Evidence You Can Use: Targeted Regulation of Abortion Providers (TRAP) Laws is designed to give advocates, service providers and policymakers the data and resources they need to engage in ongoing policy discussions in their states. It includes information on state laws and policies, a synthesis of the relevant research, information on states in which the issue has been debated in the past three years and links to state-specific data. The toolkit provides an evidence base for understanding the consequences of TRAP laws, a class of abortion restrictions that burden providers with requirements regarding their facility, equipment and staffing that have little or no benefit to patients.

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.

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.

Consequences of TRAP Laws

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

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.

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.