State abortion restrictions and child fatal-injury: an exploratory study.

• Author: Sen, Bisakha
• Position: Author abstract - Report

1. Introduction

   In 1973, the U.S. Supreme Court decision in Roe v. Wade established that all women in the U.S. had the constitutional right to terminate a pregnancy via abortion. This decision made it illegal for states to implement laws prohibiting women from obtaining abortions. However, subsequent court decisions have given states the authority to restrict abortion access in specific ways. A number of states have responded by limiting public funding of abortion services, instituting mandatory waiting periods, and requiring that at least one parent give consent or be notified before a minor can obtain an abortion. A new bill, approved by the United States Senate, imposes substantial penalties on non-parent adults who help minors cross state borders to obtain an abortion without parental involvement. It will, in all probability, be signed into law by the President before this article appears in print. There is also some speculation as to whether the latest changes in the nation's Supreme Court will eventually lead to an overturning of Roe v. Wade and leave the decision of permitting legal abortions to individual states. South Dakota has passed a law making almost all abortions illegal, which seems to be designed as a challenge to Roe v. Wade, and a similar bill is currently under consideration in Mississippi.

   Numerous studies have considered the effects of restrictive state abortion policies on the incidence of abortion (Oshfeldt and Gohmann 1994; Blank, George, and London 1996; HaasWilson 1996; Joyce and Kaestner 1996; Levine, Trainor, and Zimmerman 1996; Matthews, Ribar, and Wilhelm 1997; Cook et al. 1999; Levine 2003; Joyce, Kaestner, and Colman 2006), and most find that the policies are associated with declines in abortion. Other studies, detailed later in the paper, have considered the effects of the policies on teen births, female-headed household formation, teen sexual behavior and contraception use, and state-level prevalence of sexually transmitted diseases (STDs). Only recently have researchers turned to investigating another aspect--whether such policies impact outcomes for children. The premise is that abortion restrictions may result in more unplanned and unwanted pregnancies being carried to term, and also in disproportionately more children being born to women of low socioeconomic status (SES), minor women, single women, and women with inadequate parenting skills and resources. This provides grounds for hypothesizing that children born in the presence of abortion restrictions will experience poorer outcomes compared to children born in absence of such restrictions.

   This work is an exploratory study that considers the effects of restrictive state abortion policies on three negative outcomes for young children that are measured at the state level--fatal-injury rates due to violence (hereafter homicide), fatal-injury rates due to accidents (hereafter unintentional causes), and fatal-injury rates due to accidents other than motor vehicle crashes where the child was in the car (hereafter non-motor unintentional). Homicide-resultant fatal injuries and unintentional fatal injuries are among the five leading causes of death for young children (Anderson 2002), thus, understanding what factors influence their prevalence is important from a public health perspective. The analysis utilizes state-level cross-sectional time-series data and two-way fixed effects empirical models. The results find some associations between abortion restrictions and increases in child fatal-injury rates--specifically, between parental consent laws and homicide-resultant fatal-injury rates for white children; mandatory delays and non-motor unintentional fatal-injury rates for white children as well as homicide-resultant fatal-injury rates for black children; and no public funding and unintentional fatal-injury rates for black children.

2. Background

   A report based on the 1995 National Survey of Family Growth (Henshaw 1998) informs that in 1994, about 44.7% of all pregnancies were unintended, and 71% of pregnancies among 15 to 19-year-old women were unintended; 54% of all unintended pregnancies ended in abortion, whereas 45.3% of unintended pregnancies among 15 to 19-year-olds ended in abortion. In short, abortion services continue to be widely utilized in the United States, and state-level restrictions to abortion access can potentially affect a wide segment of the female population.

   Since 1973, when the U.S. Supreme Court legalized abortion nationwide, most states have adopted at least some strategies designed to reduce abortion access. Three of the most widely adopted policies are restrictions on publicly funded abortions, mandatory waiting periods, and parental involvement laws. Restrictions on publicly funded abortions began in 1976 with the Hyde Amendment, which eliminated federal Medicaid funding for most abortions. This legislation left Medicaid funding of abortions at the discretion of states and most states responded by adopting restrictions. At present, 16 states fund all abortions sought by Medicaid recipients, 32 states only fund abortions resulting from rape or incest or life-threatening pregnancies, and two states only fund abortions in cases of life-threatening pregnancies. (1) Mandatory waiting periods were first introduced in Mississippi, and started becoming more widely adopted after the 1992 Supreme Court decision in the case of Planned Parenthood of Southeastern Pennsylvania v. Casey, which upheld a Pennsylvania law mandating a 24-hour waiting period between when a woman sought an abortion at a clinic and when the abortion could actually be performed. By 1995, 11 states had implemented similar mandatory waiting periods, which were as long as 72 hours, and in all cases the woman was required to receive, in person from the clinic, state-mandated information regarding abortion-related complications, fetal development, and alternatives to abortion in that interim period. (2) While mandatory delays do not appear to be a major restriction at first glance, when coupled with the fact that many states have only a few abortion clinics and those sometimes offer abortion services only on selected days during the week, mandatory delays can impose time and travel costs that are prohibitive for women with limited resources. (3) States began introducing parental involvement laws soon after abortion was legalized in 1973. (4) In several states, these laws were initially enjoined by court order or not enforced, but by 1996, 26 states had binding parental-involvement laws in place. The design of these laws varies across states--some states require the consent of one or both parents for a minor seeking an abortion, while other states only required that the abortion provider notify one or both parents before the abortion is performed. (5)

   As stated earlier, numerous studies have found that the stricter policies on abortion were associated with reductions in the incidence of abortion. However, the extent to which this implies changes in birth outcomes is affected by whether the restrictions prompt women to take precautions against unwanted pregnancies, like abstinence or better contraceptive use. Readers are referred to the influential paper by Kane and Staiger (1996), which presents a theoretical model for why restrictions may even reduce births. (6) In their empirical analysis, Kane and Staiger find that presence of parental involvement laws appears to reduce birthrates among minor white teens, but they also appear to do so among non-minor teens and young adults--a counterintuitive result, since these age groups are outside the scope of such laws. Thus, they conclude that no definitive conclusions can be drawn about the effects of these abortion restrictions on birthrates. Recently published work by Joyce, Kaestner, and Colman (2006) finds an increase in birthrates among teens within the scope of parental involvement laws compared to 18-year-olds (who are outside the scope of the laws). Evans et al. (1993); Currie, Nixon, and Cole (1996); and Cook et al. (1999) find that no public funding for abortion results in increases in birthrates, whereas Levine, Trainor, and Zimmerman (1996) and Matthews, Ribar, and Wilhelm (1997) do not find any increases.

   Among studies that directly explore the effects of these laws on sexual behavior and contraception use, Levine (2001); Argys, Averett, and Rees (2002); Levine (2003); and Sen (2006) find no significant reductions in sexual activity, and, at best, weakly significant and small increases in contraception use. Studies using state-level STD prevalence rates as a proxy for prevalence of risky sexual behavior also find no significant associations between STD rates and no public funding (Sen 2003a, b) or parental involvement laws (Dee and Sen 2005).

   Thus, on balance, it appears that while the presence of abortion restrictions has reduced the incidence of abortion, it has not led to substantial changes in sexual behavior or precautions against (unwanted) pregnancies. This makes it likely that the presence of the restrictions has led to some live births that would not have occurred in their absence. There is good reason to speculate that this, in turn, might affect child outcomes. Levine et al. (1999) show that the legalization of abortion was associated with relative declines in births to teen women, single women, and non-white women. Gruber, Levine, and Staiger (1999) find that cohorts born after abortion legalization were less likely to be poor, welfare-dependent, and in single-parent households. Bitler and Zavodny (2002a) find that abortion legalization was associated with fewer children being given up for adoption--which they interpret as fewer 'unwanted' children being born, and also find that (Bitler and Zavodny 2002b) abortion legalization was associated with reductions in reports of child maltreatment. Finally, Grossman and Jacobowitz (1981) and Gruber, Levine, and...