Evaluating the Impact of a Mandatory Pre-Abortion Ultrasound Viewing Law: A Mixed Methods Study

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 a 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. 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 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.

研究背景：2013年中期起，美国威斯康星州强制要求堕胎服务提供者展示并讲解堕胎术前超声影像。本研究旨在评估该法案的实际影响。
研究方法：本研究采用混合研究设计，在威斯康星州一家堕胎医疗机构开展。我们提取了该法案实施前后各一年的病历数据，运用多变量模型、中介/调节分析以及间断时间序列分析，评估该法案、超声影像观看情况与决策确定性对患者继续妊娠概率的影响。此外，我们在法案实施后对女性患者开展深度访谈，围绕其超声影像体验进行调研，并采用改良型详尽扎根理论对访谈资料进行编码分析。
研究结果：本研究共纳入5342份病历数据。法案实施前，8.7%的患者选择继续妊娠，法案实施后该比例升至11.2%（p=0.002）。多变量模型分析显示，该法案与患者继续妊娠的更高校正比值比相关（aOR=1.23，95%置信区间CI: 1.01~1.50）。决策确定性（aOR=6.39，95% CI: 4.72~8.64）与全额自费支付（aOR=4.98，95% CI: 3.86~6.41）是与患者选择继续妊娠相关性最强的因素。超声影像观看行为完全介导了该法案与继续妊娠之间的关联。间断时间序列分析未发现该法案存在显著效应，但可能因统计效力不足，无法检出此类微弱影响。在接受访谈的23名女性中，有19名观看了超声影像。多数受访者表示超声影像未对其堕胎决策产生影响；5名受访者称其仅受到短暂情绪影响，或是更加坚定了选择堕胎的决心。另有2名受访者表示，观看超声影像帮助其决定继续妊娠，两人均提及此前存在决策不确定性。
研究结论：该法案提升了超声影像观看率，同时使继续妊娠率出现了具有统计学意义但幅度较小的增长。然而，绝大多数女性在术前已明确自身的堕胎决策，该法案并未改变她们的选择。其他因素对患者决策的影响更为显著，这提示针对限制性堕胎法案的评估应将更广泛的社会环境纳入考量范畴。