Advertisement

Access to Medication Abortion Among California's Public University Students

  • Ushma D. Upadhyay
    Correspondence
    Address correspondence to: Ushma D. Upadhyay, Ph.D., M.P.H., Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612.
    Affiliations
    Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California

    University of California Global Health Institute Center of Expertise on Women's Health, Gender, and Empowerment, Oakland, California
    Search for articles by this author
  • Alice F. Cartwright
    Affiliations
    Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California
    Search for articles by this author
  • Nicole E. Johns
    Affiliations
    Center on Gender Equity and Health, Division of Global Public Health, Department of Medicine, University of California, San Diego, California
    Search for articles by this author
Open AccessPublished:June 09, 2018DOI:https://doi.org/10.1016/j.jadohealth.2018.04.009

      Abstract

      Purpose

      A proposed California law will require student health centers at public universities to provide medication abortion. To understand its potential impact, we sought to describe current travel time, costs, and wait times to access care at the nearest abortion facilities.

      Methods

      We projected total medication abortion use based on campus enrollment figures and age- and state-adjusted abortion rates. We calculated distance and public transit time from campuses to the nearest abortion facility. We contacted existing abortion-providing facilities to determine costs, insurance acceptance, and wait times.

      Results

      We estimate 322 to 519 California public university students seek medication abortions each month. As many as 62% of students at these universities were more than 30 minutes from the closest abortion facility via public transportation. Average cost of medication abortion was $604, and average wait time to the first available appointment was one week.

      Conclusions

      College students face cost, scheduling, and travel barriers to abortion care. Offering medication abortion on campus could reduce these barriers.

      Keywords

      Implications and Contribution
      Abortion is a commonly needed health service for students attending public universities, but obtaining an abortion may be difficult for students. Offering medication abortion at campus-based student health centers, like other primary healthcare services, could reduce these barriers.
      California's state legislature is considering legislation that would require campus health centers at California's 34 public universities to provide medication abortion [

      California Legislature. SB-320 Public health: public postsecondary education: on-campus student health centers: abortion by medication techniques. 2018.

      ]. This includes 11 University of California campuses and 23 California State University campuses, encompassing 737,328 students [

      U.S. News & World Report. National Universities. Available at: https://premium.usnews.com/best-colleges/rankings/national-universities.

      ,

      U.S. News & World Report. Regional Universities. Available at: https://premium.usnews.com/best-colleges/rankings/regional-universities.

      ].
      Medication abortion, also known as medical abortion or the “abortion pill”, is available during the first 10 weeks of pregnancy and involves the use of two medications: mifepristone and misoprostol. Patients take the mifepristone at a clinic or at home and 6–72 hours later they take the misoprostol at home, where they have uterine contractions and the abortion process ensues. A follow-up visit 5–14 days later is recommended.
      Access to abortion care may be important to continued college participation and gender equity. Women who have a child while in college are less likely to graduate than those who do not, and 89% of students say that having a child while in school would make it harder to achieve their goals [
      National Center for Education Statistics
      Short-term enrollment in postsecondary education: student background and educational differences in reasons for early departure, 1996-1998.
      ,
      • Prentice M
      • Storin C
      • Robinson G
      Make it personal: how pregnancy planning and prevention help students complete college.
      ]. However, it is unknown whether campus-based services are needed. While unintended pregnancy and abortion rates are highest among people aged 18–24, the ages of most college-going students [
      • Jones RK
      • Jerman J
      Population group abortion rates and lifetime incidence of abortion: United States, 2008-2014.
      ], data on abortion incidence among college students are unavailable.
      This study aimed to assess medication abortion access among California's public university students. Specifically, we estimated current medication abortion use and travel time, costs, and appointment availability at the abortion facilities closest to each of the 34 campuses.

      Methods

      Medication abortion demand among California's public university students

      We generated projected ranges of monthly medication abortion demand using college-, age-, and state-adjusted abortion rates and estimated rates for medication abortion as preferred abortion type. Age-specific abortion rates were taken from the Guttmacher Institute's most recent nationwide projections; the mean of rates for ages 18–19 (1.8%) and 20–24 (2.8%) was used [
      • Jones RK
      • Jerman J
      Population group abortion rates and lifetime incidence of abortion: United States, 2008-2014.
      ]. We then adjusted for higher rates of abortion in California using the state-specific abortion rate (1.96%, compared with 1.46% nationally, for an adjustment factor of 1.34) [
      • Jones RK
      • Jerman J
      Abortion incidence and service availability in the United States, 2014.
      ]. Because these estimates are for all abortion types, we then adjusted for the percent of all abortions which are medication abortions. Nationally, 31% of abortions in 2014 were medication abortions; this figure served as our lower bound [
      • Jones RK
      • Jerman J
      Abortion incidence and service availability in the United States, 2014.
      ]. Given increasing popularity of medication abortion and potential higher demand with improved availability, we assumed a high bound of 50% of all abortions as medication abortions. Enrollment figures and percent of campus population that was female (as a proxy for the percent of students with uteri) were obtained from US News & World Report [

      U.S. News & World Report. National Universities. Available at: https://premium.usnews.com/best-colleges/rankings/national-universities.

      ,

      U.S. News & World Report. Regional Universities. Available at: https://premium.usnews.com/best-colleges/rankings/regional-universities.

      ].

      Facility information

      In November 2017, two research assistants made “mystery shopper” calls to all 152 abortion-providing facilities in California from a database maintained by University of California, San Francisco's Advancing New Standards in Reproductive Health program to verify the types of abortion provided, cost of abortion, acceptance of state Medicaid and other insurances, wait time until first available medication abortion appointment, and weekend appointment availability. This component of the study was approved by University of California, San Francisco's institutional review board.

      Distance and time to closest facility

      We calculated driving distance and time from every campus to every facility in the state using the Stata TRAVELTIME3 module, which uses a Google Maps API to calculate driving time and distance between points. For each closest facility, we then calculated public transit time from campus to the facility at a standard day and time (Wednesday at 4 P.M.) using Google Maps.

      Results

      Monthly usage estimates

      We estimated that in total, UC and CSU students obtain 1,038 abortions each month, and with campus availability, 322–519 of those would likely to be medication abortions (see Table 1).
      Table 1Campus-level enrollment, medication abortion estimates, travel, and closest facility information
      Campus type and nameCampus enrollmentMedication abortions per monthTravel to closest providerClosest facility information
      Total% FemaleLow estimateHigh estimateDriving (miles)Public transit (minutes)First available appointment (days)Weekend appointment availabilityCost of medication abortion
      California State University campuses
      Cal Poly San Luis Obispo20,944478131.7232Yes692
      Cal Poly Pomona23,717458144.9362No805
      CSU Bakersfield8,00260467.1635Yes580
      CSU Channel Islands6,167643510641No787
      CSU Dominguez Hills14,731637124.438-*No500
      CSU East Bay14,823617122.4248No647
      CSU Fresno24,4035811181.9309No647
      CSU Fullerton40,2355618295.38215No656
      CSU Long Beach37,4465617274.6252No805
      CSU Los Angeles27,6815813212.9232No450
      CSU Maritime Academy1,12017<1<13.77211No435
      CSU Monterey Bay7,60062465.12715No668
      CSU Northridge40,6895417283.6311No575
      CSU Sacramento30,2845614222.631-*No-*
      CSU San Bernardino20,76760101611.24720No659
      CSU San Marcos14,179617114.1467No575
      CSU Stanislaus9,282655815.8924No580
      Chico State17,287537122.2338No500
      Humboldt State8,11656469.9468Yes435
      San Diego State33,7785415231.4189No575
      San Francisco State30,2565613226.2348No435
      San Jose State32,7734813204.5338No668
      Sonoma State8,66863478.24012No435
      University of California campuses
      UC Berkeley40,1735217274.4241No435
      UC Davis35,18659172711.85511No668
      UC Hastings93056<111.4206No700
      UC Irvine33,4675314238483No500
      UC Los Angeles44,9475720333.9372Yes580
      UC Merced7,33651355.628-*No-*
      UC Riverside21,539549156.24114No575
      UC San Diego35,8214814225.8294No580
      UC San Francisco3,30064232.6283No725
      UC Santa Barbara24,34653101710.6461No787
      UC Santa Cruz17,335517113.3129Yes668
      Combined results: total or population-weighted averageTotalPopulation-weighted AverageTotalTotalPopulation-weighted AveragePopulation-weighted AveragePopulation-weighted AveragePopulation-weighted AverageAverage
      CSU campuses472,948552093374.7387.27%596
      UC campuses264,380541131826.6375.024%622
      All campuses737,328553225195.4386.413%604
      *Closest clinic could not be reached to determine next available appointment and/or cost.

      Distance and time to closest facility

      Mean driving distance from campus to the nearest abortion-providing facility was 5.5 miles one-way. Fifteen campuses (44%) were further than 5 miles from the nearest facility. Median travel time via public transit was 34 minutes one-way. Twenty two campuses (65%) were more than 30 minutes from the nearest provider via public transit. Population-weighted average distance was 5 miles driving and 38 minutes via public transit one-way. Given that two visits are recommended, population-weighted average total driving distance was 20 miles and average total public transit time was 1 hour 32 minutes.

      Facility information

      The average out-of-pocket cost of medication abortion at the facilities closest to campus was $604. Almost all facilities closest to campus accepted state Medicaid; one did not, but the next closest facility was only .05 miles further away. Average wait time until first available appointment was 7 days (range 1–20 days). Only five facilities closest to campus (15%) were ever open on weekends.

      Discussion

      Projections from this study suggest that many students attending California's public universities need abortion care, but barriers for students include traveling to a facility off-campus or attending an appointment on a weekday, for which they may miss classes. While student health centers also have limited or no weekend hours, many offer the ability to make next day or same day scheduled appointments online, making it easier to fit in an appointment in between classes and obtain care sooner. College students have limited financial resources; they are often paying for tuition and room and board, and have reduced time for employment. While it is not yet known how much students would pay for an on-campus medication abortion, the costs are likely to be the same or lower than those going to an off-campus clinic. If students face delays in accessing a medication abortion for any of these reasons, they may exceed the gestational limit of 10 weeks and no longer be able to have a medication abortion.
      Travel time is an important consideration for college students, as medication abortion must be obtained off-campus and usually requires two visits. Public transit time is salient because of low car ownership among college students; weighted by campus enrollment, 28% of UC students and 63% of CSU students have a car on campus [

      U.S. News & World Report. National Universities. Available at: https://premium.usnews.com/best-colleges/rankings/national-universities.

      ,

      U.S. News & World Report. Regional Universities. Available at: https://premium.usnews.com/best-colleges/rankings/regional-universities.

      ].
      This study is limited by an assumption that the closest abortion facility is the one that students are referred to or seek care from. However, some campuses may refer students to a campus-affiliated hospital rather than the closest public abortion facility. Additionally, these findings are limited to the campuses examined here and do not describe all barriers to seeking abortion care that college students may face. Estimates of the numbers of abortions are projections based on general population data, and actual abortion rates may differ for this population. Finally, the proposed legislation applies only to medication abortion, not aspiration abortion. Off-campus facilities may still be desirable to students who would prefer an aspiration abortion or who are not sure what type of abortion they want. Both types of first-trimester abortions could feasibly be offered on campus and ideally would be offered, so that student choice is not artificially constrained.
      If medication abortion was available on campus, the travel, logistical, and cost burdens to students seeking abortion would likely be greatly reduced. Forcing students to leave campus for abortion when other health services can be obtained on campus disproportionately burdens students who require abortion care. Low-income students are particularly impacted as the cost of abortion, cost of travel, and lost time away from classes may be particularly prohibitive.

      Acknowledgments

      The authors appreciate research assistance from Athena Edwards at University of California, Los Angeles and Aderayo Soyemi from University of California, Merced. They also thank Rachel Jones, Ph.D. at Guttmacher Institute for running special tabulations. This study was supported by a private anonymous donor. The funder had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.

      References

      1. California Legislature. SB-320 Public health: public postsecondary education: on-campus student health centers: abortion by medication techniques. 2018.

      2. U.S. News & World Report. National Universities. Available at: https://premium.usnews.com/best-colleges/rankings/national-universities.

      3. U.S. News & World Report. Regional Universities. Available at: https://premium.usnews.com/best-colleges/rankings/regional-universities.

        • National Center for Education Statistics
        Short-term enrollment in postsecondary education: student background and educational differences in reasons for early departure, 1996-1998.
        U.S. Department of Education, Washington, D.C.2002
        • Prentice M
        • Storin C
        • Robinson G
        Make it personal: how pregnancy planning and prevention help students complete college.
        American Association of Community Colleges, Washington, D.C2012
        • Jones RK
        • Jerman J
        Population group abortion rates and lifetime incidence of abortion: United States, 2008-2014.
        Am j Public Health. 2017; 107: 1904-1909
        • Jones RK
        • Jerman J
        Abortion incidence and service availability in the United States, 2014.
        Perspect Sex Reproductive Health. 2017; 49: 17-27