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.

How Effective Is Misoprostol Alone for Medication Abortion?

AbstractWith recent severe restrictions to abortion accessibility in the United States and a pending Supreme Court case challenging the Food and Drug Administration's approval of mifepristone, evidence-based strategies to protect and expand access to abortion care are needed. Two safe and effective regimens for medication abortion are widely used globally - misoprostol-only and misoprostol in combination with mifepristone. However, misoprostol-only regimens are rarely used in the United States. In 2023, the National Abortion Federation and the Society of Family Planning updated their recommended protocol for misoprostol-only for medication abortion to 800 μg of misoprostol administered buccally, sublingually, or vaginally every 3 hours for three or more doses. To characterize the data supporting this specific regimen, this article reviews the relevant literature to address the question of how effective misoprostol-only is for medication abortion. The authors conclude that the updated misoprostol regimen is highly effective and a potential strategy for expanding access to abortion.

Legal abortion requests and outcomes for women when the law is restrictive - experience from a referral centre in south-eastern Brazil

METHODS

Retrospective cohort study with review of medical records of women assisted between 2015 and 2020. The variables were socio-demographic and SV characteristics, gestational age, reactions towards pregnancy and outcome. We compared outcome groups using the chi-square test, Fisher's exact test and the Kruskal-Wallis test. The significance level was 5%.

RESULTS

We evaluated the medical records of 235 women, of which 153(65%) had undergone to abortion; 17(7.2%) had a spontaneous abortion; 19(8%) remained pregnant; 25(10.6%) had an abortion denied; and 21(8.9%) had been lost to follow-up. Out of the total number of women, 44(18.7%) were adolescents, 152(65.2%) were white and 201(88.5%) had an education ≥9 years. Women who remained pregnant had a known aggressor, disclosed the pregnancy (p < 0.001) and were more ambivalent (p < 0.001) than the other groups. Gestational age was higher in the denied abortion group than in the performed abortion group (p < 0.001).

CONCLUSION

Feelings related to decision-making about abortion affected all groups, with differences. It is important to give women space to be heard, so they can make their own decisions.

Motivations for using misoprostol for abortion outside the formal healthcare system in Colombia: a qualitative study of women seeking postabortion care in Bogotá and the Coffee Axis

BACKGROUND

In 2006, a Constitutional Court ruling partially decriminalized abortion in Colombia, allowing the procedure in cases of rape, risk to the health or life of the woman, and fetal malformations incompatible with life. Despite this less prohibitive law, some women and pregnant people preferred self-managing their abortions outside the formal healthcare system, often without accurate information. In 2018, we undertook a study to understand what motivated women to self-manage using medications that they acquired informally. Colombia has since adopted a progressive law in 2022, permitting abortion on request through the 24th week of pregnancy. However, the implementation of this law is still underway. Examining the reasons why women chose to informally self-manage an abortion after 2006 may not only highlight how barriers to legal services persisted at that time, but also could inform strategies to increase knowledge of the current abortion law and improve access to services going forward.

METHODS

In-depth interviews were conducted in 2018 with 47 women aged 18 and older who used misoprostol obtained outside of health facilities to induce an abortion, and who were receiving postabortion care in two private clinics. Interviews explored what women knew about the 2006 abortion law which was then in effect, and the reasons why they preferred informal channels for abortion care over formal healthcare services.

RESULTS

Women's motivations to use misoprostol obtained outside the formal healthcare system were influenced by lack of trust in the healthcare system along with incomplete and inaccurate knowledge of the abortion law. Conversely, women considered misoprostol obtained outside the healthcare system to be effective, affordable, and easier to access.

CONCLUSIONS

Obtaining misoprostol outside the formal healthcare system offered a more accessible and appealing prospect for some women given fears of legal repercussion and stigma toward abortion. Though this preference will likely continue despite the more liberal abortion law, strategies should be implemented to broaden knowledge of the recent change in law and to combat misinformation and stigma. This would support knowledge of and access to legal abortion for those who wish to avail themselves of these services.

Population, abortion, contraception, and the relation between biopolitics, bioethics, and biolaw in Iran

The Islamic government of Iran recently passed and announced a new law titled "Rejuvenation of the Population and Protection of the Family." This legislation is a noteworthy example of biopolitics-influenced biolaw. In terms of abortion, contraception, prenatal screening, and population control, this law clearly contrasts with women's fundamental rights and freedoms and has significant health-related consequences for different sectors of the population. A historical review of the population policies of the Islamic Republic of Iran shows the occurrence of multiple abrupt and radical changes in such policies over the past four decades. This new law, promoted by religious biopolitics, is the most recent example, and places stringent limits on abortion. According to it, all decisions concerning abortion must be made in courts rather than in health clinics. Such courts are typically presided over by male religious scholars. This law also limits prenatal screening to the degree that will increase the rate of genetic defects, especially in the population's lower socioeconomic strata. By strictly limiting access to contraception, this law will increase the rate of unwanted pregnancies and sexually transmitted diseases. This paper argues that such an influence of biopolitics on biolaw contrasts with the principles of bioethics. Still, Iran's current institution of bioethics cannot address it effectively. Therefore, a new model of interaction between bioethics, biopolitics, and biolaw is needed to prevent the detrimental consequences of such pieces of legislation. Such a paradigm shift is demanded by the current "Woman, Life, Freedom" movement of the Iranian people.

Deception by obfuscation: Studnicki et al.'s retracted longitudinal cohort study of emergency room utilization following abortion

OBJECTIVES

In November 2022, the anti-abortion advocacy group Alliance for Hippocratic Medicine filed a lawsuit against the U.S. Food and Drug Administration challenging the initial 2000 approval of mifepristone and its subsequent approvals, which removed unnecessary restrictions on its use, by disputing the medication's safety record. Such challenges relied on a study examining the incidence of emergency room visits following medication abortion with mifepristone and procedural abortion using Medicaid claims data from 1999-2015. In February 2024 that study was retracted by its publisher. In this paper, we analyzed the methods and presentations of the data used in the study.

STUDY DESIGN

We drew upon commonly accepted principles in responsible epidemiologic and scientific research to evaluate the methods and presentations of the data and organized our findings into themes.

RESULTS

We found multiple instances of methodological flaws, mischaracterizations, and obfuscations of data in this study, including use of a misleading research question and framing, analytic flaws, inappropriate use of an unvalidated proxy measure for outcomes of interest, and inappropriate and deceptive visualizations of data. In each instance, the resulting effect obfuscated and misrepresented the safety of medication abortion with mifepristone.

CONCLUSIONS

The misrepresentation and exaggeration of data promoted and exacerbated misinterpretations about the study's findings, resulting in substantial harm before it was retracted. Recognizing that ongoing judicial proceedings threaten access to conventional reproductive health care in the United States, public health policies must be informed by scientific and medical literature that is comprehensive, methodologically sound, and absent any obfuscations or misrepresentations.

IMPLICATIONS

Studnicki et al.'s study of emergency room visits after abortion misrepresented the safety of mifepristone with multiple instances of methodological flaws and obfuscations of data. While the study has now been retracted, it led to irrevocable harm, threatening access to medication abortion, which has an established safety record.

Our hands are tied: abortion bans and hesitant medicine

Trained for decades to analyze risks, benefits, unique body compositions, and complex medical scenarios, healthcare providers are now faced with one of medicine's most trying obstacles: how to practice medicine when new abortion bans contradict best practice standards. Drawn from qualitative interviews with medical providers in Tennessee, USA conducted between October 2022 and December 2022, this study shows how medical providers often must make medical decisions based on legal risks as opposed to standards of care. This is particularly significant as malpractice insurance does not cover criminal charges. In states with abortion bans, often hastily implemented and subject to changes by lawmakers, medical providers are now practicing a new kind of defensive medicine in an effort to protect themselves from legal threats. We call this hesitant medicine, where providers often experience a tension between their own legal protection and the well-being of their patients, making them hesitant to provide necessary abortion care. This has serious, far-reaching consequences. We focus on three distinct arenas impacted by this new form of defensive medicine, specifically: providers' decision-making around patient care, impacts on patient relationships, and finally, what we call the ultimate defense, leaving states with abortion bans to move to states with fewer legal risks. We conclude with commentary on potential ways to reduce the negative impacts of these trends.

'Border Country': health law in a devolved UK

How are we to understand and research health law under devolution in the UK? Building on work in law and geography, we argue that the figure of the border is key to the production and implementation of devolved health law and the variety of forms that this takes. The utility of border thinking in this context is shown through a review of thematic areas, including infectious disease control, access to health care, and abortion, each instantiating a distinct bordering process. In each, we consider recent developments in policy and legislation, framed with reference to constitutional change, and the politics of devolution in the UK. Taking Wales as an exemplary site, we argue that health law produces borders in traditional and non-traditional places. It creates and blurs territories. It is equally constituted by pluralistic bordering practices. On the basis of this theoretically informed review, we conclude by proposing a cross-disciplinary legal, ethical, and socio-legal research agenda for future research.

Race and Ethnicity of Reproductive-Age Females Affected by US State Abortion Bans

This study compares the race and ethnicity of reproductive-age females between states that implemented restrictive abortion policies after the Dobbs v Jackson Women’s Health Organization decision and states that did not.

Inflation in 2022 did not affect congressional voting, but abortion did

This study examines voting in the 2022 United States congressional elections, contests that were widely expected to produce a sizable defeat for Democratic candidates for largely economic reasons. Based on a representative national probability sample of voters interviewed in both 2020 and 2022, individuals who changed their vote from one party's congressional candidate to another party's candidate did not do so in response to the salience of inflation or declining economic conditions. Instead, we find strong evidence that views on abortion were central to shifting votes in the midterm elections. Americans who favored (opposed) legal abortions were more likely to shift from voting for Republican (Democratic) candidates in 2020 to Democratic (Republican) candidates in 2022. Since a larger number of Americans supported than opposed legal abortions, the combination of these shifts ultimately improved the electoral prospects of Democratic candidates. New voters were especially likely to weigh abortion views heavily in their vote-shifting calculus. Likewise, those respondents whose confidence in the US Supreme Court declined from 2020 to 2022 were more likely to shift from voting for Republican to Democratic congressional candidates. We provide direct empirical evidence that changes in support for the Supreme Court, a nonpartisan branch of the federal government, are implicated in partisan voting behavior in another branch of government. We explore the implications of these findings for prevalent assumptions about how economic conditions influence voting, as well as for the relationship between the judiciary and electoral politics.

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.

Provision of Medications for Self-Managed Abortion Before and After the Dobbs v Jackson Women's Health Organization Decision

Importance

The Supreme Court decision in Dobbs v Jackson Women's Health Organization overturned the right to choose abortion in the US, with at least 16 states subsequently implementing abortion bans or 6-week gestational limits. Prior research indicates that in the 6 months following Dobbs, approximately 32 360 fewer abortions were provided within the US formal health care setting. However, trends in the provision of medications for self-managed abortion outside the formal health care setting have not been studied.

Objective

To determine whether the provision of medications for self-managed abortion outside the formal health care setting increased in the 6 months after Dobbs.

Design, Setting, and Participants

Cross-sectional study using data from sources that provided abortion medications outside the formal health care setting to people in the US between March 1 and December 31, 2022, including online telemedicine organizations, community networks, and online vendors. Using a hierarchical bayesian model, we imputed missing values from sources not providing data. We estimated the change in provision of medications for self-managed abortion after the Dobbs decision. We then estimated actual use of these medications by accounting for the possibility that not all provided medications are used by recipients.

Exposure

Abortion restrictions following the Dobbs decision.

Main Outcomes and Measures

Provision and use of medications for a self-managed abortion.

Results

In the 6-month post-Dobbs period (July 1 to December 31, 2022), the total number of provisions of medications for self-managed abortion increased by 27 838 (95% credible interval [CrI], 26 374-29 175) vs what would have been expected based on pre-Dobbs levels. Excluding imputed data changes the results only slightly (27 145; 95% CrI, 25 747-28 246). Accounting for nonuse of medications, actual self-managed medication abortions increased by an estimated 26 055 (95% CrI, 24 739-27 245) vs what would have been expected had the Dobbs decision not occurred.

Conclusions and Relevance

Provision of medications for self-managed abortions increased in the 6 months following the Dobbs decision. Results suggest that a substantial number of abortion seekers accessed services despite the implementation of state-level bans and restrictions.

Conscientious commitment, professional obligations and abortion provision after the reversal of Roe v Wade

We argue that, in certain circumstances, doctors might be professionally justified to provide abortions even in those jurisdictions where abortion is illegal. That it is at least professionally permissible does not mean that they have an all-things-considered ethical justification or obligation to provide illegal abortions or that professional obligations or professional permissibility trump legal obligations. It rather means that professional organisations should respect and indeed protect doctors' positive claims of conscience to provide abortions if they plausibly track what is in the best medical interests of their patients. It is the responsibility of state authorities to enforce the law, but it is the responsibility of professional organisations to uphold the highest standards of medical ethics, even when they conflict with the law. Whatever the legal sanctions in place, healthcare professionals should not be sanctioned by the professional bodies for providing abortions according to professional standards, even if illegally. Indeed, professional organisation should lobby to offer protection to such professionals. Our arguments have practical implications for what healthcare professionals and healthcare professional organisations may or should do in those jurisdictions that legally prohibit abortion, such as some US States after the reversal of Roe v Wade.

On the importance of consistency: a response to Giubilini et al

Giubilini et al offer some helpful reflections on the conscientious provision of medical care and whether and in what circumstances professional associations ought to support the conscientious provision of abortion in circumstances where abortion is banned or heavily restricted. I have several reservations, however, about the argument developed in the article. First, the essay makes questionable use of the case of Savita Halappanavar to justify its central argument about conscientious provision. Second, there is an apparent inconsistency between this article and the authors' statements elsewhere about the conscientious refusal of care. Third, there are risks that attend to professional associations supporting practitioners who break the law, and yet Giubilini et al do not give sufficient attention to this. This response will briefly discuss these three concerns.

Addressing challenges related to the professional practice of abortion post-Roe

The landmark Roe vs Wade Supreme Court decision in 1973 established a constitutional right to abortion. In June 2022, the Dobbs vs Jackson Women's Health Organization Supreme Court decision brought an end to the established professional practice of abortion throughout the United States. Rights-based reductionism and zealotry threaten the professional practice of abortion. Rights-based reductionism is generally the view that moral or ethical issues can be reduced exclusively to matters of rights. In relation to abortion, there are 2 opposing forms of rights-based reductionism, namely fetal rights reductionism, which emphasizes the rights for the fetus while disregarding the rights and autonomy of the pregnant patient, and pregnant patient rights reductionism, which supports unlimited abortion without regards for the fetus. The 2 positions are irreconcilable. This article provides historical examples of the destructive nature of zealotry, which is characterized by extreme devotion to one's beliefs and an intolerant stance to opposing viewpoints, and of the importance of enlightenment to limit zealotry. This article then explores the professional responsibility model as a clinically ethically sound approach to overcome the clashing forms of rights-based reductionism and zealotry and to address the professional practice of abortion. The professional responsibility model refers to the ethical and professional obligations that obstetricians and other healthcare providers have toward pregnant patients, fetuses, and the society at large. It provides a more balanced and nuanced approach to the abortion debate, avoiding the pitfalls of reductionism and zealotry, and allows both the rights of the woman and the obligations to pregnant and fetal patients to be considered alongside broader ethical, medical, and societal implications. Constructive and respectful dialogue is crucial in addressing diverse perspectives and finding common ground. Embracing the professional responsibility model enables professionals to manage abortion responsibly, thereby prioritizing patients' interests and navigating between absolutist viewpoints to find balanced ethical solutions.

States' Abortion Laws Associated With Intimate Partner Violence-Related Homicide Of Women And Girls In The US, 2014-20

Women who are pregnant or recently gave birth are significantly more likely to be killed by an intimate partner than nonpregnant, nonpostpartum women of reproductive age, implicating the risk of fatal violence conferred by pregnancy itself. The rapidly increasing passage of state legislation has restricted or banned access to abortion care across the US. We used the most recent and only source of population-based data to examine the association between state laws that restrict access to abortion and trends in intimate partner violence-related homicide among women and girls ages 10-44 during the period 2014-20. Using robust difference-in-differences ecologic modeling, we found that enforcement of each additional Targeted Regulation of Abortion Providers (TRAP) law was associated with a 3.4 percent increase in the rate of intimate partner violence-related homicide in this population. We estimated that 24.3 intimate partner violence-related homicides of women and girls ages 10-44 were associated with TRAP laws implemented in the states and years included in this analysis. Assessment of policies that restrict access to abortion should consider their potential harm to reproductive-age women through the risk for violent death.

Facilitating Safe Access to Health Care through Legislative Reform - The Australian Experience

The realisation of the right to health is vulnerable to the interventions of strangers, acting on the belief that certain health care should not be permissible under the law or accessible in practice. In Australia, the key arena for such interventions has been abortion services. Drawing on empirical research undertaken by the authors, this article examines the impact of these interventions and the effectiveness of "safe access zone" laws that now operate nationwide to constrain them. After examining the unsuccessful constitutional challenge to these laws in the High Court of Australia, it considers whether safe access zones may have utility in other health care contexts.

Navigating the post-Dobbs landscape: ethical considerations from a perinatal perspective

Restrictive abortion laws have impacts reaching far beyond the immediate sphere of reproductive health, with cascading effects on clinical and ethical aspects of neonatal care, as well as perinatal palliative care. These laws have the potential to alter how families and clinicians navigate prenatal and postnatal medical decisions after a complex fetal diagnosis is made. We present a hypothetical case to explore the nexus of abortion care and perinatal care of fetuses and infants with life-limiting conditions. We will highlight the potential impacts of limited abortion access on families anticipating the birth of these infants. We will also examine the legally and morally fraught gray zone of gestational viability where both abortion and resuscitation of live-born infants can potentially occur, per parental discretion. These scenarios are inexorably impacted by the rapidly changing legal landscape in the U.S., and highlight difficult ethical dilemmas which clinicians may increasingly need to navigate.

Abortion Provision and Delays to Care in a Clinic Network in Washington State After Dobbs

Importance

The Supreme Court decision Dobbs v Jackson Women's Health Organization (Dobbs) overturned federal protections to abortion care and altered the reproductive health care landscape. Thus far, aggregated state-level data reveal increases in the number of abortions in states where abortion is still legal, but there is limited information on delays to care and changes in the characteristics of people accessing abortion in these states after Dobbs.

Objective

To examine changes in abortion provision and delays to care after Dobbs.

Design, Setting, and Participants

Retrospective cohort study of all abortions performed at an independent, high-volume reproductive health care clinic network in Washington state from January 1, 2017, to July 31, 2023. Using an interrupted time series, the study assessed changes in abortion care after Dobbs.

Exposure

Abortion care obtained after (June 24, 2022, to July 31, 2023) vs before (January 1, 2017, to June 23, 2022) Dobbs.

Main Outcome and Measure

Primary outcomes included weekly number of abortions and out-of-state patients and weekly average of gestational duration (days) and time to appointment (days).

Results

Among the 18 379 abortions during the study period, most were procedural (13 192 abortions [72%]) and funded by public insurance (11 412 abortions [62%]). The mean (SD) age of individuals receiving abortion care was 28.5 (6.44) years. Following Dobbs, the number of procedural abortions per week increased by 6.35 (95% CI, 2.83-9.86), but then trended back toward pre-Dobbs levels. The number of out-of-state patients per week increased by 2 (95% CI, 1.1-3.6) and trends remained stable. The average gestational duration per week increased by 6.9 (95% CI, 3.6-10.2) days following Dobbs, primarily due to increased gestations of procedural abortions. The average gestational duration among out-of-state patients did not change following Dobbs, but it did increase by 6 days for in-state patients (5.9; 95% CI, 3.2-8.6 days). There were no significant changes in time to appointment.

Conclusions and Relevance

These findings provide a detailed picture of changes in abortion provision and delays to care after Dobbs in a state bordering a total ban state. In this study, more people traveled from out of state to receive care and in-state patients sought care a week later in gestation. These findings can inform interventions and policies to improve access for all seeking abortion care.

State Abortion Bans Heap Burdens on Already Traumatized Rape Survivors

The laws exacerbate stigma and impede access to needed health care.