Association Between Restricted Abortion Access and Child Entries Into the Foster Care System | Law and Medicine | JAMA Pediatrics

Question 
Is restricted abortion access associated with increased entries of children into foster care?

Findings 
In this cohort study of 4 179 701 children placed into the US foster care system between 2000 and 2020, restricted abortion access was associated with an 11% increase in foster care entry. These findings were statistically significant for foster care entries of Black children and children of racial and ethnic minority groups compared with White children.

Meaning 
These findings suggest that restricted abortion access can have far-reaching consequences, including an increase in the number of children placed into the foster care system.

Importance 
The 2022 US Supreme Court decision Dobbs v Jackson Women’s Health Organization overturned federal protections to abortion care, allowing many states to severely restrict or ban access to abortion. Given the implications of the Dobbs ruling, there is a need to understand the full consequences of restricted abortion access. Before 2022, many states restricted access to safe and legal abortions through Targeted Regulation of Abortion Providers (TRAP) laws, which provide a historical mode for estimating the consequences of abortion restrictions.

Objective 
To use TRAP law enactment as a natural experiment to quantify the association between restricted abortion access and foster care entries.

Design, Setting, and Participants 
In this cohort study, data on the enactment of TRAP laws and case-level data on foster care entries were used to estimate the association between restricted abortion access and foster care entries in each of the 50 US states and the District of Columbia. The sample included children conceived between January 1, 1990, and December 31, 2011, who were placed into foster care at any point between January 1, 2000, and December 31, 2020. Data analysis was performed from January 2023 to July 2023.

Exposures 
Restricted abortion access due to state-level TRAP laws during pregnancy.

Main Outcomes and Measures 
The main outcome was the number of children entering foster care in each state, measured by year of child conception. The analysis was performed using a generalized difference-in-differences design, comparing entries into foster care in states with TRAP laws to states without TRAP laws, before and after their implementation.

Results 
This study included 4 179 701 children who were placed into foster care during the study period, with 11 016 561 entries. More than half of the children were male (51.4%), and the mean (SD) age was 7.4 (5.2) years. There was an 11% increase in foster care placement after abortion access was restricted in states with TRAP laws, relative to states without TRAP laws (incidence rate ratio [IRR], 1.11 [95% CI, 1.01-1.23]). These laws had significant consequences for Black children (IRR, 1.15 [95% CI, 1.05-1.28]) and racial and ethnic minority children (IRR, 1.15 [95% CI, 1.02-1.30]). The increase in entries due to TRAP laws was particularly attributable to housing inadequacy (IRR, 1.21 [95% CI, 1.11-1.32]).

Conclusions and Relevance 
Restricted abortion access can have numerous consequences, and these findings reveal a heightened strain on the US foster care system, particularly affecting marginalized racial and ethnic communities and financially vulnerable families. These placements have been shown to have lifelong consequences for children and substantial costs for both states and the federal government. To further examine the widespread implications of the overturning of Roe v Wade, future studies should forecast the expected increase in foster care entries and estimate the expenditure needed to support these children.