Abortion incidence and service availability in the United States, 2011

Hostilities faced by people on the frontlines of sexual and reproductive health and rights: a scoping review

Frontline workers for sexual and reproductive health and rights (SRHR) provide life-changing and life-saving services to millions of people every year. From accompanying the pregnant, delivering babies and caring for the newborn to supporting those subjected to sexual violence; from treating debilitating infections to expanding contraceptive choices; from enabling access to safe abortion services to countering homophobia: all over the world frontline SRHR carers and advocates make it possible for so many more to experience dignity in sex, sexuality and reproduction. Yet they are also subjected to hostility for what they do, for whom they provide care, for where they work and for the issues they address. From ostracistion and harassment in the workplace to verbal threats and physical violence, hostilities can extend even into their private lives. In other words, as SRHR workers seek to fulfil the human rights of others, their own human rights are put at risk. Yet, as grave as that is, it is a reality largely undocumented and thus also underestimated. This scoping review sets out to marshal what is known about how hostilities against frontline SRHR workers manifest, against whom, at whose hands and in which contexts. It is based on review of six sources: peer-reviewed and grey literature, news reports, sector surveys, and consultations with sector experts and, for contrast, literature issued by opposition groups. Each source contributes a partial picture only, yet taken together, they show that hostilities against frontline SRHR workers are committed the world over-in a range of countries, contexts and settings. Nevertheless, the narratives given in those sources more often treat hostilities as 'one-off', exceptional events and/or as an 'inevitable' part of daily work to be tolerated. That works in turn both to divorce such incidents from their wider historical, political and social contexts and to normalise the phenomena as if it is an expected part of a role and not a problem to be urgently addressed. Our findings confirm that the SRHR sector at large needs to step-up its response to such reprisals in ways more commensurate with their scale and gravity.

Contraceptive access reform and abortion: Evidence from Delaware

OBJECTIVE

To examine the effects of a comprehensive contraceptive access reform, Delaware Contraceptive Access Now, on abortion-one of the most common outcomes of unintended pregnancy.

DATA SOURCE

We used abortion data by state of residence from the Abortion Surveillance System, published by the Centers for Disease Control and Prevention. Our data covers 5 years prior to (2010-2014) and 5 years after the intervention (2015-2019).

STUDY DESIGN

We used synthetic control methods to estimate program effects. Our design compares Delaware to a weighted average of 45 control states ("synthetic Delaware"), where the quality of the comparison is assessed by its similarity to Delaware in pre-period outcome levels and trends.

DATA COLLECTION/EXTRACTION METHODS

Not applicable. We relied on secondary sources.

PRINCIPAL FINDINGS

We did not find statistically significant evidence that the program reduced abortion rates (0.61 fewer abortions per 1000 women, p-value = 0.74) on average, during the intervention period. The treatment effects were slightly larger in 2016 and 2017 (1.97 fewer abortions per 1000 women but not statistically significant) and attenuated in 2018 and 2019. This does not rule out program benefits in easing barriers to contraceptive methods or in reducing unplanned births. However, findings do suggest that increasing contraceptive access might not be an adequate substitute for restricted abortion access resulting from Dobbs v. Jackson Women's Health Organization.

CONCLUSIONS

Our results suggest that comprehensive efforts to improve contraceptive access may not reduce the need for accessible and affordable abortion care.

Experience of stigma and harassment among respondents to the 2019 Canadian abortion provider survey

OBJECTIVE

We conducted a national survey to assess the experiences of stigma and harassment among physicians and nurse practitioners providing abortions and abortion service administrators in Canada.

STUDY DESIGN

We conducted an exploratory, cross-sectional, national, anonymized, online survey between July and December 2020. Subsections of the survey explored stigma and harassment experienced by respondents, including the 35-item Revised Abortion Providers Stigma Scale and open-ended responses. We analyzed the quantitative data to generate descriptive statistics and employed a reflexive thematic analysis to interpret open-ended responses.

RESULTS

Three hundred fifty-four participants started the stigma and harassment section of the survey. Among low-volume clinicians (<30 abortions/year, 60%, n = 180) 8% reported harassment; 21% among higher volume clinicians (≥30 abortions/year, 40%, n = 119) and 47% among administrators (n = 39), most commonly picketing. The mean stigma score was 67.8 (standard deviation 17.2; maximum score 175). Our qualitative analysis identified five themes characterizing perceptions of stigma and harassment: concerns related to harassment from picketing, protestors, and the public; wanting protestor "bubble zones"; aiming to be anonymous to avoid being a target; not providing an abortion service; but also witnessing a safe and positive practice environment.

CONCLUSIONS

Being a low-volume clinician compared to higher volume clinician and administrator appears to be associated with less harassment. Clinicians providing abortion care in Canada reported mid-range abortion-related stigma scores, and expressed strong concerns that stigma interfered with their abortion provision. Our results indicate that further de-stigmatization and protection of abortion providers in Canada is needed through policy and practice interventions including bubble zones.

IMPLICATIONS

While Canadian abortion care clinicians and administrators reported relatively low incidence of harassment, our results indicate that they are concerned about stigma and harassment. However, as this was an exploratory survey, these data may not be representative of all Canadian abortion providers. Our data identify a need to support abortion clinicians and to bolster protections for dedicated abortion services.

Experiences with small and large numbers of protesters at abortion clinics in North Carolina

OBJECTIVES

To analyze the association between number of antiabortion protesters and patients' and their companions' experiences accessing abortion clinics in North Carolina.

STUDY DESIGN

In this concurrent mixed-methods study conducted in 2018-2019 at two independent abortion clinics in North Carolina, the author triangulated the methods of participant observation, descriptive statistical analysis of survey data, and thematic content analysis of open-ended responses to compare experiences of respondents who observed larger (>10) versus smaller (1-10) numbers of protesters at their clinic visit. The analytic sample contained experiences of patients and companions who saw protesters during the study period.

RESULTS

Of 1530 people approached for the survey, 886 (58%) completed the questionnaire. Overall, 655 respondents were included in the analysis. Most respondents (n = 546, 83%) saw 1 to 10 protesters, versus those who saw >10 protesters (n = 109, 17%). Respondents who saw 1 to 10 protesters had their cars stopped at higher rates (53%) than those who saw >10 protesters (40%) but reported being physically approached at similar rates (22% vs. 23%). Respondents who saw >10 protesters indicated that it was more dangerous to drive into the clinic (44% vs. 23%) and more difficult to access the clinic (65% vs. 39%), when compared with people who saw 1 to 10 protesters. Respondents who saw >10 protesters also reported that they thought about leaving more frequently (21% vs. 12%), that the protesters made them feel unsafe (44% vs. 23%), made their visit more stressful (71% vs. 59%), and protesters negatively impacted their clinic experience at higher rates (47% vs. 31%).

CONCLUSIONS

Respondents experienced logistical barriers to clinic access regardless of the number of protesters, though these worsened with larger numbers of protesters. Respondents perceived larger numbers of protesters as more intimidating and felt less safe navigating into the clinic. While all respondents made it to their appointments, these perceptions about larger numbers show how clinic protesting is an intimidating force that interferes with clinic access.

IMPLICATIONS

Showing the ways that the number of protesters relates to logistical and emotional barriers can help clinics in planning mitigation measures to address issues of clinic access for their patients and their companions.

Abortion as Essential Health Care and the Critical Role Your Practice Can Play in Protecting Abortion Access

Few obstetrician-gynecologists (ob-gyns) provide abortion care, resulting in abortion being separated from other reproductive health care. This segregation of services disrupts the ob-gyn patient-clinician relationship, generates needless costs, delays access to abortion care, and contributes to stigma. General ob-gyns have both the skills and the knowledge to incorporate abortion into their clinical practices. In this way, they can actively contribute to the protection of abortion access now with the loss of federal protection for abortion under Roe v Wade . For those who live where abortion remains legal, now is the time to start providing abortions and enhancing your abortion-referral process. For all, regardless of state legislation, ob-gyns must be leaders in advocacy by facilitating abortion care-across state lines, using telehealth, or with self-managed abortion-and avoiding any contribution to the criminalization of those who seek or obtain essential abortion care. Our patients deserve a specialty-wide concerted effort to deliver comprehensive reproductive health care to the fullest extent.

The relationship between abortion rates and economic fluctuations

We analyze the relationship between abortions and economic fluctuation at the U.S. state level for the 1995-2016 period. We do not find a statistically significant association between the overall abortion rate and the unemployment rate across the full sample period. However, we observe a procyclical association from approximately 2004 to 2010, during which a one percentage point increase in the unemployment rate is associated with a roughly 5% decrease in the abortion rate. This procyclical association is confirmed when we subsample our data to the 2005-2016 period. Our subgroup analysis indicates a procyclical association for the abortion rates for younger women, while we do not observe statistically significant associations when the analysis is stratified by race or ethnicity. The associations we observe for the younger age groups are especially pronounced in states with restrictions on Medicaid funding of abortions. Our analysis suggests that economic conditions may be an important factor in the reproductive choices by women.

Support Systems and Limitations in Therapeutic Abortion Care by the Gynecologist-Obstetrician of Public Hospitals in Peru

OBJECTIVE

 To identify the barriers to provide to women and adequately train physicians on therapeutic abortions in public hospitals in Peru.

METHODS

 Descriptive cross-sectional survey-based study. We invited 400 obstetrics and gynecology specialists from 7 academic public hospitals in Lima and 8 from other regions of Peru. Expert judges validated the survey.

RESULTS

 We collected survey results from 160 participants that met the inclusion criteria. Of those, 63.7% stated that the hospital where they work does not offer abortion training. Most of the participants consider that the position of the Peruvian government regarding therapeutic abortion is indifferent or deficient. The major limitations to provide therapeutic abortions included Peruvian law (53.8%), hospital policies (18.8%), and lack of experts (10.6%).

CONCLUSION

 Most surveyed physicians supported therapeutic abortions and showed interest in improving their skills. However, not all hospitals offer training and education. The limited knowledge of the physicians regarding the law and institutional policies, as well as fear of ethical, legal, and religious repercussions, were the main barriers for providing abortions.

Association of Provider Specialty With Abortion-Related Morbidity and Adverse Events Among Patients Having Procedural and Medication Abortions

OBJECTIVE

Since abortion was legalized throughout the United States in 1973, states have passed restrictive abortion policies, including permitting only obstetrician-gynecologist physicians (OBGYNs) to provide abortions. We are unaware of any research that directly compares patient safety-related outcomes by physician specialty. In this study, we compared major and any abortion-related morbidity and adverse events in abortion care provided by physicians of other specialties versus OBGYNs.

STUDY DESIGN

Using the IBM Watson Health MarketScan claims database, we identified privately insured individuals who had an induced abortion between January 1, 2011, and December 31, 2014. The primary outcome was major abortion-related morbidity or adverse events, and the secondary outcome was any abortion-related morbidity or adverse events occurring within 6 weeks of the abortion.

RESULTS

The study cohort included 34,764 patients who had 35,407 abortions-4,843 (13.7%) abortions provided by physicians of other specialties and 30,564 (86.3%) abortions provided by OBGYNs. Major and any abortion-related morbidity or adverse event occurred in 115 (0.3%) and 1,271 (3.6%) of 35,407 of abortions, respectively. In adjusted analyses, there was no statistically significant difference in major abortion-related morbidity or adverse events comparing physicians of other specialties versus OBGYNs (adjusted odds ratio, 1.02; 95% confidence interval, 0.59-1.75), and no statistically significant difference in any abortion-related morbidity or adverse events comparing physicians of other specialties versus OBGYNs (adjusted odds ratio, 0.91; 95% confidence interval, 0.77-1.09).

CONCLUSIONS

There were no differences in abortion-related morbidity or adverse events by physician specialty. Our findings do not support state laws limiting abortion care to OBGYN physicians.

Digital Multisided Platforms and Women’s Health: An Empirical Analysis of Peer-to-Peer Lending and Abortion Rates

Access to short-term capital remains a pressing problem for many people, especially those facing medical emergencies or needing immediate care. Peer-to-peer lending platforms have the ability to resolve these capital constraints by providing access to small to medium sums of money in an environment that is private and protective of personal information. In this study, we consider how the introduction of P2P lending platforms, and the resulting access to capital, influences local abortion rates, a medical procedure characterized by significant financial barriers and social stigma. We find that the entry of the P2P platform LendingClub is associated with an increase in the rate at which women choose to not carry to term. We argue that the availability of capital through these platforms, when combined with privacy protections, is able to reduce the financial barriers women face when accessing abortion services. This observed effect is stronger in more religious areas and areas with lower levels of education, indicating that social frictions and stigma may be higher in these areas, and also showing where providing an additional channel for funding is more influential.

New Evidence on the Effects of Mandatory Waiting Periods for Abortion

Beyond a handful of studies examining early-adopting states in the early 1990s, little is known about the causal effects of mandatory waiting periods for abortion. In this study we evaluate the effects of a Tennessee law enacted in 2015 that requires women to make an additional trip to abortion providers for state-directed counseling at least 48 hours before they can obtain an abortion. Our difference-in-differences and synthetic-control estimates indicate that the introduction of the mandatory waiting period caused a 53-69 percent increase in the share of abortions obtained during the second trimester. Our analysis examining overall abortion rates is less conclusive but suggests a reduction caused by the waiting period. To put these estimates into context, we provide back-of-the-envelope calculations on the additional monetary costs that Tennessee's MWP imposes on women seeking abortions.

Abortion Surveillance - United States, 2019

Problem/Condition

CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States.

Period Covered

2019.

Description of System

Each year, CDC requests abortion data from the central health agencies for 50 states, the District of Columbia, and New York City. For 2019, 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2010–2019. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15–44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2018 were assessed as part of CDC’s Pregnancy Mortality Surveillance System (PMSS).

Results

A total of 629,898 abortions for 2019 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2010–2019, in 2019, a total of 625,346 abortions were reported, the abortion rate was 11.4 abortions per 1,000 women aged 15–44 years, and the abortion ratio was 195 abortions per 1,000 live births. From 2018 to 2019, the total number of abortions increased 2% (from 614,820 total abortions), the abortion rate increased 0.9% (from 11.3 abortions per 1,000 women aged 15–44 years), and the abortion ratio increased 3% (from 189 abortions per 1,000 live births). From 2010 to 2019, the total number of reported abortions, abortion rate, and abortion ratio decreased 18% (from 762,755), 21% (from 14.4 abortions per 1,000 women aged 15–44 years), and 13% (from 225 abortions per 1,000 live births), respectively.

In 2019, women in their 20s accounted for more than half of abortions (56.9%). Women aged 20–24 and 25–29 years accounted for the highest percentages of abortions (27.6% and 29.3%, respectively) and had the highest abortion rates (19.0 and 18.6 abortions per 1,000 women aged 20–24 and 25–29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.7%, respectively) and had the lowest abortion rates (0.4 and 2.7 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios in 2019 were highest among adolescents (aged ≤19 years) and lowest among women aged 25–39 years. Abortion rates decreased from 2010 to 2019 for all women, regardless of age. The decrease in abortion rate was highest among adolescents compared with any other age group. From 2018 to 2019, abortion rates decreased or did not change among women aged ≤24 years; however, the abortion rate increased among those aged ≥25 years. Abortion ratios also decreased or did not change from 2010 to 2019 for all age groups, except adolescents aged <15 years. The decrease in abortion ratio was highest among women aged ≥40 years compared with any other age group. From 2018 to 2019, abortion ratios increased for all age groups, except adolescents aged <15 years.

In 2019, 79.3% of abortions were performed at ≤9 weeks’ gestation, and nearly all (92.7%) were performed at ≤13 weeks’ gestation. During 2010–2019, the percentage of abortions performed at >13 weeks’ gestation remained consistently low (≤9.0%). In 2019, the highest proportion of abortions were performed by surgical abortion at ≤13 weeks’ gestation (49.0%), followed by early medical abortion at ≤9 weeks’ gestation (42.3%), surgical abortion at >13 weeks’ gestation (7.2%), and medical abortion at >9 weeks’ gestation (1.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks’ gestation), 53.7% of abortions were early medical abortions. In 2018, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, two women died as a result of complications from legal induced abortion.

Interpretation

Among the 48 areas that reported data continuously during 2010–2019, overall decreases were observed during 2010–2019 in the total number, rate, and ratio of reported abortions; however, from 2018 to 2019, 1%–3% increases were observed across all measures.

Public Health Action

Abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies.

Effect of electromagnetic field on abortion: A systematic review and meta-analysis

Background

The increasing use of new technologies by pregnant women inevitably exposes them to the risks of the electromagnetic fields (EMFs). According to the World Health Organization, EMFs are the major sources of pollutants which harm human health. This study was aimed to evaluate the effects of EMF exposure on abortion.

Methods

Web of Science, Cochrane Library, MEDLINE, PubMed, EMBASE, Scopus, and Google Scholar were searched until 2021. Pooled odds ratio (OR) with 95% confidence interval (CI) was estimated using a random-effects model. Heterogeneity was explored using Cochran’s Q test and I² index. A meta-regression method was employed to investigate the factors affecting heterogeneity between the studies. The Newcastle-Ottawa scale was used to assess the credibility of the studies.

Results

Eligible studies (N = 17) were analyzed with a total of 57,693 participants. The mean maternal age (95% CI) was 31.06 years (27.32–34.80). Based on meta-analysis results, the pooled estimate for OR of EMF with its effects was 1.27 (95% CI: 1.10–1.46). According to the results of meta-regression, sample size had a significant effect on heterogeneity between studies (p: 0.030), but mother’s age and publication year had no significant effect on heterogeneity (p-value of bothwere >0.05). No publication bias was observed.

Conclusion

Exposure to EMFs above 50 Hz or 16 mG is associated with 1.27× increased risk of abortion. It may be prudent to advise women against this potentially important environmental hazard. Indeed, pregnant women should receive tailored counselling.

Experiences of reproductive genetic counselors with abortion regulations in Ohio

Since 2010, Ohio legislators have passed more than 15 legislative changes related to abortion and abortion providers, and nine procedural abortion clinics have closed. We investigated reproductive genetic counselors' perceptions, attitudes and self-reported practices regarding Ohio's current and proposed abortion regulations. We conducted five focus groups and two telephone interviews in 2019-2020, with a total of 19 reproductive genetic counselors. Participants discussed difficulties keeping current on abortion legislation and clinics' and hospitals' policies, resulting in anticipatory anxiety and leading to additional work to discuss the laws with patients. Participants articulated that practices of reproductive genetic counseling-and patient advocacy-are impeded by the legislation. Genetic counselors perceive negative impacts on patients' autonomy, particularly reflective of healthcare disparities of marginalized groups, which may contribute to frustration and anger. Ultimately, the mental and emotional burden on genetic counselors created by abortion legislation contributes to compassion fatigue and burnout. Our findings show that Ohio's abortion regulations negatively impact reproductive genetic counselors and their relationships with their patients. Repealing existing abortion regulations and preventing future restrictive legislation may ameliorate the negative effects of regulations on reproductive genetic counselors and their patients. In the event that these laws remain, innovative communication tools and proactive professional society advocacy are potential means to mitigate the negative impact on reproductive genetic counselors.

Expanded Access to Postabortion Contraception under Oregon's Reproductive Health Equity Act

OBJECTIVE

We describe the first 24 months of expanded family planning services for low-income immigrants under Oregon's Reproductive Health Equity Act. We examined postabortion contraceptive use in rural versus urban locations.

STUDY DESIGN

We conducted a historical cohort study of abortion services reimbursed under Reproductive Health Equity Act in the first 2 years after its implementation (2018 and 2019). Our primary outcome was shift in contraceptive tier from a less effective method before an abortion to a more effective contraceptive method after an abortion. Our key independent variable was residence in a metropolitan or nonmetropolitan area. We tested the association of nonmetropolitan residence and shift to a tier 1 or tier 2 method after the abortion, controlling for other factors, using logistic regression.

RESULTS

Our analysis included 625 abortions from across the state. After an abortion, 66% of women transitioned to a more effective form of contraception. Nonmetropolitan residence was not significantly associated with a shift from no method or a tier 3 method to tier 1 or tier 2 method (adjusted odds ratio, 1.28; 95% confidence interval, 0.81-2.02) compared with metropolitan residence.

CONCLUSIONS

The program was successful in helping women not wishing pregnancy to transition to a more effective contraceptive method post abortion, regardless of metropolitan location of residence.

Abortion and the Mission of MCH: Perspectives of MCH and Family Planning Professionals in Health Departments

INTRODUCTION

Prior research shows that maternal and child health (MCH) and family planning (FP) divisions in health departments (HDs) engage in some abortion-related activities, largely when legally mandated; some agencies also initiate abortion-related activities. Yet little is known about health department MCH/FP professionals' views on how abortion-related work aligns with their professional mission.

METHODS

Between November 2017 and June 2018, we conducted in-depth interviews with 29 MCH/FP professionals working in 22 state and local HDs across the U.S. We conducted inductive thematic analysis to identify themes regarding participants' professional mission and values in relation to abortion-related work.

RESULTS

Participants described a strong sense of professional mission. Two contrasting perspectives on abortion and the MCH/FP mission emerged: some participants saw abortion as clearly outside the scope of their mission, even a threat to it, while others saw abortion as solidly within their mission. In states with supportive or restrictive abortion policy environments, professionals' views on abortion and professional mission generally aligned with their overall state policy environment; in states with middle-ground abortion policy environments, a range of perspectives on abortion and professional mission were expressed. Participants who saw abortion as within their mission anchored their work in core public health values such as evidence-based practice, social justice, and ensuring access to health care.

DISCUSSION

There appears to be a lack of consensus about whether and how abortion fits into the mission of MCH/FP. More work is needed to articulate whether and how abortion aligns with the MCH/FP mission.

What are We Forgetting? Sexuality, Sex, and Embodiment in Abortion Research

Abortion has been alternately legalized and criminalized, tacitly approved of, and stigmatized, in various settings over time. The contours of its treatment are dependent on social and political contexts, including concern over women's sexuality, but it is not clear that existing conceptual frameworks enable expansive examination of the relationship between abortion and sexuality. We conduct a critical interpretive synthesis review of the literature that jointly engages with sexuality and abortion, focusing on the U.S., to highlight the frameworks that authors use to understand the relationship between the two. We find two conceptual frameworks of abortion and sexuality in operation: one that treats the two as discrete, causal variables that operate at the individual level; and another that focuses on how beliefs about what constitutes (in)appropriate sexuality explain ideological positions on abortion. We identify limitations of both frameworks and propose a new conceptual framework - one that highlights sexual embodiment - to inspire future research in this area and generate opportunities for knowledge extension. Such an approach, we contend, can elucidate broader social forces that shape both abortion and sexuality and bring research on abortion into conversation with recent scholarship on the important role of sexuality in other sexual and reproductive domains.

Estimating the annual domestic adoption rate and lifetime incidence of infant relinquishment in the United States. Contraception 2021;105:14-18. [PMID: 34418378 DOI: 10.1016/j.contraception.2021.08.008]

OBJECTIVES

Estimating the rate of infant relinquishment for adoption in the United States (U.S.) can inform understandings of pregnancy decision-making and adoption practice. Yet, private domestic adoptions are not systematically tracked. Most methods of estimating adoptions rely on nonmarital birth rates, despite the changing social context of nonmarital births. This analysis provides updated estimates of the rate of infant relinquishment for private domestic adoption in the United States.

STUDY DESIGN

Using data from National Council for Adoption, Centers for Disease Control, and Guttmacher Institute, I compiled annual estimates for the number and rates of births, abortions, and adoptions; calculated annual domestic infant adoption rates among all women and unmarried women of reproductive age; estimated the number of adoptions as a proportion of marital and nonmarital births; and estimated the lifetime incidence of relinquishment for U.S. women.

RESULTS

Since 1982, the annual adoption rate per 1000 U.S. women of reproductive age has been between 0.32 and 0.45, decreasing for the last 30 years. The most recent adoption rate translates to a lifetime relinquishment estimate of 0.9% of U.S. women. Based on patterns from 2002 to 2014, I estimate the current number of private domestic adoptions to be approximately 0.5% the annual number of births, or about 18,300 to 20,000 adoptions per year.

CONCLUSIONS

Despite finding a higher estimate of private domestic adoptions per year than previous estimates, adoption relinquishment rates remain dramatically lower than birth (and thus parenting) and abortion rates in the U.S.

IMPLICATIONS

National and state level information about annual adoptions is needed to inform policies regarding adoption, abortion, and support for families.

The Impact of Abortion Underreporting on Pregnancy Data and Related Research

INTRODUCTION

The impact on research findings that use pregnancy data from surveys with underreported abortions is not well-established. We estimate the percent of all pregnancies missing from women's self-reported pregnancy histories because of abortion underreporting.

METHODS

We obtained abortion and fetal loss data from the 2006-2015 National Survey of Family Growth (NSFG), annual counts of births from US vital statistics, and external abortion counts from the Guttmacher Institute. We estimated the completeness of abortion reporting in the NSFG as compared to the external counts, the proportion of pregnancies resolving in abortion, and the proportion of pregnancies missing in the NSFG due to missing abortions. Each measure was examined overall and by age, race/ethnicity, union status, and survey period.

RESULTS

Fewer than half of abortions (40%, 95% CI 36-44) that occurred in the five calendar years preceding respondents' interviews were reported in the NSFG. In 2006-2015, 18% of pregnancies resolved in abortion, with significant variation across demographic groups. Nearly 11% of pregnancies (95% CI 10-11) were missing from the 2006-2015 NSFG due to abortion underreporting. The extent of missing pregnancies varied across demographic groups and was highest among Black women and unmarried women (18% each); differences reflect both the patterns of abortion underreporting and the share of pregnancies ending in abortion.

DISCUSSION

Incomplete reporting of pregnancy remains a fundamental shortcoming to the study of US fertility-related experiences. Efforts to improve abortion reporting are needed to strengthen the quality of pregnancy data to support maternal, child, and reproductive health research.

Affordable but Inaccessible? Contraception Deserts in the US States

CONTEXT

This article focuses on whether, and the extent to which, the resources made available by Title X-the only federal policy aimed specifically at reproductive health care-are equitably accessible. Here, equitable means that barriers to accessing services are lowest for those people who need them most.

METHODS

The authors use geographic information systems (GIS) and statistical/spatial analysis (specifically the integrated two-step floating catchment area [I2SFCA] method) to study the spatial and nonspatial accessibility of Title X clinics in 2018.

FINDINGS

The authors find that contraception deserts vary across the states, with between 17% and 53% of the state population living in a desert. Furthermore, they find that low-income people and people of color are more likely to live in certain types of contraception deserts.

CONCLUSIONS

The analyses reveal not only a wide range of sizes and shapes of contraception deserts across the US states but also a range of severity of inequity.

Pregnancy in women with osteogenesis imperfecta: pregnancy characteristics, maternal, and neonatal outcomes

BACKGROUND

Women with rare diseases, such as osteogenesis imperfecta, may consider pregnancy, although data regarding outcomes, specific risks, and management strategies are lacking.

OBJECTIVE

The Brittle Bone Disorders Consortium of the National Institute of Health Rare Diseases Clinical Research Network established an Osteogenesis Imperfecta Pregnancy Registry to collect and evaluate pregnancy, maternal, and neonatal outcomes in women with osteogenesis imperfecta.

STUDY DESIGN

This was a cross-sectional, survey-based study. Appropriate participants of the Brittle Bone Disorders Consortium Contact Registry were invited to participate in the study. Self-reported information regarding pregnancy characteristics and maternal and neonatal outcomes of women with osteogenesis imperfecta was compared with that of the general population, referenced by literature-based standards. Furthermore, compared with the general population, cohorts of women and fetuses with osteogenesis imperfecta were evaluated to determine whether the presence of osteogenesis imperfecta conveyed an increase in antepartum, intrapartum, and postpartum complications and an increase in adverse neonatal outcomes.

RESULTS

Here, a total 132 participants completed the survey. Compared with the general population, women with osteogenesis imperfecta had higher rates of diabetes in pregnancy (13.3% vs 7%; 95% confidence interval, 7.0-19.6; P=.049), cesarean delivery (68.5% vs 32.7%; 95% confidence interval, 59.9-77.1; P<.001), need for blood transfusion (8.3% vs 1.5%; 95% confidence interval, 3.9-12.8; P=.019), and antepartum and postpartum fractures (relative risk, 221; 95% confidence interval, 59.3-823; P<.001). Maternal hospitalization and cesarean delivery rates were higher in individuals with moderate or severe osteogenesis imperfecta than women who reported mild osteogenesis imperfecta. Neonates born to women with osteogenesis imperfecta had higher risk of being low (26.2% vs 6.8%; P<.001) or very low birthweight (13.8% vs 1.4%; P<.001) infants than the general population. Neonates born to women with osteogenesis imperfecta had a higher rate of neonatal intensive care unit admissions (19% vs 5.68%; P<.001) and higher neonatal mortality at 28 days of life (4.8% vs 0.4%; P=.026), regardless of neonatal osteogenesis imperfecta status.

CONCLUSION

Pregnancies for women with osteogenesis imperfecta are at an increased risk of complications, including hemorrhage, fractures, diabetes mellitus, and increased neonatal morbidity.

Increasing Access to Abortion: ACOG Committee Opinion, Number 815

Individuals require access to safe, legal abortion. Abortion, although legal, is increasingly out of reach because of numerous restrictions imposed by the government that target patients seeking abortion and their health care practitioners. Insurance coverage restrictions, which take many forms, constitute a substantial barrier to abortion access and increase reproductive health inequities. Adolescents, people of color, those living in rural areas, those with low incomes, and incarcerated people can face disproportionate effects of restrictions on abortion access. Stigma and fear of violence may be less tangible than legislative and financial restrictions, but are powerful barriers to abortion provision nonetheless. The American College of Obstetricians and Gynecologists, along with other medical organizations, opposes such interference with the patient-clinician relationship, affirming the importance of this relationship in the provision of high-quality medical care. This revision includes updates based on new restrictions and litigation related to abortion.

The Association Between Intimate Partner Violence and Distance Traveled to Access Abortion in a Nationally Representative Sample of Abortion Patients

The objective of this article is to describe a secondary data analysis of the 2008 Abortion Patient Survey (APS 2008) data exploring the association between intimate partner violence (IPV) and travel distances in a national sample of patients seeking abortion services in the United States. The researchers used the 2008 APS, which is the most recent publicly available version of this dataset, to conduct chi-square tests to examine the bivariate associations between all independent and dependent variables. Prevalence ratios were calculated to determine the association between physical and sexual violence and distance traveled to get an abortion, controlling for length of pregnancy, age, education, income, poverty category, race, relationship status, insurance type, whether women went to the closest clinic, whether the pregnancy was wanted, and number of previous abortions. Results indicate that approximately 83% of the women traveled between 1 and 50 miles, 11% traveled between 51 and 100 miles, 4% traveled between 101 and 150 miles, and 3% traveled more than 151 miles to get an abortion. Prevalence ratios (PR) reveal that physical violence was significantly associated with distance traveled to get an abortion (PR = 1.15, p < .05) when all control variables were accounted for. Patients in abusive relationships that involve physical violence may have to travel longer distances to access abortion. Repeal of policy that impedes access to abortion is recommended.

Distance to an Abortion Provider and Its Association with the Abortion Rate: A Multistate Longitudinal Analysis

CONTEXT

Although one in four U.S. women has an abortion in her lifetime, barriers to abortion persist, including distance to care. This study evaluates the association between distance to care and the abortion rate, adjusting for abortion demand.

METHODS

Two analyses were conducted using a data set linking provider locations and 2000-2014 county-level abortion data for 18 states; data sources included the Census Bureau, state vital statistics offices and the Guttmacher Institute. First, a series of linear regression models were run, with and without adjustment for demographic covariates, modeling distance as both a continuous and a categorical variable. Then, an instrumental variable analysis was conducted in which being 30 or more miles from a large college-enrolled female population younger than age 25 was used as an instrument for distance to a provider. The outcome variable for all models was abortions per 1,000 women aged 25 or older. All models were adjusted for state, year and state-year interaction fixed effects.

RESULTS

Increased distance to a provider was associated with a decreased abortion rate. Each additional mile to a provider was associated with a decrease of 0.011 in the abortion rate. Compared with being within 30 miles of a provider, being between 30 and 90 miles from a provider was associated with 0.80-1.46 fewer abortions per 1,000 women. In the instrumental variable analysis, being 30 or more miles from a provider was associated with 5.26 fewer abortions per 1,000 women.

CONCLUSIONS

Distance to a provider may present a barrier to abortion by preventing access to care. Therefore, policies that increase travel distances have potential for harm.

Abortion Surveillance - United States, 2018

PROBLEM/CONDITION

CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States.

PERIOD COVERED

2018.

DESCRIPTION OF SYSTEM

Each year, CDC requests abortion data from the central health agencies for 50 states, the District of Columbia, and New York City. For 2018, 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2009-2018. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2017 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS).

RESULTS

A total of 619,591 abortions for 2018 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2009-2018, in 2018, a total of 614,820 abortions were reported, the abortion rate was 11.3 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 189 abortions per 1,000 live births. From 2017 to 2018, the total number of abortions and abortion rate increased 1% (from 609,095 total abortions and from 11.2 abortions per 1,000 women aged 15-44 years, respectively), and the abortion ratio increased 2% (from 185 abortions per 1,000 live births). From 2009 to 2018, the total number of reported abortions, abortion rate, and abortion ratio decreased 22% (from 786,621), 24% (from 14.9 abortions per 1,000 women aged 15-44 years), and 16% (from 224 abortions per 1,000 live births), respectively. In 2018, women in their 20s accounted for more than half of abortions (57.7%). In 2018 and during 2009-2018, women aged 20-24 and 25-29 years accounted for the highest percentages of abortions; in 2018, they accounted for 28.3% and 29.4% of abortions, respectively, and had the highest abortion rates (19.1 and 18.5 per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.6%, respectively) and had the lowest abortion rates (0.4 and 2.6 per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios in 2018 and throughout 2009-2018 were highest among adolescents (aged ≤19 years) and lowest among women aged 25-39 years. Abortion rates decreased from 2009 to 2018 for all women, regardless of age. The decrease in abortion rate was highest among adolescents compared with women in any other age group. From 2009 to 2013, the abortion rates decreased for all age groups and from 2014 to 2018, the abortion rates decreased for all age groups, except for women aged 30-34 years and those aged ≥40 years. In addition, from 2017 to 2018, abortion rates did not change or decreased among women aged ≤24 and ≥40 years; however, the abortion rate increased among women aged 25-39 years. Abortion ratios also decreased from 2009 to 2018 among all women, except adolescents aged <15 years. The decrease in abortion ratio was highest among women aged ≥40 years compared with women in any other age group. The abortion ratio decreased for all age groups from 2009 to 2013; however, from 2014 to 2018, abortion ratios only decreased for women aged ≥35 years. From 2017 to 2018, abortion ratios increased for all age groups, except women aged ≥40 years. In 2018, approximately three fourths (77.7%) of abortions were performed at ≤9 weeks' gestation, and nearly all (92.2%) were performed at ≤13 weeks' gestation. In 2018, and during 2009-2018, the percentage of abortions performed at >13 weeks' gestation remained consistently low (≤9.0%). In 2018, the highest proportion of abortions were performed by surgical abortion at ≤13 weeks' gestation (52.1%), followed by early medical abortion at ≤9 weeks' gestation (38.6%), surgical abortion at >13 weeks' gestation (7.8%), and medical abortion at >9 weeks' gestation (1.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 50.0% of abortions were early medical abortions. In 2017, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, two women were identified to have died as a result of complications from legal induced abortion.

INTERPRETATION

Among the 48 areas that reported data continuously during 2009-2018, decreases were observed during 2009-2017 in the total number, rate, and ratio of reported abortions, and these decreases resulted in historic lows for this period for all three measures. These decreases were followed by 1%-2% increases across all measures from 2017 to 2018.

PUBLIC HEALTH ACTION

The data in this report can help program planners and policymakers identify groups of women with the highest rates of abortion. Unintended pregnancy is a major contributor to induced abortion. Increasing access to and use of effective contraception can reduce unintended pregnancies and further reduce the number of abortions performed in the United States.

Predictors of Maternal Preference for Sex-Selective Pregnancy Termination in a Developing Nation with Restrictive Abortion Laws

INTRODUCTION

The rapid and unexpected increase in the sex ratio at birth in Nigeria between 1996 and 2014 is yet to be fully explained. The contribution of sex-selective abortion has not been explored.

METHODS

A cross-sectional survey of pregnant women was employed to address this need.

RESULTS

Preference for sex-selective abortion was noted in 8.6% of the respondents. The association between parity ≥ 4 and preference for sex-selective abortion was statistically significant. Women who were child gender-biased were significantly more likely to prefer sex-selective abortion. Experiencing intimate partner violence, and having problems with in-laws for inability to give birth to their desired gender, were predictors of maternal preference for sex-selective abortion. Women who preferred sex-selective abortion, however, felt it was necessary to campaign against gender preference.

CONCLUSION

Preference for sex-selective abortion exists in Nigeria, despite our restrictive abortion laws. However, the women's underlying reasons may include gender balancing in the family and an escape from discrimination. Improving contraceptive uptake, restriction of disclosure of fetal sex for non-medical indications, and sanctions against violent partners/oppressive in-laws are advocated. Rapid progress towards achieving a world free of the offensive gender inequalities that force women to opt for sex-selective abortion ab initio is desirable.

Association of Medicaid Expansion With Access to Abortion Services for Women With Low Incomes in Oregon

BACKGROUND

The Affordable Care Act allowed states to expand Medicaid eligibility for women with low incomes before pregnancy. Women who experience an unintended pregnancy may encounter fewer delays in accessing abortion services if they are already enrolled in Medicaid. In states where the Medicaid program includes coverage for abortion services, Medicaid expansion may increase timely access to abortion services. Oregon has expanded Medicaid and is 1 of 16 states in which the Medicaid program covers abortion services. We explored how Medicaid expansion in Oregon was associated with Medicaid-financed abortion rates and receipt of medication abortion relative to surgical abortion.

METHODS

Using Medicaid claims and eligibility data we identified women ages 19 to 43 (n = 30,367) who had abortions before the expansion period (2008-2013) and after the expansion period (2014-2016). We used American Community Survey data to estimate the annual number of Oregon women aged 19 to 43 with incomes below 185% of the federal poverty level who would be eligible for a Medicaid-financed abortion. We conducted interrupted time series analyses using negative binomial and logistic regression models.

RESULTS

Incidence of Medicaid-financed abortion increased from 13.4 in 1,000 women in 2008 to 16.3 in 2016. Medication abortion receipt increased from 11.5% of abortions in 2008 to 31.7% in 2016. For both outcomes, we identified an increasing time trend after Medicaid expansion, followed by a subsequent leveling off of the trend. By the end of 2016, incidence of Medicaid-financed abortion was 4.5 abortions per 1,000 women-years (95% confidence interval, 3.3-5.7) higher than it would have been without expansion and medication abortions comprised a 7.4 percentage point (95% confidence interval, 4.4-10.4) greater share of all abortions.

CONCLUSIONS

Medicaid expansion was associated with increased receipt of Medicaid-financed abortions and may have reduced out-of-pocket payment among women with low incomes. Increased receipt of medication abortion may indicate that expansion enhanced earlier access to services, possibly as a result of increased prepregnancy Medicaid enrollment, and this earlier access may increase reproductive autonomy and safety.

Association of Highly Restrictive State Abortion Policies With Abortion Rates, 2000-2014

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.

Trends in medication abortion and the role of low-volume and nonmetropolitan mifepristone purchasers: 2008-2011 and 2014-2017

OBJECTIVE

The objective was to examine trends in the number of low-volume and nonmetropolitan mifepristone purchasers and their role in the expansion of medication abortion.

METHODS

We use deidentified data from Danco Laboratories, the sole distributor of mifepristone during the study period, to examine trends in mifepristone distribution. We focus on customers who purchased < 100 doses a year and a subset of those who purchased < 10 doses for the periods of 2008-2011 and 2014-2017. We use data from the Guttmacher Institute Abortion Provider Census (APC) studies in 2008 and 2017 to examine the extent to which some facilities that purchased mifepristone may be missing from Guttmacher's APC.

RESULTS

Between 2008 and 2017, the number of medication abortions increased 73%, though the number of mifepristone purchasers only increased 15%. The number of low-volume mifepristone customers, or those who purchased < 100 tablets of mifepristone per year, decreased 8% over the study period, while the number purchasing < 10 tablets per year decreased 14%. However, in recent years, low-volume customers were more likely to have purchased mifepristone in multiple years. In nonmetropolitan areas, the number of sites purchasing mifepristone increased slightly but the amount of mifepristone that was purchased more than doubled between 2008 and 2017.

CONCLUSIONS

While reliance on medication abortion increased substantially between 2008 and 2017, there is no evidence that this was due to an increase in the number of facilities that purchased low volumes of mifepristone.

IMPLICATIONS

While their numbers declined, abortion providers purchasing low volumes of mifepristone likely played an important role for the individuals they cared for. Access to abortion could increase if a wider network of health care practitioners, especially those in settings that do not currently provide abortions, was able to offer medication abortion.

Standardizing abortion education: what medical schools can learn from residency programs

PURPOSE OF REVIEW

With over 50 million abortions annually and 25% of pregnancies ending in abortion worldwide, abortion is one of the most common medical procedures. Yet abortion-related topics are glaringly absent from medical school curricula in the USA with half of medical schools including no formal training or only a single lecture. We explore abortion education in US medical schools and Obstetrics and Gynecology (Ob/Gyn) residency programs. Specifically, we review efforts to improve and standardize this training.

RECENT FINDINGS

Despite documented interest in both learning and in the benefits of early exposure, medical students face a lack of educational opportunities in abortion care. Meanwhile, Ob/Gyn residency has standardized requirements for abortion care, greatly improving training and education, despite persistent challenges in universal compliance with these standards.

SUMMARY

Education in abortion care is crucially important in fostering and training future abortion providers, thereby ensuring and expanding access to safe abortion. The improvements made by standardizing abortion education in Ob/Gyn residency should encourage similar efforts in medical school in order to increase earlier and wider exposure to future physicians of all specialties. On a national level, standardizing exams for medical students by which to evaluate their understanding of abortion care would hold schools accountable for medical student education.

Survival Analysis of Patient Contraceptive Choice Method at Time of Abortion - Honolulu, Hawai'i, May 2010-December 2016

The relationship between contraceptive method choice at the time of abortion and risk for subsequent abortions is not well understood. This article uses an existing data set from the University of Hawai'i Women's Options Center between May 2010 and December 2016 to examine if such a relationship exists. A multivariate Cox proportional hazards regression survival analysis was used to evaluate contraceptive method prescribed or provided at index abortion encounters and likelihood of additional abortions. Patients who received a prescription of oral contraceptive pills, patches or rings at their index abortion were 61% more likely to have an additional abortion than those who had no contraceptive method recorded (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.14-2.28). Patients who received a long-acting reversible contraceptive method at their index abortion were 59% less likely to have an additional abortion when compared with a patient receiving no method (HR, 0.41; 95% CI, 0.20-0.86). The findings show that patients who were prescribed oral contraceptives pills, patches, or rings were more likely than patients who had no contraceptive method prescribed or provided to have more than one abortion during the data collection period. Contraceptive method choice at time of abortion is complex and providers should be thorough in their counseling about failure rates, while also remaining vigilant in supporting patient autonomy and avoiding coercive or stigmatizing language.

Abortion Reporting in the United States: An Assessment of Three National Fertility Surveys

Despite its frequency, abortion remains a highly sensitive, stigmatized, and difficult-to-measure behavior. We present estimates of abortion underreporting for three of the most commonly used national fertility surveys in the United States: the National Survey of Family Growth, the National Longitudinal Survey of Youth 1997, and the National Longitudinal Study of Adolescent to Adult Health. Numbers of abortions reported in each survey were compared with external abortion counts obtained from a census of all U.S. abortion providers, with adjustments for comparable respondent ages and periods of each data source. We examined the influence of survey design factors, including survey mode, sampling frame, and length of recall, on abortion underreporting. We used Monte Carlo simulations to estimate potential measurement biases in relationships between abortion and other variables. Underreporting of abortion in the United States compromises the ability to study abortion-and, consequently, almost any pregnancy-related experience-using national fertility surveys.

Perceived Access to Abortion Among Women in the United States in 2018: Variation by State Abortion Policy Context

Objectives. To describe perceptions of access to abortion among women of reproductive age and their associations with state abortion policy contexts.Methods. We used data from the 2018 Survey of Family Planning and Women's Lives, a probability-based sample of 2115 adult women aged 18 to 44 years in US households.Results. We found that 27.6% of women (95% confidence interval [CI] = 23.3%, 32.7%) believed that access to medical abortion was difficult and 30.1% of women (95% CI = 25.6%, 35.1%) believed that access to surgical abortion was difficult. Adjusted for covariates, women were significantly more likely to perceive access to both surgical and medical abortions as difficult when they lived in states with 4 or more restrictive abortion policies compared with states with fewer restrictions (surgical adjusted odds ratio [AOR_surgical] = 1.60, 95% CI = 1.15, 2.21; AOR_medical = 1.65, 95% CI = 1.04, 1.95). Specific restrictive abortion policies (e.g., public funding restrictions, mandatory counseling or waiting periods, and targeted regulation of abortion providers) were also associated with greater perceived difficulty accessing both surgical and medical abortions.Conclusions. State policies restricting abortion access are associated with perceptions of reduced access to both medical and surgical abortions among women of reproductive age.

Shining the light on abortion: Drivers of online abortion searches across the United States in 2018

Context

Legal abortion restrictions, stigma and fear can inhibit people’s voices in clinical and social settings posing barriers to decision-making and abortion care. The internet allows individuals to make informed decisions privately. We explored what state-level policy dimensions were associated with volume of Google searches on abortion and on the abortion pill in 2018.

Methods

We used Google Trends to quantify the relative search volume (RSV) for “abortion” and “abortion pill” (or “abortion pills” hereafter referred to as “abortion pill”) as a proportion of total search volume for all queries in each US state. We also identified the top search queries most related to “abortion” and “abortion pill” and considered these as indicators of population concern. Key exposures were healthcare cost, access and health outcomes, and number of legal restrictions and protections at the state level. In descriptive analyses, we first grouped the states into tertiles according to their RSV on “abortion” and “abortion pill”. To examine the association between each exposure (and other covariates) with the two outcomes, we used unadjusted and adjusted linear regression.

Results

The average RSV for “abortion” in the low, moderate and high tertile groups was 48 (SD = 3.25), 55.5 (SD = 2.11) and 64 (SD = 4.72) (p-value <0.01) respectively; for “abortion pill” the average RSVs were 39.6 (SD = 16.68), 61.9 (SD = 5.82) and 81.7 (SD = 6.67) (p-value < 0.01) respectively. Concerns about contraceptive availability and access, and unplanned pregnancies independently predicted the relative search volumes for abortion and abortion pill. According to our baseline models, states with low contraceptive access had far higher abortion searches. Volume of abortion pill searches was additionally positively associated with poor health outcomes, poor access to abortion facilities and non-rurality.

Conclusion

Search traffic analysis can help discern abortion-policy influences on population concerns and require close monitoring. State-policies can predict search volume for abortion and abortion pill. In 2018, concerns about contraceptives and unplanned pregnancies, predicted abortion searches. Current decreases in public contraceptive funding and the Title X Gag rule designed to block millions of people from getting care at Planned Parenthood, the largest provider of birth control and abortion care, may increase concerns about unintended pregnancies that can lead to increases in online relative volume of abortion searches.

Did parental involvement laws grow teeth? The effects of state restrictions on minors' access to abortion

We compile data on the locations of abortion providers and enforcement of parental involvement laws to document dramatic increases in the distances minors must travel if they wish to obtain an abortion without involving a parent or judge: from 58 miles in 1992 to 454 in 2016. Using both double and triple-difference estimation strategies, we estimate the effects of parental involvement laws, allowing them to vary with the distances minors might travel to avoid them. Our results confirm previous findings that parental involvement laws did not increase teen births in the 1980s, and provide new evidence that in more recent decades they have increased teen birth by an average of 3 percent. The estimated effects are increasing in avoidance distance to the point that a confidential abortion is more than a day's drive away, and also are substantially larger in the poorest quartile of counties.

Pregnant Women's Reasons for and Experiences of Visiting Antiabortion Pregnancy Resource Centers

CONTEXT

The primary mission of pregnancy resource centers is to dissuade women from choosing abortion. Reproductive health and rights advocates have asserted that these centers interfere in abortion decision making. However, the reasons pregnant women go to such centers and what they experience while there have not been examined.

METHODS

Between June 2015 and June 2017, in-depth, semistructured phone interviews were conducted with 21 pregnant women who had presented at prenatal care clinics in southern Louisiana and Baltimore, Maryland, and who had visited a pregnancy resource center. Topics covered in the interviews included reasons for visiting a center and the experience of the visit. Transcripts were analyzed first thematically and then using grounded theory.

RESULTS

Most of the women were low income and had not been considering abortion when they visited a pregnancy resource center. Respondents reported that they had gone to these centers for pregnancy-related services, material goods and social support. They chose these centers because the resources were free, and they were largely satisfied with their experiences. Nonetheless, their receipt of services and goods was limited and often contingent on participation in the centers' activities.

CONCLUSIONS

Pregnancy resource centers play a role in meeting the acute material and social needs of low-income pregnant women. However, the constraints on the resources the centers offer mean that this support cannot be part of a reliable system of care. Advocates and policymakers should take a nuanced approach to regulating these centers and consider the reasons women visit them, especially low-income women.

Second-trimester abortion attitudes and practices among maternal-fetal medicine and family planning subspecialists

BACKGROUND

Patients deciding to undergo dilation and evacuation (D&E) or induction abortion for fetal anomalies or complications may be greatly influenced by the counseling they receive. We sought to compare maternal-fetal medicine (MFM) and family planning (FP) physicians' attitudes and practice patterns around second-trimester abortion for abnormal pregnancies.

METHODS

We surveyed members of the Society for Maternal-Fetal Medicine and Family Planning subspecialists in 2010-2011 regarding provider recommendations between D&E or induction termination for various case scenarios. We assessed provider beliefs about patient preferences and method safety regarding D&E or induction for various indications. We compared responses by specialty using descriptive statistics and conducted unadjusted and adjusted analyses of factors associated with recommending a D&E.

RESULTS

Seven hundred ninety-four (35%) physicians completed the survey (689 MFMs, 105 FPs). We found that FPs had 3.9 to 5.5 times higher odds of recommending D&E for all case scenarios (e.g. 80% of FPs and 41% of MFMs recommended D&E for trisomy 21). MFMs with exposure to family planning had greater odds of recommending D&E for all case scenarios (p < 0.01 for all). MFMs were less likely than FPs to believe that patients prefer D&E and less likely to feel that D&E was a safer method for different indications.

CONCLUSION

Recommendations for D&E or induction vary significantly depending on the type of physician providing the counseling. The decision to undergo D&E or induction is one of clinical equipoise, and physicians should provide unbiased counseling. Further work is needed to understand optimal approaches to shared decision making for this clinical decision.

Factors associated with the timing of abortions

The timing of an abortion (often measured as gestational age) can have important effects on the woman's physical health and on the cost of the procedure. To the authors' knowledge, there has been only one national analysis of the factors associated with the gestational age at abortion, but it employed data from over 20 years ago. The state-specific studies that have explored abortion timing have typically examined the effects of a specific change in abortion regulations. In this study, we employ annual, state-level data covering the 1991-2014 period that measure the frequency of abortions by gestational age. We regress these measures of abortion utilization on policy, economic, demographic, and health care infrastructure characteristics. The estimates indicate that the introduction of state restrictions on Medicaid funding of abortions is associated with a 13% increase in the rate of abortions after the first trimester. We do not find a statistically significant association between parental involvement laws and the rate or percentage of post-first-trimester abortions.

Preconception counseling of females with inflammatory bowel disease

Inflammatory bowel diseases (IBD) are commonly diagnosed in women of childbearing age. As such, pregnancy is often encountered in this subset of patients. Management of pregnancy in IBD patients poses numerous challenges as ensuring the safety of the mother and the fetus is required. Disease remission prior to pregnancy is a key determinant of both the course of IBD throughout gestation and pregnancy outcome. Thus, adequate preconception care is of paramount importance in order to achieve optimal maternal and perinatal outcomes and maintain disease quiescence throughout gestation. In addition, preconception care has a major role in improving patient's knowledge, concerns and misbeliefs related to reproductive-health issues among IBD patients. In this review, we discuss the various aspects involved in the preconception care of IBD patients.

Opioid Analgesia for Medical Abortion: A Randomized Controlled Trial

OBJECTIVE

To estimate the effect of oral opioids on patient pain during first-trimester medical abortion.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial where patients up to 10 0/7 weeks of gestation undergoing a medical abortion with mifepristone and misoprostol took 10 mg oral oxycodone or placebo at onset of painful cramping. Additionally, all patients received 800-mg ibuprofen tablets, 4-mg ondansetron oral dissolving tablets, and a written prescription for adjunctive pain medication (six tablets oxycodone 5 mg). Participants used a text-messaging service to report pain scores on a numerical rating scale from 0 to 10 (0 being no pain, 10 being worst pain) for 24 hours at start of misoprostol dosing. The primary outcome was maximum pain experienced within 24 hours postmisoprostol. Our secondary outcomes were maximum pain stratified by gestational age (less than 7 weeks of gestation, 7-10 weeks of gestation), duration of maximum pain, use of adjunctive medication, presence of nausea or vomiting, and satisfaction. We needed at least 76 participants per group to differentiate a clinically important pain difference of 2 points on the numerical rating scale.

RESULTS

From May 2017 to May 2018, we randomized 172 participants (placebo group with 86, oxycodone group with 86). The study groups had comparable baseline characteristics. We found no difference between groups in median maximum pain scores (placebo 8 [range 1-10], oxycodone 8 [range 2-10], P=.92) and the median duration of maximum pain (placebo 0.75 hours range 0.01-15 vs oxycodone 1 hour range 0.02-10, P=.39). Groups were also similar in the proportion obtaining (placebo 62%, oxycodone 49%, P=.09) and using (placebo 48%, oxycodone 40%, P=.28) adjunctive medication, experiencing nausea or vomiting (placebo 59%, oxycodone 65%, P=.43) and reported satisfaction with pain medications (placebo 62%, oxycodone 65%, P=.63).

CONCLUSION

Oxycodone does not reduce the maximum level of pain experienced by women undergoing medical abortion up to 10 0/7 weeks of gestation or improve satisfaction.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03139240.

Abortion Surveillance - United States, 2016

PROBLEM/CONDITION

Since 1969, CDC has conducted abortion surveillance to document the number and characteristics of women obtaining legal induced abortions in the United States.

PERIOD COVERED

2016.

DESCRIPTION OF SYSTEM

Each year, CDC requests abortion data from the central health agencies of 52 reporting areas (the 50 states, the District of Columbia, and New York City). The reporting areas provide this information voluntarily. For 2016, data were received from 48 reporting areas. Abortion data provided by these 48 reporting areas for each year during 2007-2016 were used in trend analyses. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively.

RESULTS

A total of 623,471 abortions for 2016 were reported to CDC from 48 reporting areas. Among these 48 reporting areas, the abortion rate for 2016 was 11.6 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 186 abortions per 1,000 live births. From 2015 to 2016, the total number of reported abortions decreased 2% (from 636,902), the abortion rate decreased 2% (from 11.8 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 1% (from 188 abortions per 1,000 live births). From 2007 to 2016, the total number of reported abortions decreased 24% (from 825,240), the abortion rate decreased 26% (from 15.6 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 18% (from 226 abortions per 1,000 live births). In 2016, all three measures reached their lowest level for the entire period of analysis (2007-2016). In 2016 and throughout the period of analysis, women in their 20s accounted for the majority of abortions and had the highest abortion rates. In 2016, women aged 20-24 and 25-29 years accounted for 30.0% and 28.5% of all reported abortions, respectively, and had abortion rates of 19.1 and 17.8 abortions per 1,000 women aged 20-24 and 25-29 years, respectively. By contrast, women aged 30-34, 35-39, and ≥40 years accounted for 18.0%, 10.3%, and 3.5% of all reported abortions, respectively, and had abortion rates of 11.6, 6.9, and 2.5 abortions per 1,000 women aged 30-34, 35-39, and ≥40 years, respectively. From 2007 to 2016, the abortion rate decreased among women in all age groups. In 2016, adolescents aged <15 and 15-19 years accounted for 0.3% and 9.4% of all reported abortions, respectively, and had abortion rates of 0.4 and 6.2 abortions per 1,000 adolescents aged <15 and 15-19 years, respectively. From 2007 to 2016, the percentage of abortions accounted for by adolescents aged 15-19 years decreased 43%, and the abortion rate decreased 56%. This decrease in abortion rate was greater than the decreases for women in any older age group. In contrast to the percentage distribution of abortions and abortion rates by age, abortion ratios in 2016 and throughout the entire period of analysis were highest among adolescents and lowest among women aged 25-39 years. Abortion ratios decreased from 2007 to 2016 for women in all age groups. In 2016, almost two-thirds (65.5%) of abortions were performed at ≤8 weeks' gestation, and nearly all (91.0%) were performed at ≤13 weeks' gestation. Fewer abortions were performed between 14 and 20 weeks' gestation (7.7%) or at ≥21 weeks' gestation (1.2%). During 2007-2016, the percentage of abortions performed at >13 weeks' gestation remained consistently low (8.2%-9.0%). Among abortions performed at ≤13 weeks' gestation, the percentage distributions of abortions by gestational age were highest among those performed at ≤6 weeks' gestation (35.0%-38.4%). In 2016, 27.9% of all abortions were performed by early medical abortion (a nonsurgical abortion at ≤8 weeks' gestation), 59.9% were performed by surgical abortion at ≤13 weeks' gestation, 8.8% were performed by surgical abortion at >13 weeks' gestation, and 3.4% were performed by medical abortion at >8 weeks' gestation; all other methods were uncommon (0.1%). Among those that were eligible for early medical abortion on the basis of gestational age (i.e., performed at ≤8 weeks' gestation), 41.9% were completed by this method. In 2016, women with one or more previous live births accounted for 59.0% of abortions, and women with no previous live births accounted for 41.0%. Women with one or more previous induced abortions accounted for 43.1% of abortions, and women with no previous abortions accounted for 56.9%. Deaths of women associated with complications from abortion are assessed as part of CDC's Pregnancy Mortality Surveillance System. In 2015, the most recent year for which data were reviewed for abortion-related deaths, two women were identified to have died as a result of complications from legal induced abortion and for one additional death, it was unknown whether the abortion was induced or spontaneous.

INTERPRETATION

Among the 48 areas that reported data every year during 2007-2016, decreases in the total number, rate, and ratio of reported abortions resulted in historic lows for the period of analysis for all three measures of abortion.

PUBLIC HEALTH ACTION

The data in this report can help program planners and policymakers identify groups of women with the highest rates of abortion. Unintended pregnancy is the major contributor to induced abortion. Increasing access to and use of effective contraception can reduce unintended pregnancies and further reduce the number of abortions performed in the United States.

Implementation of mifepristone medical abortion in Canada: pilot and feasibility testing of a survey to assess facilitators and barriers

BACKGROUND

Direct primary care provision of first-trimester medical abortion could potentially address inequitable abortion access in Canada. However, when Health Canada approved the combination medication Mifegymiso® (mifepristone 200 mg/misoprostol 800 mcg) for medical abortion in July 2015, we hypothesized that the restrictions to distribution, prescribing, and dispensing would impede the uptake of this evidence-based innovation in primary care. We developed and pilot-tested a survey related to policy and practice facilitators and barriers to assess successful initiation and ongoing clinical provision of medical abortion service by physicians undertaking mifepristone training. Additionally, we explored expert, stakeholder, and physician perceptions of the impact of facilitators and barriers on abortion services throughout Canada.

METHODS

In phase 1, we developed a survey using 2 theoretical frameworks: Greenhalgh's conceptual model for the Diffusion of Innovations in health service organizations (which we operationalized) and Godin's framework to assess the impact of professional development on the uptake of new practices operationalized in Légaré's validated questionnaire. We finalized questions in phase 2 using the modified Delphi methodology. The survey was then tested by an expert panel of 25 nationally representative physician participants and 4 clinical content experts. Qualitative analysis of transcripts enriched and validated the content by identifying these potential barriers: physicians dispensing the medication, mandatory training to become a prescriber, burdens for patients, lack of remuneration for mifepristone provision, and services available in my community. To assess the usability and reliability of the online survey, in phase 3, we pilot-tested the survey for feasibility.

RESULTS

We developed and tested a 61-item Mifepristone Implementation Survey suitable to study the facilitators and barriers to implementation of mifepristone first-trimester medical abortion practice by physicians in Canada.

CONCLUSIONS

Our team operationalized Greenhalgh's theoretical framework for Diffusion of Innovations in health systems to explore factors influencing the implementation of first-trimester medical abortion provision. This process may be useful for those evaluating other health system innovations. Identification of facilitators and barriers to implementation of mifepristone practice in Canada and knowledge translation has the potential to inform regulatory and health system changes to support and scale up facilitators and mitigate barriers to equitable medical abortion provision.

Prophylactic Pregabalin to Decrease Pain During Medication Abortion: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether prophylactic pregabalin reduces pain experienced with medication abortion.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial of women initiating medication abortion with mifepristone and buccal misoprostol up to 70 days of gestation. Participants were randomized to 300 mg oral pregabalin or a placebo immediately before misoprostol. The primary outcome was maximum pain on an 11-point numerical rating scale, reported using real-time electronic surveys over 72 hours. Secondary outcomes included pain at each time point, ibuprofen and narcotic use, side effects, and satisfaction. We estimated that 110 women would be required to have 80% power to detect a difference in pain of 1.3 points.

RESULTS

Between June 2015 and October 2016, 241 women were screened and 110 were randomized (56 pregabalin, 54 placebo). Three were lost to follow-up. The primary outcome of mean maximum pain in the pregabalin group was 5.0±2.6 vs 5.5±2.2 in the placebo group (P=.32). Excluding medication taken before the study capsule, ibuprofen was used by 64% (35/55) of the pregabalin group vs 87% (45/52) placebo (P<.01). Narcotics were used by 29% (16/55) of the pregabalin group vs 50% (26/52) placebo (P<.03). More dizziness (P<.001), sleepiness (P<.04), and blurred vision (P<.05) occurred in the pregabalin group. Satisfaction scores for the analgesic regimen were higher in the pregabalin group (very satisfied: 47% vs 22%; P=.006).

CONCLUSION

Compared with placebo, 300 mg pregabalin coadministered with misoprostol during medication abortion did not significantly decrease maximum pain scores. Women who received pregabalin were less likely to require any ibuprofen or narcotic and were more likely to report higher satisfaction with analgesia, despite an increase in dizziness, sleepiness, and blurred vision.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02782169.

Contraception, Venous Thromboembolism, and Inflammatory Bowel Disease: What Clinicians (and Patients) Should Know

The peak incidence of the inflammatory bowel diseases (IBDs) is between the second and fourth decades of life, which coincides with prime reproductive years. Unplanned or mistimed pregnancies may account for nearly half of all pregnancies and are associated with adverse consequences such as a higher risk of delayed preconceptual care, increased risk of preterm birth, low birth weight, and adverse maternal and neonatal outcomes. Increased IBD activity during pregnancy is also associated with adverse pregnancy-related outcomes, such as miscarriage, intrauterine growth retardation, and preterm birth. Furthermore, the increased risk of venous thromboembolism (VTE) conferred by active IBD may be potentially augmented by hormonal contraceptives. Recent literature suggests that women with IBD seek counseling on contraception from gastroenterologists in preference to their primary care physicians. Meanwhile, attitudes and awareness regarding contraception counseling remain suboptimal, underpinning the importance and need for physician and patient education in this area. We discuss the association between contraception and IBD, benefits and risks associated with various contraceptive methods in women with IBD, and practical recommendations for clinicians caring for women with IBD. 10.1093/ibd/izz025_video1 izz025.video1 6014727518001 10.1093/ibd/izz025_video2 izz025.video2 6014726992001.