No. 16-1140
_________________________________________________
IN THE

Supreme Court of the United States
_____________
NATIONAL INSTITUTE OF FAMILY AND LIFE ADVOCATES,
D/B/A NIFLA, ET AL.,
Petitioners,
V.
XAVIER BECERRA, ATTORNEY GENERAL, ET AL.,

Respondents.

_____________

On Writ of Certiorari to the United States Court of
Appeals for the Ninth Circuit
_____________

BRIEF FOR SOCIAL SCIENCE

RESEARCHERS AS AMICI CURIAE
IN SUPPORT OF RESPONDENTS
_____________
Steven A. Zalesin

Counsel of Record

Derek Borchardt
Zachary Kolodin
PATTERSON BELKNAP
WEBB & TYLER LLP
1133 Avenue of the Americas
New York, NY 10036
(212) 336-2000
sazalesin@pbwt.com
Attorneys for Amici Curiae
February 27, 2018
_________________________________________________

 TABLE OF CONTENTS
INTEREST OF AMICI CURIAE ................................ 1
SUMMARY OF ARGUMENT ..................................... 1
ARGUMENT ............................................................... 3
I.

Research shows that crisis
pregnancy centers provide
inaccurate or potentially
misleading information regarding
abortion and contraception. ...................... 3

II.

Research demonstrates that the
vast majority of women who decide
to have an abortion are sure about
their decision, and want to avoid
delay in obtaining care............................ 10

III. Research shows that women face
financial and logistical burdens
when accessing abortion, and lack
of access to insurance may
contribute to delays. ................................ 13
a. Lack of financial resources delays
access to abortion. ................................ 14
b. Women face difficulties in
obtaining and using insurance
coverage for abortion. .......................... 18
IV. Research demonstrates the
importance of early entry into
prenatal care, but CPCs in
California do not assist women in
accessing prenatal care. .......................... 20
CONCLUSION .......................................................... 23

i

 TABLE OF AUTHORITIES
Page(s)
Statutes
CAL. Health & SAFETY CODE § 123472(a)(1) ............. 13
Other Authorities
Abortion, Miscarriage, and Breast Cancer Risk:
2003 Workshop, Nat’l Cancer Inst., https://
www.cancer.gov/types/breast/abortionmiscarriage-risk ..................................................... 6
Amanda Dennis et al., A Qualitative

Exploration of Low-Income Women’s
Experiences Accessing Abortion in
Massachusetts, 25:5 WOMEN'S HEALTH

ISSUES 463 (2015) ................................................. 18

Amy G. Bryant & Erika E. Levi, Abortion

Misinformation from Crisis Pregnancy
Centers in North Carolina, 86

CONTRACEPTION 752 (2012) ....................... 5, 6, 7, 8

Andrea Swartzendruber et al., Sexual and

Reproductive Health Services and
Related Health Information on Pregnancy
Resource Center Websites: A Statewide
Content Analysis, 28:1 WOMEN’S HEALTH

ISSUES 14, 15 (2018) ................................... 4, 5, 6, 7

ii

 APA TASK FORCE ON MENTAL HEALTH AND
ABORTION, REPORT OF THE APA TASK
FORCE ON MENTAL AND ABORTION 4
(2008), available at http://www.apa.org/
pi/wpo/mental-health-abortion-report.pdf ............ 7
Aziza Ahmed, Informed Decision Making and

Abortion: Crisis Pregnancy Centers,
Informed Consent, and the First
Amendment, 43:1 J. L., MED. & ETHICS 51

(2015) ...................................................................3-4

Corinne H. Rocca et al., Decisional Rightness

and Emotional Responses to Abortion in
the United States: A Longitudinal Study,
10:7 PLOS ONE (2015), available at

http://journals.plos.org/plosone/article?id=
10.1371/journal.pone.0128832 ............................. 12

Daniel Grossman et al., Effectiveness and

Acceptability of Medical Abortion
Provided Through Telemedicine, 118:2

OBSTETRICS AND GYNECOLOGY 296 (2011) ........... 11

Danielle Bessett et al., Out of Time and Out

of Pocket: Experiences of Women Seeking
State-Subsidized Insurance for Abortion
Care in Massachusetts, 21:S3 WOMEN’S

HEALTH ISSUES S21 (2011)................................... 18

Deborah Karasek et al., Abortion Patients’

Experience and Perceptions of Waiting
Periods: Survey Evidence Before
Arizona’s Two-Visit 24-hour Mandatory
Waiting Period Law, 26:1 WOMEN’S

HEALTH ISSUES 60 (2016) ..................................... 17
iii

 Diana Greene Foster et al., Socioeconomic

Outcomes of Women Who Receive and
Women Who Are Denied Wanted
Abortions in the United States, 108:3 AM.

J. OF PUB. HEALTH 407 (2018) .............................. 17

Eleanor A. Drey et al., Risk Factors
Associated with Presenting for Abortion
in the Second Trimester, 107:1
OBSTETRICS & GYNECOLOGY 128 (2006) .............. 19
Find a Qualified Provider to Enroll,
California Department of Health
Services, http://www.dhcs.ca.gov/
services/medi-cal/eligibility/Pages/Find-aQualified-Provider-to-Enroll.aspx (as of
Feb. 25, 2018) ....................................................... 23
Impacted by Abortion, Care-Net,
https://www.care-net.org/impacted-byabortion ................................................................ 10
Jenna Jerman et al., Barriers to Abortion

Care and Their Consequences for
Patients Traveling for Services:
Qualitative Findings from Two States,

49:2 PERSPS. ON SEXUAL & REPROD.
HEALTH 95 tbl. 2 (2017) ......................................8-9

Jenna Jerman et al., CHARACTERISTICS OF
U.S. ABORTION PATIENTS IN 2014 AND
CHANGES SINCE 2008, 7 (2016) available
at https://www.guttmacher.org/sites/
default/files/report_pdf/characteristics-usabortion-patients-2014.pdf .................................. 15

iv

 Jessica N. Sanders et al., The Longest Wait:

Examining the Impact of Utah’s 72-Hour
Waiting Period for Abortion, 26:5

WOMEN’S HEALTH ISSUES 483, 485 (2016) ..... 16, 17

Joanne D. Rosen, The Public Health Risks of
Crisis Pregnancy Centers, 44:3 PERSPS.
ON SEXUAL & REPROD. HEALTH 201 (2012) ........ 5, 7
Joyce M. Piper, Presumptive Eligibility For

Pregnant Medicaid Enrollees: Its Effects
on Prenatal Care and Perinatal Outcome,

84:10 AM. J. PUB. HEALTH 1626 (1994)................ 22

Katelyn Bryant-Comstock et al., Information

about Sexual Health on Crisis Pregnancy
Center Web Sites: Accurate for
Adolescents?, 29 J. OF PEDIATRIC &

ADOLESCENT GYNECOLOGY 22 (2016)..................... 8

Katrina Kimport et al., The Prevalence and

Impacts of Crisis Pregnancy Center Visits
among a Population of Pregnant Women,
CONTRACEPTION (forthcoming Mar. 2018)

abstract available at

http://www.contraceptionjournal.org/
article/S0010-7824(17)30262-7/fulltext ............... 20
Kimberly Kelly, Evangelical Underdogs:

Intrinsic Success, Organizational
Solidarity, and Marginalized Identities as
Religious Movement Resources, 43:4 J. OF

CONTEMP. ETHNOGRAPHY 419 (2014) ................... 20

v

 Kimberly Kelly, In the Name of the Mother:

Renegotiating Conservative Women’s
Authority in the Crisis Pregnancy
Movement, 38:1 Signs: J. of Women in

Culture and Soc’y 203 (2012) ............................. 3, 4

Lauren J. Ralph et al., Measuring Decisional

Certainty Among Women Seeking
Abortion, 95:3 CONTRACEPTION 269 (2017) ... 10, 11

Lawrence B. Finer et al., Timing of Steps

and Reasons for Delays in Obtaining
Abortions in the United States, 74:4

Contraception 334 (2006)............................... 12, 15

Liza Fuentes et al., Women’s Experiences

Seeking Abortion Care Shortly After the
Closure of Clinics Due to a Restrictive
Law in Texas, 93:4 CONTRACEPTION 292

(2016) .................................................................... 15

Lori R. Freedman et al., Religious Hospital

Policies on Reproductive Care: What Do
Patients Want to Know?, 218:2 AM. J. OF

OBSTETRICS & GYNECOLOGY 251 (2018) ................ 9

M. Antonia Biggs et al., Understanding Why

Women Seek Abortions in the United
States, 13:29 BMC WOMEN’S HEALTH 1, 5-

6 (2013) ................................................................. 14

Marian Jarlenski et al., Medicaid

Enrollment Policy Increased Smoking
Cessation Among Pregnant Women But
Had No Impact On Birth Outcomes, 33:6

HEALTH AFFS. 997 (2014) ..................................... 22
vi

 Mary Gatter et al., Relationship Between

Ultrasound Viewing and Proceeding to
Abortion, 123:1 OBSTETRICS &

GYNECOLOGY 81 (2014) ...................................10-11

Maryam Guiahi et al., Are Women Aware of

Religious Restrictions on Reproductive
Health at Catholic Hospitals? A Survey of
Women’s Expectations and Preferences
for Family Planning Care, 90

CONTRACEPTION 429 (2014) ................................... 9

Nancy E. Reichman & Julian O. Teitler,

Timing of Enhanced Prenatal Care and
Birth Outcomes in New Jersey’s
HealthStart Program, 9:2 MATERNAL &

CHILD HEALTH J. 151 (June 2005) ....................... 21

Nancy E. Reichman et al., 8:2 REV. ECON.
HOUSEH. 171 (June 2010) .................................... 21
Rachel K. Jones & Jenna Jerman, Abortion

Incidence and Service Availability in the
United States, 2014, 49:1 PERSPS. ON

SEXUAL & REPROD. HEALTH 17, 22 (2017)
available at
https://www.guttmacher.org/journals/psrh
/2017/01/abortion-incidence-and-serviceavailability-united-states-2014 ............................. 4

Rachel K. Jones & Jenna Jerman, How Far

Did US Women Travel for Abortion
Services in 2008?, 22:8 J. OF WOMEN’S

HEALTH 706 (2013) ............................................... 17

vii

 Rachel K. Jones et al., At What Cost?

Payment for Abortion Care by U.S.
Women, 23:3 WOMEN'S HEALTH ISSUES

e173 (2013) ........................................................... 14

Rachel K. Jones et al., Differences in

Abortion Service Delivery in Hostile,
Middle-Ground and Supportive States in
2014, WOMEN’S HEALTH ISSUES
(forthcoming 2018), available at

http://www.whijournal.com/article/S10493867(17)30536-4/pdf............................................. 16

Ralitza Gueorguieva et al., Length of

Prenatal Participation in WIC and Risk of
Delivering a Small for Gestational Age
Infant: Florida, 1996-2004, 13:4

MATERNAL & CHILD HEALTH J. 479 (July
2009) ..................................................................... 21

Rule 37.6 ...................................................................... 1
Sarah C.M. Roberts &, Cheri Pies, Complex

Calculations: How Drug Use During
Pregnancy Becomes a Barrier to Prenatal
Care, 15 MATERNAL & CHILD HEALTH J.

333 (2011) ............................................................. 21

Sarah C.M. Roberts et al, Do 72-hour

Waiting Periods and Two-Visits
Requirements for Abortion Affect
Women’s Certainty? A Prospective Cohort
Study, 27:4 WOMEN’S HEALTH ISSUES 400

(2017) .................................................................... 11

viii

 Sarah C.M. Roberts et al., Out-of-Pocket

Costs and Insurance Coverage for
Abortion in the United States, 24:2

WOMEN’S HEALTH ISSUES e211 (2014)13, 14, 16, 19

Sarah C.M. Roberts et al., Risk of Violence

from the Man Involved in the Pregnancy
after Receiving or Being Denied an
Abortion, 12:144 BMC MEDICINE 1 (2014) .......... 18

Sarah C.M. Roberts et al., Utah’s 72-Hour

Waiting Period for Abortion: Experiences
Among a Clinic-Based Sample of Women,

48:4 PERSPS. ON SEXUAL & REPROD.
HEALTH 179 (2016) ......................................... 15, 16

Susan A. Cohen, Still True: Abortion Does

Not Increase Women’s Risk of Mental
Health Problems, 16:2 GUTTMACHER

POL’Y REV. 13 (2013) ............................................ 12

Susie Meister, How my job talking women
out of abortions made me pro-choice, Vox
(May 26, 2016),
https://www.vox.com/2016/5/26/11760670/
crisis ..................................................................... 10
Ushma D. Upadhyay et al., Denial of

Abortion Because of Provider Gestational
Age Limits in the United States, 104:9

AM. J. OF PUB. Health 1687 (2014) .......... 13, 14, 19

Ushma D. Upadhyay et al., The Effect of

Abortion on Having and Achieving
Aspirational One-Year Plans, 15:102

BMC WOMEN’S HEALTH 1 (2015) .......................... 17
ix

 Valerie French et al., Influence of Clinician

Referral on Nebraska Women’s Decisionto-Abortion Time, 93 CONTRACEPTION 236

(2016) ...................................................................... 8

Victoria Lazariu-Bauer et al., A Comparative

Analysis of Effects of Early Versus Late
Prenatal WIC Participation on Birth
Weight: NYS, 1995, 8:2 MATERNAL &

CHILD HEALTH J. 77 (June 2004) ......................... 21

Vignetta E. Charles et al., Abortion and

Long-Term Mental Health Outcomes: A
Systematic Review of the Evidence, 78:6

CONTRACEPTION 436 (2008) ................................. 12

What is prenatal care and why is it
important, Eunice Kennedy Shriver Nat’l
Inst. of Child Health and Human Dev.,
https://www.nichd.nih.
gov/health/topics/pregnancy/
conditioninfo/prenatal-care.................................. 20
Worldwide Directory of Pregnancy Help,
HeartBeat International,
https://www.heartbeatinternational.org/w
orldwide-directory (filtered for California
as of Feb. 25, 2018) .............................................. 23

x

 INTEREST OF AMICI CURIAE1

Amici curiae are social science, public health, and
clinical researchers who have spent decades
conducting
and
publishing
research
about
reproductive medical services, including prenatal
care, abortion, and contraception. This includes
research on crisis pregnancy centers—nonprofit
organizations whose mission is to persuade women to
Amici believe that the Court’s
forgo abortion.
resolution of this matter should be informed by valid
and credible research that relates to women’s
reproductive healthcare. As explained in this brief,
this research highlights the importance of equipping
women with the information necessary to facilitate
access to healthcare resources.

A full list of amici is attached as an appendix to this
brief.
SUMMARY OF ARGUMENT

Amici respectfully submit that this Court should

consider the issues presented in this case in light of
certain social science and public health research that
underscores the importance of equipping women
with the information necessary to facilitate access to
healthcare resources.

Petitioners have filed a blanket consent to the filing of
amicus briefs, and Respondents have consented to the
filing of this brief.
1

1

 Overwhelming evidence from social science research
demonstrates that the vast majority of women who
decide to have an abortion are sure about their
choice and want to avoid delay in obtaining care. For
these women, however, crisis pregnancy centers
(“CPCs”)—nonprofit organizations whose mission is
to persuade women to forgo abortion—may serve as a
hurdle in access to care. Research shows that CPCs
in many cases portray the services they provide in a
potentially misleading way, and as such, we believe
that there is a risk that women may visit certain
CPCs based on misconceptions.
Furthermore,
irrespective of the reason women may visit a CPC,
research has shown that many CPCs disseminate
inaccurate medical information, which may risk
causing harm.
We support the disclosure requirements at issue in
this case, both in order to mitigate the
aforementioned risks and to reduce the barriers
facing women who wish to access family planning
services, abortion, and prenatal care.
Extensive
research has documented the financial and logistical
barriers that women face when accessing
reproductive healthcare, including lack of insurance.
The substantial cost of abortion for uninsured
women is a particularly high hurdle. For states like
California that have expressed a public policy
interest in making abortion accessible, ensuring
access to insurance for abortion patients is therefore
essential. The Reproductive FACT Act effectuates
this public policy interest through the requirement
that all covered pregnancy-related facilities—CPCs
and other covered facilities alike—disclose to
patients that they may be eligible for free or
2

 subsidized care through their county social services
office.
The benefits of such a disclosure may carry over to
women who want to carry their pregnancies to term
as well as to women who want an abortion. Early
access to prenatal care may provide important health
benefits, and California has a variety of public
programs designed to help women connect with and
finance such care. Although most CPCs market
themselves as providing healthcare services, they
typically do not offer prenatal care or connect women
with these public programs.
ARGUMENT
I.

Research shows that crisis pregnancy centers
provide inaccurate or potentially misleading
information
regarding
abortion
and
contraception.
CPCs are nonprofit organizations established with
the primary aim of persuading women to forgo
abortion.2 While the full number of CPCs in the
United States is unknown, prior estimates, which
amici believe are likely low, range from 2,500 to
4,000 centers across the country, compared to an
CPCs have
estimated 1,671 abortion providers.3
See, e.g., Kimberly Kelly, In the Name of the Mother:
Renegotiating Conservative Women’s Authority in the
Crisis Pregnancy Movement, 38:1 SIGNS: J. OF WOMEN IN
2

CULTURE AND SOC’Y 203, 205 (2012) (ethnographic study
of the CPC movement).
3 See Aziza Ahmed, Informed Decision Making and

Abortion: Crisis Pregnancy Centers, Informed Consent,

3

 existed since the 1970s, but the sector has
experienced exponential growth in recent decades.4
CPCs “have been widely criticized by advocacy
groups and others for deceptive practices,
misrepresenting their services, creating the
appearance
that
they
are
comprehensive
reproductive health clinics, and providing false and
misleading medical information.”5 And although
social science and public health research to date is
limited, studies have confirmed that some CPCs (a)
portray the services offered at their centers in a
potentially misleading way, and (b) disseminate
inaccurate information about reproductive health.
First, some CPCs market their services to pregnant
women and other women of reproductive age without
disclosing in advance that they do not provide
abortion or contraception. A recent study of the
websites of CPCs in Georgia found that, while almost
all of the assessed CPC websites advertised
and the First Amendment, 43:1 J. L., MED. & ETHICS 51,
51 (2015) (citing sources); Rachel K. Jones & Jenna
Jerman, Abortion Incidence and Service Availability in
the United States, 2014, 49:1 PERSPS. ON SEXUAL &
REPROD. HEALTH 17, 22 (2017), available at
https://www.guttmacher.org/journals/psrh/2017/01/
abortion-incidence-and-service-availability-united-states2014.
4 Kelly, supra note 2, at 210, 212.
5 Andrea Swartzendruber et al., Sexual and Reproductive

Health Services and Related Health Information on
Pregnancy Resource Center Websites: A Statewide
Content Analysis, 28:1 WOMEN’S HEALTH ISSUES 14, 15
(2018).

4

 pregnancy testing and options counseling (98% and
84%, respectively), over half of the websites—58%—
lacked a notice that they did not provide or refer for
abortion, and 89% lacked a notice that they did not
provide or refer for contraception.6 A study of North
Carolina CPCs, which relied on phone calls and
“secret shopper” visits (i.e., visits by researchers
posing as potential clients in order to collect data),
found that 44% of the CPCs surveyed told clients
that they offer counseling on abortion and its risks,
while 59% disclosed that they did not provide or refer
for abortions.7
Second, CPCs have been found to provide inaccurate
and misleading medical information about abortion
and contraception. For example, even though the
possibility of a relationship between abortion and
breast cancer has been thoroughly debunked,8 16% of
the CPCs visited in the North Carolina study warned
women of a link between abortion and breast cancer,
and 11% made such claims on their websites.9
Similarly, the study of Georgia CPC websites found
that 8% of websites reviewed linked abortion to

6

Id. at 16.

Amy G. Bryant & Erika E. Levi, Abortion
Misinformation from Crisis Pregnancy Centers in North
Carolina, 86 CONTRACEPTION 752, 753 (2012).
8 See Swartzendruber, supra note 5, at 16 (citing sources);
Bryant & Levi, supra note 7, at 754 (same); Joanne D.
Rosen, The Public Health Risks of Crisis Pregnancy
Centers, 44:3 PERSPS. ON SEXUAL & REPROD. HEALTH 201,
7

201 (2012) (same).
9 Bryant & Levi, supra note 7, at 753.

5

 breast cancer.10 Such CPCs persist in making these
claims in the face of overwhelming evidence to the
contrary: in 2003, more than 100 of the world’s
leading experts who study pregnancy and breast
cancer risk “concluded that having an abortion or
miscarriage does not increase a woman’s subsequent
risk of developing breast cancer.”11
The inaccurate information provided by CPCs does
not stop at unfounded claims about breast cancer.
The North Carolina study also found that counselors
at 21% of CPCs visited warned women of a phony
link between abortion and infertility.12 In fact,
medical evidence has clearly disproved the alleged
link.13
CPCs often warn of adverse mental health
consequences of abortion, such as “post-abortion
syndrome.” According to the North Carolina study,
26% of the CPCs visited claimed a link between
abortion and mental health risks and 31% made such
claims on their websites.14 The study of Georgia
CPC websites found that 36% of the websites
reviewed claimed that abortion leads to mental
health problems.15 In point of fact, “post-abortion
syndrome” is not supported by credible medical
Swartzendruber, supra note 5, at 16.
Abortion, Miscarriage, and Breast Cancer Risk: 2003
Workshop, Nat’l Cancer Inst., https://www.cancer.gov/
types/breast/abortion-miscarriage-risk.
12 Bryant & Levi, supra note 7, at 753-54.
13 See id. at 754 (citing sources).
14 Id. at 753-54.
15 Swartzendruber, supra note 5, at 16.
10
11

6

 research, nor recognized by the American
Psychological
Association
or
the
American
16
Psychiatric Association.
Indeed, according to the
American Psychological Association’s Task Force on
Mental Health and Abortion, “[t]he best scientific
evidence published indicates that among adult
women who have an unplanned pregnancy the
relative risks of mental health problems is no greater
if they have a single first-trimester abortion than if
they deliver that pregnancy.”17 And a causal link
between multiple abortions and mental health harms
has not been established.18
Beyond abortion, CPCs have also been found to
provide incorrect medical information about
contraception, often inaccurately downplaying its
efficacy.
For example, 78% of CPC websites
surveyed in Georgia that contained information
about condoms included “statements that seemed to
be designed to undermine confidence in condom
effectiveness or false statements about condom
Of the CPCs visited in North
effectiveness.”19

See Bryant & Levi, supra note 7, at 754; Rosen, supra
note 8, at 202.
17 APA TASK FORCE ON MENTAL HEALTH AND ABORTION,
REPORT OF THE APA TASK FORCE ON MENTAL AND
ABORTION 4 (2008), available at http://www.apa.org/
pi/wpo/mental-health-abortion-report.pdf.
18 Swartzendruber, supra note 5, at 19.
19 Id. at 17
16

7

 Carolina, 26%
ineffective.20

conveyed

that

condoms

are

Although research on how women respond to
potentially misleading portrayals of services offered
or inaccurate medical information is still developing,
two recent studies suggest that some women may
misunderstand the services offered by CPCs. In a
recent study of women at Nebraska abortion clinics,
15% of women surveyed reported that they had
previously contacted a CPC, while 12% reported that
they had only contacted a CPC before presenting at
the abortion clinic.21 Furthermore, these women
mentioned CPC staff when asked to identify persons
“providing healthcare and with whom [they]
discussed the pregnancy,” underscoring the need for
clear and accurate information about CPCs’
intentions and services.22 In addition, a recent
qualitative study into the barriers to abortion care
that drive women to travel long distances for an
abortion found that four out of 29 women pointed to
encounters with CPCs as having impeded their
access to care.23
20 Bryant & Levi, supra note 7, at 753. See also Katelyn
Bryant-Comstock et al., Information about Sexual Health

on Crisis Pregnancy Center Web Sites: Accurate for
Adolescents?, 29 J. OF PEDIATRIC & ADOLESCENT

GYNECOLOGY 22, 23-24 (2016).
21 Valerie French et al., Influence of Clinician Referral on
Nebraska Women’s Decision-to-Abortion Time, 93
CONTRACEPTION 236, 238-39 (2016).
22 Id. at 241.
23 See Jenna Jerman et al., Barriers to Abortion Care and

Their Consequences for Patients Traveling for Services:

8

 More broadly, research suggests that women want to
know what treatment is available at a facility before
they seek care there. Specifically, one survey found
that more than 80% of women found it somewhat or
very important to know about a hospital’s religiously
motivated restrictions on care.24
Research also
shows that women expect to receive the full range of
reproductive health services whether or not the
facility where they seek health care has a religious
affiliation.25
Based on the research that has been conducted to
date, amici believe there is a risk that some women
may visit certain CPCs with a misconception about
which services are provided and which are not, and
while there, may receive scientifically and medically
inaccurate information. Such findings indicate that
patient interests are served by disclosures about
limitations on care, and information that may
connect them with the care they seek.

Qualitative Findings from Two States, 49:2 PERSPS.

ON

SEXUAL & REPROD. HEALTH 95, 98 tbl. 2 (2017).
24 See Lori R. Freedman et al., Religious Hospital Policies
on Reproductive Care: What Do Patients Want to Know?,
218:2 AM. J. OF OBSTETRICS & GYNECOLOGY 251 (2018).
25 See Maryam Guiahi et al., Are Women Aware of

Religious Restrictions on Reproductive Health at Catholic
Hospitals? A Survey of Women’s Expectations and
90
Preferences
for
Family
Planning
Care,

CONTRACEPTION 429 (2014).

9

 II.

Research demonstrates that the vast majority of
women who decide to have an abortion are sure
about their decision, and want to avoid delay in
obtaining care.
CPCs claim that their goal is to present “abortionminded” or “abortion-determined” women with
information and counseling intended to change their
minds about their pregnancy decision. They claim
that drawing women into CPCs will have a beneficial
effect on their decision-making by promoting
alternatives to abortion. In addition, they claim that
by dissuading women from choosing abortion, they
will prevent abortion-related regret.26
Contrary to this premise, research shows that
women who present for an abortion are confident in
their decision.27 Indeed, the research demonstrates
See, e.g., Impacted by Abortion, Care-Net,
https://www.care-net.org/impacted-by-abortion (providing
resources to cope with “post-abortion pain” and promote
“post-abortion recovery”); Susie Meister, How my job
talking women out of abortions made me pro-choice, Vox
(May 26, 2016), https://www.vox.com/2016/5/26/11760670/
crisis-pregnancy-center (describing the practices of a
particular CPC, including that the author was “directed
to tell women that studies show they will regret an
abortion for the rest of their lives”).
27 Lauren J. Ralph et al., Measuring Decisional Certainty
Among Women Seeking Abortion, 95:3 CONTRACEPTION
269 (2017) (based on a survey of over 300 women in Utah
family planning facilities, finding that the level of
uncertainty in abortion decision making is comparable to
or lower than other health decisions); Mary Gatter et al.,
26

Relationship
Proceeding

Between Ultrasound Viewing and
OBSTETRICS
&
to
Abortion, 123:1

10

 that women deciding whether to have an abortion
are less conflicted than those making other common
healthcare decisions.28 And, once the decision is
made, they are unlikely to change their minds. One
study found that, among women in Utah who were
confident in their decision to have an abortion, 95%
were no less certain after they surpassed the state’s
mandatory three-day waiting period.29
Research also demonstrates that women who have
decided to have an abortion want to do so without
delay. For example, 94% of medication abortion
patients said it was very important to them to have
an abortion early in pregnancy.30 In fact, most
abortion patients, including 52% of those obtaining
abortions in the first trimester, said they would have
preferred to have had an abortion earlier, but
GYNECOLOGY 81 (2014) (based on a sample of over 15,000
women, finding that 85% of the women presenting at
California abortion clinics were confident and clear about
the decision to have an abortion, and among these,
viewing an ultrasound image of the fetus had no effect on
the ultimate decision to have an abortion).
28 Ralph, supra note 27, at 276 (finding that women were
less conflicted about the decision to have an abortion than
were all genders regarding reconstructive knee surgery,
as well as compared to men deciding on prostate cancer
treatment options).
29 Sarah C.M. Roberts et al, Do 72-hour Waiting Periods

and Two-Visits Requirements for Abortion Affect
Women’s Certainty? A Prospective Cohort Study, 27:4

WOMEN’S HEALTH ISSUES 400 (2017).
30 Daniel Grossman et al., Effectiveness and Acceptability
of Medical Abortion Provided Through Telemedicine,
118:2 OBSTETRICS AND GYNECOLOGY 296 (2011).

11

 financial limitations (or lack of knowledge about
pregnancy) caused delay.31
Furthermore, women who have had an abortion
overwhelmingly continue to believe they made the
right decision after the abortion.32 In one study of
post-abortion emotions that women experience, more
than 95% of women reported that the abortion was
the right decision at all points over the three years
following the abortion, and the feeling of decisional
rightness tended to increase over time.33
Neither does abortion have a negative effect on
women’s mental health.
Recent studies and
systematic reviews of the literature have found that,
contrary to claims made by abortion opponents,
abortion does not cause depression, suicidal ideation,
anxiety, or other mental health harms.34

Lawrence B. Finer et al., Timing of Steps and Reasons
for Delays in Obtaining Abortions in the United States,
31

74:4 CONTRACEPTION 334 (2006).
Corinne H. Rocca et al., Decisional Rightness and

32

Emotional Responses to Abortion in the United States: A
Longitudinal Study, 10:7 PLOS ONE (2015), available at

http://journals.plos.org/plosone/article?id=10.1371/journal.
pone.0128832.
33 Id. at 7.
34 See, e.g., Vignetta E. Charles et al., Abortion and Long-

Term Mental Health Outcomes: A Systematic Review of
the Evidence, 78:6 CONTRACEPTION 436, 439–448 (2008);
Susan A. Cohen, Still True: Abortion Does Not Increase
Women’s Risk of Mental Health Problems, 16:2
GUTTMACHER POL’Y REV. 13, 13–14 (2013).

12

 III.

Research shows that women face financial and
logistical burdens when accessing abortion, and
lack of access to insurance may contribute to
delays.

For women paying out of pocket, abortion is
expensive, with the median cost ranging from $490
to $1,750, depending on the timing of the
procedure.35 Such costs would consume 24% to 85%
of the monthly income of a family of four living at the
federal poverty line—a level that exceeds the
monthly income of nearly half of abortion patients.
For states like California that have expressed a
public policy interest in making abortion accessible,
ensuring access to insurance for abortion patients is
therefore essential.
The notice required of all
licensed covered facilities under the FACT Act (the
“signage requirement”)—which provides information
about how to access public programs that provide
“free or low-cost access to comprehensive family
planning services, (including all FDA-approved
methods of contraception), prenatal care, and
abortion for eligible women”—effectuates this
important state policy.36

Sarah C.M. Roberts et al., Out-of-Pocket Costs and
Insurance Coverage for Abortion in the United States,
35

24:2 WOMEN’S HEALTH ISSUES e211, e214 (2014). Other
studies have found similar cost increases over time. See,
e.g., Ushma D. Upadhyay et al., Denial of Abortion

Because of Provider Gestational Age Limits in the United
States, 104:9 AM. J. OF PUB. HEALTH 1687 (2014).

36

CAL. HEALTH & SAFETY CODE § 123472(a)(1).

13

 A.

Lack of financial resources delays access to
abortion.

For women who cannot use insurance to pay for their
abortions, the need to pay out of pocket is a
significant barrier, leading some woman to forgo
payment of other bills.37 For more than half of
women paying for an abortion out-of-pocket, these
costs were equivalent to more than one-third of
monthly personal income, and this was closer to two
thirds among those receiving later abortions.38 Lack
of financial resources is associated with longer delays
in obtaining an abortion, which may result in a
woman being unable to obtain an abortion at all due
to exceeding the gestational limit for her state or
care provider.39 Indeed, among women denied an
abortion because their pregnancies had advanced
beyond the provider’s gestational limit, the need to
raise funds to pay for the procedure was the most
commonly reported reason for delay.40
Such hardships are especially challenging because
the most common reasons that women seek abortions
are financial.41 As referenced above, nearly half of
abortion patients live below the federal poverty level
Rachel K. Jones et al., At What Cost? Payment for
Abortion Care by U.S. Women, 23:3 WOMEN'S HEALTH
37

ISSUES e173 (2013).
38 Roberts et al., supra note 35, at e214.
39 Upadhyay et al., supra note 35, at 1689.
40 Id.
41 M. Antonia Biggs et al., Understanding Why Women
Seek Abortions in the United States, 13:29 BMC
WOMEN’S HEALTH 1, 5-6 (2013).

14

 (i.e., $24,600 annual income for a family of four), and
three in four live below 200% of the poverty line.42
In such circumstances, missing one day of work—
much less two—means losing wages that an
individual or family can ill-afford to forgo.
When women face delays in obtaining an abortion,
the logistical and financial burdens they face
multiply. On average, a woman must wait at least a
week between when she attempts to make an
appointment and when she receives an abortion.43
Additionally,
in
many
cases,
personal
circumstances—such as the need to arrange for
childcare or transportation, or to raise money to pay
for the procedure—may cause additional delays.44
JENNA JERMAN ET AL., CHARACTERISTICS OF U.S.
ABORTION PATIENTS IN 2014 AND CHANGES SINCE 2008, 7
(2016), available at https://www.guttmacher.org/sites/
default/files/report_pdf/characteristics-us-abortionpatients-2014.pdf.
43 The median is seven days, while the average is 10 days.
Moreover, poorer women wait two to three days longer
than the typical woman. See Finer et al., supra note 31,
at 338, 343.
44 See Liza Fuentes et al., Women’s Experiences Seeking
42

Abortion Care Shortly After the Closure of Clinics Due to
a Restrictive Law in Texas, 93:4 CONTRACEPTION 292

(2016) (finding, in the context of the HB2-related clinic
closures, that women who had to arrange transportation
or could not take time off of work on the day of the next
available appointment were delayed even further); see
also Sarah C.M. Roberts et al., Utah’s 72-Hour Waiting

Period for Abortion: Experiences Among a Clinic-Based
Sample of Women, 48:4 PERSPS. ON SEXUAL & REPROD.

HEALTH 179, 185 (2016) (finding that having to raise
additional funds was a reason for waiting longer than the
required 72-hours).

15

 Delays also have the effect of increasing the cost of
an abortion. Abortion in the first trimester is
substantially less expensive than in the second
trimester: the median price of a surgical abortion at
10 weeks is $508, while the cost rises to $1,195 at
week 20.45 Another study found that abortion (up to
14 weeks) is $490, compared to $750 for weeks 14 to
20, and $1,750 after week 20.46 The rising cost of
abortion as gestational age increases poses a
profound challenge to the affordability of the
procedure for lower-income women. As one Utah
woman explained: “I knew the longer it took, the
more money it would cost . . . . We are living
paycheck to paycheck as it is, and if I [had] gone one
week sooner, it would have been $100 less.”47
Moreover, delays raise the cost of each step of
obtaining an abortion—not just the cost of the
procedure. For example, one recent study found that
Utah’s mandatory waiting period caused 47% of
women having an abortion to miss an extra day of
work.48 More than 60% were negatively affected in
Rachel K. Jones et al., Differences in Abortion Service
Delivery in Hostile, Middle-Ground and Supportive States
in 2014, WOMEN’S HEALTH ISSUES (forthcoming 2018),
available at http://www.whijournal.com/article/S104945

3867(17)30536-4/pdf.
Roberts et al., supra note 35. Other studies have found
similar increases over time. See, e.g., Upadhyay et al.,
supra note 35 at 1687.
47 Roberts et al., supra note 44, at 184.
48 Jessica N. Sanders et al., The Longest Wait: Examining
46

the Impact of Utah’s 72-Hour Waiting Period for
Abortion, 26:5 WOMEN’S HEALTH ISSUES 483, 485 (2016).

16

 other ways, including increased transportation costs,
lost wages by a family member or friend, or being
required to disclose the abortion to someone whom
they otherwise would not have told.49 And because
many clinics do not offer second-trimester abortions,
a woman who has been delayed into the second
trimester will typically be required to travel farther
to obtain an abortion, thereby incurring additional
travel and related costs, such as lost wages.50
As discussed above, sometimes women are delayed
past the point in time at which a state or clinic no
longer permits abortion. Denial of abortion services
due to exceeding gestational limits has serious
consequences. When women are denied wanted
abortions, they are less likely to be employed, and
more likely to fall below the poverty level—even
though they are more likely to receive increased
levels of public assistance.51 They are also less likely
to achieve aspirational plans for the coming year.52
Id.; accord Deborah Karasek et al., Abortion Patients’
Experience and Perceptions of Waiting Periods: Survey
Evidence Before Arizona’s Two-Visit 24-hour Mandatory
Waiting Period Law, 26:1 WOMEN’S HEALTH ISSUES 60
49

(2016).
Rachel K. Jones & Jenna Jerman, How Far Did US
Women Travel for Abortion Services in 2008?, 22:8 J. OF
WOMEN’S HEALTH 706 (2013).
51 Diana Greene Foster et al., Socioeconomic Outcomes of
50

Women Who Receive and Women Who Are Denied
Wanted Abortions in the United States, 108:3 AM. J. OF

PUB. HEALTH 407 (2018).
52 Ushma D. Upadhyay et al., The Effect of Abortion on
Having and Achieving Aspirational One-Year Plans,
15:102 BMC WOMEN’S HEALTH 1 (2015).

17

 And they are more likely to remain in relationships
with partners who subject them to physical
violence.53
B.

Women Face Difficulties in Obtaining and
Using Insurance Coverage for Abortion.

Research shows that women seeking abortion face
hurdles in obtaining insurance coverage, even when
public programs are available. In Massachusetts,
where public insurance covers abortion, some women
still paid out of pocket for abortion because they were
uninsured.
Most commonly, uninsured women
reported that they either (a) had applied for
insurance but not yet been approved; (b) faced
challenges in navigating the enrollment process; or
(c) had difficulty recertifying eligibility.54 Also in
Massachusetts, women who had been referred to
subsidized insurance programs at the time they were
seeking abortion widely reported that the application
process was confusing—with younger women
reporting the highest levels of confusion with the
process.55

Sarah C.M. Roberts et al., Risk of Violence from the
Man Involved in the Pregnancy after Receiving or Being
Denied an Abortion, 12:144 BMC MEDICINE 1 (2014).
54 Amanda Dennis et al., A Qualitative Exploration of
Low-Income Women’s Experiences Accessing Abortion in
Massachusetts, 25:5 WOMEN'S HEALTH ISSUES 463 (2015).
55 Danielle Bessett et al., Out of Time and Out of Pocket:
Experiences of Women Seeking State-Subsidized
Insurance for Abortion Care in Massachusetts, 21:S3
53

WOMEN’S HEALTH ISSUES S21 (2011).

18

 Lack of insurance, or problems with insurance, may
lead to delay. In a study comparing women who
received an abortion with those who were denied an
abortion because of gestational limits, women
commonly cited “insurance problems” as a factor
delaying their abortions, including administrative
and logistical problems like having to determine
whether the procedure was covered among women
with insurance, or waiting for Medicaid-based
coverage where available.56 In a study focused on
California women, women who had second trimester
abortions were more likely to report trouble with
insurance coverage as a factor causing delay than
first trimester patients.57 More generally, in states
where public insurance includes coverage for
abortion, residents are less likely to report cost as a
reason for delay.58
Given these difficulties, delays related to insurance
coverage, and burdens exacerbated by delays,
California has a compelling interest in informing
women that public programs exist, and how they can
access them.
Upadhyay et al., supra note 35, at 1689, 1691.
Eleanor A. Drey et al., Risk Factors Associated with
Presenting for Abortion in the Second Trimester, 107:1
OBSTETRICS & GYNECOLOGY 128 (2006). One confounding
factor noted by the authors is that second trimester
patients may also have been more likely to need
insurance, because the cost of the procedure rises with
gestational age. Id.
58 Sarah C.M. Roberts et al., Out-of-Pocket Costs and
Insurance Coverage for Abortion in the United States,
24:2 WOMEN’S HEALTH ISSUES e211 (2014)
56
57

19

 IV.

Research demonstrates the importance of early
entry into prenatal care, but CPCs in California
do not assist women in accessing prenatal care.
Of course, some women who visit CPCs do not want
abortions, but rather seek assistance with respect to
pregnancies they plan to carry to term.59
These
women go to CPCs to obtain pregnancy tests,
ultrasounds, and other services. Studies to date
indicate that CPCs typically do not provide onsite
prenatal care.60
Early entry into prenatal care can facilitate
behaviors that are important for birth, infant, and
child outcomes. For example, early enrollment in
prenatal care may identify and treat key health
issues, prevent harms to the fetus from ongoing use
of medications that are not safe during pregnancy,
and provide links to key services and supports that
have been shown to improve birth outcomes.61
See Kimberly Kelly, Evangelical Underdogs: Intrinsic
Success, Organizational Solidarity, and Marginalized
Identities as Religious Movement Resources, 43:4 J. OF
59

CONTEMP. ETHNOGRAPHY 419, 423 (2014); Katrina
Kimport et al., The Prevalence and Impacts of Crisis

Pregnancy Center Visits among a Population of Pregnant
Women, CONTRACEPTION (forthcoming Mar. 2018),
abstract available at http://www.contraceptionjournal.org/

article/S0010-7824(17)30262-7/fulltext.
60 Kimport et al., supra note 59.
61 See What is prenatal care and why is it important,
Eunice Kennedy Shriver Nat’l Inst. of Child Health and
Human Dev., https://www.nichd.nih.gov/health/topics/
pregnancy/conditioninfo/prenatal-care (observing that
prenatal care can help ensure the medications women

20

 Although prenatal care confers these benefits,
women may not know that they are eligible for
pregnancy-specific coverage, and bureaucratic
hurdles to enrolling can be a deterrent.62 Among the
measures found to facilitate earlier entry into
prenatal
care
is
“presumptive
eligibility.”
“Presumptive eligibility” means that states may
allow certain providers (such as local health
departments, community health centers, and
hospitals) to determine temporary eligibility for
Medicaid, and to provide prenatal care while the
take are safe); see also Nancy E. Reichman et al., 8:2 REV.
ECON. HOUSEH. 171 (June 2010) (finding that firsttrimester prenatal care appears to decrease maternal
postpartum smoking by approximately five percent);
Ralitza Gueorguieva et al., Length of Prenatal

Participation in WIC and Risk of Delivering a Small for
Gestational Age Infant: Florida, 1996-2004, 13:4

MATERNAL & CHILD HEALTH J. 479 (July 2009) (finding
that enrollment in WIC and Medicaid-funded prenatal
services was associated with reduced incidence of low
birth weight); Nancy E. Reichman & Julian O. Teitler,

Timing of Enhanced Prenatal Care and Birth Outcomes
in New Jersey’s HealthStart Program, 9:2 MATERNAL &

CHILD HEALTH J. 151 (June 2005) (finding that
initiating prenatal care in the first or second trimester
was associated with a 1-day advantage in gestational
age); Victoria Lazariu-Bauer et al., A Comparative

Analysis of Effects of Early Versus Late Prenatal WIC
Participation on Birth Weight: NYS, 1995, 8:2 MATERNAL

& CHILD HEALTH J. 77 (June 2004) (finding that infants
born to WIC participants who enrolled in prenatal care
early were heavier than those who enrolled late).
62
Sarah C.M. Roberts &, Cheri Pies, Complex

Calculations: How Drug Use During Pregnancy Becomes
a Barrier to Prenatal Care, 15 MATERNAL & CHILD

HEALTH J. 333 (2011).

21

 application is being processed.63 As a consequence,
patients can enroll in coverage and obtain care on
the spot, instead of having to wait for coverage, and
make additional visits to a health care facility when
coverage is approved.64 Presumptive eligibility has
been shown to lead to increased use of prenatal care,
and certain beneficial outcomes, such as smoking
cessation.65
Based on publicly accessible information provided by
California’s Department of Health Care Services,
CPCs generally do not enroll women who want to
continue their pregnancies into presumptive
eligibility insurance so that they can receive
subsidized prenatal care.66 The FACT Act’s signage
63 Joyce M. Piper, Presumptive Eligibility For Pregnant
Medicaid Enrollees: Its Effects on Prenatal Care and
Perinatal Outcome, 84:10 AM. J. PUB. HEALTH 1626

(1994).
Id.
65 Marian Jarlenski et al., Medicaid Enrollment Policy
64

Increased Smoking Cessation Among Pregnant Women
But Had No Impact On Birth Outcomes, 33:6 HEALTH

AFFS. 997 (2014).
66 This conclusion was derived by cross-referencing a
directory of pregnancy service providers provided by
amicus curiae HeartBeat International (“HeartBeat”)
with California’s list of providers that are eligible to
enroll women in presumptive eligibility. HeartBeat is a
501(c)(3) organization that “serves approximately 2,400
pro-life centers, maternity homes, and non-profit adoption
agencies in over 50 countries—making Heartbeat the
world’s largest such affiliate network.” Amicus Curiae
Brief of HeartBeat International at 1. Among other
services, HeartBeat provides a “Worldwide Directory of
Pregnancy Help,” which lists 357 service providers in

22

 requirement thus makes use of an opportunity to
connect women with coverage at the time and place
that they are seeking pregnancy-related services—an
opportunity that might otherwise be missed. Indeed,
neither petitioners nor their amici have identified
whether CPCs use any other means to inform women
how to obtain insurance coverage for pregnancies
that they plan to continue.
CONCLUSION
We respectfully request the Court consider the issues
presented in this case in light of the social science
and public health research discussed above.
Dated: February 27, 2018
Respectfully submitted,
Steven A. Zalesin

Counsel of Record

Derek Borchardt

California alone, of which 71 are HeartBeat affiliates.
Only 4.2% of service providers listed, and 8.4% of
HeartBeat affiliates, are eligible to enroll women into
presumptive eligibility insurance so that they can receive
subsidized prenatal care. Compare Worldwide Directory
of
Pregnancy
Help,
HeartBeat
International,
https://www.heartbeatinternational.org/worldwidedirectory (filtered for California as of Feb. 25, 2018), with
Find a Qualified Provider to Enroll, California
Department of Health Services, http://www.dhcs.ca.gov/
services/medi-cal/eligibility/Pages/Find-a-QualifiedProvider-to-Enroll.aspx (as of Feb. 25, 2018).

23

 Zachary Kolodin
PATTERSON BELKNAP
WEBB & TYLER LLP
1133 Avenue of the Americas
New York, NY 10036
(212) 336-2000
sazalesin@pbwt.com
Attorneys for Amici Curiae

24

 APPENDIX

AMICI CURIAE1
M. Antonia Biggs, PhD

University of California, San Francisco

Kelly Blanchard, MSc

Ibis Reproductive Health

Robert Blum, MD, MPH, PhD

John Hopkins Bloomberg School of Public Health

Claire Brindis, DrPH

University of California, San Francisco

Katelyn Bryant-Comstock, MPH

Duke Center for Global Reproductive Health

Carrie Cwiak, MD, MPH

Emory University, School of Medicine

Diana Greene Foster, PhD

University of California, San Francisco

Lori Freedman, PhD

University of California, San Francisco

Matt Freeman, DNP, MPH
Valerie French, MD, MAS

Institutional affiliations provided for identification
purposes only. The views expressed in this brief do not
necessarily reflect the views of amici’s affiliated
institutions.
1

A-2

 Liza Fuentes, DrPH

Guttmacher Institute

Maria Gallo, PhD

Ohio State University

Laurie Gaydos, PhD

Emory University, Rollins School of Public
Health

Caitlin Gerdts, PhD, MHS

Ibis Reproductive Health

Daniel Grossman, MD

University of California, San Francisco

Kelli Hall, PhD

Emory University, Rollins School of Public
Health

Luciana Hebert, PhD

University of Chicago

Kristine Hopkins, PhD

University of Texas at Austin

Jenna Jerman, MPH

Guttmacher Institute

Rachel K. Jones, PhD

Guttmacher Institute

Theodore Joyce, PhD

Baruch College and Graduate Center of the City
University of New York
A-3

 Megan Kavanaugh, DrPH

Guttmacher Institute

Kimberly Kelly, PhD

Mississippi State University

Katrina Kimport, PhD

University of California, San Francisco

Missy Kottke, MD, MPH, MBA

Emory University School of Medicine

Erika Levi, MD, MPH

Albert Einstein College of Medicine

Lisa Harris, MD, PhD

University of Michigan

Anna Newton-Levinson, MPH

Emory University, Rollins School of Public
Health

Nadine Peacock, PhD

University of Illinois at Chicago, School of Public
Health

Joseph E. Potter, PhD

University of Texas at Austin

Sarah CM Roberts, DrPH

University of California, San Francisco

Corinne Rocca, PhD, MPH

University of California, San Francisco
A-4

 Roger Rochat, MD

Emory University, Rollins School of Public
Health

Joanne Rosen, JD, MA

John Hopkins Bloomberg School of Public Health

Jessica Sales, PhD

Emory University, Rollins School of Public
Health

John Santelli, MD, MPH

Columbia University Mailman School of Public
Health

Amanda Jean Stevenson, PhD

University of Colorado, Boulder

Debra Stulberg, MD

University of Chicago

Andrea Swartzendruber, PhD, MPH

University of Georgia

Terri-Ann Thompson, PhD

Ibis Reproductive Health

Janet Turan, PhD, MPH

University of Alabama at Birmingham

Abigail Norris Turner, PhD

Ohio State University

A-5

 Ushma Upadhyay, PhD, MPH

University of California, San Francisco

Kari White, PhD, MPH

University of Alabama at Birmingham

Sharon Wilsnack, PhD

University of North Dakota

Laurie Schwab Zabin, PhD

John Hopkins Bloomberg School of Public Health

A-6