Evaluating the impact of a mandatory pre-abortion ultrasound viewing law: A mixed methods study

Abstract

Background: Since mid-2013, Wisconsin abortion providers have been legally required to display and describe pre-abortion ultrasound images. We aimed to understand the impact of this law.

Methods: We used a mixed-methods study design at an abortion facility in Wisconsin. We abstracted data from medical charts one year before the law to one year after and used multivariable models, mediation/moderation analysis, and interrupted time series to assess the impact of the law, viewing, and decision certainty on likelihood of continuing the pregnancy. We conducted in-depth interviews with women in the post-law period about their ultrasound experience and analyzed them using elaborative and modified grounded theory.

Results: A total of 5342 charts were abstracted; 8.7% continued their pregnancies pre-law and 11.2% post-law (p = 0.002). A multivariable model confirmed the law was associated with higher odds of continuing pregnancy (aOR = 1.23, 95% CI: 1.01-1.50). Decision certainty (aOR = 6.39, 95% CI: 4.72-8.64) and having to pay fully out of pocket (aOR = 4.98, 95% CI: 3.86-6.41) were most strongly associated with continuing pregnancy. Ultrasound viewing fully mediated the relationship between the law and continuing pregnancy. Interrupted time series analyses found no significant effect of the law but may have been underpowered to detect such a small effect. Nineteen of twenty-three women interviewed viewed their ultrasound image. Most reported no impact on their abortion decision; five reported a temporary emotional impact or increased certainty about choosing abortion. Two women reported that viewing helped them decide to continue the pregnancy; both also described preexisting decision uncertainty.

Conclusions: This law caused an increase in viewing rates and a statistically significant but small increase in continuing pregnancy rates. However, the majority of women were certain of their abortion decision and the law did not change their decision. Other factors were more significant in women's decision-making, suggesting evaluations of restrictive laws should take account of the broader social environment.

Fig 1. Conceptual model.

Fig 2. Monthly rate of viewing the ultrasound image or receiving printout.

Fig 3. Number of pregnancies by time period, decision certainty, and viewing/picture receipt status and percent of women in each category continuing their pregnancy, n = 5127^A.

^AExcludes 181 women who were not eligible for abortion at the facility and 31 women for whom data on ultrasound viewing or picture receipt was missing.

Fig 4. Adjusted monthly rate of continuing pregnancy, predicted value of segmented regression with covariates.