Most Women Denied Abortions by Texas Law Got Them Another Way

In the months after Texas banned all but the earliest abortions in September, the number of legal abortions in the state fell by about half. But two new studies suggest the total number among Texas women fell by far less — around 10 percent — because of large increases in the number of Texans who traveled to a clinic in a nearby state or ordered abortion pills online.

Two groups of researchers at the University of Texas at Austin counted the number of women using these alternative options. They found that while the Texas law — which prohibits abortion after fetal cardiac activity can be detected, or around six weeks — lowered the number of abortions, it did so much more modestly than earlier measurements suggested.

Combined, the data points to what may happen to abortion access if the Supreme Court decides to overturn Roe v. Wade when it rules on another abortion law this summer. The data shows the limitations of laws restricting abortion. Yet it also shows how restrictions erect significant obstacles, which will cause some women to carry unwanted pregnancies to term.

“The law has not done anything to change people’s need for abortion care; it has shifted where people are getting their abortion,” said Kari White, principal investigator of the university’s Texas Policy Evaluation Project and the lead researcher on the new out-of-state abortion study. She expressed surprise at how few abortions were prevented by such a sweeping set of restrictions: “The numbers are way bigger than we expected. It’s pretty astounding.”

But for the architects of the Texas law, even a modest reduction in abortions is a success.

“There’s no hesitation from our side to declare this a victory for actually protecting pre-born children from elective abortion,” said John Seago, the legislative director of Texas Right to Life, who was involved in the creation of the law. “We’re realists around here, so the best we can do is incentivize women to have their children.”

Gov. Greg Abbott, a Republican who said the bill “ensures that the life of every unborn child who has a heartbeat will be saved from the ravages of abortion” when he signed it, declined to comment on the new numbers.

As state legislatures await a Supreme Court ruling and take stock of the Texas experience this year, several have passed new abortion restrictions, even if they conflict with Roe. On Thursday night, the Florida Legislature voted to ban most abortions after 15 weeks. Somewhere between 21 and 26 states are expected to ban or substantially restrict abortion if the Supreme Court permits it. On Monday, an effort by Senate Democrats to codify abortion rights into federal law failed to attract enough votes.

Each month in the period between September 2021, when the Texas law went into effect, and the end of the year, an average of 1,400 women went to one of seven nearby states, according to one of the new studies, released Sunday. That was 12 times as many as typically sought abortions out of state before the law.

The study included seven nearby states: New Mexico, Oklahoma, Louisiana, Arkansas, Kansas, Mississippi and Colorado. Nearly half of Texans who traveled went to Oklahoma, and a quarter to New Mexico. It counted Texans who visited 34 of 44 clinics, so the total was probably higher.

An average of 1,100 women ordered abortion pills online each month from Aid Access, an overseas service that sends pills in the mail while sidestepping U.S. abortion restrictions, by connecting women with European doctors and Indian pharmacies. That is more than triple the number who ordered pills in an average month before the law, according to the second study, published last week in JAMA Network Open.

Before, there was an average of 11 requests a day. Immediately after, that spiked to 138 requests a day, and has leveled out at about 30. The study could not determine if all medication requests resulted in abortions.

“The law is semi-effective; it will not stop all abortions,” said Abigail R.A. Aiken, an author of the study, who teaches public affairs and leads a research group studying self-managed abortion at the University of Texas at Austin.

Those who were unable to get abortions are most likely to be poor, a variety of research has found. It’s expensive to travel to another state and pay for transportation, child care and lodging in addition to the procedure.

The new data covers the most common alternative methods to the in-state clinics, but does not include all Texans who got abortions.An unknown number of women most likely used other means, such as ordering pills from online pharmacies that have not published their sales numbers; crossing the border to Mexico to buy over-the-counter pills; traveling to additional states to get abortions; or using herbs or other methods for self-managing abortions.

If Roe is overturned, the same patterns may not hold nationwide, because abortion access would be even harder than it has been for Texans.

Recent research has shown that abortion pills outside formal health care settings are accessible, reliable and effective — and that information about Aid Access is increasingly being shared online. But some women don’t know it’s an option. “​​It’s been the question that has been on my mind for the last 10 years: How do you reach the ones who cannot find you?” said Rebecca Gomperts, the physician who runs Aid Access.

Also, it is technically illegal to sell prescription medicine to American patients from another country without a prescription from a doctor licensed in the United States. Enforcement is difficult, however, even as Texas and some other states have explicitly restricted medication abortion.

Without Roe, clinics would close in wide swaths of the South and Midwest. The closures would increase average driving distances to the nearest clinic to about 280 miles, up from 35 miles, for women in states without one, found research by Caitlin Knowles Myers, an economist at Middlebury College, and colleagues.

Research on past abortion laws has shown that longer distances tend to reduce abortions, as the challenges of travel mount. Groups offering financial and logistical support to Texas women said donations had decreased after a bump when the law went into effect.

The groups added they would not have enough resources to help women in so many states. Remaining clinics would most likely be overwhelmed with patients. Trust Women, which has an abortion clinic in Oklahoma, is seeing 10 times as many Texans there as it used to. That causes a ripple effect. Many Oklahomans can’t get local care and have to seek it elsewhere, said Rebecca Tong, an executive director of the clinics.

The clinics have tried to expand to meet demand, but especially in Oklahoma, where abortion would be outlawed if Roe were overturned, it’s hard to recruit doctors, she said: “Some would be leaving a full-time job with benefits, and for what?”

At Hope Medical in Shreveport, La., two-thirds of patients are now from Texas, up from one-fifth before the Texas law went into effect. The clinic used to do the majority of abortions before nine weeks, but now most patients are in their late first or early second trimester, because of the longer wait times for appointments.

“What ultimately is happening is because we are so busy and we can’t work any faster, we’re seeing women whose pregnancies were further along,” said Kathaleen Pittman, the clinic’s administrator. “It’s happening not just to Texas women but to Louisiana women because they’re having to wait too.”

Still, clinics are preparing for an even bigger surge if Roe is overturned, planning to expand capacity if abortion remains legal in their state — or, if not, to open over state lines where it is legal; offer more guidance through telemedicine; or offer pre-abortion care.

Kristina Tocce, the medical director of Planned Parenthood of the Rocky Mountains, said the influx of Texas patients had provided a preview of a possible future, in which Colorado, which is expected to keep abortion fully legal, could become a post-Roe abortion hub.

“What is going to happen when this happens to more and more states?” she said. “I don’t know, but we can’t absorb 26 states going dark.”

Note: Our calculated decline in overall abortions compares the recent numbers to a baseline of abortion numbers from before the legal change. For legal in-state abortions and requests for abortion pills, we compared the period from March to July in 2021 with the period from September to December in 2021.

For out-of-state abortions, we compared the period from March to July in 2021 with a 2019 monthly average. (Figures from early 2021 were not available.)

Because the number of abortions in Texas increased in August 2021, in anticipation of the new restrictions, we did not include that figure when establishing the historical numbers.