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Utahs 72-Hour Waiting Period for Abortion: Experiences

Among a Clinic-Based Sample of Women
CONTEXT: In 2012, Utah became the first state to enact a 72-hour waiting period for abortion. Despite debate about
the laws potential effects, research has not examined womens experiences with it.
METHODS: A cohort of 500 women recruited at four family planning facilities in Utah in 20132014 completed baseline surveys at the time of an abortion information visit and follow-up telephone interviews three weeks later. Logistic
regression and coding of open-ended responses were used to examine which women had abortions and, for those who
did not, their reasons.
RESULTS: Among the 309 women completing follow-up, 86% had had an abortion, 8% were no longer seeking abor-

tion, 3% had miscarried or discovered they had not been pregnant, and 2% were still seeking abortion; one woman
was still deciding, and the waiting period had pushed one woman beyond her facilitys gestational limit for abortion.
At the information visit, women reported little conflict about the abortion decision (mean score on a scale of 0100
was 13.9 for those who eventually had an abortion and 28.5 for others). Low decisional conflict, but not socioeconomic
status, was associated with having an abortion (odds ratio, 1.1). On average, eight days elapsed between the information visit and the abortion.
CONCLUSION: As most women in this cohort were not conflicted about their decision when they sought care, the
72-hour waiting requirement seems to have been unnecessary. Individualized patient counseling for the small minority
who were conflicted when they presented for care may have been more appropriate.
Perspectives on Sexual and Reproductive Health, 2016, 48(4):TKTK, doi: 10.1363/48e8216

Embargo date: March 24, 2016

State-level abortion restrictions such as parental involvement laws, restrictions on public funding and waiting
periods have been in place in some U.S. states for almost
40 years.13 Recently, the number of abortion restrictions
has increased dramatically; more state-level restrictions
were enacted between 2011 and 2013 than in the previous decade.4 The severity of restrictions also has increased;
waiting periods have been lengthened from 24 to 48 or 72
hours.5 To contribute to the literature on these new, more
severe restrictions, this study seeks to understand womens
experiences with Utahs 72-hour waiting period.
BACKGROUND
Waiting periods specify the amount of time women seeking an abortion must wait after receiving state-mandated
abortion information and before having the procedure.
They are often accompanied by a requirement that women
receive state-mandated abortion information in person,
instead of by phone, thereby necessitating two visits. As of
November 2015, some 27 states had waiting periods, and
13 had requirements that necessitated two visits.5 While
24-hour waiting periods do not affect abortion rates, twovisit requirements are associated with decreases in abortion rates, increases in travel out of state for abortion and
increases in the proportion of abortions that are performed
in the second trimester.6,7

A few studies have examined womens experiences

with waiting periods and two-visit requirements. A study
of Tennessees waiting period and two-visit requirement
in 1979 and 1980 found that 77% of abortion patients
reported no benefit, while 59% reported experiencing
one or more problems due to the wait.1 While women in
Tennessee cited some possible benefits to waiting, they
reported experiencing fewer benefits, and more problems,
than anticipated. On average, women also paid an additional $24 because of the waiting period, which increased
costs by 48% for low-income and 14% for higher income
women. Similarly, a 2009 study of how women in Arizona
anticipated that a 24-hour waiting period would affect
them found that most expected additional financial difficulties and logistical hardships (such as difficulties arranging child care or taking time off from work), and only a
minority expected benefits.8
The scholarly research has been accompanied by an advocacy discourse. For example, advocates for abortion rights
(who are opposed to waiting periods) focus on the extent
to which logistical difficulties of waiting periods and twovisit requirements prevent women from having abortions.9
On the other hand, some opponents of abortion rights (who
favor waiting periods) argue that waiting periods are necessary to ensure that providers give women the time and
opportunity to change their minds. Previous research has

By Sarah C.M.
Roberts, David K.
Turok, Elise Belusa,
Sarah Combellick
and Ushma D.
Upadhyay
Sarah C.M. Roberts,
and Ushma D.
Upadhyay are
assistant professors; Elise Belusa is
research manager;
Sarah Combellick
was project directorall at Advancing
New Standards in
Reproductive Health
(ANSIRH), University
of California, San
Francisco, Oakland.
David K. Turok is
associate professor,
University of Utah,
Department of Obstetrics and Gynecology,
Salt Lake City.

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Utahs Waiting Period for Abortion

found that 113% of women presenting for abortion care in

settings with no or minimal (i.e., two-hour) waiting periods
do not have abortions.1,1012 According to this research, reasons women do not have an abortion after presenting for one
include that they miscarried or discovered they had not been
pregnant, decided to continue the pregnancy, were unable to
have the abortion because of facility gestational limits and
were referred to another provider for medical reasons.1012
Yet it is not clear the extent to which these findings apply to
settings with either 24-hour or longer waiting periods.
In May 2012, Utah became the first state in which a
72-hour waiting period went into effect. Utah requires
women to have a face-to-face abortion information visit at
least 72 hours prior to having the abortion;5 this requirement necessitates at least two visits. The primary purpose
of this study was to examine womens reasons for not having an abortion under the 72-hour waiting period and twovisit requirement. We also examined costs associated with
each visit, assessed actual wait between the information
visit and the abortion, and asked women to identify the
hardest part of waiting and of making two visits.
METHODS

Study Design
University of California, San Francisco (UCSF), researchers collaborated with University of Utah family planning
researchers and four family planning facilities in Utah
that offered the abortion information visits that women
are required to make at least 72 hours before they have an
abortion. One of these facilities also was an outpatient abortion facilityone of four in Utah during the study period.
UCSF research staff trained facility staff in study procedures.
Facility staff recruited women who presented for an information visit between October 2013 and April 2014. Women
who read English or Spanish and were older than 15 were
eligible. Minors were eligible with their assent and consent from one parent. At the information visit, facility staff
informed women about the study, invited them to participate, completed informed consent with women interested
in participating and showed them how to use an iPad to
complete the baseline self-administered survey. Participants
completed this survey prior to receiving the state-mandated
abortion information and any abortion counseling the facility provided as part of routine care. UCSF research staff
completed follow-up telephone interviews with participants
three weeks later. Participants were remunerated with $10
gift cards for completing the baseline survey and $20 gift
cards for completing the follow-up interview. This study
was approved by the UCSF Committee on Human Research.

Data
Baseline. The baseline survey collected data about possible predictors of not having an abortion. Our main variables of interest were socioeconomic status and decisional
conflict. We used two dichotomous indicators of socioeconomic status: receipt of public assistance in the past 12
months and employment.

After asking women which of three options they preferred for resolving their pregnancy (having an abortion,
having the baby and raising it, and having the baby and
placing it for adoption), the survey assessed their level
of decisional conflict. To measure decisional conflict, we
used a continuous, 16-item scale that examines how conflicted patients are about their health care decision.13 Items
include I know which options are available to me, I feel
sure about what to choose and I expect to stick with my
decision. All items are rated on a 04 Likert scale; a mean
score is calculated and then multiplied by 25 for an overall score with a possible value of 0100. Scores below 25
are associated with implementing a decision and can be
considered to represent low conflict; scores above 37.5
are associated with decision delay or feeling unsure about
implementation and can be considered to reflect high conflict.13 This scale was originally applied to decision making
regarding influenza vaccination and breast cancer screening,13 and has been used in a wide range of health decisions.1418 To our knowledge, it has not previously been
used in an abortion setting. It is considered the gold standard decisional conflict scale19 and has been found to be
appropriate, reliable, valid, responsive (i.e., able to detect
important changes in a study population), interpretable,
acceptable, and feasible to administer and complete.20 The
alpha for the decisional conflict scale was 0.93, indicating
high internal consistency.
We also included measures that might confound our
primary relationship of interest and measures to describe
participant characteristics. Demographic and reproductive
health characteristics included age, household income in
the past 12 months and gestational age at which pregnancy
was discovered (all measured continuously); race (white,
black, Hispanic or other); parity (nulliparous or parous);
and religion (Protestant, Catholic, Mormon, other religion
or no religion). Mental health history reflects prior professional diagnosis of depression or anxiety. Risky drinking in
the 12 months prior to pregnancy recognition was assessed
with the AUDIT-C, a screening tool used to identify hazardous drinking or alcohol use disorders, on which a score of
3 or more out of 12 is considered indicative of risky drinking.21 Drug use in the 12 months prior to pregnancy recognition was based on self-reports of illicit or street drug use,
or recreational use of prescription drugs. Violence from
the man involved in the pregnancy indicated whether participants said that the man had ever hit, slapped, pushed,
kicked, or physically hurt them in any way. As a measure
of abortion knowledge, participants were asked which of
two statements was closer to the truth for five common
abortion myths; they also could answer dont know.
(The myths were childbirth is safer than abortion, abortion causes depression or anxiety, abortion causes breast
cancer, most women experience regret after abortion and
abortion causes infertility.) For each myth, women received
0 points for endorsing the myth, 0.5 for dont know and
1 point for selecting the more accurate statement. Scores
were summed and then divided by 5, yielding an overall
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score with a range of 01; lower scores indicated lower
knowledge.
Two aspects of womens experiences with the information visit also were assessed. The financial cost is the sum
of costs women reported incurring to attend the visit (e.g.,
for transportation, missed work, staying overnight, child
care). Disclosure measures whether, in order to attend the
visit, women had had to tell someone who had not previously known about their pregnancy that they were seeking
an abortion.
Follow-up. The follow-up interview included both
closed- and open-ended questions. The main purpose was
to assess whether women had had an abortion and, if not,
their reasons. Those who had not had an abortion were
further classified as having had a miscarriage or discovered
they had not been pregnant, still seeking abortion, still
deciding, no longer seeking abortion or being unable to
have an abortion because of the waiting period. To be classified in the last category, a woman needed to have been
pushed beyond the gestational limit at the facility where
she sought care because of the waiting period. Women who
were still pregnant at follow-up (i.e., all of the above groups
except those who had had a miscarriage or discovered that
they were not pregnant) are the group of interest. These
women were asked an open-ended question about their
reasons for not having the abortion (What are the reasons
you have not had the abortion?), followed by a closedended question that allowed selection of multiple reasons.
A number of measures explored womens experiences
with the abortion visit. Financial cost, like the cost measure
for the information visit, is the sum of costs women reported
incurring to make the abortion visit; it does not include the
cost of the abortion itself, which was measured separately.
Source of formal financial assistance includes insurance,
Medicaid, abortion funds and clinic discounts. Financial
help from other people is based on open-ended responses
about who helped pay for the abortion. Disclosure when
women used their own money indicates whether they had
had to tell someone else they were spending the money;
whom they disclosed to is based on open-ended responses.
Actual wait is the number of days that elapsed between the
information visit and the abortion procedure; women who
waited longer than 72 hours were asked an open-ended
question about reasons for waiting longer. All women were
asked open-ended questions about the hardest part of waiting 72 hours, and all those who had the abortion were
asked the hardest part of making two visits.

Analysis
Most analyses were descriptive. Predictors of still being
pregnant were assessed through bivariable and multivariable logistic regression. Because of the rarity of the outcome, a directional acyclic graph was used to identify
variables to include in the model;22 decisional conflict and
socioeconomic status were considered the main variables
of interest, and we selected a sufficient set of variables to
control for confounding. The facility where women had the

information visit was considered as a fixed effect; it was not

retained because a likelihood ratio test did not indicate it
improved model fit. Analyses were conducted in Stata 13.0.
Open-ended responses were coded inductively in
Microsoft Excel to identify themes. Reasons for not having an abortion and for waiting longer than 72 hours were
coded by the lead author; questions about codes were
resolved through consensus between the first and third
authors. Responses about the hardest part of waiting and
of making two visits were coded by the third author after
she and the first author achieved at least 80% interrater
reliability on 10% of responses.
We also conducted attrition and sensitivity analyses to
examine possible effects of loss to follow-up. For attrition,
we compared characteristics of women lost to follow-up
and those not lost to follow-up, using t tests for continuous
and chi-square tests for categorical variables.
For sensitivity, the facility in our study that performed
abortions provided information about the date of abortions
there for women who were lost to follow-up or had not had
an abortion by follow-up, per the release of personal health
information form obtained at study entry. For our first sensitivity analysis, we estimated the numerator of those who
had had an abortion as the sum of three groups: women
who reported at follow-up that they had had an abortion;
women lost to follow-up who had signed the release form
and had an abortion at that facility; and women still pregnant at follow-up who had signed the release form and had
an abortion at the facility. The denominator was the total
sample.
However, analyses of those who completed follow-up
indicate that almost 30% had their abortion at another
facility. Thus, the first sensitivity analysis likely yields an
underestimate, as it did not include abortions at other
facilities. We thus conducted a second sensitivity analysis.
For this analysis, we needed to estimate the number lost
to follow-up who signed release forms and may have had
abortions at other facilities, as well as the number lost to
follow-up who did not sign release forms and may have
had abortions at either the participating facility or another
one. To estimate the first, we used womens follow-up interview reports of where they had their abortion to calculate
the ratio of those having abortions at the study facility to
those having them elsewhere. Multiplying this ratio by the
number lost to follow-up who had a release form and had
an abortion at the study facility gave us the number lost to
follow-up who had a release form and may have had an
abortion at any facility. We then estimated this number as
a proportion of those lost to follow-up who had a release
form, and multiplied that proportion by the number with
no release form to get the estimated number who were lost
to follow-up, had no release form and may have had an
abortion at any facility. Thus, the second sensitivity analysis
estimated the numerator as the sum of four groups: those
who reported at follow-up that they had had an abortion;
those lost to follow-up who had a release form and may
have had an abortion at any facility; those lost to follow-up

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TABLE 1. Selected characteristics of participants in a

study of Utahs law requiring a 72-hour waiting period
for abortion, 20132014
Characteristic
Age (range, 16.041.4)
Race
White
Black
Hispanic
Other/mixed race
Religion
Protestant
Catholic
Mormon
Other
None
Nulliparous
Gestational age at which pregnancy was
discovered (range, 021.1 weeks)
Employed
Public assistance
Household income (range, $0300,000)
History of depression/anxiety
Risky drinking
Drug use
Violence from the man involved in the pregnancy
Abortion knowledge (range, 0.11.0)
Decisional conflict (range, 069)
Option preferred at information visit
Have an abortion
Have the baby and raise it
Have the baby and place it for adoption
Facility
1
2
3
4

% or mean
(N=500)
25.6
65
3
24
8
10
12
19
5
54
51
5.5
69
32
21,761
27
48
17
9
0.62
15
95
4
<1
58
21
8
14

Four participants reported the same date for their last menstrual period
and their discovery of the pregnancy, and were coded as having discovered
the pregnancy at zero weeks. In past 12 months. Notes: Data on characteristics for which a range is shown are means; all others are percentages.

who had no release form and may have had an abortion

at any facility; and those still pregnant at follow-up who
signed the release form and had an abortion at the study
facility. The denominator was the total sample.
RESULTS

Sample
Facility staff approached 691 women, or 74% of those who
presented for an information visit during the study period.
Eight were ineligible. In all, 500 women consented to participate and completed baseline surveys, yielding a response
rate of 73%. Because of Wi-Fi connectivity and survey software problems, baseline data for six participants were lost.
A total of 309 participants (63%) completed follow-up.
Participants average age was 25.6 (Table 1). Two-thirds
were white, and more than half had no religion. Half were
nulliparous, and the mean gestational age at which pregnancy had been discovered was 5.5 weeks. Most women
were employed, and one-third received public assistance.
Mean annual household income was $22,000. Twentyseven percent of participants had a history of depression
or anxiety, 48% engaged in risky drinking, 17% had used
drugs in the past year and 9% reported violence from the

man involved in the pregnancy. The mean abortion knowledge score was 0.62, indicating that women rejected more
myths than they endorsed.
At baseline, 95% of women indicated that they would
prefer to have an abortion, 4% preferred to have the baby
and raise it, and fewer than 1% preferred to have the baby
and place it for adoption. The mean decisional conflict score
was 15 (range, 069), indicating low conflict. Seventy-one
percent of women had scores indicating low conflict, and
8% had scores indicating high conflict (not shown).
Eighty-six percent of women who completed follow-up
(95% confidence interval, 8390) had had an abortion, 8%
were no longer seeking abortion, 3% had had a miscarriage
or discovered they had not been pregnant, and 2% were
still seeking abortion. One woman was still deciding, and
one had not had an abortion because of the 72-hour waiting period.

Predictors of and Reasons

For Not Having Abortion
Among the 27 women who reported at follow-up that
they were no longer seeking an abortion, still deciding
or pushed beyond the gestational limit, 11 (4% of those
completing follow-up) had indicated at baseline that they
preferred to have the baby, nine (3% of those completing
follow-up) had preferred abortion and had been somewhat
or highly conflicted, and seven (2% of those completing
follow-up) had preferred abortion and had low conflict.
The mean conflict score at baseline was 13.9 among those
who eventually had an abortion and 28.5 among others.
In bivariable analyses, womens likelihood of still being
pregnant at follow-up was inversely associated with their
level of abortion knowledge and the gestational age at pregnancy discovery, and positively associated with receipt of
public assistance and decisional conflict (Table 2). In the
multivariable model, only decisional conflict and timing of
discovery of pregnancy were significant (odds ratios, 1.1
and 0.8, respectively).
The most common response to the open-ended question about reasons for not having an abortion was that
the woman just couldnt do it (Table 3). Although this
response could be read as indicating a change of mind, the
nuance tended toward having been conflicted to begin with
and then deciding not to have the abortion. For example, a
19-year-old, who had given birth twice, commented:
I have always been against abortion. This would be my
third child, which is why I considered it. I just couldnt find
myself to do it.
Similarly, a 37-year-old, who had given birth four times,
responded:
It was a hard decision for me to make in the first place,
and once I made the appointment, it kind of hit home.
About two days after the [information] appointment, I
canceled the [abortion] appointment. I couldnt do it. Its
something that Ive always been against. I had my reasons
that I thought were good reasons, and then I re-reasoned
myself out of it.
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The next most common reason was financial. For example, a 20-year-old nulliparous participant reported:
[I] get paid every week, but every time I think I have
enough money, it all gets taken out in taxes, so Im just
under the amount I need. Every time I try to make an
appointment, something else comes up that I have to pay.
The next most common reason women gave for not
having had the abortion was that other people had come
through for them. A 30-year-old nulliparous woman said,
My boyfriend got his shit together. And a 24-year-old,
who had had two births, responded, I talked with my family more about it, and they support me and they are willing
to help me.
Three participants reported being too far along in pregnancy to have an abortion. This sometimes meant that
women felt too far along for their own comfort. A 33-yearold participant, who had had two births, explained:
Had I not had to do the first appointment, I would
have been able to have the abortion earlier. But because
I had to wait so long to schedule the first appointment,
by the time I was able to gather funds, get child care and
find a way to get to the second appointment, I was 13
weeks, and I wasnt comfortable with getting the abortion
anymore.
An 18-year-old nulliparous woman discovered at her
abortion appointment that she was 20 weeks pregnant,
rather than 14, and was beyond the gestational limit at
her facility. A 26-year-old, who had given birth once, was
pushed beyond her facilitys gestational limit because of the
72-hour waiting period.
Two women mentioned that the first visit was part of
exploring options, and two mentioned wanting more time
to think. One reported logistical challenges scheduling the
abortion appointment.
In response to the closed-ended question,, the top two
reasons women gave for not having had an abortion were
a change of mind (cited by 71% of women who were still
pregnant, or 8% of women overall) and the cost of the procedure (47% and 5%, respectively). The next four reasons
related to other people. Whereas womens open-ended
responses referred to other peoples having come through
for them, the closed-ended responses had a different
nuance: Others had not wanted them to have an abortion,
they had needed to keep the abortion secret from family or
employers, and they had needed help with logistics.

Costs
Participants spent a mean of $44 (range, $0590) on costs
related to the information visit. Twenty-five percent paid
more than 5% of their monthly household income on these
costs, and 10% paid more than 17%. Participants who
had an abortion spent a mean of $103 (range, $01,330)
on costs related to the abortion visit and paid a mean of
$387 (range, $02,280) for the abortion. The costs for the
information visit represent 11% of the cost of the abortion
and 9% of the costs of the abortion plus the abortion visit.
Among women who had an abortion, 20% received finan-

TABLE 2. Odds ratios (and 95% confidence intervals) from bivariable and multivariable analyses assessing characteristics associated with womens likelihood of still
being pregnant at follow-up
Characteristic

Bivariable
(N=300)

Multivariable
(N=279)

Abortion knowledge
Age
Risky drinking
Drug use
Public assistance
Decisional conflict
Employed
Gestational age at which pregnancy was discovered
History of depression/anxiety

0.06 (0.010.40)**
1.01 (0.951.08)
0.50 (0.231.06)
0.63 (0.211.89)
2.99 (1.446.18)**
1.06 (1.041.09)***
0.54 (0.261.13)
0.81 (0.651.00)*
1.90 (0.904.00)

0.55 (0.055.78)
1.02 (0.941.10)
0.50 (0.201.29)
0.75 (0.212.75)
1.70 (0.684.28)
1.06 (1.031.10)***
0.79 (0.312.03)
0.79 (0.621.00)*
1.73 (0.674.45)

*p<.05. **p<.01. ***p<.001. Note: Gestational age at which pregnancy was discovered was missing data for
more women (16) than any other measure; in a model that used a categorical measure of this variable and
included a missing category, the main substantive findings did not change.

cial help from a formal source, mostly abortion funds or

clinic discounts (19%); 42% received help from another
person, mostly the man involved in the pregnancy, a boyfriend or a partner (32%).
Even when women used their own money, 26% had had
to tell someone else they were spending it. Of these, 77%
had had to tell the man involved in the pregnancy, a boyfriend or a partner.
To make logistical arrangements for the information visit,
6% had had to disclose that they were seeking abortion
to one or more people, including bosses, coworkers, men
involved in the pregnancies, family members, friends and
child care providers.

TABLE 3. Percentage of women still pregnant at follow-up and of all women

completing follow-up who gave various responses to open- and closed-ended
questions about why they had not had the abortion
Reason

Still pregnant
(N=34)

All
(N=309)

Open-ended
Just couldnt do it
Financial reasons
Other people came through
Too far along
Had been exploring options
Wanted more time to think
Logistics

53
18
12
9
6
6
3

6
2
1
1
1
1
<1

Closed-ended
Changed mind
Cost of the procedure
Others opposed the abortion
Needed to keep appointment secret from family
Needed to keep appointment secret from employer
Had to get partner or family member to help with logistics
No insurance/problems with coverage
Still deciding about the abortion
Difficulty finding time
Needed to keep appointment secret from partner
Travel costs
Difficulty arranging child care
Difficulty getting time off from work or school
Did not know where to go
Difficulty figuring out how to get to the clinic
Difficulty finding a doctor who would do the abortion this far along
Difficulty arranging care for an elder or other family member
Other

71
47
38
38
26
24
24
15
15
14
12
12
9
6
6
3
3
6

8
5
4
5
3
3
3
2
2
2
1
1
1
1
1
<1
<1
1

Child care, transportation, cost or something else.

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TABLE 4. Difficulties of the waiting period and of the twovisit requirement most commonly cited as the hardest
parts, and percentage of women completing follow-up who
reported them
Difficulty

Waiting period
Wanting the abortion to be over with
Gestational age
Feeling sure about the decision
Feeling nervous about the procedure
Questioning the decision
Feeling physically sick
Feeling frustrated
Scheduling the appointment
Dwelling on the decision
Missing work

22
11
10
9
8
7
6
6
6
6

Two visits
Taking time off from work
Distance to the clinic
Time
Scheduling the appointment
Arranging child care
Cost
Waiting
Travel costs
Travel arrangements
Friend/companion logistics

22
16
13
8
7
6
6
6
5
5

Women who had an abortion waited about eight days

between the information visit and the abortion (mean, 8.8;
median, 8; mode, 8). The four most common reasons for waiting more than 72 hours were appointment availability (48%),
the womans own logistics (19%), the need to make financial
arrangements (9%) and the need for more time to think (6%).

Hardest Part
The most common difficulty women had with waiting
was wanting the abortion to be over with (reported by
22% of those completing follow-up interviewsTable 4).
Women reporting this difficulty expressed knowing what
they wanted to do, but feeling that they could not move on
until they had the abortion. For example, in the words of a
22-year-old nulliparous woman:
I had to wait like a week and a half. That was killing me.
Im a person that wants to get everything over and done
with once Ive made a decision, so that was hard. I wanted
it over and done with to move on with my life.
For some, wanting it to be over with was expressed
as frustration at being powerless to implement their decision. An 18-year-od nulliparous women, for example, said,
Knowing that I had to wait after deciding what I wanted to
do and not having control over my own life and my body
made me mad.
Three of the 10 most difficult aspects of waiting focused on
the abortion decision: feeling sure about it (reported by 10%
of women); questioning it (8%); and dwelling on it, without
necessarily expressing certainty or uncertainty (6%).
Nervousness about the procedure also was common
(reported by 9% of women). A 39-year-old, who had had
four births, responded, Just stress of how the procedure
is going to go because you just want to get it over with. I
couldnt sleep for three nights.

For some, nervousness related to advancing gestation,

as they feared being too far along for a medication abortion. For example, a 25-year-old nulliparous participant
reported, I was just anxious to go in for the procedure. I
was more nervous that I was maybe more than nine weeks
along and that I would have to have the surgery. For others, advancing gestation created concern that the fetus was
getting bigger, that they were developing an attachment to
it, that they would be beyond their comfort zone for having
an abortion and that costs would increase. A 22-year-old,
who had given birth once, responded that it was difficult
just being ready to do it and still having the baby grow
while youre trying to wait.When you want to do it,
you dont want to wait for it to develop even more. And a
36-year-old, who also had had one birth, said:
I knew the longer it took, the more money it would
cost.We are living paycheck to paycheck as it is, and if
I [had] gone one week sooner, it would have been $100
less.
Other reported difficulties (mentioned by 67% of
women) were feeling physically sick, with ongoing nausea
and other pregnancy symptoms, and logistical challenges.
Almost all of the top 10 hardest parts of having to make
two visits related to logistics and associated costs. Most
common (reported by 22% of women) was having to miss
work, but women also mentioned difficulties with travel
(logistics, cost, distance and the need to arrange for other
people to travel with them), with scheduling the appointment and arranging child care, and with the time required.
The comments of a 30-year-old mother of three, who lived
in Idaho, reflected many of these difficulties:
Financially it was just hard. Its hard to take time away
from things I could be doing. It made it inconvenient. I
could have stayed in Utah in between, but I have three
children, so I couldnt stay there. I had to make the trip,
come back home and do the regular stuff, and then plan
another trip.

Additional Analyses
In our attrition analyses, only gestational age at which pregnancy was discovered was associated with loss to followup; those lost to follow-up reported slightly later discovery
than others (mean, 5.3 vs. 5.9 weeks). In the first sensitivity analysis, we estimate that 72% of all participants had
an abortion. In the second one, which takes into account
that some women may have had abortions at sites other
than the study facilities, we estimate that 89% of the 500
participants had an abortion.
DISCUSSION
Overall, Utahs 72-hour waiting period and two-visit
requirement did not prevent women who presented for
information visits at the study facilities from having abortions, but did burden women with financial costs, logistical
hassles and extended periods of dwelling on decisions they
had already made. They also led some women to worry
that they may not be able to have the type of abortion they
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preferred and pushed at least one woman beyond her facilitys gestational limit for abortion.
Our findings raise questions about some aspects of
advocacy arguments and are consistent with others. For
example, although some advocates argue that logistical difficulties presented by two-visit requirements and waiting
periods make women unable to have abortions,2 this was
not the case in our study cohort. However, we did find that
having to make two visits created logistical and financial
difficulties, including increasing the cost of having an abortion by about 10%. We also confirmed findings from other
studies indicating that women had difficulty finding money
for their abortions.23 While we do not know for sure, the
increased costs associated with having to make two visits
may have exacerbated existing challenges women face in
paying for abortion in a state where Medicaid coverage for
abortion is available only in limited circumstances,24 as is
the case in Utah and 32 other states.25
We also found that the waiting period, though mandated
at 72 hours, actually turned into more than a week. For
women at early gestations and without pregnancy symptoms, the wait did not appear to have had tangible effects,
although it led to prolonged nervousness about the procedure and forced attention to a decision they had already
made and were ready to implement. For women who
preferred medication abortion and women further along
in their pregnancies, though, the wait potentially contributed to their not being able to have their preferred type of
abortion and incurring extra costs. In one case, the waiting
period pushed a woman past her personal comfort point;
in another, it pushed a woman beyond her facilitys gestational limit for abortion.
Other advocates argue that waiting periods are needed
to give women time to change their minds.2628 Eight percent of women reported changing their minds. We note
that a change of mind may best describe only those who
indicated at the information visit that they preferred having
an abortion and were not conflicted about their decision,
and who then decided to continue their pregnancies. Some
women who reported changing their minds were conflicted
at the information visit. The fact that women were generally not changing their minds in the narrower sense is confirmed by multivariable analyses that found that baseline
decisional conflict was strongly associated with having an
abortion, as has been found elsewhere.10 Our estimate of
2% changing their minds from unconflicted at the information visit to continuing the pregnancy is in the range of the
proportions found changing their minds (13%) in settings
with no or minimal waiting periods.1,10,12 It therefore seems
that requiring women to wait 72 hours may not affect the
proportion changing their minds, although more research
should be done using methods that allow for direct comparisons of the proportions of women who change their
minds under varying waiting periods.
To be clear, one side of the advocacy discourse ignores
the few who are conflicted when they present for abortion
care and then continue their pregnancies, and assumes

that only financial and logistical barriers prevent women

from having abortions. The other side assumes that most
women are conflicted and need extra protection to make
a decision. Neither is the case. Rather, our data confirm
findings from other studies indicating that the vast majority of women have made a decision when they present for
abortion and that most who present have an abortion.1012
Our estimate of the proportion of women with some or
a high level of conflict is higher than those in some other
studies of abortion patients.10,11 One possible explanation is
that some women who presented for the information visit
were just exploring options at that time. Another possibility, which should be examined in future research, is that
conflict among women presenting for care varies across
states, because of factors such as policy environment and
abortion attitudes. We note that only a small minority of
women (8%) had levels of decisional conflict that correspond to a clinical level of concern,19 and this proportion
is close to estimates of the proportions reporting less than
high certainty in other studies of abortion patients.10,11 If
further research continues to confirm that only a minority are conflicted, it would seem more appropriate to use
individualized patient education and counseling to assist
those who are conflictedan approach that providers at
many facilities already take11than to resort to a blunt policy instrument like a law that requires all women seeking
abortion care to face additional logistical hassles and costs.

Limitations and Strengths

Some limitations are worth noting. First, we collected data
only after the 72-hour waiting period went into effect. Thus,
we are unable to make comparisons with experiences under
Utahs earlier 24-hour waiting period. Second, because only
a small number of women were still pregnant at followup, we could consider only a small number of measures in
multivariable analyses. Third, while our response rate was
very good, our follow-up rate was lower than we had hoped
(although it was within the range seen in other longitudinal
abortion studies).29 Our overall proportion who had had
an abortion at follow-up was within the range of statewide
estimates of those having an abortion after presenting for
an information visit in Utah during this same time period,30
and sensitivity analyses provide upper and lower bounds for
our estimate. We note that only one variable we examined
(gestational age at which pregnancy was discovered) was
associated with loss to follow-up; our multivariable model
indicated that earlier discovery of pregnancy was associated
with not having an abortion. That those lost to follow-up
discovered pregnancy later suggests that more of them may
have had an abortion. A greater proportion of those lost to
follow-up having an abortion would be consistent with the
estimate from our second sensitivity analysis and on the
higher end of the 95% confidence interval in our main analysis. Those further along among women lost to follow-up
could also have been less likely to have an abortion because
they decided they were too far along or could not find a provider. Fourth, this study was conducted in Utah, a state with

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Utahs Waiting Period for Abortion

a large Mormon, primarily white population. Also, other

states, such as South Dakota,5 require women to have the
information visit with the same physician who will provide
the abortion, thus, in practice, likely limiting the visit to the
same facility where they have the abortion. Consequently,
laws such as South Dakotas could impose greater travel and
financial burdens than those found in our study.
This study also has strengths. First, it contributes to
understanding womens experiences with new, harsher
abortion restrictions. Second, by recruiting women when
they presented for an information visit and then following up with all participants, we were able to identify and
interview women who did not have abortions after seeking them. Rather than speculating about how restrictions
affect womenespecially women who do not have abortionswe have womens own descriptions of these experiences. Third, by collecting data at two time points, we
prospectively examined how variables that preexisted the
information visit contributed to womens experiences. Had
we surveyed women only at follow-up, their retrospective
responses may have been biased by what they had ended
up doing. Fourth, we included both closed- and openended responses, and found that the open-ended responses
added important nuance to the close-ended ones.

Conclusion
As most women in this cohort were not conflicted about
their decision when they sought care, the 72-hour waiting requirement seems to have been unnecessary.
Individualized patient counseling for the small minority
who were conflicted when they presented for care may
have been more appropriate.
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Acknowledgments
This study was funded by an anonymous foundation. The sponsor
had no involvement in study design; in the collection, analysis or
interpretation of data; in the writing of the report; or in the decision
to submit the article for publication. The authors thank Rana Barar,
Mattie Boehler-Tatman, Ivette Gomez, Heather Gould, Sandi Ma,
Brenly Rowland, Danielle Sinkford and Alejandra Vargas-Johnson
for research and project assistance, and the facilities in Utah for
their collaboration.

Author contact: Sarah.Roberts@ucsf.edu

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