The Challenges in Measurement for Abortion Access and Use in Research Post-Dobbs

In June 2022, the Supreme Court dramatically altered the nature of abortion law in the United States. Dobbs v. Jackson Women's Health Organization reversed 50 years of national legal protection, allowing states to criminalize abortion care, partially or fully. Since that time, many scholars have expressed interest in understanding the impact of that change on some aspect of society: medicine, demography, economics, law, public opinion, voting, culture, etc. Readers of this journal, however, are likely interested in the impact of the Dobbs ruling on health. This interest is merited, given the lasting impact this legal change may have on the lives of women, and other people with the capacity for pregnancy, generally and marginalized populations specifically. However, before rushing into research on impact, there is a more foundational need that must be addressed: such research requires new approaches to measuring abortion access and use, concepts that are often referenced but rarely defined with the context and nuance needed to understand their meaning. Since the 1970s, definitions of abortion access have been centered on the abortion provider and constraints on clinical practice, rather than the pregnant person. A clear example of this lens is access as measured via the percentage of women living in a county without an abortion provider (Finer and Henshaw, 2003Finer L.B. Henshaw S.K. Abortion incidence and services in the United States in 2000.Perspectives on Sexual and Reproductive Health. 2003; 35: 6-15Crossref PubMed Google Scholar; Henshaw, 1998Henshaw S.K. Abortion incidence and services in the United States, 1995-1996.Family Planning Perspectives. 1998; 30: 263-287Crossref PubMed Scopus (92) Google Scholar; Henshaw et al., 1984Henshaw S.K. Forrest J.D. Blaine E. Abortion services in the United States, 1981 and 1982.Family Planning Perspectives. 1984; 16: 119-127Crossref PubMed Scopus (24) Google Scholar; Henshaw and Van Vort, 1990Henshaw S.K. Van Vort J. Abortion services in the United States, 1987 and 1988.Family Planning Perspectives. 1990; 22: 102-142Crossref PubMed Scopus (46) Google Scholar; Jones and Jerman, 2014Jones R.K. Jerman J. Abortion incidence and service availability in the United States, 2011.Perspectives on Sexual and Reproductive Health. 2014; 46: 3-14Crossref PubMed Scopus (231) Google Scholar; Jones et al., 2022Jones R.K. Kirstein M. Philbin J. Abortion incidence and service availability in the United States, 2020.Perspectives on Sexual and Reproductive Health. 2022; 54: 128-141Crossref PubMed Scopus (16) Google Scholar; Jones and Kooistra, 2011Jones R.K. Kooistra K. Abortion incidence and access to services in the United States, 2008.Perspectives on Sexual and Reproductive Health. 2011; 43: 41-50Crossref PubMed Scopus (245) Google Scholar; Weinstock et al., 1976Weinstock E. Tietze C. Jaffe F.S. Dryfoos J.G. Abortion need and services in the United States, 1974-1975.Family Planning Perspectives. 1976; 8: 58-69Crossref PubMed Google Scholar). Such approaches remain largely unchallenged, save the call for more geographic precision (Seymour et al., 2022Seymour J.W. Milechin D. Upadhyay U.D. Wise L.A. Rudolph A.E. Improving our estimates: assessing misclassification of abortion accessibility in the United States.Annals of Epidemiology. 2022; 76: 98-107Crossref PubMed Scopus (1) Google Scholar). Secondary measures of service delivery—gestational age limits, cost, times of operation, and harassment—are also measured at the level of the abortion provider (Jerman and Jones, 2014Jerman J. Jones R.K. Secondary measures of access to abortion services in the United States, 2011 and 2012: gestational age limits, cost, and harassment.Women's Health Issues. 2014; 24: e419-e424Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar; McGowan et al., 2020McGowan M.L. Norris A.H. Bessett D. Care churn — why keeping clinic doors open isn’t enough to ensure access to abortion.New England Journal of Medicine. 2020; 383: 508-510Crossref PubMed Scopus (26) Google Scholar). Indeed, proximity to an abortion-providing facility is also used to predict an abortion rate for a community (Myers, 2021Myers C.K. Measuring the burden: The effect of travel distance on abortions and births. IZA Discussion Papers(14556).https://www.econstor.eu/bitstream/10419/245607/1/dp14556.pdfDate: 2021Date accessed: March 23, 2023Google Scholar). Before Dobbs, provider proximity was used to estimate the anticipated impact of potential and enacted abortion restrictions on abortion use (Chakraborty et al., 2022Chakraborty P. Murawsky S. Smith M.H. McGowan M.L. Norris A.H. Bessett D. How Ohio's proposed abortion bans would impact travel distance to access abortion care.Perspectives on Sexual and Reproductive Health. 2022; 54: 54-63Crossref PubMed Scopus (6) Google Scholar; Myers et al., 2019Myers C. Jones R. Upadhyay U. Predicted changes in abortion access and incidence in a post-Roe world.Contraception. 2019; 100: 367-373Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar). And even today, miles needed to travel dominates the headlines of the impact of abortion restrictions (Rader et al., 2022Rader B. Upadhyay U.D. Sehgal N.K. Reis B.Y. Brownstein J.S. Hswen Y. Estimated travel time and spatial access to abortion facilities in the US before and after the Dobbs v Jackson Women's Health decision.JAMA. 2022; 328: 2041-2047Crossref PubMed Scopus (14) Google Scholar). This approach, while useful, reinforces the primacy of abortion providers over the agency of the person seeking to end a pregnancy. It also flattens the discussion of abortion access and is markedly out of step with changes in abortion service delivery. Abortions are available in other ways besides traveling to a brick-and-mortar facility. Beginning in July 2020, prompted by the public health emergency and formally codified via a careful review of new evidence, the Food and Drug Administration (FDA) removed the in-person dispensing requirements for mifepristone. Although aspects of telehealth had been integrated into abortion service delivery for years prior, the ability to deliver medications via mail accelerated the provision of medication abortion through telehealth services, which are now legally allowed in 25 states and the District of Columbia (KFF, 2023KFF (The Henry J. Kaiser Family Foundation)The availability and use of medication abortion.https://www.kff.org/womens-health-policy/fact-sheet/the-availability-and-use-of-medication-abortion/Date: 2023Date accessed: April 30, 2023Google Scholar). According to the most recent data on abortion provision, telehealth medication abortion services offered from businesses that only offer that care and do not also have a brick-and-mortar facility comprised 9% of all abortions provided since the Dobbs decision (We Count, 2023We Count#WeCount report April 2022 to December 2022.https://www.societyfp.org/wp-content/uploads/2023/03/WeCountReport_April2023Release.pdfDate: 2023Date accessed: May 1, 2023Google Scholar). Medication abortion is also available to a limited extent even in states where it is technically prohibited. Residents with some internet sophistication may use the mail-forwarding option, in which they claim to be in a state where abortion is legal and have medications mailed to that location and then rerouted to them in the banned location. This option is promoted through an advertising campaign by the organization mayday.health. Another common way for obtaining abortion pills is via the international telehealth medication abortion service known as Aid Access. A study of requests to the service following the Dobbs decision suggests a significant increase in awareness of this route to care across all U.S. states (Aiken et al., 2022Aiken A.R. Starling J.E. Scott J.G. Gomperts R. Requests for self-managed medication abortion provided using online telemedicine in 30 US states before and after the Dobbs v Jackson Women’s Health Organization decision.JAMA. 2022; 328: 1768-1770Crossref PubMed Scopus (15) Google Scholar). The media has widely covered the website Plan C (see https://www.plancpills.org/media-categories/press), where people can find international vendors from whom they can purchase abortion drugs directly. In addition, networks of activists are providing abortion pills as well as information and support to help people self-manage their abortions, building from international community distribution models (Kitchener, 2022Kitchener C. Covert network provides pills for thousands of abortions in U.S. post Roe. The Washington Post.https://www.washingtonpost.com/politics/2022/10/18/illegal-abortion-pill-network/Date: 2022Date accessed: May 1, 2023Google Scholar; Kitroeff, 2021Kitroeff N. Mexico, activists plan to help women in U.S. get abortions. The New York Times, New York City, NY2021: A8Google Scholar). Journalistic accounts of these practices suggest that these options collectively are supporting a large number of people in states where abortions are banned or heavily restricted (McCann, 2023McCann A. Inside the online market for overseas abortion pills. The New York Times, New York City, NY2023https://www.nytimes.com/interactive/2023/04/13/us/abortion-pill-order-online-mifepristone.htmlDate accessed: May 1, 2023Google Scholar). In addition to changes in how care is provided, measuring access predominantly as proximity to a clinic ignores the well-documented, significant role cost of and payment for abortion plays in abortion access. Perhaps the most consistent finding in research with people seeking abortion care in the United States is the preeminence of raising money as a barrier to care and a psychological stressor (Dennis et al., 2014Dennis A. Manski R. Blanchard K. Does Medicaid coverage matter?: a qualitative multi-state study of abortion affordability for low-income women.Journal of Health Care for the Poor and Underserved. 2014; 25: 1571-1585Crossref PubMed Scopus (18) Google Scholar; Ely et al., 2017Ely G.E. Hales T. Jackson D.L. Maguin E. Hamilton G. The undue burden of paying for abortion: An exploration of abortion fund cases.Social Work in Health Care. 2017; 56: 99-114Crossref PubMed Scopus (31) Google Scholar; Jones et al., 2013Jones R.K. Upadhyay U.D. Weitz T.A. At what cost? Payment for abortion care by US women.Women's Health Issues. 2013; 23: e173-e178Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar; Moseson et al., 2022Moseson H. Seymour J.W. Zuniga C. Wollum A. Katz A. Thompson T.A. Gerdts C. “It just seemed like a perfect storm”: A multi-methods feasibility study on the use of Facebook, Google Ads, and Reddit to collect data on abortion-seeking experiences from people who considered but did not obtain abortion care in the United States.PLoS One. 2022; 17: e0264748Crossref PubMed Scopus (6) Google Scholar; Roberts et al., 2014Roberts S.C. Gould H. Kimport K. Weitz T.A. Foster D.G. Out-of-pocket costs and insurance coverage for abortion in the United States.Women's Health Issues. 2014; 24: e211-e218Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar; Upadhyay et al., 2017Upadhyay U.D. Kimport K. Belusa E.K.O. Johns N.E. Laube D.W. Roberts S.C.M. Evaluating the impact of a mandatory pre-abortion ultrasound viewing law: a mixed methods study.PLoS One. 2017; 12: e0178871Crossref PubMed Scopus (15) Google Scholar, Upadhyay et al., 2021Upadhyay U.D. McCook A.A. Bennett A.H. Cartwright A.F. Roberts S.C. State abortion policies and Medicaid coverage of abortion are associated with pregnancy outcomes among individuals seeking abortion recruited using Google Ads: A national cohort study.Social Science & Medicine. 2021; 274: 113747Crossref PubMed Scopus (20) Google Scholar). Before the Dobbs decision, three-quarters of all abortion patients were at or below 200% of the federal poverty level, and these individuals were more likely to have public insurance or be uninsured (Jerman et al., 2016Jerman J. Jones R.K. Onda T. Characteristics of US abortion patients in 2014 and changes since 2008. Guttmacher Institute, Issue, New York2016Google Scholar; Jones and Jerman, 2017Jones R.K. Jerman J. Population group abortion rates and lifetime incidence of abortion: United States, 2008–2014.American Journal of Public Health. 2017; 107: 1904-1909Crossref PubMed Scopus (179) Google Scholar). Since 1976, the problematic Hyde Amendment has prohibited federal Medicaid from paying for abortions; although states have the option to provide coverage with state funds, only 16 states do so (Guttmacher Institute, 2023Guttmacher InstituteState funding of abortion under Medicaid [fact sheet] State Laws and Policies, Issue.https://www.guttmacher.org/state-policy/explore/state-funding-abortion-under-medicaidDate: 2023Date accessed: May 1, 2023Google Scholar). As a result, most low-income individuals are required to pay out-of-pocket for abortion care. Studies spanning three decades find that, because of the Hyde Amendment, approximately one-quarter of Medicaid-eligible pregnant people living in states without coverage do not obtain a desired abortion (Henshaw et al., 2009Henshaw S.K. Joyce T.J. Dennis A. Finer L.B. Blanchard K. Restrictions on Medicaid funding for abortions: A literature review. Guttmacher Institute, New York2009Google Scholar; Roberts et al., 2019Roberts S.C. Johns N.E. Williams V. Wingo E. Upadhyay U.D. Estimating the proportion of Medicaid-eligible pregnant women in Louisiana who do not get abortions when Medicaid does not cover abortion.BMC Women's Health. 2019; 19: 1-8Crossref PubMed Scopus (20) Google Scholar). Further, the financial burden presented by other care options is a leading factor in why pregnant people seek care from Aid Access (Johnson et al., 2021Johnson D.M. Madera M. Gomperts R. Aiken A.R. The economic context of pursuing online medication abortion in the United States.SSM-Qualitative Research in Health. 2021; 1: 100003Crossref PubMed Scopus (2) Google Scholar), and the inability to pay for abortion is a major driver in preferring to self-manage an abortion more generally (Moseson et al., 2022Moseson H. Wollum A. Goode B. Campos A. Key K. Bommaraju A. Jeyifo M. Shariyf Q. Stern M.S. Jacobs A. P016 Experiences of self-managed abortion in Indiana: Financial barriers to clinical care and a need for information on self-managed medication abortion.Contraception. 2022; 116: 77Google Scholar). Lack of financial support also shapes the abortion decision, with people who might choose abortion ruling it out as an option before even seeking abortion care (Kimport, 2022Kimport K. No real choice: how culture and politics matter for reproductive autonomy. Rutgers University Press, 2022Google Scholar; O'Donnell et al., 2018O'Donnell J. Goldberg A. Lieberman E. Betancourt T. “I wouldn’t even know where to start”: unwanted pregnancy and abortion decision-making in Central Appalachia.Reproductive Health Matters. 2018; 26: 98-113Crossref Scopus (21) Google Scholar). With this context, the inadequacy of spatial measurement of access is clear: Put simply, residing near a facility when one cannot pay for a desired abortion does not constitute access to care. In the face of seismic changes caused by the Dobbs ruling, the limitations of our conceptualization of abortion access are glaring. However, even more concrete concepts, such as abortion use, show similar weaknesses. Like abortion access, abortion use remains undertheorized. In 2013, researchers (including an author of this commentary) advocated for a public health approach that was attentive to abortion use disparities rather than conceptualizing them as individual failures or necessitating racialized approaches to fertility control (Dehlendorf et al., 2013Dehlendorf C. Harris L.H. Weitz T.A. Disparities in abortion rates: a public health approach.American Journal of Public Health. 2013; 103: 1772-1779Crossref PubMed Scopus (85) Google Scholar). As abortion rates and ratios potentially change for racial-ethnic populations in the United States as a result of Dobbs, a more sophisticated attention to health equity in both measurement and interpretation is essential. The characteristics of the abortion-using population in the United States reflect the compounding health and economic inequities and the effects of structural racism (Dehlendorf et al., 2010Dehlendorf C. Diedrich J. Drey E. Postone A. Steinauer J. Preferences for decision-making about contraception and general health care among reproductive age women at an abortion clinic.Patient Education and Counseling. 2010; 81: 343-348Crossref PubMed Scopus (64) Google Scholar). Before Dobbs, most abortions were obtained by people of color (Jones and Jerman, 2017Jones R.K. Jerman J. Population group abortion rates and lifetime incidence of abortion: United States, 2008–2014.American Journal of Public Health. 2017; 107: 1904-1909Crossref PubMed Scopus (179) Google Scholar) despite most Americans identifying as White. Post-Dobbs, because Black people are more likely to live in states with restrictive abortion laws and low-income people traditionally have lower access to health information, scholars rightfully assert that low-income populations and people of color will have the most difficulty accessing a desired abortion (Artiga et al., 2022Artiga S. Hill L. Ranji U. Gomez I. What are the implications of the overturning of Roe v. Wade for racial disparities? [Issue Brief] Racial Equity and Health Policy, Issue.https://www.kff.org/racial-equity-and-health-policy/issue-brief/what-are-the-implications-of-the-overturning-of-roe-v-wade-for-racial-disparities/Date: 2022Date accessed: March 28, 2022Google Scholar; Foster, 2022Foster D.G. New abortion bans will increase existing health and economic disparities.American Journal of Public Health. 2022; 112: 1276-1277Crossref PubMed Scopus (1) Google Scholar; Redd et al., 2023Redd S.K. Mosley E.A. Narasimhan S. Newton-Levinson A. AbiSamra R. Cwiak C. Rice W.S. Estimation of multiyear consequences for abortion access in Georgia under a law limiting abortion to early pregnancy.JAMA Network Open. 2023; 6: e231598Crossref PubMed Scopus (1) Google Scholar). To date, however, efforts to measure those impacts remain elusive. The Dobbs ruling not only curtails legal abortion in many states, but it also hobbles the data available to understand the population-level impact of the loss of national legal protection for abortion. Historically, data on the overall racial-ethnic demographics of abortion patients came from one of two sources. The first source is data reported to state health and/or vital statistics departments by abortion providers, as required by some state laws, and then submitted by the states under a voluntary agreement to the Centers for Disease Control and Prevention (CDC). Before Dobbs, these data were available to some extent for 29 states and the District of Columbia (although race and ethnicity measures are often painfully limited, with categorization such as Hispanic yes/no and White/Black/Other) (Kortsmit et al., 2022Kortsmit K. Nguyen A.T. Mandel M.G. Clark E. Hollier L.M. Rodenhizer J. Whiteman M.K. Abortion Surveillance—United States, 2020.MMWR Surveillance Summaries. 2022; 71: 1-27Crossref PubMed Scopus (5) Google Scholar). Today, 10 of those reporting states have now banned abortion care, and three others have significantly limited services. We can anticipate further reductions in both legal abortion and data as state legislators seek to further restrict abortion in large population states including Florida and Georgia. The second source is data collected by the Guttmacher Institute via the Abortion Patient Survey, which is conducted at a randomly selected representative sample of U.S. abortion-providing facilities and was frequently used to address limitations in the data produced by the CDC. This point-of-care survey also measures socioeconomic status of abortion clients. The most recently collected data via this instrument is from 2020 and the article reporting the findings includes a warning that future efforts to measure patient characteristics will be limited by an inability to select a representative sample of abortion providers (Jones and Chiu, 2023Jones R.K. Chiu D.W. Characteristics of abortion patients in protected and restricted states accessing clinic-based care 12 months prior to the elimination of the federal constitutional right to abortion in the United States.Perspectives on Sexual and Reproductive Health. 2023; (Epub ahead of print)Crossref PubMed Scopus (1) Google Scholar). Scholars new to the field of abortion studies may imagine using more traditional tools for understanding health care utilization, such as billing claims or prescription data. Unfortunately, because of the extensive marginalization of abortion from mainstream health care, these data are limited. As discussed earlier, the prohibition on federal Medicaid means that there are no claims data for abortion care that capture the patients who pay out-of-pocket; this includes almost all patients from states where abortion is criminalized. Similarly, prescription data do not exist for abortion care. Medication abortions now constitute more than half of all U.S. abortions (Jones et al., 2022Jones R.K. Nash E. Cross L. Philbin J. Krirstein M. Medication abortion now accounts for more than half of all us abortions [policy analysis].https://www.guttmacher.org/article/2022/02/medication-abortion-now-accounts-more-half-all-us-abortionsDate: 2022Date accessed: June 6, 2022Google Scholar). Yet, because of the unwarranted restrictions the FDA placed on mifepristone, until recently, abortion providers were only permitted to dispense the drug directly to the patient rather than write a prescription for medication (Baker, 2023Baker C.N. History and politics of medication abortion in the United States and the rise of telemedicine and self-managed abortion.Journal of Health Politics, Policy and Law. 2023; : 10449941Crossref PubMed Google Scholar). Although some patients do receive mailed drugs from one of two specialty mail-order pharmacies, this transaction does not follow the traditional pattern of a pharmaceutical prescription and thus is not recorded in the datasets scholars routinely use to study drug utilization. Neither of the two manufacturers of the medication abortion drug mifepristone, nor their distributors that work with the providers who dispense the medications to the patient, have information on clients who receive these medications. And although the newest FDA changes allow pharmacies to specialty certify themselves so as to be able to fill mifepristone prescriptions, none have done so yet. Given these challenges, it may seem sensible to the reader of this commentary to replace point-of-service measurement or health care data with population-level surveys; after all, that might also allow the capturing of people who wanted and did not access abortion care. Further, it might provide the opportunity to contextualize the experience of abortion within a broader set of reproductive and health experiences. However, there is a significant body of published literature on the inability of retrospective population-based surveys to measure abortion experiences (Desai et al., 2021Desai S. Lindberg L.D. Maddow-Zimet I. Kost K. The impact of abortion underreporting on pregnancy data and related research.Maternal and Child Health Journal. 2021; 25: 1187-1192Crossref PubMed Scopus (9) Google Scholar; Fu et al., 1998Fu H. Darroch J.E. Henshaw S.K. Kolb E. Measuring the extent of abortion underreporting in the 1995 National Survey of Family Growth.Family Planning Perspectives. 1998; 30: 128-138Crossref PubMed Scopus (159) Google Scholar; Jagannathan, 2001Jagannathan R. Relying on surveys to understand abortion behavior: some cautionary evidence.American Journal of Public Health. 2001; 91: 1825-1831Crossref PubMed Scopus (96) Google Scholar; Jones and Forrest, 1992Jones E.F. Forrest J.D. Underreporting of abortion in surveys of US women: 1976 to 1988.Demography. 1992; 29: 113-126Crossref PubMed Scopus (232) Google Scholar; Lindberg et al., 2020Lindberg L. Kost K. Maddow-Zimet I. Desai S. Zolna M. Abortion reporting in the United States: An assessment of three national fertility surveys.Demography. 2020; 57: 899-925Crossref PubMed Scopus (25) Google Scholar; Tierney, 2019Tierney K.I. Abortion underreporting in add health: findings and implications.Population Research and Policy Review. 2019; 38: 417-428Crossref Scopus (22) Google Scholar). Newer experiments have not improved on these significant limitations (Lindberg et al., 2022Lindberg L.D. Maddow-Zimet I. Mueller J. VandeVusse A. Randomized experimental testing of new survey approaches to improve abortion reporting in the United States.Perspectives on Sexual and Reproductive Health. 2022; (Epub ahead of print)Crossref PubMed Scopus (1) Google Scholar) despite rigorous formative work (Mueller et al., 2023Mueller J. Kirstein M. VandeVusse A. Lindberg L.D. Improving abortion underreporting in the USA: a cognitive interview study.Culture, Health & Sexuality. 2023; 25: 126-141Crossref PubMed Scopus (2) Google Scholar). One study in this journal found that a list experiment offers some promise for measuring abortion prevalence (Kissling and Jackson, 2022Kissling A. Jackson H.M. Estimating prevalence of abortion using list experiments: findings from a survey of women in Delaware and Maryland.Women's Health Issues. 2022; 32: 33-40Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar), but another study using the same method could not replicate that result (Hood et al., 2022Hood R.B. Moseson H. Smith M. Chakraborty P. Norris A.H. Gallo M.F. Comparison of abortion incidence estimates derived from direct survey questions versus the list experiment among women in Ohio.PLoS One. 2022; 17: e0269476Crossref PubMed Scopus (2) Google Scholar). Individual investigators continue to try to improve these methods, but to date no federal entity has acknowledged the inadequacy of national surveys to capture abortion history nor the way these shortcomings limit our understanding of pregnancy data more generally (Desai et al., 2021Desai S. Lindberg L.D. Maddow-Zimet I. Kost K. The impact of abortion underreporting on pregnancy data and related research.Maternal and Child Health Journal. 2021; 25: 1187-1192Crossref PubMed Scopus (9) Google Scholar). The challenge of collecting abortion data via population-level surveys is made even more difficult by the reality that many people will now be asked to report on activity that may be criminalized in the state in which they live. Scholars of abortion outside the United States have long grappled with the question of how to measure abortion when it is not legal (Popinchalk et al., 2022Popinchalk A. Beavin C. Bearak J. The state of global abortion data: an overview and call to action.BMJ Sexual & Reproductive Health. 2022; 48: 3-6Crossref PubMed Scopus (8) Google Scholar). They have used list experiments (Moseson et al., 2017Moseson H. Treleaven E. Gerdts C. Diamond-Smith N. The list experiment for measuring abortion: what we know and what we need.Studies in Family Planning. 2017; 48: 397-405Crossref PubMed Scopus (25) Google Scholar), respondent-driven sampling (Gerdts et al., 2022Gerdts C. Jayaweera R.T. Motana R. Bessenaar T. Wesson P. Incidence of and experiences with abortion attempts in Soweto, South Africa: respondent-driven sampling study.JMIR Public Health and Surveillance. 2022; 8: e38045Crossref PubMed Scopus (1) Google Scholar), and post-abortion care facilities-based measurement (Sully et al., 2018Sully E.A. Madziyire M.G. Riley T. Moore A.M. Crowell M. Nyandoro M.T. Chipato T. Abortion in Zimbabwe: a national study of the incidence of induced abortion, unintended pregnancy and post-abortion care in 2016.PLoS One. 2018; 13: e0205239Crossref PubMed Scopus (20) Google Scholar). Each of these methods has something to offer and is limited in its application to the U.S. abortion context. Indeed, several of the most recent efforts to improve abortion responses in surveys have attempted to apply these techniques without success (Lindberg et al., 2022Lindberg L.D. Maddow-Zimet I. Mueller J. VandeVusse A. Randomized experimental testing of new survey approaches to improve abortion reporting in the United States.Perspectives on Sexual and Reproductive Health. 2022; (Epub ahead of print)Crossref PubMed Scopus (1) Google Scholar). Collecting data on criminalized activities is always difficult, but the expansive hostility to abortion in the U.S. may make this problem even more challenging. In addition to criminalizing abortion providers, abortion opponents also target all those who seek to enable a pregnant person to obtain an abortion, whether in or outside the formal health care setting. As a result, third-party data collection may also become impossible. Hospitals in states with abortion bans are refusing to care for patients losing pregnancies (Belluck, 2022Belluck P. They Had Miscarriages, and New Abortion Laws Obstructed Treatment. The New York Times, New York City, NY2022https://www.nytimes.com/2022/07/17/health/abortion-miscarriage-treatment.htmlDate accessed: May 1, 2023Google Scholar; Chrisnot and Takei, 2023Chrisnot A.M. Takei G. Miscarriage care: the collateral damage of abortion bans. The Big Picture.https://thinkbigpicture.substack.com/p/strict-abortion-laws-affect-miscarriageDate: 2023Google Scholar). In Texas, abortion organizations that help people with funding and logistical support to leave the state have been threatened with criminal prosecution for their actions (Douglas and Klibanoff, 2023Douglas E. Klibanoff E. Abortion funds languish in legal turmoil, their leaders fearing jail time if they help Texans. Texas Tribune, Austin, TX2023https://www.texastribune.org/2022/06/29/texas-abortion-funds-legal/Date accessed: May 1, 2023Google Scholar). Also in Texas, three women are being charged with murder for helping a friend obtain abortion pills (Klibanoff, 2023Klibanoff E. Three Texas women are sued for wrongful death after allegedly helping friend obtain abortion medication. The Texas Tribune, Austin, TX2023https://www.texastribune.org/2022/06/29/texas-abortion-funds-legal/Date accessed: May 1, 2023Google Scholar). Idaho recently passed a law making it a crime to assist a minor with exiting the state to obtain an abortion without parental permission (Chen, 2023Chen D. Idaho bans out-of-state abortions for minors without parent’s consent. The New York Times, New York City, NY2023https://www.nytimes.com/2023/04/05/us/idaho-out-of-state-abortions-minors-ban.htmlDate accessed: May 1, 2023Google Scholar). Hostile state legislators have threatened corporations and their executives with fines and imprisonment if they pay for their employees to leave the state to obtain an abortion (Wise, 2023Wise J. Sidley targeted as Republicans warn firms on abortion pledges. Bloomberg Law.https://news.bloomberglaw.com/business-and-practice/sidley-targeted-as-republicans-warn-firms-on-abortion-pledgesDate: 2023Date accessed: May 1, 2023Google Scholar). All these efforts create an enormous culture of fear around disclosing any information about abortion activity in a state where it is criminalized. Given these realities, obtaining disclosures directly from individuals or organizations will be challenging. As such, the field may want to look for technological solutions involving big data. One such approach, which thus far has met with limited success, is analyzing online searches (Guendelman et al., 2022Guendelman S. Pleasants E. Cheshire C. Kong A. Exploring Google searches for out-of-clinic medication abortion in the United States during 2020: infodemiology approach using multiple samples.JMIR Infodemiology. 2022; 2: e33184Crossref PubMed Google Scholar). The privacy implications of search-analysis tools are of significant concern to legal reproductive rights experts (Park, 2023Park E. Reproductive health care data free or for sale: post-Roe surveillance and the ‘three corners' of privacy legislation needed. NYU Review of Law & Social Change, New York City, NY2023Google Scholar), and some online brokers such as Google have promised to delete geolocating information for abortion online searching following the Dobbs decision (Grant, 2022Grant N. Google says it will delete location data when users visit abortion clinics. The New York Times, New York City, NY2022https://www.nytimes.com/2022/07/01/technology/google-abortion-location-data.htmlDate accessed: May 1, 2023Google Scholar). The Biden administration recently released proposed new rules for increasing the protection of reproductive health patient information (Office of the Secretary, 2023Office of the SecretaryHIPAA privacy rule to support reproductive health care privacy. (2023-07517).https://www.federalregister.gov/documents/2023/04/17/2023-07517/hipaa-privacy-rule-to-support-reproductive-health-care-privacyDate: 2023Date accessed: May 1, 2023Google Scholar). All these important efforts to protect privacy and shield abortion seekers from criminalization will necessarily conflict with researchers’ desires to access information that could potentially help them measure abortion use in the post-Dobbs world. In this moment when legal abortion is no longer accessible in many states and those who might help pregnant people obtain abortions face threats and intimidation, the field is in desperate need of better ways to measure abortion access and use in the U.S. Unfortunately, research is hobbled by the absence of a conceptual model for access to care that goes beyond proximity to an abortion-providing facility and considers multiple pathways to care, the important role of paying for abortion, and other critical variables to abortion attainment. In addition, because of abortion stigma, the field now finds itself with two incomplete and limited pre-Dobbs data sources about abortion use, the CDC state abortion surveillance data and the Guttmacher Abortion Patient Survey. Neither of these can be used to measure the impact of Dobbs on the populations traditionally more dependent on the need for abortion care, people of color and people with incomes below the federal poverty level.