Abortion incidence and service availability in the United States, 2020

Long-acting reversible contraceptive preference and initiation among clinic-based and telemedicine medication abortion patients at one academic health system in California

OBJECTIVES

To examine possible differences in postabortion long-acting reversible contraception (LARC) preference and initiation among clinic-based medication abortion and telemedicine medication abortion patients.

STUDY DESIGN

We examined electronic medical records among 576 medication abortion patients at one health system in California between 2020 and 2022.

RESULTS

Overall, 25% of patients preferred LARC and 21% initiated LARC. Among those who preferred LARC, 77% initiated LARC. No statistically significant differences were found in LARC preference or initiation across medication abortion modalities.

CONCLUSIONS

In this health system, clinic-based medication abortion and telemedicine medication abortion patients did not differ in postabortion LARC preference or initiation.

Memorable Messages about Pregnancy and Abortion from the Perspective of College-Enrolled Emerging Adults

Emerging adults are the age group in the U.S. most likely to become pregnant, have a child, receive abortions, and be most supportive of legal abortion. To gain insight into these seemingly contradictory facts and attitudes, this study examines emerging adults' memorable messages about abortion and pregnancy to understand the beliefs, norms, values, and expectations circulating for younger adults. Ninety-two emerging adult college students provided memorable messages about both abortion and pregnancy. Utilizing thematic co-occurrence analysis, messages about pregnancy and abortion were characterized by three themes: political ideologies of sex, healthcare experience, and life-changing. Emerging adults described the messages as making them feel knowledgeable, empowered, and scared. Two theoretical relationships were identified: (1) pregnancy is connected to the political ideologies of sex with reactions of feeling empowered and scared and (2) abortion is connected to the politics of sex and the reactions of feeling knowledgeable and scared. Theoretical implications for the theory of memorable messages and practical applications for emerging adults are discussed.

Barriers to providing procedural abortion care among trained clinicians: An evaluation of an abortion training program

OBJECTIVES

Understand the barriers and facilitators that clinicians face in delivering procedural abortion care following participation in an abortion training program and how these barriers may differ based on professional characteristics (e.g. specialty, career stage) and institutional factors (e.g., clinic policies).

STUDY DESIGN

This analysis is part of a larger evaluation of a clinical training program focused on equipping clinicians with procedural abortion skills. Data collection occurred 07/2020-01/2024 and included semi-structured interviews and post-program surveys collected annually following program completion. Program participants who completed at least two surveys are included.

RESULTS

Forty-four ob-gyn and family medicine physicians met the inclusion criteria for this study. About one-third of program participants provided procedural abortion care 6 months following training and at their last survey (18-, 30- or 42 months post-training), and one-third did not provide at either time point. Barriers and facilitators for those providing abortion care often changed as program participants became more established in their practices (particularly post-residency). While local and state policies influenced the ability to provide care, other institutional and professional factors, including career stage, were often reported with some differences by specialty and career stage.

CONCLUSIONS

Structural and institutional barriers proved significant to those seeking to provide care post-training. Institutions looking to support abortion care should also ensure that this support is given to family medicine physicians. As program participants often had challenges finding work, training programs should focus on helping program participants build networks of providers to provide comprehensive training and job placement support.

IMPLICATIONS

Institutional, career and personal factors have compounding effects on individuals' ability to utilize their abortion training. While abortion training programs are helpful in training providers, program participants from these programs need additional networking and institutional supports to be able to provide procedural abortion care.

Explaining the sharp decline in birth rates in Canada and the United States in 2020

Birth rates in Canada and the United States declined sharply in March 2020 and deviated from historical trends. This decline was absent in similarly developed European countries. We argue that the selective decline was driven by incoming individuals, who would have traveled from abroad and given birth in Canada and the United States had there been no travel restrictions during the COVID-19 pandemic. Furthermore, by leveraging data from periods before and during the COVID-19 travel restrictions, we quantified the extent of births by incoming individuals. In an interrupted time series analysis, the expected number of such births in Canada was 970 per month (95% CI, 710-1200), which is 3.2% of all births in the country. The corresponding estimate for the United States was 6700 per month (95% CI, 3400-10 000), which is 2.2% of all births. A secondary difference-in-differences analysis gave similar estimates, at 2.8% and 3.4% for Canada and the United States, respectively. Our study reveals the extent of births by recent international arrivals, which hitherto has been unknown and infeasible to study.

Abortion provision and characteristics of abortion patients in an academic medical center in Washington state before and after Dobbs

OBJECTIVE

To examine abortion care in the largest academic medical center in Washington, a state protective of abortion rights, before and after the Supreme Court Dobbs decision.

METHODS

This retrospective cohort study evaluated abortion provision at the University of Washington between January 1, 2022 and October 31, 2023. Data on patient sociodemographic and clinical characteristics were extracted from electronic medical records. We assessed differences in patient sociodemographics, clinical characteristics, and type of care (medication vs. procedural) comparing the pre-Dobbs (January 1, 2022- June 23, 2022) and post-Dobbs (June 24, 2022 - October 31, 2023) periods using chi-squared tests for categorical variables and t-tests for continuous variables.

RESULTS

Among the 494 abortions performed during the study period, most were procedural (63%) and performed in the hospital setting (68%), over one-third (37%) had a fetal anomaly, and 4% were among individuals from out of state. The distribution of gestational duration was bimodal: over one-third of abortions occurred at less than 8 weeks gestation (34%) and 38% were 18 weeks or greater. The weekly number of abortions remained stable and there were minimal significant differences in patient characteristics or type of care comparing the pre-and-post Dobbs periods.

CONCLUSION

Academic medical centers provide comprehensive abortion services that span primary to complex specialty care. The minimal changes in abortion care following Dobbs suggests academic medical centers have important patient care and training opportunities to expand abortion access in Washington state.

The Role of Medication Abortion Provision in US States Without Total Abortion Bans, 2023

BACKGROUND

Medication abortion has accounted for an increasing share of abortions in the United States (US) since the Food and Drug Administration's approval of mifepristone in 2000. This study offers updated estimates of medication abortions provided within the formal healthcare system in 2023 in US states without total abortion bans as well as a discussion of recent trends in medication abortion provision.

METHODS

The Guttmacher Institute's Monthly Abortion Provision Study employs data from monthly samples of providers in a Bayesian hierarchical model to produce estimates of abortions provided within the formal healthcare system. We estimate the number and share of medication abortions provided in 2023 in states without total abortion bans and the share of abortions provided through telemedicine-only clinics.

RESULTS

Clinicians provided 648,500 medication abortions within the formal healthcare system in 2023 in states without total bans (90% uncertainty interval: 640,720-657,860), representing 63% of all abortions. Ten percent of all abortions were provided by telemedicine-only clinics. The number of medication abortions provided in US states without total abortion bans increased by 19% between 2019 and 2020, and by 32% between 2020 and 2023.

DISCUSSION

Medication abortion plays a critical role in the US abortion access landscape. Medication abortion provision has accelerated since 2019, likely due to COVID-era policies that facilitated the expansion of telemedicine medication abortion provision. This shift has created essential access for individuals navigating abortion bans and other barriers to care since the removal of federal abortion protections.

Weight and Procedural Abortion Complications: A Systematic Review

OBJECTIVE

To systematically assess the existing empiric evidence regarding a potential relationship between higher body weight and procedural abortion complications.

DATA SOURCES

EMBASE, MEDLINE, CINAHL, Web of Science, Google Scholar, and Clinicaltrials.gov were searched.

METHODS OF STUDY SELECTION

Our search identified 409 studies, which were uploaded to Covidence for review management; 133 duplicates were automatically removed. A team of two reviewers screened 276 studies, and a third reviewer resolved conflicts. Studies were included if they 1) consisted of peer-reviewed research published between 2010 and 2022, 2) were conducted in the United States, 3) included people with a higher body weight (body mass index [BMI] 30 or higher) in the study sample, and 4) assessed at least one outcome of procedural abortion safety stratified by a measure of body weight.

TABULATION, INTEGRATION, AND RESULTS

We extracted study data using Covidence and calculated an odds ratio for each study to facilitate the synthesis of results. Six studies assessing a total of 38,960 participants were included. No studies found a significant relationship between procedural abortion complications and higher body weight overall. Subgroup analysis from one study identified a significant increase in complications specifically among participants with BMIs higher than 40 who had second-trimester abortions. All studies used a retrospective cohort design and fulfilled Newcastle-Ottawa Scale criteria to be considered good quality. Studies varied in terms of clinical settings, patient populations, gestations assessed, clinician training levels, and care protocols.

CONCLUSION

Overall, higher body weight was not associated with an increased risk of procedural abortion complications in the included studies. The practice of referring patients undergoing procedural abortion with a higher body weight for hospital-based care is not based on recent safety evidence. On the contrary, this practice threatens the health of people with a higher body weight by potentially delaying their access to abortion care, extending their pregnancies into later gestations, and blocking their ability to access an abortion altogether.

The limitations of using Medicaid administrative data in abortion research

OBJECTIVES

To identify limitations of abortion data in national Medicaid claims files by comparing abortion counts in Medicaid claims data with state abortion estimates.

STUDY DESIGN

We used procedure (Current Procedural Terminology/Healthcare Common Procedure Coding System) and drug (National Drug Code) codes to identify abortion claims in 2009 and 2010 Medicaid Analytic eXtract (MAX) and 2020 Transformed Medicaid Statistical Information System Analytic File (TAF) data. We compared the number of abortions in MAX and TAF to the number of expected abortions covered by Medicaid overall and by state. Based on recent published research, we estimated expected Medicaid-covered abortions as 62% of total abortions in states using state funds to cover abortion services for Medicaid enrollees and 0.9% in states that follow Hyde restrictions.

RESULTS

MAX data identified 11% (38,668/345,480) of expected Medicaid-covered abortions in 2009 and 13% (44,528/330,801) of expected Medicaid-covered abortions in 2010. In 2020 TAF data, we found 25% (69,728/279,048) of the expected Medicaid-covered abortions. Among the 16 states that used state funds to cover abortions for Medicaid enrollees in 2020, the majority had <10% of expected Medicaid-covered abortions (n = 8). Three states had between 10% and 50% of expected abortions. Four states had between 51% and 75% of expected abortions. One state had insufficient data for reporting.

CONCLUSIONS

Abortion claims in MAX/TAF are an undercount of abortions covered by Medicaid, and this undercount varies across states. Variation in reporting across states and across time likely introduces bias into research trying to use MAX/TAF abortion claims across states and time. Researchers should use extreme caution when using MAX/TAF for abortion-related research.

IMPLICATIONS

Researchers should use caution when using the Medicaid Analytic eXtract and Transformed Medicaid Statistical Information System Analytic Files for abortion-related research questions.

Measuring abortion in claims data: What is the state of the science?

Health care insurance claims are an increasingly common data source for health outcomes research. While researchers have successfully used several claims data sources for many obstetric and gynecologic questions, the use of claims data for abortion and contraception research poses a number of challenges. In this update on the state of the science in identifying abortion in claims data, we review claims data generally, describe commonly used claims data sources, and detail specific reasons why abortion may be underestimated in claims even when employing best practices. We provide examples of successful approaches for identifying abortion in claims and importantly, spell out limitations when making comparisons across site of care, states, and policy contexts. As increased attention is turned to identifying abortion across diverse settings, it is critical best practices are applied so that the most appropriate inferences regarding abortion incidence across contexts over time are drawn.

Increasing Access to Abortion: ACOG Committee Statement No. 16

Legal and accessible abortion care is a necessary component of comprehensive health care. Access to abortion is threatened by local, state, and federal government restrictions; limitations on insurance coverage of abortion care; restrictions on funding for training; restrictions imposed by hospitals and health care systems; stigma; violence against health care professionals who provide abortion care; and a subsequent dearth of health care professionals who provide this care. Since the Dobbs v. Jackson Women's Health Organization decision, the abortion landscape is an ever-changing and shifting map of abortion restrictions and protections based on state-level interpretations and definitions of abortion care. This is confusing and chilling to both patients and health care professionals, who must learn to navigate a web of conflicting and varying state laws. Legislative restrictions fundamentally interfere with the patient-health care professional relationship and decrease access to abortion, particularly for individuals with low incomes and those living long distances from health care professionals. This Committee Statement continues the American College of Obstetricians and Gynecologists' previous calls for advocacy to oppose and overturn restrictions, to improve access, and to affirm abortion as an essential component of health care.

Abortion Rate Increased And Birth Rate Decreased After Introduction Of Medicaid Abortion Coverage In Illinois

The Hyde Amendment prohibits US federal spending on abortion, including federal Medicaid dollars. Seventeen states cover abortion care in their Medicaid programs, using state funds, but causal evidence on how Medicaid coverage for abortion affects pregnancy outcomes is limited. Using a difference-in-differences design and 2014-21 birth and abortion data from the Centers for Disease Control and Prevention that predate the US Supreme Court's Dobbs decision in 2022, we evaluated a 2018 policy introducing Medicaid coverage for abortion in Illinois. This change increased the number of abortions in the state by 2.43 per 1,000 reproductive-age females, an 18.2 percent increase, and reduced births by 1.66 per 1,000 reproductive-age females, a 2.8 percent decrease, relative to twenty-nine comparison states that did not cover abortion during the study period. Subgroup analyses of birth rates suggested that decreases in birth rates were more pronounced among Black and Hispanic residents, residents in counties with higher poverty rates, and residents closer to an abortion facility. Our finding suggests that Medicaid can play an important role in abortion access.

No-Test Telehealth Medication Abortion Services Provided by US-Based Clinicians in 21 States and the District of Columbia, 2020‒2022

Objectives. To evaluate the association between distance from closest abortion facility and number of fulfilled requests through no-test telehealth medication abortion (NTMA) asynchronous service. Methods. Using deidentified 2020-2022 electronic medical record data from Aid Access users in US states where NTMA is prescribed by US-based clinicians, we describe individual user demographics and their resident county characteristics. We conducted a county-level geospatial analysis of distance to abortion facility (Myers Abortion Facility Database) on fulfilled requests using Poisson regression. Results. US-based clinicians fulfilled NTMA requests to 8411 individuals in 21 states and the District of Columbia. Each 100-mile increase in distance to an abortion facility increased per-capita NTMA by 61% (95% confidence interval [CI] = 26%, 86%). Most individuals were aged 20 to 29 years (54%), had no living children (57%), were less than 6 weeks' gestation (62%), and lived in urban areas (65%). Almost half (49%) lived in higher socially vulnerable counties compared with 17% in less socially vulnerable counties. Conclusions. In the United States, telehealth medication abortion is a critically important service for individuals who are young, socially vulnerable, and living in counties far from abortion care facilities. Public Health Implications. With abortion now banned or highly restricted in 22 US states, telehealth abortion services are necessary to maintain essential reproductive health services. (Am J Public Health. 2025;115(2):221-231. https://doi.org/10.2105/AJPH.2024.307892).

A Proof-of-Concept Study of Ulipristal Acetate for Early Medication Abortion

BACKGROUND

The current regimen for early medication abortion in many countries is mifepristone and misoprostol, but mifepristone is relatively expensive and limited in many regions. Ulipristal acetate, with a similar chemical profile, might be an alternative. This proof-of-concept study evaluated ulipristal acetate and misoprostol for medication abortion through 63 days of gestation.

METHODS

We conducted a two-stage clinical study to choose an effective and acceptable ulipristal-misoprostol regimen. First, we undertook a dose-finding study. Sixty-six participants were randomly assigned to either 60 mg or 90 mg of oral ulipristal, followed by 800 μg of buccal misoprostol. Because the two groups had similar efficacy and safety profiles, we opted for the 60-mg ulipristal dose for an open-label study with 100 additional participants, resulting in a total of 133 participants using the same regimen. To evaluate acceptability, we applied a structured questionnaire at the end of the follow-up visit.

RESULTS

Pregnancy termination occurred with the combination of oral ulipristal 60 mg and buccal misoprostol 800 μg in 129 out of 133, or 97.0%, (95% confidence interval [CI], 94.1 to 99.9%), of participants. Among those for whom this regimen did not result in pregnancy termination, one participant had a completion with sharp curettage, two received manual vacuum aspiration, and one underwent a repeat medication abortion with misoprostol alone. Side effects included chills (77.4%; 95% CI, 70.3 to 84.5%), diarrhea (66.9%; 95% CI, 59.0 to 74.8%), and nausea (48.1%; 95% CI, 39.7 to 56.5%). No serious adverse events were reported. The regimen was deemed "acceptable" or "highly acceptable" by 97.7% (95% CI, 95.2 to 100.0%) of participants.

CONCLUSIONS

This study suggests that ulipristal acetate followed by misoprostol is an effective and acceptable medication abortion regimen with no reported serious adverse events. (This project is supported by the OPTions Initiative. The study registered as ISRCTN35625202.).

A New Tool for Estimating the Number of Pregnant People in the United States

BACKGROUND

Knowing the approximate number of women of reproductive age (ie, 15-49 years) who are pregnant at a point in time in the United States can aid in emergency preparedness resource allocation. The Centers for Disease Control and Prevention (CDC) released a pregnancy estimator toolkit in 2012, which could be used to estimate the number of pregnant people in a geographic area at a point in time. This original toolkit did not account for pregnancy losses before 20 weeks of gestation; however, an updated toolkit released by the CDC in May 2024 uses a ratio of live births to estimate the number of pregnancy losses before 20 weeks at a point in time for improved estimation of total pregnant people at a point in time.

INSTRUMENT

We used the CDC's updated reproductive health tool, "Estimating the Number of Pregnant Women in a Geographic Area."

EXPERIENCE

Using publicly available data for 2020, we gathered the necessary input values, including total births, fetal deaths, and induced abortions, and applied the equation available in the CDC toolkit to estimate the number of pregnant people in the United States at any point in time in 2020.

CONCLUSION

In 2020, there were 75,582,028 women of reproductive age in the United States, and we estimate that approximately 2,962,052 or 3.9% of women of reproductive age were pregnant at any point in time in the United States.

Abortion Provision at New York State Regional Perinatal Centers Following Implementation of the Reproductive Health Act

OBJECTIVE

Signed in 2019, New York State's Reproductive Health Act enabled expansion of abortion care up to 28 weeks for any indication. This study aimed to describe how implementation of the New York State Reproductive Health Act affected abortion provision among the state's regional perinatal centers (RPCs)-tertiary referral centers for complex pregnancies that may care for patients seeking abortion later in pregnancy. A secondary objective was to identify barriers to and facilitators of expanding abortion care.

METHODS

From January to May 2023, we recruited clinicians from the 17 New York RPCs, including family planning specialists, maternal-fetal medicine specialists, and genetic counselors. Respondents completed an online survey. We then invited respondents to complete an in-depth interview. We calculated descriptive statistics to characterize the study population and summarize survey responses. We analyzed qualitative interview data using thematic analysis.

RESULTS

Twenty-nine respondents completed the survey, representing 16 of 17 New York State RPCs. Seventeen respondents, representing 11 RPCs, completed an interview. All institutions provided abortion care. Twenty-three of 29 survey respondents (79%) reported barriers to providing abortion for any indication after 24 weeks from last menstrual period (LMP). Eighteen of 29 (62%) reported barriers to providing abortion after 24 weeks LMP for maternal or fetal indications. The most commonly reported barriers in the survey results were staff resistance and institutional policy. During interviews, respondents identified staff discomfort, restrictive institutional policies, and lack of clarity around policy as barriers, while highlighting advocates and collaboration within their institutions as facilitators to expansion of abortion services later in pregnancy.

CONCLUSIONS

RPCs in New York State face barriers in providing abortion, especially after 24 weeks LMP, even though they are ideally situated to provide such care. These barriers exist despite the legality of abortion after 24 weeks in New York and policy efforts to expand access to abortion.

Placenta accreta spectrum in the second trimester: a clinical conundrum in procedural abortion care

Given the limitations in perioperative management strategies available at freestanding abortion clinics, abortion providers must commonly discern which patients are too complicated for procedural abortions at their center and must be referred for a hospital-based abortion. The need to transition from freestanding clinics to hospital-based abortion care can lead to delays in completing an abortion and significant social, economic, and psychological repercussions for the pregnant individual. One significant clinical problem that exemplifies the issue of who can be safely taken care of at a freestanding abortion clinic is when the placenta accreta spectrum is suspected. Placenta accreta spectrum is one of the major contributors to maternal morbidity and mortality in the United States, requiring coordinated multidisciplinary management to ensure the safest outcome for the pregnant individual. In this Clinical Opinion, we review the literature focused on identifying individuals at risk for placenta accreta spectrum >14+0 weeks gestation, delineate an algorithm to improve the frequency of timely referrals to hospital-based abortion providers, and propose next steps for future training goals and research on placenta accreta spectrum in the second trimester between complex family planning and maternal-fetal medicine subspecialists.

A Cross-Sectional Epidemiological Study of Abortions in a Rural Area of Delhi

Background

Abortions in India are increasing despite the laws to legalize them. Many abortions are conducted through unsafe practices and are underreported. To determine the prevalence of abortions in women of a reproductive age group in a rural area of Delhi and to determine associated factors.

Methodology

A cross-sectional study was conducted among married women in the reproductive age group residing in Barwala village, Delhi/NCR. An interview schedule was used to interview 315 women, and information was obtained for socio-demography, use of contraceptives, medical history, and history of abortions. Chi-square and Fisher's exact test were used for analyzing the association of abortions with other variables.

Results

Of all 315 women, 47% had a history of one or more abortions. Of all pregnancies (n = 953), 25.6% ended in abortions (n = 244). Of the total number of abortions reported, 60.7% (n = 148) were induced, while 39.3% (n = 96) were spontaneous. Of induced abortions, only 35% were safe, while 65% were unsafe abortions. Age of mother, age at marriage, history of contraception use, and gender of first child were significantly associated with abortions. However, no significant association was found with socio-economic status, education, and occupation of women and their spouses. Only 1.3% women knew that abortions are legal in India.

Conclusion

A high proportion of women are going for induced abortions, of which a greater proportion is that of unsafe abortions. There is also lack of knowledge about the legalisation of abortions in India.

Adaptations to COVID-19 by US abortion clinics: Analysis of Society of Family Planning survey data

OBJECTIVE

Analyze changes in abortion practices during the early coronavirus disease 2019 (COVID-19) pandemic.

STUDY DESIGN

Sites recruited by Society of Family Planning participated in a longitudinal descriptive analysis comprising three surveys between February and October 2020. Average monthly total and medication abortion volume was analyzed by χ2 and linear regression.

RESULTS

Total average volume of abortion services did not change among participating sites (p = 0.79). Volume and proportion of medication abortion increased over the study period (p = 0.02, p < 0.01).

CONCLUSIONS

The early COVID-19 pandemic marked a shift toward medication abortion.

IMPLICATIONS

Our findings are interlaced in a national trend predating the Dobbs ruling, likely accelerated by the COVID-19 pandemic.

Abortion access barriers shared in "r/abortion" after Roe: a qualitative analysis of a Reddit community post-Dobbs decision leak in 2022

With drastic changes to abortion policy, the months following the Dobbs leak and subsequent decision in 2022 were a uniquely uncertain and difficult time for abortion access in the United States. To understand experiences of challenges to abortion access during that time, we used a hybrid inductive and deductive thematic coding approach to analyse descriptions of barriers and their impacts shared in an abortion subreddit (r/abortion). A simple random sample of 10% of posts was obtained from those shared from 02 May 2022 through 23 December 2022; comments were purposively sampled during the coding process. In this sample of submissions (n = 523 posts, 88 comments), people described structural barriers identified in past research, including state abortion bans and gestational limits, high costs, limited appointment availability, and long travel required. Posters also commonly described known social barriers, including limited social support and abortion stigma. Several impactful barriers not well-described in past research emerged inductively, including wait time for receiving mail-ordered abortion medication, low credibility of online ordering platforms, and concerns about legal risks of accessing abortion or related medical care. The most common consequences of experiencing barriers were adverse mental health outcomes, delayed access to care, and being compelled to self-manage their abortion because of access barriers. This analysis provides timely insights into the experiences and impacts of abortion access barriers in a group of people with a range of engagement with clinical abortion care, lived experiences, and points in their abortion processes, with public health implications for mental health and abortion access.

Examining service delivery patterns before and after implementation of a direct-to-patient telehealth service providing medication abortion in Australia

In August 2016, MSI Australia (MSIA) brought to scale a direct-to-patient telehealth medication abortion service. We used MSIA's patient management systems from January 2015 to December 2018 to assess changes in the proportion of abortion patients obtaining care after 13 weeks' gestation, proportion of abortion patients obtaining medication abortion versus procedural abortion and proportion of abortion patients from regional and remote versus metropolitan areas. The proportions of abortion patients obtaining care before 13 weeks' gestational duration and those from regional and remote residents did not change between the pre- and post-periods. We observed an increase in medication abortion use that was greater among those in regional and remote areas than those in metropolitan areas.

Abortion Surveillance - United States, 2022

Problem/Condition

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

Period Covered

2022.

Description of System

Each year, CDC requests abortion data from the central health agencies for the 50 states, the District of Columbia, and New York City. For 2022, a total of 48 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 47 reporting areas provided data each year during 2013-2022. 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 2021 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS).

Results

For 2022, a total of 613,383 abortions were reported to CDC from 48 reporting areas. Among 47 reporting areas with data each year during 2013-2022, in 2022, a total of 609,360 abortions were reported, the abortion rate was 11.2 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 199 abortions per 1,000 live births. From 2021 to 2022, the total number of abortions decreased 2% (from 622,108 total abortions), the abortion rate decreased 3% (from 11.6 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 2% (from 204 abortions per 1,000 live births). From 2013 to 2022, the total number of reported abortions decreased 5% (from 640,154), the abortion rate decreased 10% (from 12.4 abortions per 1,000 women aged 15-44 years), and the abortion ratio increased 1% (from 198 abortions per 1,000 live births).In 2022, women in their 20s accounted for more than half of abortions (56.5%). Women aged 20-24 and 25-29 years accounted for the highest percentages of abortions (28.3% and 28.2%, respectively) and had the highest abortion rates (18.1 and 18.7 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 3.6%, respectively) and had the lowest abortion rates (0.4 and 2.5 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios were highest among adolescents (aged ≤19 years) and lowest among women aged 30-39 years.From 2021 to 2022, abortion rates decreased among women aged ≥20 years and did not change among adolescents (aged ≤19 years). Abortion rates decreased from 2013 to 2022 among all age groups, except women aged 30-34 years for whom it increased. The decrease in the abortion rate from 2013 to 2022 was highest among adolescents compared with other age groups. From 2021 to 2022, abortion ratios increased for adolescents and decreased among women aged ≥20 years. From 2013 to 2022, abortion ratios increased among adolescents and women aged 20-34 years and decreased among women aged ≥35 years.In 2022, the majority (78.6%) of abortions were performed at ≤9 weeks' gestation, and nearly all (92.8%) were performed at ≤13 weeks' gestation. During 2013-2022, the percentage of abortions performed at >13 weeks' gestation remained low (≤8.7%). In 2022, the highest percentage of abortions were performed by early medication abortion at ≤9 weeks' gestation (53.3%), followed by surgical abortion at ≤13 weeks' gestation (35.5%), surgical abortion at >13 weeks' gestation (6.9%), and medication abortion at >9 weeks' gestation (4.3%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 70.2% of abortions were early medication abortions. In 2021, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, five women died as a result of complications from legal induced abortions.

Interpretation

Among the 47 areas that reported data continuously during 2013-2022, overall decreases were observed over this time in the number and rate of reported abortions and an increase was observed in the abortion ratio; in addition, from 2021 to 2022, decreases of 2%-3% 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.

The importance of abortion training for obstetrician-gynecologists: A comparison of the United States, Sweden, and Ghana

Since 2020, World Health Organization guidelines state that universal access to abortion care is critical for individual and community health, and for the realization of human rights. Yet the right to access safe abortion care is severely restricted in many countries. This article outlines institutional and educational systems in the USA, Sweden, and Ghana, which all require obstetrics and gynecology (ob-gyn) training to include abortion care but vary in implementation. It argues that regardless of the political environment, the specialty should protect abortion training worldwide. In Sweden and Ghana, ob-gyn residents are required to participate in abortion training, while in the USA they are permitted to opt out. In Sweden, practicing ob-gyn specialists are required to provide abortion care, whereas in Ghana and the USA, this care is optional, leading to geographic disparities in abortion care access in these two countries. In the USA, the Supreme Court's Dobbs ruling jeopardizes programs' abilities to meet the training mandate, a requirement that was insufficiently implemented even before the ruling. It is critical that all clinicians are well-equipped to provide accurate information to their patients and provide pre- and post-abortion care. For this reason, we recommend that abortion is included in all undergraduate medical education programs in accordance with the recommendations of FIGO (the International Federation of Gynecology & Obstetrics). To meet WHO guidelines that require ob-gyn specialists to provide abortion care in an emergency, we urge FIGO to create a guideline about expectations for abortion training integration in obstetrics and gynecology.

Impact of State Abortion Policies on Family Medicine Practice and Training After Dobbs v Jackson Women's Health Organization

PURPOSE

The Dobbs v Jackson Women's Health Organization (Dobbs) Supreme Court decision revoked the constitutional right to abortion. Now, restrictive state abortion laws may contribute to the shortage and strain already felt in primary care practice, especially related to the provision of reproductive health care. The purpose of this study is to evaluate perceived impacts of state abortion legislation on family medicine clinicians' practice and medical education regarding reproductive health care.

METHODS

Ten questions were added to the 2022 Council of Academic Family Medicine Educational Research Alliance general membership survey to evaluate impact on relevant themes in reproductive health care and training after the Dobbs decision. Responses were categorized by severity of restriction of state abortion policies.

RESULTS

Of 1,196 respondents, 49.7% reported employment in states with very restrictive or restrictive abortion policies. The 991 respondents with clinical responsibilities reported significant (P <.05) changes in their counseling practices, clinical decision making, worry of legal risks, and trust in patients' self-reported reproductive medical history, compared with peers in protective states. Perceived patient trust toward clinicians remained unchanged. Almost one-half of clinical respondents reported an absence of reproductive health care guidance or recommendations. Restrictive abortion policies significantly (P <.05) reduced the desirability and confidence in resident training programs.

CONCLUSIONS

Reported changes to clinical activities and training, coming early after the Dobbs decision, affect our current and future workforce and therefore, our patients. Future studies are needed to document continued impact of state restrictions and inform policy to support family medicine clinicians in reproductive health practice and education.

Economic analysis of foregoing Rh immunoglobulin for bleeding in pregnancy <12 weeks gestation

OBJECTIVES

To perform cost analyses of foregoing RhD blood type testing and administration of Rh immunoglobulin (RhIg) for bleeding in pregnancy at <12 weeks gestation in the United States.

STUDY DESIGN

We created a decision-analytic model comparing the current standard treatment pathway for patients who have threatened, spontaneous, or induced abortion in the United States, with a new pathway foregoing RhD testing and administration of RhIg for those who are RhD-negative at <12 weeks gestation, assuming that the risk of sensitization is 0%. We derived population and cost estimates from the current literature and calculated the number needed to treat (NNT) and number needed to screen to avoid one case of fatal hemolytic disease of the fetus and newborn. We performed sensitivity analyses assuming Rh-sensitization risks of 1.5% and 3% and varying the subsequent pregnancy rates from 44% to 100%.

RESULTS

The annual savings to health care payers in the United States of foregoing RhD testing and RhIg administration with bleeding events at <12 weeks are $5.5 million/100,000 total pregnancies, assuming the sensitization risk is 0%. In sensitivity analyses with a sensitization risk of 1.5% and subsequent pregnancy rate of 84.3% foregoing Rh testing and RhIg administration would save $2.8 million/100,000 pregnancies, with a NNT of 7322 and a number needed to screen of 48,816. At a 3% sensitization rate, the current standard treatment pathway is most economical.

CONCLUSIONS

There is an opportunity to save as much as $5.5 million/100,000 pregnancies by withholding RhIg in specific situations and conserving it for use later in pregnancy.

IMPLICATIONS

Cost analyses support foregoing RhD blood type screening and RhIg administration at <12 weeks gestation if the sensitization rate is <3%. By deimplementing this low-value care, payers in the United States can save as much as $5.5 million/100,000 pregnancies and conserve RhIg for use later in pregnancy.

Society of Family Planning Clinical Recommendation: Induction of fetal asystole before abortion Jointly developed with the Society for Maternal-Fetal Medicine

This document serves as a revision to the Society of Family Planning's 2010 guidelines, integrating literature on new techniques and research and addressing the clinical, medical, and sociolegal questions surrounding the induction of fetal asystole. Insufficient evidence exists to recommend routine induction of fetal asystole before previable medication and procedural abortion. However, at periviable gestations and after fetal viability, inducing fetal asystole before abortion prevents the infrequent but serious occurrence of unanticipated expulsion of a fetus with cardiorespiratory activity (Best Practice). Defining viability is complicated as it represents a physiological continuum impacted by gestational duration along with multiple other individual clinical factors and circumstances; therefore, the exact gestational duration to offer fetal asystole will depend on the setting and clinical circumstances. If induction of fetal asystole before abortion is available, we recommend engaging in patient-centered counseling regarding the risks and benefits of induction of fetal asystole in the setting of each unique pregnancy scenario and the patient's beliefs and priorities (Best Practice). We recommend that clinicians identify the optimal pharmacologic agent to administer for a given clinical scenario based on factors such as availability of each agent; the time frame in which fetal asystole needs to be established; and clinicians' technical ability, preferences, and practice (Best Practice). Potassium chloride, lidocaine, and digoxin are all acceptable pharmaceutical agents to induce fetal asystole before abortion. To establish asystole rapidly, we suggest the use of potassium chloride (via intracardiac or intrafunic injection) or lidocaine (via intracardiac or intrafunic injection) (GRADE 2C), although intrathoracic administration of lidocaine may be acceptable. We recommend potassium chloride not be used if intracardiac or intrafunic location cannot be achieved to avoid the risk of accidental administration to the pregnant individual and because insufficient data support its efficacy via other intrafetal locations (GRADE 1C). When using digoxin, we recommend intrafetal administration (GRADE 1C), although intraamniotic administration may be acceptable depending on a clinician's technical ability and setting. Because digoxin may take several hours to induce asystole, an alternative agent should be considered in settings where fetal asystole must be confirmed rapidly.

Emerging approaches to male contraception

BACKGROUND

Currently, approximately half of all pregnancies worldwide are unintended. Contraceptive use significantly reduces the risk of unintended pregnancy; however, options for men are particularly limited. Consequently, efforts are underway to develop novel, safe, and effective male contraceptives.

RESULTS

This review discusses research into emerging male contraceptive methods that either inhibit sperm production or impair sperm function. It focuses on those in the preclinical or early clinical stages of development.

Abortion

Induced abortion is safe, is common, and reduces pregnancy-related maternal morbidity and mortality. Internal medicine physicians are uniquely positioned to counsel patients on their pregnancy options, assess medical risks of pregnancy in the context of comorbidities, refer for abortion care when the patient desires it, or provide abortion care themselves. Clinicians can also provide anticipatory guidance about what patients should expect if they seek abortion care.

Online Medication Abortion Direct-to-Patient Fulfillment Before and After the Dobbs v Jackson Decision

Importance

Online pharmacies have emerged as stakeholders in abortion care since the US Food and Drug Administration (FDA) relaxed in-person dispensing requirements in 2020. The role of online pharmacies in dispensing abortion medications following the Dobbs v Jackson Women's Health Organization decision on June 24, 2022, is understudied.

Objective

To describe medication abortion prescription fulfillment patterns for 1 online pharmacy 1 year before and after the Dobbs v Jackson decision, considering patient, prescriber, and state policy characteristics.

Design, Setting, and Participants

This cross-sectional study assesses deidentified medication abortion prescription fulfilment data from 1 online pharmacy. Prescribers sent prescription requests to the online pharmacy, which dispensed abortion medications to patients by mail. The study sample included prescription requests fulfilled by the online pharmacy between June 20, 2021, and June 24, 2023, for patients aged at least 18 years who received the combined medication abortion regimen. Data were analyzed from July 2023 to July 2024.

Exposures

The US Supreme Court Dobbs v Jackson decision on June 24, 2022.

Main Outcomes and Measures

Patient and prescriber characteristics are described, including patient age, state to which the prescription was sent, medications prescribed, and prescribing prescriber's clinic care modality (in-person only, hybrid [in-person and virtual], and virtual only). States were grouped according to the Guttmacher Institute classification of policy support for abortion (most or very supportive, somewhat supportive, and somewhat restrictive). Fulfillment trends were disaggregated by prescriber modality and state policy environment; 2 states with similar telehealth but differing coverage policies (Illinois and Colorado) were compared.

Results

The dataset included 87 942 observations. Most prescriptions were sent to individuals younger than 30 years (57.1%), with a mean (SD) age of 28.7 (6.4) years. Throughout the study period, the greatest volume of prescription requests came from states with most or very supportive policies and from prescribers at virtual-only platforms. More prescriptions were sent in the year after Dobbs v Jackson (daily mean [SD], 88.5 [47.2] prescriptions in March 2022 vs 201.5 [97.5] prescriptions in March 2023) with fulfillment spikes following the Dobbs v Jackson leak on May 2, 2022, and decision on June 24, 2022. State policy contexts mirrored the overall trends, while prescriber modality trends were unique, with a big spike in fulfillment at 12 weeks after the Dobbs v Jackson decision for hybrid clinics compared with in-person-only clinics and telehealth-only platforms, which saw their largest spikes in mean daily prescription fulfillment the week immediately after Dobbs v Jackson. Illinois and Colorado had similar fulfillment trends, with spikes immediately following the Dobbs v Jackson decision and overall higher fulfillment after Dobbs v Jackson, with a daily mean (SD) of 10.5 (7.0) prescriptions in Illinois and 8.8 (5.7) prescriptions in Colorado in March 2022 versus 26.6 (13.6) prescriptions in Illinois and 16.7 (10.1) prescriptions in Colorado in March 2023.

Conclusions and Relevance

These findings illustrate the increasingly critical role online pharmacies play in direct-to-patient abortion care provision in the US and the strong linkages between virtual-only prescribers and online pharmacies. These findings suggest that barriers to accessing online pharmacies for abortion care should be removed.

Society of Family Planning Clinical Recommendation: Induction of fetal asystole before abortion Jointly developed with the Society for Maternal-Fetal Medicine☆,☆☆

This document serves as a revision to the Society of Family Planning's 2010 guidelines, integrating literature on new techniques and research and addressing the clinical, medical, and sociolegal questions surrounding the induction of fetal asystole. Insufficient evidence exists to recommend routine induction of fetal asystole before previable medication and procedural abortion. However, at periviable gestations and after fetal viability, inducing fetal asystole before abortion prevents the infrequent but serious occurrence of unanticipated expulsion of a fetus with cardiorespiratory activity (Best Practice). Defining viability is complicated as it represents a physiological continuum impacted by gestational duration along with multiple other individual clinical factors and circumstances; therefore, the exact gestational duration to offer fetal asystole will depend on the setting and clinical circumstances. If induction of fetal asystole before abortion is available, we recommend engaging in patient-centered counseling regarding the risks and benefits of induction of fetal asystole in the setting of each unique pregnancy scenario and the patient's beliefs and priorities (Best Practice). We recommend that clinicians identify the optimal pharmacologic agent to administer for a given clinical scenario based on factors such as availability of each agent; the time frame in which fetal asystole needs to be established; and clinicians' technical ability, preferences, and practice (Best Practice). Potassium chloride, lidocaine, and digoxin are all acceptable pharmaceutical agents to induce fetal asystole before abortion. To establish asystole rapidly, we suggest the use of potassium chloride (via intracardiac or intrafunic injection) or lidocaine (via intracardiac or intrafunic injection) (GRADE 2C), although intrathoracic administration of lidocaine may be acceptable. We recommend potassium chloride not be used if intracardiac or intrafunic location cannot be achieved to avoid the risk of accidental administration to the pregnant individual and because insufficient data support its efficacy via other intrafetal locations (GRADE 1C). When using digoxin, we recommend intrafetal administration (GRADE 1C), although intraamniotic administration may be acceptable depending on a clinician's technical ability and setting. Because digoxin may take several hours to induce asystole, an alternative agent should be considered in settings where fetal asystole must be confirmed rapidly.

Comparison of No-Test Telehealth and In-Person Medication Abortion

Importance

In the US, access to medication abortion using history-based (no-test) eligibility assessment, including through telehealth and mailing of mifepristone, has grown rapidly. Additional evidence on the effectiveness and safety of these models is needed.

Objective

To evaluate whether medication abortion with no-test eligibility assessment and mailing of medications is as effective as in-person care with ultrasonography and safe overall.

Design, Setting, and Participants

Prospective, observational study with noninferiority analysis. Sites included 4 abortion-providing organizations in Colorado, Illinois, Maryland, Minnesota, Virginia, and Washington from May 2021 to March 2023. Eligible patients were seeking medication abortion up to and including 70 days' gestation, spoke English or Spanish, and were aged 15 years or older.

Exposure

Study groups reflected the model of care selected by the patient and clinicians and included: (1) no-test (telehealth) eligibility assessment and mailing of medications (no-test + mail) (n = 228); (2) no-test eligibility assessment and pickup of medications (no-test + pickup) (n = 119); or (3) in-person with ultrasonography (n = 238).

Main Outcomes and Measures

Effectiveness, defined as a complete abortion without the need for repeating the mifepristone and misoprostol regimen or a follow-up procedure, and safety, defined as an abortion-related serious adverse event, including overnight hospital admission, surgery, or blood transfusion. Outcomes were derived from patient surveys and medical records. Primary analysis focused on the comparison of the no-test + mail group with the in-person with ultrasonography group.

Results

The mean age of the participants (N = 585) was 27.3 years; most identified as non-Hispanic White (48.6%) or non-Hispanic Black (28.1%). Median (IQR) gestational duration was 45 days (39-53) and comparable between study groups (P = .30). Outcome data were available for 91.8% of participants. Overall effectiveness was 94.4% (95% CI, 90.7%-99.2%) in the no-test + mail group and 93.3% (95% CI, 88.3%-98.2%) in the in-person with ultrasonography group in adjusted models (adjusted risk difference, 1.2 [95% CI, -4.1 to 6.4]), meeting the prespecified 5% noninferiority margin. Serious adverse events included overnight hospitalization (n = 4), blood transfusion (n = 2), and emergency surgery (n = 1) and were reported by 1.1% (95% CI, 0.4%-2.4%) of participants, with 3 in the no-test + mail group, 3 in the in-person with ultrasonography group, and none in the no-test + pickup group.

Conclusions and Relevance

This prospective, observational study found that medication abortion obtained following no-test telehealth screening and mailing of medications was associated with similar rates of complete abortion compared with in-person care with ultrasonography and met prespecified criteria for noninferiority, with a low prevalence of adverse events.

Abortion Education for Medical Students in an Era of Increased Abortion Restrictions

Following the Supreme Court's decision in Dobbs v Jackson Women's Health in June 2022, many states restricted or banned abortion. Medical educators have focused on how this change impacts abortion training for residents, but schools must also adapt undergraduate medical education. Medical schools provide the foundation for future physicians' knowledge and attitudes on abortion. Comprehensive, high-quality abortion education for all medical students is essential for the future of abortion care. Here, we present how education champions can lead curricular improvements in abortion education in the preclinical, clerkship, and postclerkship phases of undergraduate medical education.

Making sense of the economics of abortion in the United States

In 2023 the editors of Perspectives on Sexual and Reproductive Health issued a special call for papers related to the economics of abortion. Ten of those submissions are included in this volume and address critical issues including: (1) the role Medicaid continues to play in abortion access and how changes in state Medicaid coverage of abortion have expanded and restricted abortion care use; (2) how low-income individuals without insurance coverage for abortion utilize resources from abortion funds and through crowdsourcing platforms; (3) how the price of medication abortion has decreased with the availability of telemedicine medication abortion and how providers of that service are making efforts to reduce those prices even further; and (4) how legally restricting abortion access has significant economic implications for state economies and the US society as a whole. In this introduction, I review the general scope of prior research on the economics of abortion in the US as it relates to stigma-induced silences, abortion seekers, abortion providers, and abortion assistance organizations. I then highlight the new contributions made by the articles contained in this special issue.

"Trust Women": Characteristics of and learnings from patients of a Shield Law medication abortion practice in the United States

INTRODUCTION

The 2022 Massachusetts Shield Law protects telemedicine providers who care for abortion seekers in other states from criminal, civil, and licensure penalties. In this article we explore the characteristics of patients of The Massachusetts Medication Abortion Access Project (The MAP).

METHODS

The MAP is an asynchronous telemedicine service that offers mifepristone/misoprostol to abortion seekers in all 50 states who are at or under 11 weeks pregnancy gestation on initial intake. The MAP charges USD250 using a pay-what-you-can model. We analyzed medical questionnaires and payments submitted by patients who received care from The MAP during its first 6 months of operations using descriptive statistics and for content and themes.

RESULTS

From October 1, 2023-March 31, 2024, 1994 patients accessed care through The MAP. Almost all (n = 1973, 99%) identified as women/girls and about half (n = 984, 49%) were aged 20-29. The MAP cared for patients in 45 states; 84% (n = 1672) of these patients received pills in abortion ban or restricted southern states. Patients paid USD134.50 on average; 29% (n = 577) paid USD25 or less. Nearly two-thirds (n = 1293, 65%) received subsidized care; financial hardship featured prominently in patient comments.

DISCUSSION

Considerable demand exists for medication abortion care from Shield Law providers. The MAP demonstrates that providers can trust women and other pregnancy capable people to decide for themselves whether to obtain medication abortion pills by mail and to pay what they can afford without being required to justify their need. Identifying ways to support Shield Law provision and further subsidize abortion care are needed.

Medication and procedural abortion uptake during a period of increasing abortion hostility

Hundreds of state-level abortion restrictions were implemented in the US between 2010 and 2020. Medication abortion was being widely adopted during this same period. Understanding the impact of health policies and political climate will improve the delivery of and access to reproductive healthcare in a period of rapid change. To measure the association between state abortion hostility and mifepristone and procedural abortion rates, we conducted a state-level repeated cross-sectional study using 2010-2020 employer-sponsored insurance claims data from Merative MarketScan. The exposure of interest was a 13-point state-level abortion hostility score based on the presence of policies which either reduce or protect access to abortion. Outcomes of interest were annual mifepristone and procedural abortion claims per 100,000 enrollees. We used a linear mixed model adjusting for urbanicity, age group, and year. We assessed whether temporal trends in abortion claims were modified by state abortion hostility by interacting year with two measurements of abortion hostility: baseline score in 2010 and change from baseline score. We found that median state-level mifepristone claims increased from 20 to 37 per 100,000 included enrollees; meanwhile, median procedural abortions claims decreased from 69 to 20 per 100. For mifepristone, every unit increase in a state's baseline abortion hostility score was associated with 7.5 (CI, -12 to -3.6) fewer mifepristone claims per 100,000 in 2010. For states with baseline hostility and change scores of zero, we did not observe a significant time trend over the 11 year study period. For every unit increase in baseline hostility, the time trend changed by 0.5 fewer claims (CI, -0.8 to -0.2) per 100,000 per year. States with higher baseline abortion hostility had fewer overall abortions, less uptake of mifepristone abortions, and slower decline in procedural abortions between 2010 and 2020. Changes in hostility from new restrictions during this time period did not significantly impact claims. Advocates for abortion access must simultaneously attend to individual abortion policies and the overall political climate. Updated research on the relationship between political climate and the evolving clinical landscape of abortion care is needed to inform this work.

Medicaid's role in alleviating some of the financial burden of abortion: Findings from the 2021-2022 Abortion Patient Survey

BACKGROUND

Medicaid is the most common type of health insurance held by abortion patients, but the Hyde amendment prohibits the use of Medicaid to pay for this care. Seventeen states allow state Medicaid funds to cover abortion.

METHODS

We used data from a national sample of 6698 people accessing abortions at 56 facilities across the United States between June 2021 and July 2022. We compare patient characteristics and issues related to payment for the abortion across patients residing in states where state Medicaid funds covered abortion (Medicaid states) and those where it did not (Hyde states). We also examine which abortion patient populations were most likely to use Medicaid in states where it covers abortion care.

RESULTS

In Medicaid states, 62% of respondents used this method to pay for care while a majority of individuals in Hyde states, 82%, paid out of pocket. Some 71% of respondents in Medicaid states paid USD0 and this was substantially lower, 10%, in Hyde states. In Hyde states, two-thirds of respondents had to raise money for the abortion (e.g., by delaying bills) compared to 28% in Medicaid states. Within Medicaid states, groups most likely to rely on this method of payment included respondents who identified as Black (70%) or Latinx (66%), those in the lowest income group (78%) and those having second-trimester abortions (75%).

DISCUSSION

When state Medicaid funds cover abortion, it substantially reduces the financial burden of care. Moreover, it may increase access for groups historically marginalized within the health care system.

The impact of state Medicaid coverage of abortion on people accessing care in three states

CONTEXT

Medicaid is a major funder of reproductive health services, including family planning and pregnancy-related care, especially for people with limited income and people of color. Federal Medicaid funds cannot be used for abortion however 16 states allow state Medicaid funds to pay for abortion. In recent years, Illinois and Maine implemented, and West Virginia discontinued, state Medicaid coverage of abortion.

METHODOLOGY

With retrospective procedure- and patient-level data obtained from clinics in these three states, we used an interrupted time series design, multivariable regression models, and descriptive statistics to assess changes in procedure volume and patients' share of total procedure price (patient price).

RESULTS

In Maine and Illinois, implementing state Medicaid coverage of abortion contributed to an immediate overall increase in abortion access (as seen by a rise in monthly procedure volume at the time of the policy's implementation), a decrease in patient price (by 36% in Maine and 44% in Illinois) after policy implementation as compared to pre-implementation, and overall improved access among people of color. Conversely, when West Virginia discontinued coverage, access to care decreased, patient price increased by 130%, and the share of abortion procedures among people of color decreased.

CONCLUSIONS

In the fragmented abortion access landscape of the post-Roe era, our study provides new evidence that financial assistance offered through state Medicaid policies that cover abortion may be most helpful to those facing traditional structural inequities to access, while discontinuation of Medicaid coverage of abortion further burdens those already economically marginalized.

State Abortion Policy and Moral Distress Among Clinicians Providing Abortion After the Dobbs Decision

Importance

Moral distress occurs when individuals feel powerless to do what they think is right, including when clinicians are prevented from providing health care they deem necessary. The loss of federal protections for abortion following the Dobbs v Jackson Women's Health Organization Supreme Court decision may place clinicians providing abortion at risk of experiencing moral distress, as many could face new legal and civil penalties for providing care in line with professional standards and that they perceive as necessary.

Objective

To assess self-reported moral distress scores among abortion-providing clinicians following the Dobbs decision overall and by state-level abortion policy.

Design, Setting, and Participants

This survey study, conducted from May to December 2023, included US abortion-providing clinicians (physicians, advanced practice clinicians, and nurses). A purposive electronic survey was disseminated nationally through professional listservs and snowball sampling.

Exposure

Abortion policy in each respondent's state of practice (restrictive vs protective using classifications from the Guttmacher Institute).

Main Outcomes and Measures

Using descriptive statistics and unadjusted and adjusted negative binomial regression models, the association between self-reported moral distress on the Moral Distress Thermometer (MDT), a validated psychometric tool that scores moral distress from 0 (none) to 10 (worst possible), and state abortion policy was examined.

Results

Overall, 310 clinicians (271 [87.7%] women; mean [SD] age, 41.4 [9.7] years) completed 352 MDTs, with 206 responses (58.5%) from protective states and 146 (41.5%) from restrictive states. Reported moral distress scores ranged from 0 to 10 (median, 5) and were more than double for clinicians in restrictive compared with protective states (median, 8 [IQR, 6-9] vs 3 [IQR, 1-6]; P < .001). Respondents with higher moral distress scores included physicians compared with advanced practice clinicians (median, 6 [IQR, 3-8] vs 4 [IQR, 2-7]; P = .005), those practicing in free-standing abortion clinics compared with those practicing in hospitals (median, 6 [IQR, 3-8] vs 4 [IQR, 2-7]; P < .001), those no longer providing abortion care compared with those still providing abortion care (median, 8 [IQR, 4-9] vs 5 [IQR, 2-8]; P = .004), those practicing in loss states (states with the greatest decline in abortion volume since the Dobbs decision) compared with those in stable states (unadjusted incidence rate [IRR], 1.72 [95% CI, 1.55-1.92]; P < .001; adjusted IRR, 1.59 [95% CI, 1.40-1.79]; P < .001), and those practicing in surge states (states with the greatest increase in abortion volume since the Dobbs decision) compared with those in stable states (unadjusted IRR, 1.27 [95% CI, 1.11-1.46]; P < .001; adjusted IRR, 1.24 [95% CI, 1.09-1.41]; P = .001).

Conclusions and Relevance

In this purposive national survey study of clinicians providing abortion, moral distress was elevated among all clinicians and more than twice as high among those practicing in states that restrict abortion compared with those in states that protect abortion. The findings suggest that structural changes addressing bans on necessary health care, such as federal protections for abortion, are needed at institutional, state, and federal policy levels to combat widespread moral distress.

An assessment of clinical outcomes of medication abortion without pretreatment ultrasonography in Planned Parenthood, United States, 2020-2021

OBJECTIVES

Routine ultrasound before medication abortion (MAB) may create an impediment to expanding abortion access. This study examines clinical outcomes of MAB without pretreatment ultrasound evaluation at Planned Parenthood health centers in multiple states.

STUDY DESIGN

We conducted a secondary analysis of data from 23 US-based Planned Parenthood affiliates that provided MAB without pretreatment ultrasound for eligible patients from March 2020 to December 2021. Affiliates aggregated electronic health record data from MABs at ≤77 days gestation (based on self-report of last menstrual period) without a pretreatment ultrasound (N = 18,041). Among MABs with known outcomes (N = 9821), we calculated the incidence rates and 95% confidence intervals (CI) for completed abortion, ongoing pregnancy, subsequent procedure, emergency department/hospital visits associated with MAB, ectopic pregnancies, and gestational duration greater than 77 days.

RESULTS

Among MABs with known outcomes, 96.3% had a complete abortion (95% CI = 95.9%-96.7%), and 2.0% had an ongoing pregnancy (95% CI = 1.7%-2.3%). Four percent had a subsequent procedure (95% CI = 3.6%-4.4%), and 2.3% had a documented emergency department/hospital visit (95% CI = 2.0%-2.6%). Less than 1% had a confirmed ectopic pregnancy (0.15%, 95% CI = 0.09%-0.25%) and had a gestational duration later identified to be greater than 77 days (0.13%, 95% CI = 0.05%-0.29%).

CONCLUSIONS

Our calculated incidence rates of clinical outcomes align with rates from the previous literature on MAB and from the emerging literature on MAB without pretreatment ultrasonography. Findings from this analysis suggest that MAB without pretreatment ultrasound is safe and effective for eligible patients.

IMPLICATIONS

This large US study found that medication abortion without pretreatment ultrasonography results in similar clinical outcomes to prepandemic models that include pretreatment ultrasonography. Medication abortion without a pretreatment ultrasound may be adopted by abortion providers seeking to expand options for their patients as access to abortion continues to erode.

What's Behind the Dramatic Pre-2020 Declines in Hispanic/Latina Adolescent Childbearing? Decomposing Change by Age, Origin, and Nativity

PURPOSE

To assess whether the large declines in adolescent childbearing among Hispanic adolescents over the period 2000-2019 have been driven by co-occurring changes in the composition of the Hispanic population and, if so, whether they have done so differentially by Hispanic subgroup.

METHODS

We use birth counts from the United States vital statistics system and population denominators from the United States decennial census long form 5-percent Public Use Microdata and the American Community Survey to conduct a decomposition analysis apportioning observed declines in Hispanic adolescent childbearing to: (1) compositional shifts in nativity, age, and region-of-origin and (2) subgroup changes in childbearing rates.

RESULTS

The Hispanic adolescent fertility rate fell by over 71% from 2000 to 2019, with Mexican-Origin, United States-born, and younger adolescents exhibiting the steepest declines (79%, 70%, and 80% declines, respectively). Results from the decomposition analysis show that almost 90% of the decline is due to within-group rate change, with some variability by subgroup and by decade. Only 10% of the decline was due to compositional changes, with shifts in nativity driving much of the effect.

DISCUSSION

Declines in Hispanic adolescent childbearing over the last decades have occurred in spite of substantial shifts in the composition of the Hispanic population, not because of them. These findings set the stage for a more detailed examination of the drivers of change in sexual activity, contraceptive use, and abortion, all of which are proximate determinants of adolescent pregnancy and childbearing. Additionally, a focus on more distal factors is needed, including the role that changing political, societal, and economic conditions in the United States have for early fertility patterns.

Fertility in a Pandemic: Evidence from California

The COVID-19 pandemic was accompanied by social and economic changes previously associated with fertility delay and reduction, sparking widespread discussion of a "baby bust" in the U.S. We examine fertility trends using restricted vital statistics data from California, a diverse population of 40 million contributing 12% of U.S. births. Using time series models that account for longer-run fertility trends, we observe modest, short-term reductions in births from mid 2020 through early 2021. Birth counts in subsequent months matched or even eased the pace of fertility decline since the 2008 recession and are unlikely a function of the pandemic alone. Responses to the pandemic were heterogeneous. Fertility declined markedly among the foreign-born population, largely driven by changes in net migration. Among the U.S.-born population, the short-term pandemic-attributable reductions were largest among older, highly educated people, suggesting mechanisms of fertility reduction disparately accessible to those with the most resources. We find no evidence of a strong population fertility response to the pandemic's accompanying employment shock, providing additional evidence of a growing divide between macroeconomic conditions and fertility patterns in the U.S.

Self-Managed Abortion Attempts Before vs After Changes in Federal Abortion Protections in the US

Importance

With decreasing access to facility-based abortion in the US, an increase in self-managed abortion (SMA) using various methods is anticipated. To date, no studies have examined changes in SMA in the shifting policy landscape.

Objective

To estimate changes in SMA prevalence among the general US population from before to after the Supreme Court's June 2022 decision overturning federal abortion protections.

Design, Setting, and Participants

Serial cross-sectional surveys were administered throughout the US from December 10, 2021, to January 11, 2022, and June 14 to July 7, 2023. Participants included online panel members assigned female sex at birth, ages 18 to 49 years (or ages 15-17 years if a household member), who were English- or Spanish-speaking.

Exposure

Year of the survey (2021-2022 vs 2023).

Main Outcome and Measures

Participants were asked whether they had "ever taken or done something on their own, without medical assistance, to try to end a pregnancy" and, if so, details of their experience. Changes in the weighted SMA prevalence between survey years were examined, factors associated with SMA experience were identified, and projected lifetime SMA prevalence was calculated using discrete-time event history models, accounting for abortion underreporting.

Results

Median age of the participants was 32.5 (IQR, 25-41) years in 2021-2022 (n = 7016) and 32.0 (IQR, 24-40) in 2023 (n = 7148). Across both years, approximately 14% were non-Hispanic Black, 21% were Hispanic, and 54% were non-Hispanic White. The weighted adjusted proportion that ever attempted SMA was 2.4% (95% CI, 1.9%-3.0%) in 2021-2022 and 3.4% (95% CI, 2.8%-4.0%) in 2023-an increase of 1.0% (95% CI, 0.2%-1.7%; P = .03). Projected lifetime SMA prevalence accounting for abortion underreporting was 10.7% (95% CI, 8.6%-12.8%). In adjusted analyses, SMA experience was higher among non-Hispanic Black (4.3%; 95% CI, 2.8%-5.8%) vs other racial and ethnic (2.7%; 95% CI, 2.2%-3.1%) groups (P = .04) and sexual and gender minority (5.0%; 95% CI, 3.4%-6.6%) vs heterosexual or cisgender (2.5%; 95% CI, 2.0%-2.9%) participants (P < .001). Approximately 4 in 10 (45.3% in 2021 and 39.0% in 2023) SMA attempts occurred before age 20 years. The methods used included herbs (29.8% [2021-2022] vs 25.9% [2023]), physical methods (28.6% [2021-2022] vs 29.7% [2023]), or alcohol or other substances (17.9% [2021-2022] vs 18.6% [2023]). Few participants (7.1% [2021-2022] vs 4.7% [2023]) sought emergency care for a complication.

Conclusions and Relevance

In this serial nationally representative survey study, increased SMA was observed following the loss of federal abortion protections. The findings revealed increased SMA use among marginalized groups, most often with ineffective methods. These findings suggest the need to expand access to alternative models of safe and effective abortion care and ensure those seeking health care post-SMA do not face legal risks.

An estimate of lifetime incidence of abortion in the United States using the 2021-2022 Abortion Patient Survey

OBJECTIVES

The Guttmacher Institute estimated that, in 2014, 24% of US women of reproductive age would have an abortion by age 45 if the 2014 abortion rate was maintained. This study updates the estimated lifetime incidence of abortion in the year(s) just prior to the Dobbs decision, which removed federal protections for abortion.

STUDY DESIGN

We used data from the Guttmacher Institute's 2021-2022 Abortion Patient Survey and population data for 2020 and 2021 from the Census Bureau, as well as abortion counts from the Guttmacher Institute's 2020 Abortion Provider Census, to estimate abortion rates, first-abortion rates, and cumulative abortion rates, all by age group. We calculated multiple estimates of lifetime incidence under varying hypothetical conditions as tests of sensitivity.

RESULTS

We estimate that 24.7% (95% CI: 22.9-26.3) of women aged 15-44 in 2020 would have had an abortion by age 45 if abortion rates in 2020 remain constant. These figures changed slightly when we examined scenarios assuming a 5% increase in abortion between 2020 and 2021 (25.9, 95% CI: 24.0-27.6) and when we adjusted for the potential overrepresentation of adolescent and young adult respondents in the 2021-2022 Abortion Patient Survey (23.9, 95% CI: 22.2-25.6).

CONCLUSIONS

In the year(s) prior to the Dobbs decision, one-quarter of US women would have been expected to have at least one abortion in their lifetime if abortion rates for those years stayed the same.

IMPLICATIONS

Significant numbers of individuals are being affected by abortion bans, but we are unable to predict how these restrictions will impact abortion incidence or the lifetime incidence in the coming years.

Interest in and Support for Alternative Models of Medication Abortion Provision Among Patients Seeking Abortion in the United States

INTRODUCTION

Medication abortion is safe and effective, but restrictions still limit patients from accessing this method. Alternative models of medication abortion provision, namely advance provision, over-the-counter (OTC), and online, could help improve access to care for some, although there is limited evidence about abortion patients' interest in these models.

METHODS

Between 2017 and 2019, we administered a cross-sectional survey to abortion patients at 45 clinics across 15 U.S. states to explore their interest in and support for advance provision, OTC, and online abortion access. We assessed relationships between sociodemographic characteristics and interest in and support for each model using bivariate logistic regressions and present perceived advantages and disadvantages of each model, as described by a subset of participants.

RESULTS

Among 1,965 people enrolled, 1,759 (90%) initiated the survey. Interest in and support for advance provision was highest (72% and 82%, respectively), followed by OTC (63% and 72%) and online access (57% and 70%). In bivariate analyses, non-Hispanic Black and Asian/Pacific Islander respondents expressed lower interest and support for the online model and Alaska Native/Native American respondents expressed higher interest in an OTC model, as compared with white respondents. Among 439 participants naming advantages and disadvantages of each model, the most common advantages included convenience and having the abortion earlier. The most common disadvantages were not seeing a provider first and possibly taking pills incorrectly.

CONCLUSIONS

Although most abortion patients expressed interest in and support for alternative models of medication abortion provision, variation in support across race/ethnicity highlights a need to ensure that abortion care service models meet the needs and preferences of all patients, particularly people from historically underserved populations.

Experiences with and unmet needs for medication abortion support: A qualitative study with US abortion support providers

INTRODUCTION

Quality abortion care must be person-centered. Although academic literature has focused on full-spectrum and abortion doulas supporting instrumentation abortion (also referred to as procedural abortion) clients, clients undergoing medication abortion remain understudied and may have unique needs. We aimed to understand United States (US) abortion support providers' perceptions of medication abortion clients' support needs by exploring which needs they address, which needs remain unmet, and how remote support provision might help address client needs.

METHODOLOGY

Between April and October 2018, we conducted 60- to 90-min semi-structured, in-depth interviews by telephone with medication abortion support providers. The interviews focused on their experiences providing support to medication abortion clients in the US. We used a deductive thematic analysis approach.

RESULTS

We interviewed 16 abortion support providers affiliated with nine US-based organizations. Six participants provided in-person support to medication abortion clients, five provided remote support, and five provided both remote and in-person support. Both in-person and remote providers described offering support that addressed clients' informational, emotional, physical, spiritual, and logistical needs. Through participant narratives, we identified interwoven benefits and challenges to remote support care provision. Participants highlighted that most medication abortion clients did not have a support provider.

DISCUSSION

Participants revealed that abortion support providers, including remote support providers, can be a critical component of high-quality abortion care provision. More work is needed to ensure all abortion clients have access to support services as the abortion landscape in the US continues to evolve.

'I could see myself doing something like that': US women's engagement with characters who experience abortion, adoption and surrogacy on Little Fires Everywhere

Building on existing scholarship examining how audiences interpret reproductive experiences on film and television, we investigate how viewers make meaning of representations of motherhood, abortion, adoption, and surrogacy on the Hulu television miniseries Little Fires Everywhere. We recruited twenty-one participants to watch the series and conducted three virtual focus groups of seven women each. Based on the racial identities of the main characters in the series, we segmented these groups by race: one group each of white women, Black women, and Chinese American women. Focus groups were facilitated by moderators who matched the racial and ethnic backgrounds of each group. We asked participants about their overall reactions to the series, their impressions of various characters, and each reproductive health plotline. Participants expressed both tender and critical reactions to characters who endured motherhood, surrogacy and adoption, yet most participants were overtly critical of Lexie, the character who obtained an abortion. We argue that this is likely because the character of Lexie is written as largely unsympathetic, leaving audiences with little opportunity to form a parasocial relationship with her. We discuss the implications of this for cultural conversations and understandings of abortion more broadly.

Understanding the Impacts of the Supreme Court Case FDA v Alliance for Hippocratic Medicine

This Viewpoint outlines the potential effects of the Supreme Court case regarding mifepristone restrictions: a decision for the FDA would allow current dispensing, while ruling against the FDA would severely curtail access to reproductive health options.

Understanding medication abortion ineligibility due to gestational age among a cohort of patients in Southern California

OBJECTIVE

Medication abortion (MAB) is safe and effective up to 77 days gestation. Limited data are available on how often patients are ineligible for MAB due to advanced gestational age and how many of those ineligible go on to receive procedural abortion.

STUDY DESIGN

Retrospective analysis of electronic health records from Planned Parenthood of the Pacific Southwest (PPPSW) from January - December 2021. PPPSW has four procedural abortion sites and 15 MAB-only clinics that offered appointments only if last menstrual period-based GA was ≤70 days or unknown. Patients >70 days gestation by intake ultrasound at a MAB-only clinic were referred to a procedural center.

RESULTS

Of 11,684 patients presenting for MAB at MAB-only sites 2224 (19%) did not receive a MAB; 3.8% (N = 444) presented past 70 days gestation and were thus ineligible due to gestational age limits. Of those ineligible (N = 444), 234 (53%) measured between 71-77 days of gestation. Three quarters (75.7%) of those ineligible went on to receive a procedural abortion at PPPSW after a mean wait time of 10 days. In multivariable analysis, no demographic factors were associated with higher odds of receiving a procedural abortion.

CONCLUSIONS

Presenting for MAB past a gestational age limit was uncommon, supporting safety of no-test MAB protocols. A quarter of people ineligible for MAB due to gestational age did not receive a procedural abortion at PPPSW. If MAB were offered up to 77 days, half of patients who were denied MAB due to gestational age could have received MAB, expanding patient access.

IMPLICATIONS

Being ineligible for MAB due to advanced gestational age was uncommon. Increasing MAB gestational age limits from 70 days to 77 days could further improve abortion access.