Racial/ethnic and educational inequities in restrictive abortion policy variation and adverse birth outcomes in the United States

Abstract

Background: To examine racial/ethnic and educational inequities in the relationship between state-level restrictive abortion policies and adverse birth outcomes from 2005 to 2015 in the United States.

Methods: Using a state-level abortion restrictiveness index comprised of 18 restrictive abortion policies, we conducted a retrospective longitudinal analysis examining whether race/ethnicity and education level moderated the relationship between the restrictiveness index and individual-level probabilities of preterm birth (PTB) and low birthweight (LBW). Data were obtained from the 2005-2015 National Center for Health Statistics Period Linked Live Birth-Infant Death Files and analyzed with linear probability models adjusted for individual- and state-level characteristics and state and year fixed-effects.

Results: Among 2,250,000 live births, 269,253 (12.0%) were PTBs and 182,960 (8.1%) were LBW. On average, states had approximately seven restrictive abortion policies enacted from 2005 to 2015. Black individuals experienced increased probability of PTB with additional exposure to restrictive abortion policies compared to non-Black individuals. Similarly, those with less than a college degree experienced increased probability of LBW with additional exposure to restrictive abortion policies compared to college graduates. For all analyses, inequities worsened as state environments grew increasingly restrictive.

Conclusion: Findings demonstrate that Black individuals at all educational levels and those with fewer years of education disproportionately experienced adverse birth outcomes associated with restrictive abortion policies. Restrictive abortion policies may compound existing racial/ethnic, socioeconomic, and intersecting racial/ethnic and socioeconomic perinatal and infant health inequities.

Keywords: Abortion; Adverse birth outcomes; Education; Health disparities; Health inequities; Health policy; Health services research; Race/ethnicity; Reproductive health services; US state laws.

Fig. 1

Predictive Margins and Average Marginal Effects of Racial/Ethnic (Dichotomous) Inequities in Relationship between Restrictiveness Index and Preterm Birth. Note: Results are predictive margins and average marginal effects from multivariate linear probability models estimating the moderating effect of race/ethnicity (dichotomous) on the relationship between the standardized lagged restrictiveness index and the probability of preterm birth among all 50 states and Washington, D.C. Final sample size included people not missing any data on race/ethnicity, restrictiveness index, preterm birth, and covariates. All models adjust for individual-level sociodemographic characteristics, state-level sociodemographic, economic, and political characteristics, and state and year fixed effects. Standard errors clustered at the state level

Fig. 2

Predictive Margins and Average Marginal Effects of Educational Inequities in Relationship between Restrictiveness Index and Low Birthweight. Note: Results are predictive margins and average marginal effects from multivariate linear probability models estimating the moderating effect of education level on the relationship between the standardized lagged restrictiveness index and the probability of low birthweight among all 50 states and Washington, D.C. Final sample size included people not missing any data on education level, restrictiveness index, low birthweight, and covariates. All models adjust for individual-level sociodemographic characteristics, state-level sociodemographic, economic, and political characteristics, and state and year fixed effects. Standard errors clustered at the state level