Importance: Although abortion is common in the United States, patients face substantial barriers to obtaining an abortion. Recently enacted abortion restrictions pose such barriers.

Objectives: To assess the association between a state legislative climate that is highly restrictive toward abortion provision and the abortion rate and to evaluate whether distance to a facility providing abortion care mediates the association between legislative climate and the abortion rate.

Design, Setting, and Participants: This cohort study examined county-of-residence abortion rates from all states that publicly provided them and used data on abortion restrictions, facility locations, and county demographic characteristics for the years 2000 to 2014. The association between legislative climate and abortion rates was evaluated using propensity score-weighted, linear regression difference-in-difference analysis. All models included state and year fixed effects and standard errors adjusted for state-level clustering.

Exposures: Highly restrictive legislative climate, defined as having at least 3 of 4 types of abortion restrictions; distance to a high-volume facility providing abortion care (ie, performing ≥395 abortions per year) in miles.

Main Outcomes and Measures: County-level abortion rate, defined as abortions per 1000 women per year.

Results: Abortion rate data were obtained from 1178 counties in 18 states for a median of 12.5 years (range, 5-14). The median abortion rate was 2.89 per 1000 women (interquartile range, 1.71-4.46 per 1000 women). A highly restrictive legislative climate, when compared with a less restrictive one, was associated with 0.48 fewer abortions per 1000 women (95% CI, -0.92 to -0.04 abortions per 1000 women; P =.03). Adjusted for distance to a facility providing abortion care, a highly restrictive legislative climate was associated with 0.44 fewer abortions per 1000 women (95% CI, -0.85 to -0.03; P =.04). Each mile to a facility was associated with 0.02 fewer abortions per 1000 women (95% CI, -0.03 to -0.01 abortions per 1000 women; P =.003). Legislative climate was not significantly associated with distance to a facility providing abortion care (change in distance associated with highly restrictive climate, -2.73 [95% CI, -6.02 to 0.57] miles; P =.10).

Conclusions and Relevance: This study provides evidence that a state legislative climate that is highly restrictive toward abortion provision is associated with a lower abortion rate. The cumulative effect of restrictive policies may pose a barrier to abortion access.