Of those, a total of 10 hospitals (or 13%) said these services are available. Our research indicates that up to 13  other hospitals may provide limited abortion care, but they would not say so on the phone.

Furthermore, our hospital survey gauged the willingness of these facilities to furnish referrals to women seeking abortion care. Of the 66 hospitals that said they do not provide abortions, two-thirds of them (66%) attempted to suggest an alternative source of care.  Unfortunately, half of these 44 "referrals” were to a facility that did not provide abortions, contained incorrect contact information, or directed our caller to the phonebook. Nine (20%) referred the caller to a facility that offers abortion and provided contact information or a location, while another 13 (30%) recommended a legitimate provider but failed to include those details.  As a result, it appears that fewer than half (41%) of all hospitals in the Commonwealth provide abortion care or offer legitimate referrals for these services.

REGIONAL AND SOCIOECONOMIC IMPACTS

Today, residents of the Western, Central, and Southeast regions may have to travel great distances to reach a generally accessible provider of any type in their region, while residents of the Boston, Northeast and Metro West regions have more options.

With only one abortion provider, women in the Southeast are more isolated from critical reproductive health services and there is no abortion care on the Cape. The geographically large Central region also has only one clinic, while the Western region – which is approximately twice the size of the Central region – has a total of two accessible providers (two other providers serve women in a small part of the region and do not widely advertise their services). Finally, while the Metro West also has only one provider that readily accepts new patients seeking abortions, women in that area can reach the Boston region’s seven accessible providers with relative ease.

In total, 43% of Massachusetts counties have no generally accessible abortion providers at all. These include Barnstable, Dukes, Franklin, Hampshire, Nantucket, and Plymouth Counties with a total of 124,180 women at risk for unintended pregnancy.8

Regional disparities in abortion services also contribute to socioeconomic obstacles to accessing necessary healthcare. Although the Massachusetts Medicaid program (MassHealth) provides coverage for abortion care, many facilities are unable to accept patients with this coverage.9 Just less than one-half of all clinics providing abortion care cannot receive MassHealth reimbursements because they are, technically, private practices As a result, they are forced to perform the abortions in nearby hospitals in order to bill MassHealth, assuming the hospitals allow such care to be provided. Thus, women living below the poverty line find their choices limited due to their reliance on publicly funded health care. And these restrictions exacerbate regional disparities by eliminating even more options in underserved regions.

These women are also unlikely to have the means to travel and pay for hotel stays in other parts of Massachusetts where abortion may be less expensive or available to women who rely on public health insurance. These financial barriers to abortion care may cause many women to delay their procedures as they continue to work to save money to pay out-of-pocket costs. Even women eligible for subsidized care may face delays due to the time required to process MassHealth applications.10 And, as women are forced to delay their procedures, their options are further reduced due to differences among providers in offering first- and second-trimester services.

ABORTION CARE TRAINING

Massachusetts has six obstetrics and gynecology residency programs and five family medicine residency programs. Of these, one obstetrics and gynecology and four family medicine programs do not currently offer training in abortion care. Those programs not providing abortion care training are all located outside of Boston. Meanwhile, like the provision of abortion care, the training programs that do offer complete training in reproductive health care are concentrated in the Boston area: Five of the six programs are in Boston proper, while one is located in Worcester. The overall decline in clinics and hospitals providing abortion care further limits the availability of training in abortion care.

CONCLUSION

Today, women face numerous unnecessary obstacles to reproductive health care. In Massachusetts and across the country, the number of abortion providers has declined, and those that remain are concentrated in urban areas. Cost and distance continue to present challenges for women in need of this time-sensitive procedure. To make the right to choose truly meaningful for the women of the Commonwealth, access to abortion care and professional training should be expanded beyond the Metro Boston area, especially to the Western, Central, and Southeast regions.



METHODOLOGY

NARAL Pro-Choice Massachusetts surveyed women’s health care providers across the Commonwealth in both 2008-2009 and 2011 to ascertain the number of abortion care providers and key information about their practices. All data categorizing providers by factors such as cost, types of services, and gestational age range of services were acquired in the 2008-2009 survey. We received responses electronically or in writing and used follow-up phone calls and e-mails to make any necessary clarifications.

The term "clinics” refers to licensed clinics and private practices specializing in women’s reproductive health care. In order to determine the number of clinics currently providing abortion care in 2008, we surveyed every clinic and private practice that had been listed at least once in the Abortion Access Project’s (AAP) annual directory of abortion providers from 2002-2006 (the AAP stopped publishing these directories after 2006). In addition, we sent surveys to any clinic or private office to which we were provided referrals during the hospital survey process. In 2011 we reconfirmed with known providers.

Determining the number of hospitals providing abortion care is a more complex process, as discussed in this report. In 2008, a trained researcher sent written surveys from NARAL Pro-Choice Massachusetts and then called all 55 hospitals with obstetrics and gynecology services in the Commonwealth, assuming the role of a pregnant woman inquiring about the availability of abortion services. Of the 55 hospitals, only 7 responded affirmatively to our mystery client. These calls were followed by written requests for clarification for any hospital that was previously listed in the AAP directory and either failed to return the written survey or whose survey response conflicted with the result of the mystery client call.

In addition, a follow-up mystery client call survey was performed during summer/fall of 2011. Similar methods were employed as during the 2008 survey; however, calls were placed to all 75 hospitals in Massachusetts and referral information was gathered, ideally, by the hospital offering it or, if necessary, the mystery client was instructed to ask for a referral. In approximately one-third of cases, the hospital refused to provide referral information, could not provide referral information, or was so hostile that our mystery caller felt too uncomfortable to ask. 

Unplanned pregnancy data was obtained from the Behavioral Risk Factor Surveillance System (BRFSS), which is administered statewide by the Massachusetts Department of Public Health(MDPH)’s Health Survey Program. Data for this indicator is available every other survey year, beginning in 1998 and ending in 2006. The most recent data on the number of women of reproductive age living in Massachusetts districts, also from 2006, came to us from the Guttmacher Institute; their methodologies are available online.

The regions described in this report correspond to the regions described in the BRFSS report. A map and an index of individual towns are available online. To summarize, the Western region includes Berkshire, Franklin, Hampden, and Hampshire Counties with four additional towns from Worcester County. The Central region comprises most of Worcester County, six northwestern towns from Middlesex County and three western towns from Norfolk County. The Northeast region is comprised of Essex County and portions of Middlesex County. The Southeast region includes Barnstable, Bristol, Dukes, and Nantucket Counties, as well as most of Plymouth County and some of Norfolk County. The Metro West region is comprised of most of Middlesex and Norfolk Counties and some of Plymouth County. Finally, the Boston region includes Boston, Brookline, Cambridge, Chelsea, Revere, Somerville, and Winthrop.


REFERENCES

(1) See Methodology for definition of "clinic” for the purpose of this analysis.

(2) Finer LB et al., Timing of steps and reasons for delays in obtaining abortions in the United States, Contraception, 2006, 74(4):334–344, cited at Guttmacher.

(3) Bartlett LA et al., Risk factors for legal induced abortion-related mortality in the United States, Obstetrics & Gynecology, 2004, 103(4):729–737, cited at Guttmacher.

(4) In Massachusetts, like across the nation, nine in ten abortions occur in the first trimester. Massachusetts Department of Public Health, Registry of Vital Records and Statistics, Bureau of Health Information, Statistics, Research, and Evaluation, Abortions in Massachusetts: 10 Tables, May 2009 (89.5 percent); Elam-Evans LD et al., Abortion surveillance—United States, 2000, Morbidity and Mortality Weekly Report, 2003, Vol. 52, SS-12 (89 percent).

(5)Massachusetts Department of Public Health, Registry of Vital Records and Statistics, Bureau of Health Information, Statistics, Research, and Evaluation, Abortions in Massachusetts: 10 Tables, May 2010.

(6) Jones RK et al., Abortion in the United States: incidence and access to services, 2008, Perspectives on Sexual and Reproductive Health, 2011, 43(1):41-50.

(7) Supra, note 5.

(8) Guttmacher Institute, Contraceptive Needs and Services, 2006: Detailed County Tables, Massachusetts, cited at Guttmacher.

(9) Unlike most other outpatient surgeries, abortion procedures in Massachusetts must be performed in "licensed clinics” or hospitals in order to be eligible for MassHealth reimbursements. Because of this, many licensed physicians whose practices meet guidelines for office-based surgeries in general cannot get reimbursed by MassHealth for performing abortions. Furthermore, after the 18th week of gestation, abortions must be performed in a hospital to be eligible for MassHealth reimbursements. See 130 Mass. Code Regs 484.005

(10) Although pregnant women are eligible for expedited coverage while awaiting their MassHealth eligibility determination, the interim coverage is limited to prenatal care. See 130 Mass. Code Regs 505.003  and 130 Mass. Code Regs 450.105(F)


© October 2011

 
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