The Impact of Insurance Status and State-of-Residence on Abortion Decision-Making in Spina Bifida

Insurance coverage for abortion varies by state, and fetal centers often care for patients traveling from out-of-state. How insurance status and state-of-residence impact pregnancy decision-making for spina bifida remains unclear. We evaluated whether insurance payor and state-of-residence are associated with consideration and subsequent completion of abortion among patients with spina bifida.

We conducted a retrospective study of singletons with spina bifida at a fetal center. Exposures were residence (in-state vs. out-of-state) and insurance (governmental vs. private). Because state laws influence abortion coverage, the exposure was modeled as an interaction term. Primary outcomes were abortion consideration and completion. Abortion consideration was determined by a nurse intake coordinator. Before presentation at our fetal center, patients were asked whether they were considering abortion. If they answered "yes" or "maybe," then the patient was classified as considering abortion.

Among 149 patients (63.7% in-state; 72.5% private insurance), 127 had complete decision-making data, with 40.2% (51/127) considering abortion and 27.6% (35/127) completing abortion. Governmental insured patients were more likely to reside in-state than privately insured. Insurance had no association with abortion intent or completion. However, when the interaction term was introduced, in-state residents with private insurance had higher risk of abortion consideration (relative risk [RR] = 2.17, 95% confidence interval [CI]: 1.02-4.60) but not completion (RR = 1.94, 95% CI: 0.86-4.40) versus out-of-state private insurance patients. In a sub-analysis, abortion consideration and completion did not differ pre- vs. post-2019 Illinois Reproductive Health Act.

Abortion consideration for spina bifida is associated with insurance status and state-of-residence. Fetal care centers that serve regions of the country should be aware of the sociopolitical and economic differences of their patient catchment. Further evaluation of state-specific restrictions on insurance coverage for abortion care may elucidate barriers to the spectrum of spina bifida management options.

· Abortion consideration is associated with joint modeling of state-of-residence and insurance status.. · Insurance payor among those who considered and completed abortion was not altered by the Illinois Reproductive Health Act (RHA).. · Counseling for spina bifida should include considerations for insurance status and state-of-residence..