How Ohio's proposed abortion bans would impact travel distance to access abortion care

Abstract Context Since March 2021, the Ohio legislature has been actively considering laws that would ban abortion if the United States Supreme Court overturns the Roe v. Wade decision that legalized abortion nationally in 1973. Methods We used a national database of publicly advertised abortion facilities to calculate driving distances for Ohioans before and after the activation of proposed abortion bans. Using a legal analysis of abortion laws following the overturn of Roe, we determined which states surrounding Ohio would continue providing abortion care. We calculated distances from each Ohio county centroid to the nearest open abortion facility in three scenarios: (1) as of February 2022, (2) the best‐case post‐Roe scenario (two of the five surrounding states continue to offer abortion care), and (3) worst‐case post‐Roe scenario (no surrounding states continue to offer abortion care). We calculated population‐weighted distances using county‐level data about women aged 15–44 years from the 2019 American Community Survey. Results In February 2022, all Ohio county centroids were at most 99 miles from an abortion facility (median = 50 miles). The best‐case post‐Roe scenario shows 62 of Ohio's 88 counties to be 115–279 miles away from the nearest facility (median = 146). The worst‐case shows 85 counties to be 191–339 miles away from the nearest facility (median = 264). The current average population‐weighted driving distance from county centroid to the nearest facility is 26 miles; the post‐Roe scenarios would increase this to 157 miles (best‐case) or 269 miles (worst‐case). Conclusions Ohio's proposed abortion bans would substantially increase travel distances to abortion care, impacting over 2.2 million reproductive‐aged Ohioans.


INTRODUCTION
The Supreme Court of the United States (US) first recognized the constitutional right to abortion in the 1973 case Roe v. Wade (commonly referred to as Roe). This landmark decision prohibited states from banning abortion prior the third trimester of pregnancy; after this point, 1992, Planned Parenthood v. Casey asked the US Supreme Court to decide the constitutionality of state restrictions on abortion throughout pregnancy, including in the first trimester. 1 The US Supreme Court ruled to protect the essence of Roe, that is, uphold the individual right to abortion, but to allow a number of state restrictions. 1 Specifically, states could regulate abortion before viability (approximately 24 weeks gestation) so long as the regulation in question did not place an "undue burden…in the path of a woman seeking an abortion." 1,2 Once the US Supreme Court established the right to abortion, as well as how states could regulate the practice, many states began passing laws to restrict the circumstances under which people could obtain abortion care. These state-level restrictions directly affected abortion seekers (e.g., restricting use of public insurance to pay for abortions, enacting mandatory waiting periods) and specifically targeted abortion providers (e.g., requiring clinics to establish medically unnecessary agreements with hospitals to transfer patients or to comply with medically unnecessary building requirements). The current accessibility of abortion in the United States thus varies by state and is characterized by a patchwork of service availability resulting in vast abortion deserts, or large geographic areas where abortion is unavailable. 3 The implementation of existing abortion restrictions has coincided with facility closures, increased wait times, and differences in care offerings, [4][5][6][7][8][9] creating barriers to care, including long travel distances for abortion seekers. Current estimates of interstate travel suggest between 6% and 7% of patients already cross state lines to receive abortion care. [10][11][12] The consequences of longer travel distance for abortion care are well established, including increased costs, 5,13 delays to care, 14,15 inability to receive one's preferred method of care, 16 and increased stress. 15 In this way, increased travel for abortion care creates unnecessary barriers to health care. 10,17 Such barriers are sometimes insurmountable and lead to undesired continued pregnancies. Additionally, they are inequitably experienced, 10,18,19 adding to the increased health inequities experienced generally by people with fewer financial resources and people of color. 20 In addition to state laws determining how abortion care is provided, states have passed laws banning abortion, including pre-Roe, pre-viability, pregnancy duration, method, reason, and trigger bans. 21 Pre-Roe bans are abortion laws that were established prior to 1972 and became unenforceable after the ruling in Roe, yet remain on the books. Pre-viability bans attempt to prohibit abortion before a fetus is considered viable. Pregnancy duration bans, which seek to bar abortion after a certain point in a pregnancy (e.g., 6-week, 12-week, or 20-week bans) or after the detection of specific embryonic or fetal development markers (e.g., "heartbeat" bans), are common. Method bans proscribe certain abortion procedures, such as dilation and extraction (D&X) or dilation and evacuation (D&E). Reason bans disallow abortions sought for specific reasons, such as the presence of genetic anomalies, or because of presumptive sex or race. In addition, a number of states have passed "trigger bans," that is complete or severe bans on abortion that are contingent on and would be "triggered" by the US Supreme Court overturning or weakening Roe. As of February 2022, 12 states had passed laws that would prohibit abortion throughout pregnancy if Roe falls: Arkansas, Idaho, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, and Utah. 21 Trigger laws and other types of outright bans would be enforceable only if Roe is overturned; providers in states with such laws would no longer be able to offer abortion care. Residents of these states seeking an abortion would need to travel across state lines for care within the formal health system. While many ban types are currently considered unconstitutional, the US Supreme Court will soon issue a decision in Dobbs v. Jackson Women's Health Organization that could significantly change the legal abortion landscape. Indeed, some legal analysts expect that the US Supreme Court will either overrule or severely curtail Roe. 22,23 The consequences of such a ruling could allow the reconsideration and enactment of state abortion bans that are currently considered unconstitutional and could have profound impacts on abortion access, amplifying challenges experienced by abortion seekers and increasing the negative health, financial, and social outcomes associated with being denied a wanted abortion. [24][25][26][27][28][29] Ohio is considering multiple options for severely restricting abortion

Setting
Ohio is a state located in the Midwestern region of the US, bordered by Indiana, Kentucky, West Virginia, Pennsylvania, Michigan, and Lake Erie. It has the seventh highest population among US states, at about 11.8 million people. 32 Ohio has a highly restrictive abortion policy climate. As of February 2022, some of Ohio's abortion restrictions included an in-person facility visit followed by a 24-h waiting period, a 22-week gestational limit, limits on use of public health insurance for abortion, a reason ban for fetal diagnosis or indication of Down syndrome, parental consent and judicial bypass requirements, and written transfer agreement requirements for abortion facilities. 33,34 Ohio lawmakers also passed a six-week gestation ban, which is currently blocked by the federal court, but could go into effect in a post-Roe scenario. SB 123/HB 598 and/or HB 480 would threaten abortion access in Ohio further. Most of Ohio's neighboring states have multiple abortion restrictions and generally hostile abortion policy climates. 35

Analytic approach
To calculate one-way driving distance before and after enactment of SB 123/HB 598 and/or HB 480, we used Advancing New Standards in For all three scenarios, we calculated an average populationweighted distance for the state of Ohio using the following equation: where PWD Ohio is the population-weighted distance for Ohio, P i is the number of cisgender women of reproductive age (15-44 years old) in county i, P Ohio is the number of cisgender women aged 15-44 years in Ohio, and d i is the driving distance from county centroid to the nearest abortion facility for county i. We obtained the number of women aged 15-44 years for each county using 5-year estimates from the 2019 American Community Survey. 39 We also calculated population-  Across all Ohio counties, the current average population-weighted oneway driving distance from county centroid to the nearest facility is 26 miles (see Table 1). If Roe falls and an Ohio abortion ban is enacted, the average population-weighted one-way driving distance from county centroid to the

DISCUSSION
If an abortion ban in Ohio were to go into effect, Ohioans will have to go out-of-state for facility-based abortion care, resulting in huge increases in travel distance. The median one-way driving distance from county centroid to facility would rise from 50 to 146 miles, or 264 miles depending on accessibility in Michigan and Pennsylvania, in a post-Roe scenario.
With population-weighted averages, we evaluated the combination of distance and the number of people who would be impacted, and we found that the impact of pre-to post-Roe change is even greater when the geographic distribution of women of reproductive age is taken into account. The post-Roe population-weighted one-way driving distance would increase from 26 to 157 miles (best case) or 269 miles (worst case), parking, and an overnight stay where the abortion will take place, increasing costs associated with seeking abortions.
In addition to more costs, delays, and reduced care options, increased barriers to abortion access will inevitably result in some people to not be able to obtain their desired abortion, as increased distance to abortion care creates barriers for people seeking care 5,13-16 and is associated with lower rates of utilization. 44 These barriers disproportionally affect people from lower socioeconomic backgrounds and people of color. 10,18,19 Denial of a wanted abortion can cause severe negative consequences for the pregnant person, such as increase in short-term anxiety, stress, and low self-esteem 25 ; poorer physical health 24,26 ; economic insecurity 27,28 ; and greater exposure to violence from an intimate partner. 29 Actual travel distances could be greater than our estimates for many people-particularly for residents of rural counties, who may have to travel even farther to reach the nearest highway-because our analysis computed driving distances for each county starting in the county centroid. We note several additional burdens not captured in our analysis of increases in distance to travel. First, many patients do not have access to their own vehicles; relying on public transportation for longer distances would take far more time and be more logistically complicated. Second, abortion facilities do not all have the same gestational limits nor provide the same services, 45 so distance traveled by people who have specific parameters for care may be far greater. Third, we include facilities that do not provide instrumentation abortions in these analyses, which may underestimate how far people in need of this method, or receiving care at later gestations, must travel. Fourth, we cannot account for the fact that people might also choose to travel further than the first available facility for abortion care. 46 Finally, in a post-Roe scenario, abortion facilities in states where abortion will remain accessible will likely experience an influx of patients traveling from states where abortion is banned, leading to facility congestion. 47 Thus, open abortion facilities may not be able to handle the increase in patient demand and wait times may be longer than usual. 48,49 The resulting expanded wait times may preclude some people from obtaining care within the gestational limit of the facility.
An abortion ban would substantially increase driving distance to obtain abortion services for most Ohioans, forcing them to travel across state lines to access abortion care. Many Ohioans, especially those living in rural areas, already experience the substantial consequences of long travel distances for abortion care. 10,38 Our projections suggest that SB 123/HB 598 and/or HB 480 would force all Ohioans into this reality, one which compounds the burden for those who already experience the most inequities in access to healthcare.

ACKNOWLEDGMENT
This study was funded by a philanthropic foundation that makes grants anonymously.