Development of methods to assess geographic variation in reproductive health behaviors and outcomes over the life course

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Abortion is a common reproductive health experience in the U.S. Annual abortion rates are known to vary by both socio-demographic characteristics and state contexts. Annual incidence of abortion has changed substantially over time and differentially by state. Little is known, however, about cumulative lifetime abortion incidence and its socio-demographic associations at the state level. The main substantive goal of this study is to fill these knowledge gaps using data through 2019 for six states that subsequently experienced radically different policy and legal changes after the Dobbs versus Jackson Women’s Health Organization decision. The study states consist of two with relatively liberal abortion policies, located in the Mid-Atlantic (Delaware and Maryland), and four with more restrictive laws and policies respectively in the Midwest (Iowa and Ohio) and the Southeast (Alabama and South Carolina). A first methodological goal is the successful development and testing of an indirect question method, the “abortion list experiment”, thereby overcoming severe survey underreporting of abortion in direct self-report questions. A second methodological goal is the estimation of state level cumulative lifetime abortion incidence of abortion for real cohorts. Real-cohort measures are especially important when levels are changing over time, as they have been in the U.S. over recent decades, and are very likely to do so under the new policy and legal context post-Dobbs. The aims of the study are to advance understanding: 1) of cumulative lifetime abortion incidence through the end of the reproductive ages for real cohorts at the state level; 2) of state-specific abortion differentials by variables for which there are reliable external denominator data available such as for race/ethnicity, education, and income; 3) of state-specific abortion differentials by theoretically-important variables for which there are no reliable external denominator data available, such as for perceived and experienced barriers to health care access and enrollment in Medicaid and other health insurance types; and 4) of how state contexts, laws, and policies are associated with differences in patterns of socio-demographic and health- care disparities by state. This research will develop and validate methodologies that can subsequently be applied to post-Dobbs v. Jackson Women’s Health Organization state-level data, and will develop pre-Dobbs estimates against which to evaluate life-course and socio- demographic levels and differentials of abortion by state and groups of states post-Dobbs.