Intimate relationships after receiving versus being denied an abortion: A 5-year prospective study in the United States

CONTEXT

When an individual seeking an abortion cannot obtain one, carrying that pregnancy to term may affect both her relationship with the man involved in the pregnancy and her prospects for new intimate relationships. We aimed to assess the impact of receiving versus being denied a wanted abortion on women's intimate relationships, up to 5 years after seeking an abortion in the United States.

METHODS

Using mixed-effects regression models, we compared relationship outcomes among women who presented for abortion care just under facilities' gestational age limits ("Near-limit abortion patients," n = 452) with those who presented just over, were denied an abortion ("Turnaways," n = 146) at 30 US facilities.

RESULTS

At 1 week post-abortion seeking, the predicted probability of being in a relationship with the man involved in the pregnancy was 58%, gradually declining to 27% at 5 years with no significant differences between those who received and those who were denied an abortion. However, from 2 to 5 years post-abortion seeking, participants who were denied an abortion had double the odds (aOR = 2.01, 95% CI: 1.09-3.69) of being in a poor intimate relationship, with a predicted probability of being in a poor relationship of 14% among those denied an abortion compared with 9% among those who received one (p < 0.05).

CONCLUSIONS

Carrying an unwanted pregnancy to term does not increase the chance of being in an intimate relationship with the man involved in the pregnancy but may have negative implications for the quality of future relationships up to 5 years post-abortion seeking.

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.

A cross-sectional study examining consideration of self-managed abortion among people seeking facility-based care in the United States

Introduction

With increasing restrictions on abortion across the United States, we sought to understand whether people seeking abortion would consider ending their pregnancy on their own if unable to access a facility-based abortion.

Methods

From January to June 2019, we surveyed patients seeking abortion at 4 facilities in 3 US states. We explored consideration of self-managed abortion (SMA) using responses to the question: “Would you consider ending this pregnancy on your own if you are unable to obtain care at a health care facility?” We used multivariable Poisson regression to assess associations between individual sociodemographic, pregnancy and care-seeking characteristics and prevalence of considering SMA. In bivariate Poisson models, we also explored whether consideration of SMA differed by specific obstacles to abortion care.

Results

One-third (34%) of 741 participants indicated they would definitely or probably consider ending the pregnancy on their own if unable to obtain care at a facility. Consideration of SMA was higher among those who reported no health insurance (adjusted prevalence ratio [aPR] = 1.66; 95% Confidence Interval [CI] 1.12–2.44), described the pregnancy as unintended (aPR = 1.53; 95% CI 1.08–2.16), were seeking abortion due to concerns about their own physical or mental health (aPR = 1.50, 95% CI 1.02, 2.20), or experienced obstacles that delayed their abortion care seeking (aPR = 2.26, 95% CI 1.49, 3.40). Compared to those who would not consider SMA, participants who would consider SMA expressed higher difficulty finding an abortion facility (35 vs. 27%, p = 0.019), figuring out how to get to the clinic (29 vs 21%, p = 0.021) and needing multiple clinic visits (23 vs 17%, p = 0.044).

Conclusions.

One in three people seeking facility-based abortion would consider SMA if unable to obtain abortion care at a facility. As abortion access becomes increasingly restricted in the US, SMA may become more common. Future research should continue to monitor people’s consideration and use of SMA and ensure that they have access to safe and effective methods.

Accuracy of self-assessment of gestational duration among people seeking abortion

BACKGROUND

Mifepristone, used together with misoprostol, is approved by the United States Food and Drug Administration for medication abortion through 10 weeks' gestation. Although in-person ultrasound is frequently used to establish medication abortion eligibility, previous research demonstrates that people seeking abortion early in pregnancy can accurately self-assess gestational duration using the date of their last menstrual period.

OBJECTIVE

In this study, we establish the screening performance of a broader set of questions for self-assessment of gestational duration among a sample of people seeking abortion at a wide range of gestations.

STUDY DESIGN

We surveyed patients seeking abortion at 7 facilities before ultrasound and compared self-assessments of gestational duration using 11 pregnancy dating questions with measurements on ultrasound. For individual pregnancy dating questions and combined questions, we established screening performance focusing on metrics of diagnostic accuracy, defined as the area under the receiver operating characteristic curve, sensitivity (or the proportion of ineligible participants who correctly screened as ineligible for medication abortion), and proportion of false negatives (ie, the proportion of all participants who erroneously screened as eligible for medication abortion). We tested for differences in sensitivity across individual and combined questions using McNemar's test, and for differences in accuracy using the area under the receiver operating curve and Sidak adjusted P values.

RESULTS

One-quarter (25%) of 1089 participants had a gestational duration of >70 days on ultrasound. Using the date of last menstrual period alone demonstrated 83.5% sensitivity (95% confidence interval, 78.4-87.9) in identifying participants with gestational durations of >70 days on ultrasound, with an area under the receiver operating characteristic curve of 0.82 (95% confidence interval, 0.79-0.85) and a proportion of false negatives of 4.0%. A composite measure of responses to questions on number of weeks pregnant, date of last menstrual period, and date they got pregnant demonstrated 89.1% sensitivity (95% confidence interval, 84.7-92.6) and an area under the receiver operating curve of 0.86 (95% confidence interval, 0.83-0.88), with 2.7% of false negatives. A simpler question set focused on being >10 weeks or >2 months pregnant or having missed 2 or more periods had comparable sensitivity (90.7%; 95% confidence interval, 86.6-93.9) and proportion of false negatives (2.3%), but with a slightly lower area under the receiver operating curve (0.82; 95% confidence interval, 0.79-0.84).

CONCLUSION

In a sample representative of people seeking abortion nationally, broadening the screening questions for assessing gestational duration beyond the date of the last menstrual period resulted in improved accuracy and sensitivity of self-assessment at the 70-day threshold for medication abortion. Ultrasound assessment for medication abortion may not be necessary, especially when requiring ultrasound could increase COVID-19 risk or healthcare costs, restrict access, or limit patient choice.

Mail-order pharmacy dispensing of mifepristone for medication abortion after in-person clinical assessment

OBJECTIVE(S)

To estimate the effectiveness, acceptability, and feasibility of medication abortion with mifepristone dispensed by a mail-order pharmacy after in-person clinical assessment.

STUDY DESIGN

This is an interim analysis of an ongoing prospective cohort study conducted at five sites. Clinicians assessed patients in clinic and, if they were eligible for medication abortion and ≤ 63 days' gestation, electronically sent prescriptions for mifepristone 200 mg orally and misoprostol 800 mcg buccally to a mail-order pharmacy, which shipped medications for next-day delivery. Participants completed surveys three and 14 days after enrollment, and we abstracted medical chart data.

RESULTS

Between January 2020 and April 2021 we enrolled 240 participants and obtained clinical outcome information for 227 (94.6%); 3 reported not taking either medication. Of those with abortion outcome information (N = 224), 216 (96.4%) completed day-3 and 212 (94.6%) day-14 surveys. Of the 224 that took medications, none reported taking past 70 days' gestation, and complete medication abortion occurred for 217 participants (96.9%, 95% CI 93.7%-98.7%). Most received medications within three days (82.1%, 95% CI 76.5%-86.9%). In the day-3 survey, 95.4% (95% CI 91.7%-97.8%) reported being very (88.4%) or somewhat (6.9%) satisfied with receiving medications by mail. In the day-14 survey, 89.6% (95% CI 84.7%-93.4%) said they would use the mail-order service again if needed. Eleven (4.9%, 95% CI 2.5%-8.6%) experienced adverse events; two were serious (one blood transfusion, one hospitalization), and none were related to mail-order pharmacy dispensing.

CONCLUSIONS

Medication abortion with mail-order pharmacy dispensing of mifepristone appears effective, feasible, and acceptable to patients.

IMPLICATIONS

The in-person dispensing requirement for mifepristone, codified in the drug's Risk Evaluation and Mitigation Strategy, should be removed.

Timing of pregnancy discovery among women seeking abortion. Contraception 2021;104:642-647. [PMID: 34363842 DOI: 10.1016/j.contraception.2021.07.110]

OBJECTIVE

Little is known about the incidence and causes of delay in recognition of pregnancy. Delay in pregnancy recognition is associated with later presentation for abortion and exacerbates the burdens in accessing care. Using Turnaway study data, this study assessed the prevalence of later pregnancy recognition among a sample of people who obtained or were denied a wanted abortion.

STUDY DESIGN

The Turnaway Study included telephone interviews of 956 women who sought an abortion in the first trimester or just over or under the gestational limit of one of 30 abortion facilities across the United States and in-depth interviews with 31 who completed 5 years of surveys. We describe women's experiences discovering pregnancy and conducted multivariate analyses assessing factors associated with later pregnancy discovery (after 13 weeks since last menstrual period [LMP]).

RESULTS

Most women seeking second trimester abortions recognized their pregnancy more than 8 weeks after their LMP; more than 1 in 5 recognized pregnancy after 20 weeks. In interviews, women explained that recognition was delayed because of a lack of pregnancy symptoms or concurrence of other conditions with symptoms similar to pregnancy. According to multivariate analyses, women who had never given birth (adjusted odds ratio [aOR] = 1.71; 95% confidence interval [CI]: 1.24, 2.35) and those who used hormonal contraceptives in the month of conception (aOR = 1.83; 95% CI: 1.35, 2.47) were more likely to discover pregnancy after 13 weeks.

CONCLUSION

Laws imposing gestational limits will make abortion unavailable to people who discover pregnancy after the limit. Such bans are likely to disproportionately affect people using contraceptive methods to prevent pregnancy and those who have never given birth.

IMPLICATIONS

Some pregnant people have few pregnancy symptoms and/or have conditions with symptoms similar to pregnancy, such as irregular periods or chronic pain. Gestational limits to abortion are likely to disproportionately affect people who recognize pregnancy later in pregnancy, particularly those without prior pregnancy experiences and who are using contraception.

Pharmacists' knowledge, perspectives, and experiences with mifepristone dispensing for medication abortion

BACKGROUND

The U.S. Food and Drug Administration (FDA) restricts dispensing of mifepristone for medication abortion to certified health care providers at clinical facilities, thus prohibiting pharmacist dispensing. Allowing mifepristone dispensing by pharmacists could improve access to medication abortion.

OBJECTIVE

To assess the feasibility of pharmacists dispensing mifepristone to patients who have undergone evaluation for eligibility and counseling for medication abortion by a clinician.

METHODS

Before providing a study training on medication abortion, we administered baseline surveys to pharmacists who participated in a multisite mifepristone-dispensing intervention. The survey assessed medication abortion knowledge-using a 15-item score-and perceptions about the benefits and challenges of the model. We administered follow-up surveys in the study's final month that also assessed the pharmacists' satisfaction and experiences with mifepristone dispensing. To investigate the association of the study intervention with the pharmacists' knowledge, perceptions, and experiences dispensing mifepristone, we conducted multivariable linear regression analyses using generalized estimating equation models, accounting for clustering by individual.

RESULTS

Among the 72 pharmacists invited from 6 pharmacies, 47 (65%) completed the baseline surveys, and 56 (78%) received training. At the study's end (mean 18 months later), 43 of the 56 pharmacists who received training (77%) completed the follow-up surveys. At follow-up, 36 (83%) respondents were very or somewhat satisfied with mifepristone dispensing, and 24 (56%) reported experiencing no challenges dispensing mifepristone. Four (6%) of the 72 pharmacists invited objected to participating in mifepristone dispensing. In regression analyses, average knowledge scores, perceived ease of implementation, and level of support for the pharmacist-dispensing model were higher at follow-up (P < 0.001).

CONCLUSION

Most pharmacists were willing to be trained, dispensed mifepristone with few challenges when given the opportunity, were satisfied with the model, and had higher knowledge levels at follow-up. Our findings support removal of FDA's restriction on pharmacist dispensing of mifepristone.

"It's Worked Well for Me": Young Women's Reasons for Choosing Lower-Efficacy Contraceptive Methods

STUDY OBJECTIVE

To understand the diverse reasons why some young women choose contraceptive methods that are less effective at preventing pregnancy, including condoms, withdrawal, and emergency contraception pills, even when more effective contraceptive methods are made available to them.

DESIGN

In-depth interviews with young women at family planning clinics in July-November 2016. Interview data were thematically coded and analyzed using an iterative approach.

SETTING

Two youth-serving family planning clinics serving predominantly Latinx and African American communities in the San Francisco Bay Area, California.

PARTICIPANTS

Twenty-two young women ages 15-25 years who recently accessed emergency contraception to prevent pregnancy.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Young women's experiences using different methods of contraception, with specific attention to methods that are less effective at preventing pregnancy.

RESULTS

Young women reported having previously used a range of higher- and lower-efficacy contraceptive methods. In interviews, they described affirmative values that drive their decision to use lower-efficacy methods, including: a preference for flexibility and spontaneity over continual contraceptive use, an emphasis on protecting one's body, and satisfaction with the method's effectiveness at preventing pregnancy. Some young women described using a combination of lower-efficacy methods to reduce their pregnancy risk.

CONCLUSION

Young women make contraceptive decisions on the basis of preferences and values that include, but are not limited to, effectiveness at preventing pregnancy. These reasons are salient in their lives and need to be recognized as valid by sexual health care providers to ensure that young women receive ongoing high-quality care.

"I'll just deal with this on my own": a qualitative exploration of experiences with self-managed abortion in the United States

Background

A growing body of evidence indicates that some people seek options to terminate a pregnancy without medical assistance, but experiences doing so have largely been documented only among people accessing a clinic-based abortion. We aim to describe self-managed abortion (SMA) experiences of people recruited outside of clinics, including their motivations for SMA, pregnancy confirmation and decision-making processes, method choices, and clinical outcomes.

Methods

In 2017, we conducted 14 in-depth interviews with self-identified females of reproductive age who recently reported in an online survey administered to Ipsos’ KnowledgePanel that, since 2000, they had attempted SMA while living in the United States. We asked participants about their reproductive histories, experiences seeking reproductive health care, and SMA experiences. We used an iterative process to develop codes and analyzed transcripts using thematic content analysis methods.

Results

Motivations and perceptions of effectiveness varied by whether participants had confirmed the pregnancy prior to SMA. Participants who confirmed their pregnancies chose SMA because it was convenient, accessible, and private. Those who did not test for pregnancy were motivated by a preference for autonomy and felt empowered by the ability to try something on their own before seeking facility-based care. Participants prioritized methods that were safe and available, though not always effective. Most used herbs or over-the-counter medications; none used self-sourced abortion medications, mifepristone and/or misoprostol. Five participants obtained facility-based abortions and one participant decided to continue the pregnancy after attempting SMA. The remaining eight reported being no longer pregnant after SMA. None of the participants sought care for  SMA complications; one participant saw a provider to confirm abortion completion.

Conclusions

There are many types of SMA experiences. In addition to those who pursue SMA as a last resort (after facing barriers to facility-based care) or as a first resort (because they prefer homeopathic remedies), our findings show that some individuals view SMA as a potential interim step worth trying after suspecting pregnancy and before accessing facility-based care. These people in particular would benefit from a medication abortion product available over the counter, online, or in the form of a missed-period pill.

Some people in the United States (US) attempt to end a pregnancy on their own without medical supervision. What we know about this experience comes from studies focused on people who go to clinics. In this study, we conducted 14 interviews with self-identified women ages 18–49 who recently reported attempting to end a pregnancy on their own and who were recruited outside of the clinic setting. We asked participants about their fertility histories, experiences seeking reproductive health care, and experiences ending a pregnancy without medical assistance. Those who took a pregnancy test and then chose to end the pregnancy on their own did so because it was convenient, accessible, and private. Those who did not test for pregnancy felt empowered by the ability to try something on their own before seeking facility-based care. All participants prioritized methods that were safe and available, though not always effective. After they attempted to end the pregnancy on their own, five participants accessed abortion care in facilities, one decided to continue the pregnancy, and eight were no longer pregnant. Our findings show that, in addition to people who end a pregnancy on their own as a last resort (after facing barriers to facility-based care) or as a first resort (because of preferences for homeopathic methods), a third group values having an interim step to try after suspecting pregnancy and before accessing facility-based care. These people would particularly benefit from a medication abortion product available over the counter, online, or in the form of a missed-period pill.

Pre-Abortion Informed Consent Through Telemedicine vs. in Person: Differences in Patient Demographics and Visit Satisfaction

PURPOSE

Utah law requires patients to have a face-to-face "informed consent" visit at least 72 hours prior to abortion. Planned Parenthood Association of Utah (PPAU) offers this visit via telemedicine as an alternative to an in-person visit, which can require burdensome travel. This novel study identifies factors associated with using telemedicine for informed consent, patients' reasons for using it, and experiences with it, compared to in-person informed consent.

METHODS

In 2017 and 2018, patients 18 years and older seeking abortion at PPAU completed a self-administered online survey about their experiences with the informed consent visit. We used linear and logistic regression models to compare participants' demographic characteristics by informed consent visit type, and descriptive statistics to describe reasons for using each visit type and experiences with the visit. Multivariable logistic regression models examined associations between visit type and satisfaction.

RESULTS

Responses from 166 telemedicine patients and 217 in-person informed consent patients indicate that telemedicine participants would have had to travel significantly further than in-person participants traveled to attend the visit at the clinic (mean of 65 miles versus 21 miles, p < .001). In multivariable analyses, telemedicine participants had higher odds of being "very satisfied" with the visit (aOR, 2,89; 95% CI: 1.93-4.32) and "very comfortable" asking questions during the visit (aOR, 3.76; 95% CI: 2.58-5.49), compared to participants who attended in-person visits.

CONCLUSIONS

Telemedicine offers a convenient, acceptable option for mandated pre-abortion informed consent visits and reduces the burden of additional travel and associated barriers for some patients, particularly those who live further away from clinics.

The Role of Health Care Providers in Young Women's Attitudes about and Willingness to Use Emergency Contraceptive Pills

BACKGROUND

Emergency contraceptive pills (ECPs) are an underused resource among adolescent and young adult women who have unprotected sex. This analysis examines young women's attitudes about and willingness to use ECPs, with particular attention to their experiences with health care providers.

METHODS

Sexually active young women (ages 15-25, assigned female at birth, N = 212) completed a self-administered survey at 10 family planning clinics in the San Francisco Bay Area. Participants reported attitudes about ECP effectiveness, safety, effect on sex drive, and whether it should not be taken often, and their willingness to use ECPs in the next 3 months. The predictors of interest were past and current contraceptive experiences with health care providers. Data were analyzed through descriptive statistics and multivariable logistic regression analyses controlling for sociodemographic characteristics, prior contraceptive use, pregnancy history, and pregnancy intentions.

RESULTS

Most young women agreed that ECPs are effective at preventing pregnancy (75%) and safe to use (71%); few reported that they reduce sex drive (11%). Yet, the majority (62%) believed ECPs should not be taken often and only 35% reported willingness to use ECPs. In multivariable analyses, more positive health care experiences were associated with more positive attitudes about ECP safety, less concern that ECPs should not be taken often, and greater willingness to use ECPs (p < .05).

CONCLUSIONS

Health care providers play an important role in the acceptance and provision of ECPs, especially for young women who prefer ECPs over other contraceptive methods. In particular, providers can use the contraceptive visit as an opportunity to destigmatize repeat ECP use.

Reasons for and Logistical Burdens of Judicial Bypass for Abortion in Illinois

PURPOSE

Minors seeking abortion in states with parental involvement requirements can obtain judicial bypass (JB) as an alternative. Research on minors' reasons for choosing bypass and the logistical obstacles associated with bypass is limited, yet needed to assess potential burdens introduced by mandated parental involvement.

METHODS

Using data from all minors represented in JB proceedings by the Illinois Judicial Bypass Coordination Project in 2017 and 2018, we present descriptive statistics summarizing minors' demographic characteristics, reasons for seeking bypass, individuals involved in decision-making, and distances traveled and time elapsed to attend the court hearing.

RESULTS

Most minors obtaining bypass (n = 150) agreed to participate (n = 128). Just more than half (55%) were aged 17 years and lived with one parent (54%). A minority were already parenting (5%) and/or lived with someone besides a parent or on their own (16%). The reasons for bypass included concern about being forced to continue the pregnancy (50%), fear of being kicked out of their home and/or cut off financially (41%), having no/minimal relationship with parents (15%), and fear of physical/emotional abuse (13%). Minors traveled an average of 24 miles one-way (range 1-270 miles) to a courthouse for their hearing. On average, 6.4 days elapsed between contacting the Judicial Bypass Coordination Project and the hearing.

CONCLUSIONS

Judicial bypass can offer young people an opportunity to retain autonomy in decision-making, potentially avoiding abuse and other negative outcomes. However, even in a state with a well-organized network of attorneys, JB contributes 1 week to minors' abortion-seeking timeline and necessitates traveling long distances.