Impact of State-Level Reproductive Health Legislation on Access to and Use of Reproductive Health Services and Reproductive Health Outcomes: A Systematic Scoping Review in the Affordable Care Act Era

Womens Health Issues. 2021 Mar-Apr;31(2):114-121. doi: 10.1016/j.whi.2020.11.005. Epub 2020 Dec 7.


Introduction: We systematically reviewed the literature to understand the associations between state-level reproductive health policies and reproductive health care outcomes and describe policy impacts on reproductive health outcomes among women aged 18 and older. We focused on research conducted after the implementation of the Patient Protection and Affordable Care Act to understand the influence of state-level policies in the context of existing federal policy.

Methods: Standard search terms were used to search PubMed for studies published between March 10, 2010, and August 31, 2019. Studies were included that reflected original U.S.-based research testing associations between state-level policies (i.e., laws related to family planning, maternity care, and abortion) and reproductive health outcomes related to those services (e.g., prenatal care use) among adults. Reference lists of systematic reviews were searched to improve the identification of relevant studies. Studies were excluded if they were reviews, qualitative or mixed-methods studies, or descriptive studies, or if a state was not the unit of analysis. After dual review, agreement on inclusion of studies was 100%.

Results: Search results returned 1,529 articles; 56 (3.59%) met the inclusion criteria for a full review based on title and abstract review. After dual independent review, eight were selected for inclusion. Two included all 50 states and Washington, DC; one included Oregon and Washington; and the remaining studies included single states (Texas, Arizona, Ohio, and Utah). One-half of the studies (n = 4) focused solely on restrictive abortion legislation. Restricting access to family planning and abortion services (e.g., mandatory waiting periods) were associated with negative outcomes (e.g., additional interventions for medication abortion). Expanding maternity care through Medicaid reform and autonomous midwifery laws were associated with positive outcomes (e.g., prenatal care use).

Conclusions: Our review identified eight studies that were largely focused on only one key aspect of reproductive health policy. Findings suggest that state-level legislation could have considerable impact on the reproductive health care that women have access to and receive, as well as the related outcomes. Research in this area remains limited. Rigorous evaluations of the relationship between the breadth of reproductive health policies and related health outcomes are needed, as is an exploration of barriers to the conduct of this type of research.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.
  • Systematic Review

MeSH terms

  • Adolescent
  • Adult
  • Arizona
  • Female
  • Humans
  • Maternal Health Services*
  • Oregon
  • Patient Protection and Affordable Care Act
  • Pregnancy
  • Reproductive Health
  • Reproductive Health Services*
  • Texas
  • United States
  • Utah