BACKGROUND

Abortion providers in the United States are subject to strict evidence-based regulations (such as state licensing requirements, federal workplace safety requirements, association requirements and medical ethics) created specifically to ensure patient safety. However, nearly half of states have imposed additional regulations, targeted specifically at abortion clinics that go beyond what is necessary to ensure patient safety. These laws are referred to as targeted regulation of abortion providers, or TRAP laws, and their primary purpose is to limit access to abortion.

Most TRAP laws apply a state’s standards for ambulatory surgical centers (ASCs) to abortion clinics, even though surgical centers tend to provide riskier, more invasive procedures and use higher levels of sedation. In some cases, TRAP laws also extend to physicians’ offices where abortions are performed and even to sites where only medication abortion is administered. TRAP regulations often include minimum measurements for room size and corridor width—requirements that may necessitate relocation or costly changes to a clinic’s physical layout and structure. Some regulations also mandate that clinicians performing abortions have admitting privileges at a local hospital, even though complications from abortion that require hospital admission are rare, so abortion providers are unlikely to meet minimum annual patient admissions that some hospitals require. TRAP requirements set standards that are intended to be difficult, if not impossible, for providers to meet. Instead of improving patient care, these laws endanger patients by reducing the total number of abortion facilities that are able to stay open under these financial and administrative constraints, thus making safe services harder to obtain.

In June 2016, the U.S. Supreme Court struck down two of the most burdensome TRAP laws, which had been enacted in Texas; the regulations required physicians who provide abortions to establish official relationships with local hospitals and required abortion facilities to meet the state’s standards for ASCs. Both of these requirements were unnecessary to ensure patient safety and did little to improve patient care. In Whole Woman’s Health v. Hellerstedt, the Supreme Court did not find any evidence to support the need for these requirements and concluded that the restrictions created an undue burden for women seeking abortion services. While the decision in Whole Woman’s Health does not automatically nullify all TRAP requirements, it has paved the way to challenge other states’ TRAP laws.

STATE LAWS AND POLICIES

For a chart of current laws and policies in each state that related to targeted regulation of abortion providers, see Targeted Regulation of Abortion Providers.

For information on state laws and policies related to other sexual and reproductive health and rights issues, see State Laws and Policies, issue-by-issue fact sheets updated monthly by the Guttmacher Institute’s policy analysts to reflect the most recent legislative, administrative and judicial actions.

RELEVANT DATA AND ANALYSIS

Admitting Privileges

Hospital admitting privileges allow providers to admit patients to a particular hospital and to personally provide specific medical services at that hospital. Requirements that abortion providers have such privileges are unnecessary to ensure continuity of patient care and likely do little to ensure safe emergency care. Instead, they create barriers to abortion services.

  • Abortion providers in the United States adhere to evidence-based standards that include protocols for the management of medical emergencies and emergency transport.1–3
  • Fewer than 0.5% of abortion patients in the United States experience a major complication that requires hospitalization.4,5
  • In the unusual event that complications develop, federal law requires a patient to be treated by any hospital, regardless of whether or where her abortion provider has admitting privileges.6  
  • A few of the state TRAP laws require the hospital at which providers have admitting privileges to be within a specified distance of the abortion clinic.7 However, a patient experiencing a complication in the days following an abortion would likely seek care from the hospital closest to her home (not necessarily the hospital at which the provider has privileges).
  • Admitting privileges are difficult for providers to obtain, because the agreement often requires that providers live near the hospital and that they admit a certain number of patients a year.1 Because abortion is so safe, an abortion provider will rarely, if ever, have to admit patients to a hospital and is unlikely to meet the admissions threshold.
  • States that require abortion providers to have hospital admitting privileges effectively give hospitals undue power over whether abortion services are provided,1 as the inability of abortion providers to gain admitting privileges may contribute to abortion clinic closures. Closures may in turn result in delays or a complete lack of access for women seeking abortion services (see “Consequences of TRAP Laws” below).
  • Abortion services in the United States are highly concentrated in metropolitan areas, meaning that many rural women already have limited access to abortion services: In 2014, at least 20% of women aged 15–44 lived 50 or more miles from the nearest abortion clinic.8 Requiring a provider to have admitting privileges can reduce abortion access in rural areas that have no hospitals nearby.

Facility Regulations

Similar to admitting privilege requirements, physical facility requirements included in TRAP laws are unnecessary and cannot be justified as contributing to patient care.

  • Abortion providers already follow rigorously developed standards to protect patients. In the face of such evidence-based regulations, TRAP requirements are superfluous and unnecessary.
    • Abortion is an extremely safe medical procedure. Only 0.3% of abortion patients in the United States experience a major complication that requires hospitalization.4,5
    • Clinics and providers are required to comply with federal and state safety standards. Federal standards include those set by the Occupational Safety and Health Administration, the Health Insurance Portability and Accountability Act of 1996 and the Clinical Laboratory Improvement Amendments of 1988; state regulations include building fire codes, professional licensing standards and continuing education requirements.9    
    • The World Health Organization (WHO) has made it clear that abortions can be safely performed in outpatient clinics and physicians’ offices.2 WHO guidelines state that regulation of abortion providers and settings “should be based on evidence of best practices and be aimed at ensuring safety, good quality and accessibility.”
    • Guidelines created by the National Abortion Federation (NAF) are updated annually and include standards on topics such as infection prevention; use of antibiotics, analgesia and sedation; and treatment of complications. Adherence to the guidelines is a condition of membership for abortion clinics.1,3  
    • Like NAF, Planned Parenthood Federation of America also maintains detailed requirements for affiliates offering abortion services. These organizational guidelines, which require that functioning equipment and medication be available onsite to handle emergencies, also require clinics to have protocols for the management of emergencies, including written and readily available directions for contacting external emergency assistance.1
  • Requiring facilities that provide abortion to meet the same standards as ambulatory surgical centers (ASCs) cannot be justified as protecting patients’ health and safety.1 These standards go well beyond what is necessary to ensure clinics are prepared to handle an emergency.
    • ASCs are intended to provide riskier and more invasive procedures and use higher levels of sedation than abortion clinics do.
    • Standards for ASCs often include requirements for the physical plant, such as minimum dimensions for procedure rooms and hospital-grade ventilation systems. Meeting these requirements does not improve patient care, and compliance can often be expensive and logistically difficult.
    • Some states require all tenants in the building to comply with certain ASC regulations (such as inspecting fire extinguishers monthly instead of annually). These requirements place providers in the position of having to ensure that all other building tenants are compliant—essentially giving other tenants the power to close clinics patients rely on for safe abortion services.
  • Controversy over optional fetal tissue donation—to further medical research or for transplantation into patients undergoing experimental treatments—has been used to drum up support for additional TRAP laws, but the issue does not affect abortion patient care or the safety of an abortion procedure and thus does not justify further clinic regulations.
  • Disposal of fetal tissue by abortion providers has become a controversial issue following the release of deceptively edited videos in 2015 aimed at discrediting Planned Parenthood and other abortion providers. However, treatment of the fetal tissue as medical waste has been the norm for nearly a century.10 Abortion providers comply with standard protocols for handling and disposing of surgically removed tissue.3 Regulations to require burial or cremation of fetal tissue further stigmatize abortion services and pregnancy loss, and may contradict the wishes of abortion patients.

Consequences of TRAP Laws

TRAP laws place unreasonable burdens on abortion providers and can result in clinic closures.

  • The number of clinics in Texas fell sharply between 2013 and 2014 because of admitting privilege requirements.11 As a result, the number of Texas women whose closest abortion clinic was more than 100 miles away more than tripled in that time. Complying with the physical plant requirements included in many state laws can be exorbitantly expensive for abortion providers. In 2013, the Virginia Department of Health estimated that on average, compliance with new regulations at clinics would cost up to $1 million per site.12 (In 2016, the state revised its regulations by repealing the most burdensome requirements.)

Impact of Delaying Abortion

When clinics close, delays in obtaining abortion services may increase. Delaying the procedure increases both the risk and the costs associated with having an abortion.

  • Clinic closures compound the barriers many women already face and could cause an increase in delayed abortions.13 In a 2014 national study of abortion patients, characteristics associated with experiencing a delay before an abortion included exposure to disruptive events, living at least 50 miles from a provider and living in a state with a waiting period.14 Delays averaged 7.6 days, but 7% of patients sampled waited more than 14 days for their appointment.
  • The risk of complications from abortion—although exceedingly small at any point—increases later in pregnancy. The risk of death associated with abortion rises from 0.3 deaths for every 100,000 abortions at or before eight weeks to 6.7 per 100,000 at 18 weeks or later.15 
  • Delays in seeking abortion can be a significant burden for poor women. In 2012, the median charge for an abortion was $495 at 10 weeks’ gestation and $1,350 at 20 weeks’ gestation.16 Forty-nine percent of women who obtained abortions in 2014 had incomes below the federal poverty level (FPL).17 (The 2017 FPL, which is similar to that for 2014, is $12,060 per year for a single woman with no children and $16,240 for a woman with one child.18)
  • Clinic closures typically mean women have to travel longer distances to receive services; as a result, they have to arrange for transportation and may need child care and time off from work. Nearly 60% of women who experienced a delay in obtaining an abortion in 2014 cited the time it took to make arrangements and raise money as reasons for that delay.14
  • Most women are able to have an abortion early in pregnancy, but women who rely on financial assistance, are young, are black, or have at most a high school education are more likely than other groups to experience delays in obtaining an abortion.19

DATA CENTER

RECENT STATE ACTION ON THIS ISSUE

States that have addressed this issue over the past three years are listed below.

EState enacted a relevant measure

V: State vetoed measure

A: State adopted measure in at least one chamber

 

States that require abortion facilities to meet ambulatory surgical center requirements 

Arizona (2017)

E

Arkansas (2017)

E

Indiana (2015)

E

Minnesota (2016, 2017)

A, V

Missouri (2017)

A

Tennessee (2015)

E

Texas (2017)

A

 

States that require abortion providers to have a relationship with a hospital, such as admitting privileges or a transfer agreement

Arkansas (2015)

E

Florida (2016)

E

Indiana (2016)

E

 

States that require medication abortion providers to meet TRAP requirements, including having a relationship with a hospital 

Arkansas (2015)

E

Indiana (2015, 2017)

E

Missouri (2017)

E

Ohio (2015)

E

 

States that limit abortion providers’ ability to dispose of fetal tissue

Indiana (2016)

E

Louisiana (2016)

E

Missouri (2017)

A

Ohio (2016)

A

Tennessee (2016)

E

Texas (2017)

E

REFERENCES

1. Gold RB and Nash E, TRAP laws gain political traction while abortion clinics—and the women they serve—pay the price, Guttmacher Policy Review, 2013, 16(2):7–12, https://www.guttmacher.org/gpr/2013/06/trap-laws-gain-political-traction-while-abortion-clinics-and-women-they-serve-pay-price.  

2. World Health Organization, Safe Abortion: Technical and Policy Guidance for Health Systems, 2012, http://www.who.int/reproductivehealth/publications/unsafe_abortion/9789241548434/en.

3. National Abortion Federation (NAF), Clinical Policy Guidelines for Abortion Care, 2017, https://5aa1b2xfmfh2e2mk03kk8rsx-wpengine.netdna-ssl.com/wp-content/uploads/2017-CPGs-for-Abortion-Care.pdf.

4. Weitz TA et al., Safety of aspiration abortion performed by nurse practitioners, certified nurse midwives, and physician assistants under a California legal waiver, American Journal of Public Health, 2013, 103(3):454–461.

5. Upadhyay UD et al., Incidence of emergency department visits and complications after abortion, Obstetrics & Gynecology, 2015, 125(1):175–183.

6. Emergency Medical Treatment and Labor Act, 42 USC 1395dd.

7. Guttmacher Institute, Targeted regulation of abortion providers, State Laws and Policies (as of February 2018), 2018, https://www.guttmacher.org/state-policy/explore/targeted-regulation-abortion-providers.

8. Bearak JM, Burke KL and Jones RK, 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(11):e493–500.

9. NAF, The TRAP: Targeted Regulation of Abortion Providers, 2017, https://5aa1b2xfmfh2e2mk03kk8rsx-wpengine.netdna-ssl.com/wp-content/uploads/TRAP_Fact_Sheet_SEPTEMBER_2017.pdf.

10. Morgan LM, “Properly disposed of”: a history of embryo disposal and the changing claims on fetal remains, Medical Anthropology, 2002, 21(3–4):247–274.

11. Texas Policy Evaluation Project (TxPEP), Rapidly changing access to abortion in Texas, 2013, http://www.utexas.edu/cola/orgs/txpep/_files/pdf/Rapidly-Changing-Access-to-Abortion-in-TX-18Jul2014.jpg.

12. Virginia Department of Health, Regulations for Licensure of Abortion Facilities, Proposed Regulation Agency Background Document, Jan. 8, 2013, http://townhall.virginia.gov/L/GetFile.cfm?File=C:\TownHall\docroot\58\3563\6315\AgencyStatement_VDH_6315_v2.pdf.

13. TxPEP, Abortion Wait Times in Texas: The Shrinking Capacity of Facilities and the Potential Impact of Closing Non-ASC Clinics, 2015, http://sites.utexas.edu/txpep/files/2016/01/Abortion_Wait_Time_Brief.pdf.

14. Jones RK and Jerman J, Time to Appointment and Delays in Accessing Care Among U.S. Abortion Patients, New York: Guttmacher Institute, 2016, https://www.guttmacher.org/report/delays-in-accessing-care-among-us-abortion-patients.

15. Zane S et al., Abortion-related mortality in the United States: 1998–2010, Obstetrics & Gynecology, 2015, 126(2):258–265.

16. Jerman J and Jones RK, Secondary measures of access to abortion services in the U.S., 2011–2012: gestational age limits, cost, and harassment, Women’s Health Issues, 2014, 24(4):e419–e424, https://www.guttmacher.org/sites/default/files/pdfs/pubs/journals/j.whi.2014.05.002.pdf.

17. Jerman J, Jones RK and Onda T, Characteristics of U.S. Abortion Patients in 2014 and Changes Since 2008, New York: Guttmacher Institute, 2016, https://www.guttmacher.org/report/characteristics-us-abortion-patients-2014.

18. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Poverty guidelines, 2017, https://aspe.hhs.gov/poverty-guidelines.

19. Jones RK and Jerman J, Characteristics and circumstances of U.S. women who obtain very early and second-trimester abortions, PLoS ONE, 2017, 12(1):e0169969, https://www.guttmacher.org/article/2017/01/characteristics-and-circumstances-us-women-who-obtain-very-early-and-second.