Training health professionals to reduce overreporting of birthing people who use drugs to child welfare

BACKGROUND

Health care providers are a key source of reports of infants to child welfare related to birthing people's substance use. Many of these reports are overreports, or reports that exceed what is legally mandated, and reflect racial bias. We developed and evaluated a webinar for health professionals to address overreporting related to birthing people's substance use.

METHODS

This evaluation study collected data from health professionals registering to participate in a professional education webinar about pregnancy, substance use, and child welfare reporting. It collected baseline data upon webinar registration, immediate post-webinar data, and 6 month follow-up data. Differences in both pre-post-and 6 month follow-up data were used to examine changes from before to after the webinars in beliefs, attitudes, and practices related to pregnant and birthing people who use drugs and child welfare reporting.

RESULTS

592 nurses, social workers, physicians, public health professionals, and other health professionals completed the baseline survey. More than half of those completing the baseline survey (n = 307, 52%) completed one or both follow-up surveys. We observed statistically significant changes in five of the eleven opioid attitudes/beliefs and in four of the nine child welfare attitudes/beliefs from baseline to follow-ups, and few changes in "control statements," i.e. beliefs we did not expect to change based on webinar participation. All of the changes were in the direction of less support for child welfare reporting. In particular, the proportion agreeing with the main evaluation outcome of "I would rather err on the side of overreporting to child welfare than underreporting to child welfare" decreased from 41% at baseline to 28% and 31% post-webinar and at 6-month follow up (p = 0.001). In addition, fewer participants endorsed reporting everyone at the 6 month follow-up than at baseline (12% to 22%) and more participants endorsed reporting no one at the 6-month follow-up than at baseline (28% to 18%), p = 0.013.

CONCLUSIONS

Webinars on the legal, scientific, and ethical aspects of reporting that are co-developed with people with lived experience may be a path to reducing health professional overreporting to child welfare related to birthing people's substance use.

Associations between alcohol taxes and varied health outcomes among women of reproductive age and infants

OBJECTIVE

No studies have examined whether alcohol taxes may be relevant for reducing harms related to pregnant people's drinking.

METHOD

We examined how beverage-specific ad valorem, volume-based, and sales taxes are associated with outcomes across three data sets. Drinking outcomes came from women of reproductive age in the 1990-2020 US National Alcohol Surveys (N = 11 659 women $\le$ 44 years); treatment admissions data came from the 1992-2019 Treatment Episode Data Set: Admissions (N = 1331 state-years; 582 436 pregnant women admitted to treatment); and infant and maternal outcomes came from the 2005-19 Merative Marketscan® database (1 432 979 birthing person-infant dyads). Adjusted analyses for all data sets included year fixed effects, state-year unemployment and poverty, and accounted for clustering by state.

RESULTS

Models yield no robust significant associations between taxes and drinking. Increased spirits ad valorem taxes were robustly associated with lower rates of treatment admissions [adjusted IRR = 0.95, 95% CI: 0.91, 0.99]. Increased wine and spirits volume-based taxes were both robustly associated with lower odds of infant morbidities [wine aOR = 0.98, 95% CI: 0.96, 0.99; spirits aOR = 0.99, 95% CI: 0.98, 1.00] and lower odds of severe maternal morbidities [wine aOR = 0.91, 95% CI: 0.86, 0.97; spirits aOR = 0.95, 95% CI: 0.92, 0.97]. Having an off-premise spirits sales tax was also robustly related to lower odds of severe maternal morbidities [aOR = 0.78, 95% CI: 0.64, 0.96].

CONCLUSIONS

Results show protective associations between increased wine and spirits volume-based and sales taxes with infant and maternal morbidities. Policies that index tax rates to inflation might yield more public health benefits, including for pregnant people and infants.

What attributes of abortion care affect people's decision-making? Results from a discrete choice experiment

OBJECTIVES

We aimed to measure both stated and experimentally "revealed" abortion provision preferences among US people with capacity for pregnancy.

STUDY DESIGN

In July 2022, we recruited US residents assigned female sex at birth and aged 18 to 55 years using Prolific, an online survey hosting platform. We asked participants what first-trimester abortion method and delivery model they would prefer. We also assessed abortion care preferences with a discrete choice experiment, which examined the relative importance of the following care attributes: method, distance, wait time for appointment, delivery model (telehealth vs in-clinic), and cost.

RESULTS

More than half of the 887 respondents (59%) self-reported a slight (22%) or strong (37%) preference for medication compared to aspiration abortion; 11% stated no preference. Our discrete choice experiment found that cost and wait time had a greater effect on hypothetical decision-making than did method and delivery model (discrete choice experiment average importances = 44.3 and 23.2, respectively, compared to 15.9 and 8.2, respectively). Simulations indicated that holding other attributes constant, respondents preferred medication to aspiration abortion and telehealth to in-clinic care.

CONCLUSIONS

This study, the first to examine abortion preferences in the United States, using a discrete choice experiment, demonstrates the importance of wait time and cost in abortion care decision-making. Our work indicates that for this population, factors related to health care financing and organization may matter more than clinical aspects of care.

IMPLICATIONS

Although people in this study preferred medication to aspiration abortion and telehealth to in-clinic care, wait time and cost of care played a greater role in care decision-making. Focusing solely on clinical aspects of care (i.e., method, delivery model) may ignore other attributes of care that are particularly important for potential patients.

Is legal recreational cannabis associated with cannabis use during pregnancy, beliefs about safety, and perceived community stigma?

BACKGROUND

Among pregnant and recently pregnant people we investigated whether legal recreational cannabis is associated with pregnancy-related cannabis use, safety beliefs, and perceived community stigma.

METHODS

In 2022, we surveyed 3571 currently and recently pregnant English- or Spanish-speaking adults in 37 states. Primary outcomes included cannabis use during pregnancy and two continuous scale measures of beliefs about safety and perceived community stigma. Using generalized linear models and mixed effects ordinal logistic regression with random effects for state, we assessed associations between legal recreational cannabis and outcomes of interest, controlling for state-level and individual-level covariates and specifying appropriate functional form.

RESULTS

Those who reported cannabis use during pregnancy were more likely to believe it is safe and to perceive community stigma compared to those who did not report use during pregnancy. Legal recreational cannabis was not associated with cannabis use during pregnancy, continuation or increase in use, frequency of use, or safety beliefs. Legal recreational cannabis was associated with lower perceived community stigma (coefficient: -0.07, 95% CI: -0.13, -0.01), including among those who reported use during (coefficient = -0.22, 95% CI: -0.40, -0.04) and prior to but not during (coefficient = -0.19, 95% CI: -0.37, -0.01) pregnancy.

CONCLUSION

Findings do not support concerns that legal recreational cannabis is associated with cannabis use during pregnancy or beliefs about safety. Legal recreational cannabis may be associated with lower community stigma around cannabis use during pregnancy, which could have implications for pregnant people's disclosure of use and care-seeking behavior.

Relationships Between Alcohol Policies and Infant Morbidities and Injuries

INTRODUCTION

Previous research has found that policies specifically focused on pregnant people's alcohol use are largely ineffective. Therefore, the purpose of this study is to analyze the relationships between general population policies regulating alcohol physical availability and outcomes related to pregnant people's alcohol use, specifically infant morbidities and injuries.

METHODS

Outcome data were obtained from Merative MarketScan, a longitudinal commercial insurance claims data set. Policy data were obtained from the National Institute on Alcohol Abuse and Alcoholism's Alcohol Policy Information System, the National Alcohol Beverage Control Association, and Liquor Handbooks and merged using policies in effect during the estimated year of conception. Relationships between state-level policies regulating sites, days/hours, and government monopoly of liquor sales and infant morbidities and injuries were examined. Analyses used logistic regression with individual controls, fixed effects for state and year, state-specific time trends, and SEs clustered by state. The study analysis was conducted from 2021 to 2023.

RESULTS

The analytic sample included 1,432,979 infant-birthing person pairs, specifically people aged 25-50 years who gave birth to a singleton between 2006 and 2019. A total of 3.1% of infants had a morbidity and 2.1% of infants had an injury. State government monopoly on liquor sales was associated with reduced odds of infant morbidities and injuries, whereas gas station liquor sales were associated with increased odds of infant morbidities and injuries. Allowing liquor sales after 10PM was associated with increased odds for infant injuries. No effect was found for allowing liquor sales in grocery stores or on Sundays.

CONCLUSIONS

Findings suggest that limiting alcohol availability for the general population may help reduce adverse infant outcomes related to pregnant people's alcohol use.

Reconsidering the use of urine drug testing in reproductive settings

The urine drug test is ubiquitous within reproductive healthcare settings. Although the test can have evidence-based use for a patient and clinician, in practice, it is often applied in ways that are driven by bias and stigma, do not correctly inform decisions about clinical aspects of patient care, and cause devastating ripple effects through social and legal systems. This paper proposes a framework of guiding questions to prompt reflection on (1) the question the clinical team is trying to answer, (2) whether a urine drug test answers the question at hand, (3) how testing benefits compare with the associated risks, (4) a more effective tool for clinical decision-making if the urine drug test does not meet the standards for use, and (5) individual and institutional biases affecting decision-making. We demonstrate the use of this framework using 3 common uses of the urine drug test within abortion care and labor and delivery settings.

Pregnancy-specific alcohol policies and admissions to substance use disorder treatment for pregnant people in the USA

AIMS

We examined relationships between pregnancy-specific alcohol policies and admissions to substance use disorder treatment for pregnant people in the USA.

METHODS

We merged state-level policy and treatment admissions data for 1992-2019. We aggregated data by state-year to examine effects of nine pregnancy-specific alcohol policies on the number of admissions of pregnant women where alcohol was reported as the primary, secondary, or tertiary substance related to the treatment episode (N = 1331). We fit Poisson models that included all policy variables, state-level controls, fixed effects for state and year, state-specific time trends, and an offset variable of the number of pregnancies in the state-year to account for differences in population size and fertility.

RESULTS

When alcohol was reported as the primary substance, civil commitment [incidence rate ratio (IRR) 1.45, 95% CI: 1.10-1.89] and reporting requirements for assessment and treatment purposes [IRR 1.36, 95% CI: 1.04-1.77] were associated with greater treatment admissions. Findings for alcohol as primary, secondary, or tertiary substance were similar for civil commitment [IRR 1.31, 95% CI: 1.08-1.59] and reporting requirements for assessment and treatment purposes [IRR 1.21, 95% CI: 1.00-1.47], although mandatory warning signs [IRR 0.84, 95% CI: 0.72-0.98] and priority treatment for pregnant women [IRR 0.88, 95% CI: 0.78-0.99] were associated with fewer treatment admissions. Priority treatment findings were not robust in sensitivity analyses. No other policies were associated with treatment admissions.

CONCLUSIONS

Pregnancy-specific alcohol policies related to greater treatment admissions tend to mandate treatment rather than make voluntary treatment more accessible, raising questions of ethics and effectiveness.

Clinician views on reporting pregnant and birthing patients who use alcohol and/or drugs to child welfare

BACKGROUND

Multiple health professional associations have expressed concern with policies that require clinician reporting of pregnant people's substance use to child welfare, including that reporting negatively affects patient outcomes and the patient-provider relationship. However, research has shown that clinicians continue to report pregnant and birthing patients at high rates.

OBJECTIVE

This study aimed to explore clinician views on reporting pregnant and birthing patients who use alcohol or drugs during pregnancy to child welfare and whether there are patterns in the types of decisions that clinicians agree with, disagree with, or feel conflicted about.

STUDY DESIGN

In-depth interviews were conducted with 37 hospital-based clinicians (13 obstetrics and gynecology physicians, 12 emergency medicine physicians, 10 family medicine physicians, and 2 advance practice registered nurses) in the United States. The participants discussed one or more patient cases where they or someone else on the care team had to decide whether to report that patient to child welfare related to their use of alcohol or drugs during pregnancy. Cases were categorized on the basis of whether the participant agreed, disagreed, or was conflicted by the reporting decision in that case. Patterns were explored by patient-level factors, provider specialty, and whether the participant perceived that the decision was influenced by a state or hospital policy.

RESULTS

A total of 53 patient cases (average 2 per interview) were identified. The participants typically described cases where they agreed with the decision to report or believed there was no other option than reporting. These cases typically involved patients who used nonprescribed opioids during pregnancy, were experiencing factors (eg, unstable housing and untreated mental health disorders) in addition to substance use, and/or left the hospital against medical advice without their infant. Moreover, some participants, mostly obstetricians and gynecologists, described cases where they felt conflicted about or disagreed with the decision to report. These cases typically involved pregnant patients using cannabis and patients reported because of hospital and/or state policy. Only 1 participant described a case where they disagreed with the decision to not report.

CONCLUSION

The participants agreed with most, but not all, child welfare reporting decisions. When participants disagreed or felt conflicted with reporting decisions, these feelings were almost entirely related to decisions to report, which, in some cases, were prompted by hospital or state policies. Policies may prompt reporting that exceeds what clinicians believe is appropriate.

Association of Pregnancy-Specific Alcohol Policies With Infant Morbidities and Maltreatment

Importance

Research has found associations of pregnancy-specific alcohol policies with increased low birth weight and preterm birth, but associations with other infant outcomes are unknown.

Objective

To examine the associations of pregnancy-specific alcohol policies with infant morbidities and maltreatment.

Design, Setting, and Participants

This retrospective cohort study used outcome data from Merative MarketScan, a national database of private insurance claims. The study cohort included individuals aged 25 to 50 years who gave birth to a singleton between 2006 and 2019 in the US, had been enrolled 1 year before and 1 year after delivery, and could be matched with an infant. Data were analyzed from August 2021 to April 2023.

Exposures

Nine state-level pregnancy-specific alcohol policies obtained from the National Institute on Alcohol Abuse and Alcoholism's Alcohol Policy Information System.

Main Outcomes and Measures

The primary outcomes were 1 or more infant injuries associated with maltreatment and infant morbidities associated with maternal alcohol consumption within the first year. Logistic regression, adjusting for individual-level and state-level controls, and fixed effects for state, year, state-specific time trends, and SEs clustered by state were used.

Results

A total of 1 432 979 birthing person-infant pairs were included (mean [SD] age of birthing people, 32.2 [4.2] years); 30 157 infants (2.1%) had injuries associated with maltreatment, and 44 461 (3.1%) infants had morbidities associated with alcohol use during pregnancy. The policies of Reporting Requirements for Assessment/Treatment (adjusted odds ratio [aOR], 1.28; 95% CI, 1.08-1.52) and Mandatory Warning Signs (aOR, 1.18; 95% CI, 1.10-1.27) were associated with increased odds of infant injuries but not morbidities. Priority Treatment for Pregnant Women Only was associated with decreased odds of infant injuries (aOR, 0.83; 95% CI, 0.76-0.90) but not infant morbidities. Civil Commitment was associated with increased odds of infant injuries (aOR, 1.26; 95% CI, 1.08-1.48) but decreased odds of infant morbidities (aOR, 0.57; 95% CI, 0.53-0.62). Priority Treatment for Pregnant Women and Women With Children was associated with increased odds of both infant injuries (aOR, 1.12; 95% CI, 1.00-1.25) and infant morbidities (aOR, 1.08; 95% CI, 1.03-1.13). Reporting Requirements for Child Protective Services, Reporting Requirements for Data, Child Abuse/Neglect, and Limits on Criminal Prosecution were not associated with infant injuries or morbidities.

Conclusions and Relevance

In this cohort study, most pregnancy-specific alcohol policies were not associated with decreased odds of infant injuries or morbidities. Policy makers should not assume that pregnancy-specific alcohol policies improve infant health.

Association of Mandatory Warning Signs for Cannabis Use During Pregnancy With Cannabis Use Beliefs and Behaviors

Importance

As states have legalized recreational cannabis use, some have enacted policies mandating point-of-sale warning signs with information on harms of using cannabis during pregnancy. While research has found such warning signs are associated with increased adverse birth outcomes, reasons why are unclear.

Objective

To examine whether exposure to cannabis warning signs is associated with cannabis-related beliefs, stigma, and use.

Design, Setting, and Participants

This cross-sectional study used data from a population-based online survey conducted from May to June 2022. Participants included pregnant and recently pregnant (within past 2 years) members of the national probability KnowledgePanel and nonprobability samples in all US states and Washington, the District of Columbia, where recreational cannabis is legal. Data were analyzed from July 2022 to April 2023.

Exposure

Living in 1 of 5 states with a warning signs policy.

Main Outcomes and Measures

Outcomes of interest were self-reported beliefs (linear) that cannabis use during pregnancy is not safe, should be punished, and is stigmatized and cannabis use during pregnancy (dichotomous). Regressions, accounting for survey weights and clustering by state, examined associations of warning signs with cannabis-related beliefs and use.

Results

A total of 2063 pregnant or recently pregnant people (mean [SD] weighted age, 32 [6] years) completed the survey, and 585 participants (weighted, 17%) reported using cannabis during their pregnancy. Among people who used cannabis during their pregnancy, living in a warning signs state was associated with beliefs that cannabis use during pregnancy was safe (β = -0.33 [95% CI, -0.60 to -0.07]) and that people who used cannabis during pregnancy should not be punished (β = -0.40 [95% CI, -0.73 to -0.07]). Among people who did not use cannabis before or during pregnancy, living in a warning signs state was associated with beliefs that use was not safe (β = 0.34 [95% CI, 0.17 to 0.51]), that people should be punished for use (β = 0.35 [95% CI, 0.24 to 0.47]), and that use was stigmatized (β = 0.35 [95% CI, 0.07 to 0.63]). Warning signs policies were not associated with use (adjusted odds ratio, 1.11 [95% CI, 0.22 to 5.67]).

Conclusions and Relevance

In this cross-sectional study of warning signs and cannabis-related use and beliefs, warning signs policies were not associated with reduced cannabis use during pregnancy or with people who used cannabis believing use during pregnancy was less safe but were associated with greater support for punishment and stigma among people who did not use cannabis.

Association of Race With Urine Toxicology Testing Among Pregnant Patients During Labor and Delivery

This cohort study assesses the association of race with receipt of urine toxicology testing and a positive test result among pregnant patients admitted to the hospital for delivery.

Health care provider reporting practices related to self-managed abortion

BACKGROUND

Health care providers reporting patients to government authorities is a main way people attempting self-managed abortion (SMA) become exposed to legal risks. Little is known about health care provider decision-making regarding SMA reporting.

METHODS

We conducted semi-structured interviews with 37 clinicians who provided care in hospital-based obstetrics or emergency departments (13 obstetricians/gynecologists, two advance practice registered nurses providing obstetrics care, 12 emergency medicine physicians, and 10 family medicine physicians) throughout the United States. The interview guide asked participants to describe one or more cases of caring for a patient who may have attempted SMA and about related reporting decisions. We coded responses to answer two questions: What comes to mind for health care providers when asked to think about experiences caring for a patient who may have attempted SMA? Based on health care provider experiences, how might people who providers suspect may have attempted SMA end up reported?

RESULTS

About half of participants had cared for someone who may have attempted SMA for that pregnancy. Only two mentioned SMA with misoprostol. Most participants described cases where they were unsure whether the patient had attempted to end their pregnancy on purpose. In most instances, participants mentioned that that the possibility of reporting never occurred to them nor came up. In some cases, participants described a reporting "adjacent" practice - e.g. beginning processes that could lead to substance use, domestic violence, or self-injury/suicide-related reports - or considered reporting related to a perceived need to report abortion complications. In two cases, hospital staff reported to the police and/or Child Protective Services related to the SMA attempt. These involved passing of a fetus after 20 weeks outside the hospital and a domestic violence incident.

CONCLUSION

Reporting patients who may have attempted SMA may occur via provider perception of a need to report abortion complications and fetal demises, particularly at later gestations, and other reporting requirements (e.g. substance use, domestic violence, child maltreatment, suicide/self-harm).

Out-of-State Travel for Abortion among Texas Residents following an Executive Order Suspending In-State Services during the Coronavirus Pandemic

During the COVID-19 pandemic, existing and new abortion restrictions constrained people's access to abortion care. We assessed Texas abortion patients' out-of-state travel patterns before and during implementation of a state executive order that prohibited most abortions for 30 days in 2020. We received data on Texans who obtained abortions between February and May 2020 at 25 facilities in six nearby states. We estimated weekly trends in the number of out-of-state abortions related to the order using segmented regression models. We compared the distribution of out-of-state abortions by county-level economic deprivation and distance traveled. The number of Texas out-of-state abortions increased 14% the week after (versus before) the order was implemented (incidence rate ratio [IRR] = 1.14; 95% CI: 0.49, 2.63), and increased weekly while the order remained in effect (IRR = 1.64; 95% CI: 1.23, 2.18). Residents of the most economically disadvantaged counties accounted for 52% and 12% of out-of-state abortions before and during the order, respectively (p < 0.001). Before the order, 38% of Texans traveled ≥250 miles one way, whereas during the order 81% traveled ≥250 miles (p < 0.001). Texans' long-distance travel for out-of-state abortion care and the socioeconomic composition of those less likely to travel reflect potential burdens imposed by future abortion bans.

Disseminating Evidence on Abortion Facilities to Health Departments: A Randomized Study of E-mail Strategies

Given the politicization of abortion, professionals working in U.S. health departments (HDs) may not be receptive to communications about abortion, despite often regulating abortion facilities. This paper reports results of a randomized, prospective, observational study to test the effects of e-mail language when disseminating evidence on abortion to HD professionals. Our sample was 302 HD employees who oversee healthcare facilities inspection/regulation in all 50 U.S. state HDs, clustered by HD and randomized into two study groups. In November-December 2019, we sent biweekly e-mails containing links to a website summarizing evidence on abortion facility regulation. E-mails/headers sent to one group emphasized public health values and did not include the word abortion; e-mails/headers to the other group used the word abortion. Primary outcome measures were e-mail open rates and click-through rates. Among 221 participants to whom e-mails were deliverable, the overall open rate was 36%. Open rate was 25% for PH values and 46% for abortion groups (p < .05). Effects were moderated by state abortion policy environment: in both supportive and restrictive environments, participants in the abortion messaging group were statistically more likely to open e-mails than those in the PH values group. There was no difference between groups in states with middle-ground abortion policy environments. Among participants opening at least one e-mail, 19% clicked through to the website, with no significant difference by group. This study demonstrates that repeated targeted e-mail campaigns can reach HD professionals with research summaries. Concerns that communications to HDs should avoid the word abortion are unsupported.

Relationship between mandatory warning signs for cannabis use during pregnancy policies and birth outcomes in the Western United States

As U.S. states legalize recreational cannabis, some enact policies requiring Mandatory Warning Signs for cannabis during pregnancy (MWS-cannabis). While previous research has found MWS for alcohol during pregnancy (MWS-alcohol) associated with increases in adverse birth outcomes, research has not examined effects of MWS-cannabis. This study uses Vital Statistics birth certificate data from June 2015 - June 2017 in seven western states and policy data from NIAAA's Alcohol Policy Information System and takes advantage of the quasi-experiment created by Washington State's enactment of MWS-cannabis in June 2016, while nearby states did not. Outcomes are birthweight, low birthweight, gestation, and preterm birth. Analyses use a Difference-in-Difference approach and compare changes in outcomes in Washington to nearby states in the process of legalizing recreational cannabis (Alaska, California, Nevada) and, as a secondary analysis, nearby states continuing to criminalize recreational cannabis (Idaho, Montana, Wyoming). Birthweight was -7.03 g lower (95% CI -10.06, -4.00) and low birthweight 0.3% higher (95% CI 0.0, 0.6) when pregnant people were exposed to MWS-cannabis than when pregnant people were not exposed to MWS-cannabis, both statistically significant (p = 0.005 and p = 0.041). Patterns for gestation, -0.014 weeks earlier (95% CI -0.038, 0.010) and preterm birth 0.2% higher (95% CI -0.2, 0.7), were similar, although not statistically significant (p = 0.168 and 0.202). The direction of findings was similar in secondary analyses, although statistical significance varied. Similar to MWS-alcohol, enacting MWS-cannabis is associated with an increase in adverse birth outcomes. The idea that MWS-cannabis provide a public health benefit is not evidence-based.

Reaching Consensus on Politicized Topics: A Convening of Public Health Professionals to Discuss Appropriate Abortion Activities for US Health Departments

CONTEXT

Public health professionals, particularly those in state and local health departments, do not always have clear understandings of their roles related to politically controversial public health topics. A process of consensus development among public health professionals that considers the best available evidence may be able to guide decision making and lay out an appropriate course of action.

APPROACH

In May 2020, a group of maternal and child health and family planning professionals working in health departments, representatives of schools of public health, and members of affiliated organizations convened to explore values and principles relevant to health departments' engagement in abortion and delineate activities related to abortion that are appropriate for health departments. The convening followed a structured consensus process that included multiple rounds of input and opportunities for feedback and revisions.

OUTCOMES

Convening participants came to consensus on principles to guide engagement in activities related to abortion, a set of activities related to abortion that are appropriate for health departments, and next steps to support implementation of such activities.

LESSONS LEARNED

The experience of the convening indicates that consensus processes can be feasible for politically controversial public health topics such as abortion.

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.

A gender-focused multilevel analysis of how country, regional and individual level factors relate to harm from others' drinking

BACKGROUND

The aim of this study was to examine how gender, age and education, regional prevalence of male and female risky drinking and country-level economic gender equality are associated with harms from other people's drinking.

METHODS

24,823 adults in ten countries were surveyed about harms from drinking by people they know and strangers. Country-level economic gender equality and regional prevalence of risky drinking along with age and gender were entered as independent variables into three-level random intercept models predicting alcohol-related harm.

FINDINGS

At the individual level, younger respondents were consistently more likely to report harms from others' drinking, while, for women, higher education was associated with lower risk of harms from known drinkers but higher risk of harms from strangers. Regional rate of men's risky drinking was associated with known and stranger harm, while regional-level women's risky drinking was associated with harm from strangers. Gender equality was only associated with harms in models in models that did not include risky drinking.

CONCLUSIONS

Youth and regional levels of men's drinking was consistently associated with harm from others attributable to alcohol. Policies that decrease the risky drinking of men would be likely to reduce harms attributable to the drinking of others.

Abortion at 12 or more weeks' gestation and travel for later abortion care among Mississippi residents

OBJECTIVE

To assess the association between indicators of economic disadvantage and geographic accessibility of reproductive health services and abortions ≥12 weeks' gestation in Mississippi.

STUDY DESIGN

This cross-sectional study used data on Mississippi residents who obtained abortion care from 12 of 14 facilities in Mississippi, Alabama, Louisiana, and Tennessee in 2018. We estimated logistic regression models to assess the association between levels of county deprivation, the number of obstetrician/gynecologists per 10,000 women, and one-way distance to the nearest facility with having an abortion ≥12 weeks' gestation. We compared the median one-way distance to the facility where patients <12 weeks', 12-15 weeks', and ≥16 weeks' gestation received care, using Kruskal-Wallis tests.

RESULTS

Of the 4,455 Mississippi residents who obtained abortions, 73% were Black, 59% lived ≥50 miles from a facility, and 60% obtained care in Mississippi. Overall, 764 (17.2%) abortions were performed ≥12 weeks' gestation. In adjusted models, those in counties with moderate (OR, 1.47; 95% CI: 1.15-1.90) and high (OR: 1.36, 95% CI: 1.01-1.83) (vs low) levels of economic deprivation and counties with 0.1-1.4 (vs ≥2.5) obstetrician/gynecologists per 10,000 women (OR: 1.55; 95% CI: 1.06-2.27) had higher odds of obtaining an abortion ≥12 weeks' gestation. Mississippi residents who obtained abortions ≥16 weeks' gestation traveled a median 143 miles one way to the facility where they received care, compared to 69 miles and 60 miles traveled by those <12 weeks' and 12-15 weeks' gestation, respectively (p<.001).

CONCLUSIONS

Many Mississippi residents obtained abortion care ≥12 weeks' gestation, which is related to greater economic constraints and limited geographic access to reproductive health services.

IMPLICATIONS

People's need for abortions ≥12 weeks' gestation may be higher in communities with limited access to reproductive health services and among those living in areas with greater economic disadvantage. State laws that narrow gestational limits would increase long-distance travel for later abortion care, and disproportionately affect those with fewer resources.

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.

Pregnant people's experiences discussing their cannabis use with prenatal care providers in a state with legalized cannabis

BACKGROUND

As cannabis legalization spreads, so do concerns about potential harms from use during pregnancy. Legalization may facilitate improved patient-provider interactions about cannabis use. Yet little is known about pregnant people's discussions of cannabis use with healthcare providers in an environment where recreational cannabis is legal.

METHODS

In May-August 2019, we conducted semi-structured in-depth interviews with 33 pregnant or postpartum people in California who used cannabis during pregnancy, and explored their discussions with healthcare providers about their cannabis use. We audio-recorded and transcribed interviews, and conducted thematic analysis using inductive and deductive methods.

RESULTS

Participants were diverse by age, race/ethnicity, and socio-economic position. Most reported daily cannabis use, both before and during pregnancy. Most participants did not disclose their cannabis use to their prenatal care providers, due to fears of being reported to child protective services (CPS), or fears of provider judgment. Participants reported that few providers initiated any discussions about cannabis use in pregnancy with them; some participants interpreted this omission as tacit endorsement of cannabis use in pregnancy. When participants and providers did discuss cannabis use in pregnancy, participants heard a wide range of sometimes-conflicting health messages, as well as some legal threats.

CONCLUSIONS

This study documents notable deficits in patient-provider interactions about cannabis. Pregnant patients' fears of being reported to CPS and separated from their children for cannabis use persist despite cannabis legalization. Providers' role as potential reporters to CPS appears to pose a significant barrier to comprehensive, compassionate counseling and education on cannabis use in pregnancy.

Dismantling the legacy of failed policy approaches to pregnant people's use of alcohol and drugs

Most U.S. states have one or more pregnancy-specific alcohol or drug policies. However, research evidence indicates that some of these policies lead to increases in adverse birth outcomes, including low-birthweight and preterm birth. We offer explanations for why these ineffective policies related to pregnant people's use of alcohol and drugs in the U.S. exist, including: abortion politics; racism and the 'War on Drugs'; the design and application of scientific evidence; and lack of a pro-active vision. We propose alternative processes and concepts to guide strategies for developing new policy approaches that will support the health and well-being of pregnant people who use alcohol and drugs and their children. Processes include: involving people most affected by pregnancy-specific alcohol and drug policies in developing alternative policy and practice approaches as well as future research initiatives. Additionally, we propose that research funding support the development of policies and practices that bolster health and well-being rather than primarily documenting the harms of different substances. Concepts include accepting that policies adopted in response to pregnant people's use of alcohol and drugs cause harms and working to do better, as well as connecting to efforts that re-envision the child welfare system in the U.S.

Disruptions to Abortion Care in Louisiana During Early Months of the COVID-19 Pandemic

Objectives. To examine changes in abortions in Louisiana before and after the COVID-19 pandemic onset and assess whether variations in abortion service availability during this time might explain observed changes. Methods. We collected monthly service data from abortion clinics in Louisiana and neighboring states among Louisiana residents (January 2018‒May 2020) and assessed changes in abortions following pandemic onset. We conducted mystery client calls to 30 abortion clinics in Louisiana and neighboring states (April‒July 2020) and examined the percentage of open and scheduling clinics and median waits. Results. The number of abortions per month among Louisiana residents in Louisiana clinics decreased 31% (incidence rate ratio = 0.69; 95% confidence interval [CI] = 0.59, 0.79) from before to after pandemic onset, while the odds of having a second-trimester abortion increased (adjusted odds ratio [AOR] = 1.91; 95% CI = 1.10, 3.33). The decrease was not offset by an increase in out-of-state abortions. In Louisiana, only 1 or 2 (of 3) clinics were open (with a median wait > 2 weeks) through early May. Conclusions. The COVID-19 pandemic onset was associated with a significant decrease in the number of abortions and increase in the proportion of abortions provided in the second trimester among Louisiana residents. These changes followed service disruptions.

Changes in Abortion in Texas Following an Executive Order Ban During the Coronavirus Pandemic

This study assesses changes in abortions performed and at what gestational age following a Texas order postponing non–medically necessary surgeries due to the COVID-19 pandemic compared with abortions performed during the same months in 2019.

State abortion policies and Medicaid coverage of abortion are associated with pregnancy outcomes among individuals seeking abortion recruited using Google Ads: A national cohort study

OBJECTIVE

A major challenge to understanding barriers to abortion is that those individuals most affected may never reach an abortion provider, making the full impact of restrictive policies difficult to measure. The Google Ads Abortion Access Study used a novel method to recruit individuals much earlier in the abortion-seeking process. We aimed to understand how state-level abortion policies and Medicaid coverage of abortion influence individuals' ability to obtain wanted abortions.

METHODS

We employed a stratified sampling design to recruit a national cohort from all 50 states searching Google for abortion care. Participants completed online baseline and 4-week follow-up surveys. The primary independent variables were: 1) state policy environment and 2) state coverage of abortion for people with Medicaid. We developed multivariable multinomial mixed effects models to estimate the associations between each state-level independent variable and pregnancy outcome.

RESULTS

Of the 874 participants with follow-up data, 48% had had an abortion, 32% were still seeking an abortion, and 20% were planning to continue their pregnancies at 4 weeks follow-up. Individuals in restricted access states had significantly higher odds of planning to continue the pregnancy at follow-up than participants in protected access states (aOR = 1.70, 95% CI = 1.08, 2.70). Individuals in states that do not provide coverage of abortion for people with Medicaid had significantly higher odds of still seeking an abortion at follow-up (aOR = 1.80, 95% CI = 1.24, 2.60). Individuals living in states without Medicaid coverage were significantly more likely to report that having to gather money to pay for travel expenses or for the abortion was a barrier to care.

CONCLUSIONS

Restrictive state-level abortion policies are associated with not having an abortion at all and lack of coverage for abortion is associated with prolonged abortion seeking. Medicaid coverage of abortion appears critical to ensuring that all people who want abortions can obtain them.

Pregnant Women's Acceptability of Alcohol, Tobacco, and Drug Use Screening and Willingness to Disclose Use in Prenatal Care

PURPOSE

Despite the prevalence of alcohol, tobacco, and other drug (ATOD) use screening as part of prenatal care, pregnant women's perspectives on screening are largely absent from research and clinical practice. This study examines pregnant women's acceptability of ATOD screening and willingness to disclose their ATOD use in prenatal care.

METHODS

Pregnant women completed a self-administered survey and structured interview at four prenatal care facilities in Louisiana and Maryland (N = 589). Participants reported the acceptability of screening and their willingness to honestly disclose their ATOD use to their provider. Data were analyzed through descriptive statistics, tests of proportions, simple regression models, and coding of open-ended responses.

RESULTS

Nearly all pregnant women found screening acceptable for alcohol (97%), tobacco (98%), and other drug use (97%) during prenatal care. The acceptability of alcohol use screening was higher among those who reported binge drinking (98% vs. 96%; p = .002) and risky alcohol consumption (99% vs. 96%; p = .018). The acceptability of screening for other drugs was higher among women reporting binge drinking (98% vs. 96%; p = .032) and other drug use (98% vs. 96%; p = .058). Almost all pregnant women indicated that they were willing to disclose their alcohol (99%), tobacco (99%), and other drug use (98%) to their provider.

CONCLUSIONS

Almost all women considered verbal screening for ATOD use during prenatal care acceptable and indicated that they were willing to honestly disclose their ATOD use. Verbal screening may allow for the opportunity to initiate safe, nonjudgmental conversations about women's substance use, risk, and goals for their ATOD use, pregnancy, and parenting.

A qualitative exploration of women's experiences discovering pregnancies in the emergency department

Objectives

The few studies examining pregnancy testing in emergency departments (EDs) address pregnancy-related physical risks. Here, we examine experiences of people who discover pregnancies in EDs.

Methods

Between 2015 and 2017, as part of a larger study, we conducted interviews with 29 women in Southern Louisiana (n = 13) and Baltimore, MD (n = 16), who reported discussing their pregnancy during an ED visit. We analyzed these interviews for content and themes.

Results

Respondents reported diagnosis of pregnancy as a routine and straightforward component of care received in EDs. They reported receiving diagnostic studies and therapeutic interventions to rule out and treat complications of pregnancy and care for what brought them to the ED to begin with, such as treatments for nausea and vomiting; education about physical symptoms and nutrition-related needs during pregnancy; and referrals to prenatal care. However, we find evidence of unmet needs related to patient-centered communication, such as providing emotional care to women discovering pregnancies in EDs and lack of support for transitions to abortion care.

Conclusions

While diagnosis of pregnancy in the ED may be routine for ED clinicians, it is not necessarily routine or straightforward for people receiving the diagnosis. ED clinicians should not assume that all people who discover their pregnancies in the ED want to continue their pregnancy. People who discover pregnancies in EDs may benefit from patient-centered communication and support for the range of transitions to care people might need in addition to the routinely provided diagnostic and therapeutic interventions.

Implications

ED clinicians may need additional training and support to ensure that they can meet the range of needs of people who discover their pregnancies in the ED.

"Alcohol During Pregnancy? Nobody Does That Anymore": State Legislators' Use of Evidence in Making Policy on Alcohol Use in Pregnancy

OBJECTIVE

In recent years, U.S. states have passed many laws addressing alcohol use in pregnancy, despite limited evidence on the impact of such policies. This study explores how state legislators use evidence when making policy on alcohol use in pregnancy.

METHOD

Study data are drawn from semistructured interviews with 29 state lawmakers and their aides in Maryland, North Carolina, and Virginia, conducted in March through July 2017. Interview transcripts were coded and analyzed by inductive and deductive methods.

RESULTS

Despite evidence on the harms of alcohol use in pregnancy, most lawmakers did not express concern about this topic. Instead, they expressed concern about opioid use in pregnancy. Personal experiences, anecdotes, and known contacts influenced legislators' views on substance use in pregnancy, whereas evidence, for the most part, did not. The intermediaries who typically bring evidence about problems and solutions to legislators did not appear to be raising the issue of alcohol use in pregnancy on legislators' agenda.

CONCLUSIONS

Basic evidence on the prevalence and harms of alcohol use in pregnancy did not appear to influence state lawmakers' policy priorities. Concern over opioid use in general may provide a window of opportunity to educate legislators on the relative scope and harms of alcohol and opioid use in pregnancy. It remains unclear why states are passing alcohol-in-pregnancy policies. More research is needed to explore how state lawmakers form their understanding of substance use in pregnancy and related policies.

Healthcare costs for abortions performed in ambulatory surgery centers vs office-based settings

BACKGROUND

Several states require that abortions be provided in ambulatory surgery centers. Supporters of such laws argue that they make abortions safer, yet previous studies have found no differences in abortion-related morbidities or adverse events for abortions performed in ambulatory surgery centers versus office-based settings. However, little is known about how costs of abortions provided in ambulatory surgery centers differ from those provided in office-based settings.

OBJECTIVE

To compare healthcare expenditures for abortions performed in ambulatory surgery centers versus office-based settings using a large national private insurance claims database.

MATERIALS AND METHODS

A retrospective cohort study compared expenditures for abortions performed in ambulatory surgery centers versus office-based settings. Data on women who had abortions in an ambulatory surgery center or office-based setting between January 1, 2011, and December 31, 2014 were obtained from the MarketScan Commercial Claims and Encounters database. The sample was limited to women who were continuously enrolled in their insurance plans for at least 1 year before and at least 6 weeks after the abortion. Healthcare expenditures were assessed separately for the index abortion and the 6-week period after the abortion. Costs were measured from the perspective of the healthcare system and included all payments to the provider, including insurance company payments and any patient out-of-pocket payments.

RESULTS

Overall, 49,287 beneficiaries who had 50,311 abortions met inclusion criteria. Of the included abortions, 47% were first-trimester aspiration, 27% first-trimester medication, and 26% second-trimester or later abortions. Most abortions (89%) were provided in office-based settings, with 11% provided in ambulatory surgery centers. Unadjusted mean index abortion costs were higher in ambulatory surgery centers than in office-based settings ($1704 versus $810; P < .001). After adjusting for patient clinical and demographic characteristics, costs of index abortions were $772 higher (95% confidence interval, $746-$797), total follow-up costs for abortions that had any follow-up care were $1099 higher (95% confidence interval, $1004-$1,195), and total follow-up costs for abortions that had an abortion-related morbidity or adverse event were not significantly different in ambulatory surgery centers compared to office-based settings. There were also no significant differences in the likelihood of having any follow-up care or abortion-related event follow-up care.

CONCLUSION

Abortions performed at ambulatory surgery centers are significantly more costly than those performed in office-based settings, with no difference in the likelihood of receiving follow-up care. Laws requiring that abortions be provided in ambulatory surgery centers may only result in increased costs for abortions, with no effect on abortion safety.

Approaches, barriers, and facilitators to abortion-related work in U.S. health departments: perspectives of maternal and child heath and family planning professionals

BACKGROUND

Public health agencies in the United States have engaged in abortion-related activities for nearly 50 years. Prior research indicates that, while most state health departments engage in some abortion-related work, their efforts reflect what is required by law rather than the breadth of core public health activities. In contrast, local health departments appear to engage in abortion-related activities less often but, when they do, initiate a broader range of activities.

METHODS

This study aimed to: 1) describe the abortion-related activities undertaken by maternal and child health (MCH) and family planning professionals in state and local health departments; 2) understand how health departments approach their programmatic work on abortion, and 3) examine the facilitators and barriers to whether and how abortion work is implemented. Between November 2017 and June 2018, we conducted key informant interviews with 29 professionals working in 22 state and local health departments across the U.S. Interview data were thematically coded and analyzed using an iterative approach.

RESULTS

MCH and family planning professionals described a range of abortion-related activities undertaken within their health departments. We identified three approaches to this work: those mandated strictly by law or policy; those initiated when mandated by law but informed by public health principles (e.g., scientific accuracy, expert engagement, lack of bias, promoting access to care) in implementation; and those initiated by professionals within the department to meet identified needs. More state health departments engaged in activities when mandated, and more local health departments initiated activities based on identified needs. Key barriers and facilitators included political climate, funding opportunities and restrictions, and departmental leadership.

CONCLUSIONS

Although state health departments are tasked with implementing legally-required abortion-related activities, some agencies bring public health principles to their mandated work. Efforts are needed to engage public health professionals in developing and implementing best practices around engaging in abortion-related activities.

Experiences of harassment and empowerment after sharing personal abortion stories publicly

Objective

In recent years, in an attempt to counter stigma and increase empathy, public education campaigns have encouraged people to share their personal abortion stories. This exploratory study sought to document negative and positive experiences of those who have shared their abortion stories publicly.

Study design

We conducted an anonymous online survey of people who have shared their abortion story publicly (N = 88), recruited via partners affiliated with two abortion story-sharing campaigns. The survey asked about the context in which respondents shared their abortion story, any negative and positive experiences online and in “real life” as a result of story sharing, and any problems or benefits resulting from these experiences. We analyzed survey data using descriptive statistics, bivariate analyses and categorizing responses to open-ended questions.

Results

Sixty percent of respondents reported experiencing harassment and other negative incidents after sharing their story publicly. These experiences contributed to emotional stress, problems with loved ones and difficulties at work and/or school. These harms were reported even by many respondents who used only a first name or alias when sharing their story. Despite this, positive experiences as a result of story sharing were reported by four out of five respondents and motivated many to continue sharing their story.

Conclusions

This exploratory study indicates that many people who share their abortion story publicly find it to be an empowering, rewarding experience. Yet they also experience harassment and threats at high rates. Future research should explore both positive and negative experiences in more depth.

Implications

Sharing one's personal abortion story as part of a public education campaign can be a positive, empowering experience. Nevertheless, policymakers, journalists and reproductive health advocates should recognize the potential harms experienced by people who share their abortion story publicly and consider measures to support these individuals.

Complex situations: Economic insecurity, mental health, and substance use among pregnant women who consider - but do not have - abortions

We examine characteristics and experiences of women who considered, but did not have, an abortion for this pregnancy. Participants were recruited at prenatal care clinics in Louisiana and Maryland for a mixed-methods study (N = 589). On self-administered surveys and structured interviews, participants were asked if they had considered abortion for this pregnancy and, if so, reasons they did not obtain one. A subset (n = 83), including participants who considered abortion for this pregnancy, completed in-depth phone interviews. Multivariable logistic regression analyses examined characteristics associated with having considered abortion and experiencing a policy-related barrier to having an abortion; analyses focused on economic insecurity and of mental health/substance use as main predictors of interest. Louisiana interviews (n = 43) were analyzed using modified grounded theory to understand concrete experiences of policy-related factors. In regression analyses, women who reported greater economic insecurity (aOR 1.21 [95% CI 1.17, 1.26]) and more mental health diagnoses/substance use (aOR 1.29 [1.16, 1.45] had higher odds of having considered abortion. Those who reported greater economic insecurity (aOR 1.50 [1.09, 2.08]) and more mental health diagnoses/substance use (aOR 1.45 [95% CI 1.03, 2.05] had higher odds of reporting policy-related barriers. Interviewees who considered abortion and were subject to multiple restrictions on abortion identified material and instrumental impacts of policies that, collectively, contributed to them not having an abortion. Many described simultaneously navigating economic insecurity, mental health disorders, substance use, and interpersonal opposition to abortion from family and the man involved in the pregnancy. Current restrictive abortion policies appear to have more of an impact on women who report greater economic insecurity and more mental health diagnoses/substance use. These policies work in concert with each other, with people’s individual complex situations–including economic insecurity, mental health, and substance use–and with anti-abortion attitudes of other people to make abortion care impossible for some pregnant women to access.

Racial differences in the relationship between alcohol/pregnancy policies and birth outcomes and prenatal care utilization: A legal epidemiology study

OBJECTIVES

State policies regarding alcohol use during pregnancy (alcohol/pregnancy policies) have been in effect for more than 40 years. Previous research finds some policies increase adverse birth outcomes and decrease prenatal care utilization. This research examines whether effects of alcohol/pregnancy policies vary by race; the general hypothesis is that health benefits of policies are concentrated among White women and health harms of policies are concentrated among Black women.

METHODS

This study uses 1972-2015 Vital Statistics data and policy data from NIAAA's Alcohol Policy Information System and original legal research. The dataset includes more than 150 million singleton births. Outcomes are preterm birth (PTB), low birthweight (LBW), and prenatal care utilization. Logistic regression models include raceXpolicy interaction terms as main predictors, adjust for individual- and state-level controls, include fixed effects for state, year and state-specific time trends, and account for clustering by state.

RESULTS

The impact of alcohol/pregnancy policies varied by race for preterm birth, varied in a few cases for low birthweight, and generally did not vary for prenatal care utilization. The hypothesis regarding the direction of differential effects was not supported. Six policies had an adverse impact on PTB and/or LBW for White women. Findings differed for Black women; for Black women, four policies had a beneficial impact for PTB and one had an adverse impact for LBW.

CONCLUSIONS

The impact of alcohol/pregnancy policies on birth outcomes varies by race. Future research should explore why some policies appear to have opposite effects for White v. Black women.

Estimating the proportion of Medicaid-eligible pregnant women in Louisiana who do not get abortions when Medicaid does not cover abortion

Background

To estimate the proportion of pregnant women in Louisiana who do not obtain abortions because Medicaid does not cover abortion.

Methods

Two hundred sixty nine women presenting at first prenatal visits in Southern Louisiana, 2015–2017, completed self-administered iPad surveys and structured interviews. Women reporting having considered abortion were asked whether Medicaid not paying for abortion was a reason they had not had an abortion. Using study data and published estimates of births, abortions, and Medicaid-covered births in Louisiana, we projected the proportion of Medicaid births that would instead be abortions if Medicaid covered abortion in Louisiana.

Results

28% considered abortion. Among women with Medicaid, 7.2% [95% CI 4.1–12.3] reported Medicaid not paying as a reason they did not have an abortion. Existing estimates suggest 10% of Louisiana pregnancies end in abortion. If Medicaid covered abortion, this would increase to 14% [95% CI 12, 16]. 29% [95% CI 19, 41] of Medicaid eligible pregnant women who would have an abortion with Medicaid coverage, instead give birth.

Conclusions

For a substantial proportion of pregnant women in Louisiana, the lack of Medicaid funding remains an insurmountable barrier to obtaining an abortion. Forty years after the Hyde Amendment was passed, lack of Medicaid funding for abortion continues to have substantial impacts on women’s ability to obtain abortions.

Costs associated with policies regarding alcohol use during pregnancy: Results from 1972-2015 Vital Statistics

BACKGROUND AND OBJECTIVE

As of 2016, 43 US states have policies regarding alcohol use during pregnancy. A recent study found that out of eight state-level alcohol/pregnancy policies, six are significantly associated with poorer birth outcomes, and two are not associated with any outcomes. Here we estimate the excess numbers of low birthweight (LBW) and preterm births (PTB) related to these policies and their associated additional costs in the first year of life.

METHODS

Cost study using birth certificate data for 155,446,714 singleton live births in the United States between 1972-2015. Exposures were state- and month/year-specific indicators of having each of eight alcohol/pregnancy policies in place. Outcomes were excess numbers of LBW and PTB and associated costs in the first year of life. Fixed effects regressions with state-specific time trends were used for statistical analyses in 2018.

RESULTS

In 2015, policies mandating warning signs were associated with an excess of 7,375 LBW; policies defining alcohol use during pregnancy as child abuse/neglect were associated with an excess of 12,372 PTB; these excess adverse outcomes are associated with additional costs of $151,928,002 and $582,698,853 in the first year of life, respectively.

CONCLUSIONS

Multiple state-level alcohol pregnancy policies lead to increased prevalence of LBW and PTB, which cost hundreds of millions of dollars annually. Policymakers should consider adverse public health impacts of alcohol/pregnancy policies before expanding extant policies to new substances or adopting existing policies in new states.

New Estimates of the Mean Ethanol Content of Beer, Wine, and Spirits Sold in the United States Show a Greater Increase in Per Capita Alcohol Consumption than Previous Estimates

BACKGROUND

Recent increases in alcohol-related morbidity and mortality have not occurred alongside notable increases in per capita alcohol consumption (PCC). This discrepancy may be partially due to U.S. PCC estimates not including annual estimates of the percentage of alcohol by volume (%ABV) of beer, wine, and spirits, but rather relying on time-invariant %ABV values.

METHODS

Building on a prior study covering 1950 to 2002, estimates of the annual mean %ABV of beer, wine, and spirits sold in the United States were calculated using the %ABV of major brands and sales of each beverage type for each state and nationally for the period 2003 to 2016. We applied these estimates to the calculation of annual beverage-specific and total PCC, and made descriptive comparisons between our PCC estimates and those estimates using invariant %ABV values.

RESULTS

For all beverage types, our mean %ABV estimates increased nationally and for all but 5 states. The PCC estimates from wine and spirits utilizing variable %ABV values were lower than estimates using invariant %ABV, and consumption from beer was higher. Our total PCC estimates were also lower than %ABV-invariant estimates; however, the percent change for %ABV-invariant estimates was 5.8% compared to a 7.9% change in our %ABV-variant estimates over the 2003 to 2016 period.

CONCLUSIONS

Given the application of PCC estimates to understand changes in alcohol-related morbidity and mortality, the inclusion of annual estimates of the %ABV of alcoholic beverages sold in the United States is necessary to ensure the precision of PCC measures such that the conclusions drawn from these applications are accurate and valid.

Differential Effects of Pregnancy-Specific Alcohol Policies on Drinking Among Pregnant Women by Race/Ethnicity

Purpose: Alcohol use during pregnancy is a significant public health concern. Nearly all U.S. states have enacted policies targeting alcohol use during pregnancy, but there has been little research examining their impact, particularly across racial/ethnic groups.

Methods: Using data from the Behavioral Risk Factor Surveillance System and about eight state-level, pregnancy-specific alcohol policies from 1985 to 2016, the aim of this study was to examine the differential effects of these policies on drinking among pregnant women by race/ethnicity.

Results: We found evidence of differential effects for priority treatment, prohibitions on criminal prosecution, and civil commitment policies. In relation to priority treatment policies, effects benefited versus harmed different racial/ethnic groups depending on whether the priority treatment policies were for pregnant women only or if they gave priority to both pregnant women and pregnant women with children.

Conclusions: Findings from this study suggest that benefits and harms from these policies do not appear to be equitably distributed across different racial/ethnic groups. Research considering the impact of alcohol/pregnancy policies should consider differential effects by race/ethnicity.

Admitting privileges and hospital-based care after presenting for abortion: A retrospective case series

Objective

To examine the pathways of care for abortion patients transferred or referred to emergency departments (EDs) or hospitals before and after abortion‐providing physicians obtained hospital admitting privileges.

Data Sources

This case series was based on retrospective chart review at three abortion clinics in which physicians had obtained admitting privileges in the previous 5 years.

Study Design

We identified patients who were transferred or referred to a hospital or ED. Patients were grouped according to the pathway by which their care was transferred or referred to the ED/hospital.

Principal Findings

Both before and after admitting privileges, the majority of patients were referred to a hospital before the abortion was attempted and most were for suspected ectopic pregnancy or to perform the abortion in a hospital. Direct ambulance transfer from the facility to the ED/hospital was the least common pathway. We observed few changes in practice from before to after admitting privileges. Preexisting mechanisms of coordination and communication facilitated care that was tailored for the specific patient.

Conclusions

We did not find evidence that physician admitting privileges influenced the pathways through which abortion patients obtain hospital‐based care, as existing mechanisms of collaboration between hospitals and abortion facilities allowed for management of patients who sought hospital‐based care.

Should prenatal care providers offer pregnancy options counseling?

BACKGROUND

Professional guidelines indicate that pregnancy options counseling should be offered to pregnant women, in particular those experiencing an unintended pregnancy. However, research on whether pregnancy options counseling would benefit women as they enter prenatal care is limited. This study examines which women might benefit from options counseling during early prenatal care and whether women are interested in receiving counseling from their prenatal care provider.

METHODS

At four prenatal care facilities in Louisiana and Maryland, women entering prenatal care completed a self-administered survey and brief structured interview (N = 586). Data were analyzed through descriptive statistics, bivariate analyses, multivariate multinomial logistic regression, and coding of open-ended responses.

RESULTS

At entry into prenatal care, most women reported that they planned to continue their pregnancy and raise the child. A subset (3%) scored as having low certainty about their decision on the validated Decision Conflict Scale, indicating need for counseling. In addition, 9% of women stated that they would be interested in discussing their pregnancy options with their prenatal care provider. Regression analyses indicated some sociodemographic differences among women who are in need of or interested in options counseling. Notably, women who reported food insecurity in the prior year were found to be significantly more likely to be in need of options counseling (RRR = 3.20, p < 0.001) and interested in options counseling (RRR = 5.48, p < 0.001) than those who were food secure. Most women were open to discussing with their provider if their pregnancy was planned (88%) or if they had considered abortion (81%). More than 95% stated they would be honest with their provider if asked about these topics.

CONCLUSIONS

Most women are certain of their decision to continue their pregnancy at the initiation of prenatal care. However, there is a subset of women who, despite entering prenatal care, are uncertain of their decision and wish to discuss their options with their health care provider. Screening tools and/or probing questions are needed to support prenatal care providers in identifying these women and ensuring unbiased, non-directive counseling on all pregnancy options.

Inclusion of LGBTQ persons in research related to pregnancy risk: a cognitive interview study

INTRODUCTION

Recently, researchers have begun considering whether and how to include lesbian, gay, bisexual, transgender and queer (LGBTQ) people in research about abortion and contraception care. Including LGBTQ people in research about abortion and contraception care, as well as the risk for unintended pregnancy more broadly, requires accurate assessment of risk for unintended pregnancy, which involves different considerations for LGBTQ people.

METHODS

We created a survey with existing sexual orientation and gender identity measures, new reproductive anatomy questions to guide skip patterns, gender neutral terminology in sexual and behavioural risk questions, and existing contraception and pregnancy intentions questions that were modified to be gender neutral. We then assessed the appropriateness of these measures through cognitive interviews with 39 individuals aged 18-44 years who were assigned female at birth and identified as LGBTQ. Participants were recruited in the San Francisco Bay Area of California, Baltimore, Maryland and other cities.

RESULTS

Existing demographic questions on sexual orientation and gender identity were well received by participants and validating of participant reported identities. Participants responded positively to new reproductive anatomy questions and to gender neutral terminology in sexual behaviour and pregnancy risk questions. They felt skip patterns appropriately removed them out of inappropriate items (eg, use of contraception to avoid unintended pregnancy); there was some question about whether pregnancy intention measures were widely appropriate or should be further restricted.

CONCLUSIONS

This study provides guidance on ways to appropriately evaluate inclusion of LGBTQ people in abortion and contraception research.

Drug Use During Pregnancy Policies in the United States From 1970 to 2016

As U.S. states legalize marijuana and as governmental attention is paid to the “opioid crisis,” state policies pertaining to drug use during pregnancy are increasingly important. Little is known about the scope of state policies targeting drug use during pregnancy, how they have evolved, and how they compare to alcohol use during pregnancy policies.

Method:

Our 46-year original data set of statutes and regulations in U.S. states covers the entirety of state-level legislation in this policy domain. Data were obtained through original legal research and from the National Institute on Alcohol Abuse and Alcoholism’s Alcohol Policy Information System. Policies were analyzed individually as well as by classification as punitive toward or supportive of women.

Results:

The number of states with drug use during pregnancy policies has increased from 1 in 1974 to 43 in 2016. Policies started as punitive. By the mid- to late 1980s, supportive policies emerged, and mixed policy environments dominated in the 2000s. Overall, drug/pregnancy policy environments have become less supportive over time. Comparisons of drug laws to alcohol laws show that the policy trajectories started in opposite directions, but by 2016, the results were the same: Punitive policies were more prevalent than supportive policies across states. Moreover, there is a great deal of overlap between drug use during pregnancy policies and alcohol/pregnancy policies.

Conclusion:

This study breaks new ground. More studies are needed that explore the effects of these policies on alcohol and other drug use by pregnant women and on birth outcomes.

Association of Facility Type With Procedural-Related Morbidities and Adverse Events Among Patients Undergoing Induced Abortions

IMPORTANCE

Multiple states have laws requiring abortion facilities to meet ambulatory surgery center (ASC) standards. There is limited evidence regarding abortion-related morbidities and adverse events following abortions performed at ASCs vs office-based settings.

OBJECTIVE

To compare abortion-related morbidities and adverse events at ASCs vs office-based settings.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of women with US private health insurance who underwent induced abortions in an ASC or office-based setting (January 1, 2011-December 31, 2014). Outcomes were abstracted from a large national private insurance claims database during the 6 weeks following the abortion (date of final follow-up, February 11, 2015).

EXPOSURES

Facility type for abortion (ASCs vs office-based settings, including facilities such as abortion clinics, nonspecialized clinics, and physician offices).

MAIN OUTCOMES AND MEASURES

The primary outcome was any abortion-related morbidity or adverse event (such as retained products of conception, abortion-related infection, hemorrhage, and uterine perforation) within 6 weeks after an abortion. Two secondary outcomes, both subsets of the primary outcome, were major abortion-related morbidities and adverse events (such as hemorrhages treated with a transfusion, missed ectopic pregnancies treated with surgery, and abortion-related infections that resulted in an overnight hospital admission) and abortion-related infections.

RESULTS

Among 49 287 women (mean age, 28 years [SD, 7.3]) who had 50 311 induced abortions, (23 891 [47%] first-trimester aspiration, 13 480 [27%] first-trimester medication, and 12 940 [26%] second trimester or later), 5660 abortions (11%) were performed in ASCs and 44 651 (89%) in office-based settings. Overall, 3.33% had an abortion-related morbidity or adverse event; 0.32% had a major abortion-related morbidity or adverse event; and 0.74% had an abortion-related infection. In adjusted analyses, there was no statistically significant difference between ASCs vs office-based settings, respectively, in the rates of abortion-related morbidities or adverse events (3.25% vs 3.33%, difference, -0.08%; [corrected] 95% CI, -0.58% to 0.43%; adjusted OR, 0.97; 95% CI, 0.81-1.17), major morbidities or adverse events (0.26% vs 0.33%; difference, -0.06%; 95% CI, -0.18% to 0.06%; adjusted OR, 0.78; 95% CI, 0.45-1.37), or infections (0.58% vs 0.77%; difference, -0.16%; 95% CI, -0.35% to 0.03%; adjusted OR, 0.75; 95% CI, 0.52-1.09).

CONCLUSIONS AND RELEVANCE

Among women with private health insurance who had an induced abortion, performance of the abortion in an ambulatory surgical center compared with an office-based setting was not associated with a significant difference in abortion-related morbidities and adverse events. These findings, in addition to individual patient and individual facility factors, may inform decisions about the type of facility in which induced abortions are performed.

Forty Years of State Alcohol and Pregnancy Policies in the USA: Best Practices for Public Health or Efforts to Restrict Women's Reproductive Rights?

Aims

Alcohol consumption during pregnancy remains a public health problem despite >40 years of attention. Little is known about how state policies have evolved and whether policies represent public health goals or efforts to restrict women's reproductive rights.

Methods

Our data set includes US state policies from 1970 through 2013 obtained through original legal research and from the National Institute for Alcohol Abuse and Alcoholism's (NIAAA)'s Alcohol Policy Information System. Policies were classified as punitive to women or supportive of them. The association between numbers of punitive policies and supportive policies in 2013 with a measure of state restrictions on reproductive rights and Alcohol Policy Effectiveness Scores (APS) was estimated using a Pearson's correlation.

Results

The number of states with alcohol and pregnancy policies has increased from 1 in 1974 to 43 in 2013. Through the 1980s, state policy environments were either punitive or supportive. In the 1990s, mixed punitive and supportive policy environments began to be the norm, with punitive policies added to supportive ones. No association was found between the number of supportive policies in 2013 and a measure of reproductive rights policies or the APS, nor was there an association between the number of punitive policies and the APS. The number of punitive policies was positively associated, however, with restrictions on reproductive rights.

Conclusion

Punitive alcohol and pregnancy policies are associated with efforts to restrict women's reproductive rights rather than effective efforts to curb public health harms due to alcohol use in the general population. Future research should explore the effects of alcohol and pregnancy policies.

Short Summary

The number of states with alcohol and pregnancy policies has increased since 1970 (1 in 1974 and 43 in 2013). Alcohol and pregnancy policies are becoming increasingly punitive. These punitive policies are associated with efforts to restrict women's reproductive rights rather than policies that effectively curb alcohol-related public health harms.

The development of facility standards for common outpatient procedures and implications for the context of abortion

Background

In recent years, an increasing number of states have enacted laws that impose specific requirements for facilities in which abortions are performed. In this study, we sought to understand the processes used to develop facility standards in the context of other, less politically charged areas of health care and consider implications for the context of abortion.

Methods

We conducted key informant interviews with 20 clinicians and accreditation professionals involved in facility standards development for common outpatient procedures (endoscopy, gynecology, oral surgery, plastic surgery). We examined the motivations for and processes used in facility standards development, use of scientific evidence in standards development, and decision-making in the absence of evidence. Interview data were thematically coded and analyzed using an iterative approach.

Results

In contrast to U.S. state laws that target abortion facilities, standards for other outpatient procedures are commonly set by committees of clinicians organized by professional associations or accreditation organizations. These committees seek to establish standards that ensure patient safety without placing unnecessary burden on clinicians in practice. They aim to create evidence-based standards but can be hampered by lack of relevant research. In the absence of research evidence, committees rely on their clinical expertise and sense of best practices in decision-making. According to respondents, considerations of potential harm (e.g., deeper levels of sedation, invasiveness), rather than the specific procedure, should prompt additional requirements.

Conclusions

If facility standards in the context of abortion were developed through processes similar to other outpatient procedures, 1) professionals who perform the procedure would be involved in standards development and 2) in the absence of clear research evidence, the expertise of clinicians, and the guidelines and standards of other organizations, are used to describe a best practice standard of care.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3048-3) contains supplementary material, which is available to authorized users.

The prevalence and impacts of crisis pregnancy center visits among a population of pregnant women

OBJECTIVES

Investigations into Crisis Pregnancy Centers (CPCs) have documented the provision of deceptive information about abortion, but it is unclear how many pregnant women actually visit CPCs and what impact visits have on their pregnancy decision-making.

STUDY DESIGN

We conducted a mixed-methods study. We surveyed patients at one of two local abortion clinics and three prenatal clinics in Southern Louisiana about whether they had visited a CPC for this pregnancy and conducted in-depth interviews with prenatal patients who reported a CPC visit about their experience.

RESULTS

We surveyed 114 abortion patients and 269 prenatal patients, and interviewed 12 prenatal patients about their CPC visit. Just 6% of abortion patients (n=7) and 5% of prenatal patients (n=14) visited a CPC for this pregnancy. Prenatal patients went to CPCs primarily for free pregnancy tests and reported receiving information about abortion from CPC staff that was inaccurate. They also generally recognized the CPC was antiabortion, ideologically Christian, and not a medical establishment. Only three had been considering abortion at the time of their visit and reported that the visit impacted their plan for the pregnancy. However, all three also faced additional barriers to abortion, including inability to find an abortion provider, difficulty securing funding, gestational limits, ambivalence about choosing abortion, and opposition to abortion from family members.

CONCLUSIONS

We do not find evidence that pregnant women regularly seek CPC services or that CPCs persuade women who are certain abortion is the right decision for them to continue their pregnancies.

IMPLICATIONS

Given little evidence that CPCs impact pregnant women's decision-making on a broad scale, future research should examine other aspects of CPCs, such as their role in the antiabortion movement and/or the impact of CPC visits on maternal health and birth outcomes among women who continue their pregnancies.

Changes in Alcohol, Tobacco, and Other Drug Use Over Five Years After Receiving Versus Being Denied a Pregnancy Termination

Objective:

Research on effects of pregnancy termination on women’s alcohol, tobacco, and other drug (ATOD) use suffers from methodological and conceptual problems. Improving on prior methodologies, this study examines changes in ATOD use over 5 years among women seeking terminations.

Method:

Data are from the Turnaway Study, a longitudinal study of 956 women seeking terminations at 30 U.S. facilities. Participants presented just below a facility’s gestational limit and received terminations (Near-Limits) or just beyond the limit and were denied terminations (Turnaways). Using mixed-effects logistic regression, we assessed differences in ATOD use over 5 years among Near-Limits and Turnaways.

Results:

There were no differences in ATOD use before pregnancy recognition; 1 week after termination seeking, Turnaways had lower odds than Near-Limits of any and heavy episodic alcohol use (p < .001), but not alcohol problem symptoms, tobacco use, or other drug use. Although both groups increased in any alcohol use over time, Turnaways increased more rapidly. Neither group increased any other ATOD measures over time. Turnaways’ lower odds of heavy episodic alcohol use at 1 week after termination seeking were maintained throughout the subsequent 5 years. There was no differential change in problem alcohol use or in tobacco or other drug use over time, yet fewer Turnaways than Near-Limits reported problem alcohol symptoms 6 months through 3.5 years.

Conclusions:

There is no indication that terminating a pregnancy led women to increase heavy episodic or problem alcohol use or to increase tobacco or other drug use. Women denied terminations had temporary or sustained reductions in all alcohol measures, but not tobacco or other drugs, suggesting that relationships between pregnancy/parenting and ATOD differ across substances.