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

Abortion-related morbidity and mortality in Sierra Leone: results from a 2021 cross-sectional study

BACKGROUND

Unsafe abortion remains a significant driver of maternal morbidity and mortality. We aimed to assess the severity of abortion complications among post-abortion care (PAC) clients in Sierra Leone and factors associated with more severe complications.

METHODS

We applied the Prospective Morbidity Survey (PMS) among PAC patients and their providers in 142 facilities in Sierra Leone between August and October 2021. We administered a total of 522 patient PMS surveys and 513 provider PMS surveys. To assess post-abortion complication severity, we utilized a five-level severity classification system ranging from mild to maternal death. We conducted bivariate and multivariable tests to assess factors associated with the severity of complications. Dependent variables included demographic characteristics and delays to care reported by PAC patients.

RESULTS

Overall, 36% of PAC patients had mild complications, 30% moderate, 27% severe, and 8% near-miss. One person died. Many women experienced delays to care, particularly in realizing care was needed, deciding to seek care, and arriving at the health facility. Controlling for facility level, the risk of experiencing a severe or near-miss complication or death was not significantly associated with the patient's sociodemographic characteristics, except age and number of pregnancies; compared to adolescents 19 and under, PAC patients aged 20-24 had significantly lower risk of a severe/near-miss complication or death, while PAC patients with 2-4 pregnancies had significantly higher risk of a severe/near-miss complication or death compared to PAC patients experiencing their first pregnancy. Delays in accessing care were significantly associated with having more severe complications; patients were more likely to suffer the most severe complications if they had to wait longer than one hour to be attended to, or did not receive complete treatment within 12 h.

CONCLUSIONS

Compared to regional and global estimates, the burden of abortion-related complications in Sierra Leone is high. The recent effort to liberalize abortion law is promising; this potential legal reform must be paired with the expansion of safe abortion services to reduce abortion-related morbidity and mortality in the country. In the absence of legal change, our analysis also emphasizes the need to ensure PAC services are always free of cost, that women are aware of the availability and legality of PAC, and that facilities have the human and material resources needed to handle these cases.

Abortion After Pregnancy Occurrence with Contraceptive Use Among Veterans

Objective: Many people report becoming pregnant while using contraception. Understanding more about this phenomenon may provide insight into pregnant people's responses to and healthcare needs for these pregnancies. This study explores the outcome (e.g., birth, miscarriage, abortion) of pregnancies among Veterans in which conception occurred in the month of contraceptive use. Study Design: We used data from the Examining Contraceptive Use and Unmet Need Study, a telephone-based survey conducted in 2014-2016 of women Veterans (n = 2302) ages 18-44 receiving primary care from the Veterans Health Administration. For each pregnancy, we estimated the relationship between occurrence in the month of contraceptive use and the outcome of the pregnancy using multinomial logistic regression, controlling for relevant demographic, clinical, and military factors and clustering of pregnancies from the same Veteran. Results: The study included 4436 pregnancies from 1689 Veterans. Most participants were ≥30 years of age (n = 1445, 85.6%), identified as non-Hispanic white (n = 824, 51.6%), and lived in the Southern United States (n = 994, 55.6%). Nearly 60% (n = 1007) of Veterans who had ever been pregnant reported experiencing a pregnancy in the month of contraceptive use; a majority of those pregnancies (n = 1354, 80.9%) were described as unintended. In adjusted models, pregnancies occurring in the month of contraceptive use were significantly more likely to end in abortion (aOR: 1.76, 95% CI: 1.42-2.18) than live birth. Conclusions: Pregnancy while using contraception is common among Veterans; these pregnancies are more likely to end in abortion than live birth. Given widespread restrictions to reproductive health services across much of the United States, ensuring Veterans' access to comprehensive care, including abortion, is critical to supporting reproductive autonomy and whole health.

[Abortions and the life course: insights based on pairfam data]

INTRODUCTION

Despite the social and political importance of abortion, little quantitative research has been done on the individual circumstances of women who have had abortions in Germany. This article takes an empirical and descriptive look at the individual, economic, and partnership conditions under which such decisions are made.

METHODS

Data from the first 13 waves (2008-2021) of the German Family Panel (pairfam) were analyzed. Data from women who had an abortion were compared with those who carried the pregnancy to term in terms of individual characteristics, economic, and partnership circumstances. The sample consists of 1511 observations from 1082 respondents, including 216 abortions and 1295 births. The data were analyzed by means of descriptive analysis.

RESULTS

Abortions are associated with several individual, economic, and partnership characteristics. Abortions are relatively less frequent when women are in good health and more frequent when they already have two or more children. In addition, the financial situation of women who have an abortion is comparatively worse. They are also more likely to be single or dissatisfied with their partnership.

DISCUSSION

The findings suggest that the decision to terminate a pregnancy by abortion is made in the context of specific life circumstances. This article highlights the need for further research into the complexities involved.

A global scoping review of the circumstances of care seeking for abortion later in pregnancy

Understanding the circumstances of abortions later in pregnancy provides insight about the barriers and delays to timely care. Limited synthesized information is available on these circumstances, especially from low and middle incomes countries. Reviewing what is reported in the literature about the circumstances of abortion later in pregnancy and the methodological approaches used to study this is needed to reveal evidence gaps. The purpose of this study is to describe what is documented and methodological approaches used in existing literature on the circumstances and characteristics associated with seeking care for abortion later in pregnancy reported in population and facility-based studies. We conducted a scoping review of peer-reviewed research in OVID/PubMed, Embase, Scopus, SocIndex, and LILACs from 2007-2024 that described the circumstance, sociodemographic characteristics, population- or facility-based proportion of abortion later in pregnancy (≥12 weeks of gestation or "second trimester") reported in the literature. We screened 2598 records by title and/or abstract and 668 of those by full text. We included 78 studies that described the circumstances around seeking care for abortion later in pregnancy from qualitative data (12 studies); included information on associated characteristics from quantitative data (15 studies); reported a population- (17 studies) or facility-based (45 studies) proportion of abortion later in pregnancy. Prominent themes included health system challenges, late pregnancy recognition, financial challenges, and delayed decision making. Low economic status and adolescence were commonly associated characteristics. Population and facility-based studies lacked standardization when reporting durations of gestation. Facility studies reported a wide variety of populations and number of facilities. Circumstances surrounding abortions later in pregnancy include health system challenges, late pregnancy recognition, financial issues, and delayed decision-making, which intersect to compound and extend delays. More research guided by clear methods and standard definitions when reporting on population and facility-based proportions of abortions later in pregnancy is needed to reveal evidence gaps and better inform policies and programs.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposure

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

Main Outcome and Measures

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

Results

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

Conclusions and Relevance

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

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

Gone and Forgotten? Predictors of Birth History Omissions in India

Background

Fertility histories are subject to measurement errors such as incorrect birth dates, incorrect birth orders, incorrect sex, and omissions. These errors can bias demographic estimates such as fertility rates and child mortality rates.

Objective

We focus on births missing in fertility histories. We estimate the prevalence of such omissions and study their associated factors.

Methods

We leverage a panel survey (the India Human Development Survey) where the same women were interviewed in two waves several years apart. We compare data across waves and identify omitted births. Omissions in the second wave are modeled as a function of several child, mother, household, and survey interviewer variables. Models are fit separately to omissions reported alive or dead in the first wave.

Results

We conservatively estimate the prevalence of omissions at 4%. A large majority of omitted births are those of dead children, especially infants, with children in poorer households at greater risk of being omitted. For children alive in wave 1, female children are much more likely to be omitted in wave 2 compared to male children. Interviewers can detect respondent behaviors associated with omissions.

Conclusions

Omissions in fertility histories are non-ignorable. They do not randomly occur but affect some population sub-groups and some interview contexts more than others.

Contributions

We investigate the understudied but important phenomenon of omitted births in fertility histories. We bring attention to possible biases in demographic estimates. We shed light on the survey process and propose strategies for minimizing the bias through improved survey design.

"Technically an abortion": Understanding perceptions and definitions of abortion in the United States

Anti-abortion legislation in the United States exploits misinformation and ignores medical definitions to curtail access to essential healthcare. Little is known about how individuals most likely to need this care define abortion, in general or as distinct from miscarriage, and how this might impact access to, utilization of, and experiences of care. Using mixed-method card sort and vignette data from cognitive interviews (n = 64) and a national online survey (n = 2009), we examined individuals' understandings of pregnancy outcomes including abortion and miscarriage. Our findings show that people hold varying ideas of what constitutes an abortion. Many respondents considered 'intent' when classifying pregnancy outcomes and focused on intervention to distinguish between miscarriages and abortions. Particularly, medical intervention was found as a defining feature of abortion. Lack of knowledge regarding pregnancy experiences and ambiguity surrounding early stages of pregnancy also influenced respondents' understanding of abortion. We find that abortion and miscarriage definitions are socially constructed and multi-layered. Advancing our understanding of abortion and miscarriage definitions improves reproductive health research by elucidating potential areas of confusion that may lead to misreporting of reproductive experiences as well as highlighting ways that blurred definitions may be exploited by abortion opponents.

Self-reported abortion experiences in Ethiopia and Uganda, new evidence from cross-sectional community-based surveys

Unsafe abortion is a major contributor to maternal morbidity and mortality. To gain insight into the ways in which abortion restrictions and stigma may shape reproductive health outcomes, we present self-reported data on abortions in Ethiopia and Uganda and compare these findings across the two varying legal contexts. W investigate differences in sociodemographic characteristics by whether or not a woman self-reported an abortion, and we describe the characteristics of women's most recent self-reported abortion. In Ethiopia only, we classified abortions as being either safe, less safe, or least safe. Finally, we estimate minimum one-year induced abortion incidence rates using the Network Scale-Up Method (NSUM). We find that women who self-reported abortions were more commonly older, formerly married, or had any children compared to women who did not report an abortion. While three-quarters of women in both settings accessed their abortion in a health facility, women in Ethiopia more commonly used public facilities as compared to in Uganda (23.0% vs 12.6%). In Ethiopia, 62.4% of self-reported abortions were classified as safe, and treated complications were more commonly reported among least and less safe abortions compared to safe abortions (21.4% and 23.1% vs. 12.4%, respectively). Self-reported postabortion complications were more common in Uganda (37.2% vs 16.0%). The NSUM estimate for the minimum one-year abortion incidence rate was 4.7 per 1000 in Ethiopia (95% CI 3.9-5.6) and 19.4 per 1000 in Uganda (95% C 16.2-22.8). The frequency of abortions and low levels of contraception use at the time women became pregnant suggest a need for increased investments in family planning services in both settings. Further, it is likely that the broadly accessible nature of abortion in Ethiopia has made abortions safer and less likely to result in complications in Ethiopia as compared to Uganda.

Contraceptive Behavior Dynamics and Unintended Pregnancy: A Latent Transition Analysis

The average U.S. woman wants to have two children; to do so, she will spend about three years pregnant, postpartum, or trying to become pregnant, and three decades trying to avoid pregnancy. However, few studies have examined individual patterns of contraceptive use over time. These trajectories are important to understand given the high rate of unintended pregnancy and how little we know about the complex relationship between contraceptive use, pregnancy intention, and patterns of reproductive behavior. We use data from the 2015-2017 National Survey of Family Growth to examine reproductive behavior and pregnancies across three years of calendar data. We identify seven behavior typologies, their prevalence, how women transition between them, and how pregnancies affect transitions. At any given time, half of women are reliably using contraception. A small proportion belong to a high pregnancy risk profile of transient contraceptive users, but some transition to using condoms or other methods consistently. An unintended pregnancy may initiate a transition into stable contraceptive use for some women, although that is primarily condom use. These findings have important implications for the ways contraception fits into women's lives and how that behavior interacts with relationships, sex, and life stage trajectories.

Respondent-Driven Sampling for Estimation of the Cumulative Lifetime Incidence of Abortion in Soweto, Johannesburg, South Africa: A Methodological Assessment

Respondent-driven sampling (RDS) is a potential strategy for addressing challenges in accurate estimation of abortion incidence, but it relies on often untested assumptions. We conducted an RDS study to estimate the cumulative lifetime incidence of abortion in Soweto, Johannesburg, South Africa (April-December 2018), to evaluate whether RDS assumptions were met, and to compare RDS estimates of incidence with estimates adjusted for employment and age based on census data. A total of 849 participants were recruited from 11 seed participants between April and December 2018. The assumption that individuals can identify target population members and the assumption of approximation of sampling with replacement was met. There were minor violations of the assumptions of seed independence from the final sample and reciprocity of ties. Assumptions of accurate degree reporting and random recruitment were not met. Failure to meet assumptions yielded a study sample with different employment characteristics than those of the target population; this could not be resolved by standard RDS methods. The RDS estimate of cumulative lifetime abortion incidence was 12.1% (95% confidence interval: 9.8, 14.3), and the employment-adjusted estimate was 16.9% (95% confidence interval: 12.8, 22.1). We caution researchers in using RDS for representative estimates of abortion incidence. Use of postsurvey weights to adjust for differences in characteristics between the sample and the target population may yield more representative results.

"Have you ever wanted or needed an abortion you did not get?" Data from a 2022 nationally representative online survey in the United States

OBJECTIVE

Describe the prevalence of considering, wanting, and not obtaining a wanted abortion among a nationally representative sample of 15-44 year olds in the United States who had ever been pregnant.

STUDY DESIGN

We analyzed data from ever-pregnant respondents (unweighted n = 1789) from a larger online survey about contraceptive access using the nationally representative AmeriSpeak panel. Among those not obtaining wanted abortions, weighted frequencies for sociodemographic characteristics and reasons for not getting the abortion are presented.

RESULTS

Nearly 6% of the full sample reported having wanted an abortion they did not obtain. In open-ended responses, respondents most frequently reported individual reasons (43.8%) for not getting an abortion (e.g., changing their mind; personal opposition) and financial, logistical, or informational barriers (24.7%) likely related to policy. A quarter (24.1%) of the sample reported a past abortion. Among those who reported no past abortions, about one-fifth had considered abortion in the past, and 6.8% had wanted or needed one. Among those reporting no prior abortions who had considered abortion, only a third (34.3%) also report ever wanting or needing one.

CONCLUSIONS

This study begins to quantify the experience, even before the Supreme Court's 2022 decision in Dobbs v. Jackson Women's Health Organization, of being unable to obtain a wanted abortion. Additionally, findings suggest that people in a national sample will answer questions about whether and why they did not obtain a wanted abortion.

IMPLICATIONS

This study provides the first known national estimates of lifetime history of not getting a wanted abortion. Survey questions can be used for future research. Prospective and ongoing measurement of the inability to get a wanted abortion could be one part of documenting the effects of Dobbs on abortion access.

Pregnancies in the United States by Desire for Pregnancy: Estimates for 2009, 2011, 2013, and 2015

We examine whether changes in U.S. pregnancy, birth, and abortion rates between 2009 and 2015 reflect underlying change in the incidence of pregnancies classified by retrospectively reported pregnancy desires: pregnancies reported as having occurred at about the right time, later than wanted, too soon, or not wanted at all, and those for which individuals expressed other feelings, including uncertainty, ambivalence, or indifference. We calculate the proportionate distributions of these pregnancies and rates among U.S. women aged 15-44, as well as change over time, overall and among age groups. Characterization of desires for a past pregnancy shifted in a number of ways between 2009 and 2015, and changes across age groups were not uniform. Rates of pregnancies reported as occurring later than wanted increased among older women, while rates of pregnancies reported as occurring too soon decreased among all women. These findings shed light on previous research documenting an increasing age at first birth, increasing rates of pregnancy and childbearing among the oldest age groups, and changes in patterns of contraceptive use, particularly among young women. Our analysis explores limitations and challenges of two major sources of data on pregnancies in the United States and their measures of retrospectively reported pregnancy desires.

Impact of the global gag rule on women's contraceptive use and reproductive health outcomes in Ethiopia: a pre-post and difference-in-difference analysis

OBJECTIVE

To assess the impacts of the Protecting Life through Global Health Assistance policy (otherwise known as the expanded global gag rule (GGR)) on women's sexual and reproductive health (SRH) in Ethiopia. The GGR prohibits all non-US non-governmental organisations (NGOs) receiving US Government global health funding from providing, referring or advocating for abortion.

DESIGN

Pre-post analysis and difference-in-difference analysis.

SETTING

Six regions of Ethiopia (Tigray, Afar, Amhara, Oromiya, SNNPR and Addis Ababa).

PARTICIPANTS

Panel of 4909 reproductive-age women recruited from the Performance Monitoring for Accountability 2018 survey, administered face-to-face surveys in 2018 and 2020.

MEASURES

We assessed impacts of the GGR on contraceptive use, pregnancies, births and abortions. Due to the 2019 'Pompeo Expansion' and widespread application of the GGR, we use a pre-post analysis to investigate changes in women's reproductive outcomes. We then use a difference-in-differences design to measure the additional effect of NGOs refusal to comply with the policy and the resulting loss in funding; districts are classified as more exposed if organisations impacted by lost funding were providing services there and women are classified based on their district.

RESULTS

At baseline, 27% (n=1365) of women were using a modern contraceptive (7% using long-acting reversible contraceptive methods (LARCs) and 20% using short-acting methods. The pre-post analysis revealed statistically significant declines from 2018 to 2020 in the use of LARCs (-0.9, 95% CI: -1.6 to -0.2) and short-acting methods (-1.0, 95% CI: -1.8 to -0.2). These changes were deviations from prior trends. In our difference-in-differences analysis, women exposed to non-compliant organisations experienced greater declines in LARC use (-1.5, 95% CI: -2.9 to -0.1) and short-acting method use (-1.7, 95% CI: -3.2 to -0.1) as compared with less-exposed women.

CONCLUSIONS

The GGR resulted in a stagnation in the previous growth in contraceptive use in Ethiopia. Longer-term strategies are needed to ensure that SRH progress globally is protected from changes in US political administrations.

Induced abortions of women living with HIV in Finland 1987-2019: a national register study

BACKGROUND

Recent data on the rate and risk factors of induced abortion among women living with HIV (WLWH) are limited. Our aim was to use Finnish national health register data to 1) determine the nationwide rate of induced abortions of WLWH in Finland during 1987-2019, 2) compare the rates of induced abortions before and after HIV diagnosis over different time periods, 3) determine the factors associated with terminating a pregnancy after HIV diagnosis, and 4) estimate the prevalence of undiagnosed HIV at induced abortions to see whether routine testing should be implemented.

METHODS

A retrospective nationwide register study of all WLWH in Finland 1987-2019 (n = 1017). Data from several registers were combined to identify all induced abortions and deliveries of WLWH before and after HIV diagnosis. Factors associated with terminating a pregnancy were assessed with predictive multivariable logistic regression models. The prevalence of undiagnosed HIV at induced abortion was estimated by comparing the induced abortions among WLWH before HIV diagnosis to the number of induced abortions in Finland.

RESULTS

Rate of induced abortions among WLWH decreased from 42.8 to 14.7 abortions/1000 follow-up years from 1987-1997 to 2009-2019, more prominently in abortions after HIV diagnosis. After 1997 being diagnosed with HIV was not associated with an increased risk of terminating a pregnancy. Factors associated with induced abortion in pregnancies that began after HIV diagnosis 1998-2019 were being foreign-born (OR 3.09, 95% CI 1.55-6.19), younger age (OR 0.95 per year, 95% CI 0.90-1.00), previous induced abortions (OR 3.36, 95% CI 1.80-6.28), and previous deliveries (OR 2.13, 95% CI 1.08-4.21). Estimated prevalence of undiagnosed HIV at induced abortion was 0.008-0.029%.

CONCLUSIONS

Rate of induced abortions among WLWH has decreased. Family planning should be discussed at every follow-up appointment. Routine testing of HIV at all induced abortions is not cost-effective in Finland due to low prevalence.

Improving abortion underreporting in the USA: a cognitive interview study

Abortion is a difficult-to-measure behaviour with extensive underreporting in surveys, which compromises the ability to study and monitor it. We aimed to improve understanding of how women interpret and respond to survey items asking if they have had an abortion. We developed new questions hypothesised to improve abortion reporting, using approaches that aim to clarify which experiences to report; reduce the stigma and sensitivity of abortion; reduce the sense of intrusiveness of asking about abortion; and increase respondent motivation to report. We conducted cognitive interviews with cisgender women aged 18-49 in two US states (N = 64) to assess these new approaches and questions for improving abortion reporting. Our findings suggest that including abortion as part of a list of other sexual and reproductive health services, asking a yes/no question about lifetime experience of abortion instead of asking about number of abortions, and developing an improved introduction to abortion questions may help to elicit more accurate survey reports. Opportunities exist to improve survey measurement of abortion. Reducing the underreporting of abortion in surveys has the potential to improve sexual and reproductive health research that relies on pregnancy histories.

Randomized experimental testing of new survey approaches to improve abortion reporting in the United States

CONTEXT

Abortions are substantially underreported in surveys due to social stigma, compromising the study of abortion, pregnancy, fertility, and related demographic and health outcomes.

METHODS

In this study, we evaluated six methodological approaches identified through formative mixed-methods research to improve the measurement of abortion in surveys. These approaches included altering the placement of abortion items in the survey, the order of pregnancy outcome questions, the level of detail, the introduction to the abortion question, and the context of the abortion question, and using graduated sensitivity. We embedded a preregistered randomized experiment in a newly designed online survey about sexual and reproductive health behaviors (N = 6536). We randomized respondents to experimental arms in a fully crossed factorial design; we estimated an average treatment effect using standardized estimators from logistic regression models, adjusted for demographic covariates associated with reporting.

RESULTS

None of the experimental arms significantly improved abortion reporting compared to the control condition.

CONCLUSION

More work is needed to improve reporting of abortion in future surveys, particularly as abortion access becomes increasingly restricted in the United States. Despite this study's null results, it provides a promising path for future efforts to improve abortion measurement. It is proof of concept for testing new approaches in a less expensive, faster, and more flexible format than embedding changes in existing national fertility surveys.

Recent trend and correlates of induced abortion in China: evidence from the 2017 China Fertility Survey

BACKGROUND

Although there are more than 10 million induced abortions per year in China, there are few comprehensive, systematic, and characteristic-based data on induced abortions among Chinese women. This study aims to examine the overall trend in induced abortions in China and to analyze the correlation between induced abortions and some socio-economic factors.

METHODS

Drawing from the 2017 China Fertility Survey, this study analyzed induced abortions using multiple indicators from period and cohort perspectives on a sample of 240,957 women. The indicators include the abortion rate and proportion, average age at the time of induced abortion, age-specific cumulative proportions, and the number of induced abortions by cohort. The analysis also differentiated based on residency, ethnicity, education level, and marital status. A binomial logistic regression model was used to examine the association between induced abortions and socio-economic factors.

RESULTS

Between 2006 and 2016, among women aged 15-49, there was an increase in the induced abortion rate and the average age of women who had induced abortions, but a decline in the proportion of abortions. The proportion of induced abortion was higher among premarital than post-marital pregnancies, among unintended than planned pregnancies. Women with induced abortion experiences accounted for less than 30% of all cohorts, and the cumulative number of induced abortions per woman in each cohort was less than 0.45. These indicators varied with birth cohort, residence, ethnicity, education level, and marital status. The results of binomial logistic regression confirmed the association between induced abortion and these socio-economic variables. Sex-selective abortions of female fetuses still exist, despite the government's considerable efforts to eliminate them.

CONCLUSION

The practice of induced abortions differs by cohort and socio-economic characteristics. The profile of women who resort to abortions in China has shifted from well-educated urban women to rural, less-educated women. More effective measures should be taken by the government to reduce the number of induced abortions among women with higher abortion risks.

Declines in Non-marital Births Among Black Women Between 2004 and 2014: Are Recent Trends the Result of Increases in Contraception?

Non-marital birth rates for women in their twenties began declining in 2008, but the mechanisms driving this decline are not yet well understood. Using a proximate determinants of fertility framework and decomposition techniques, we consider the importance of changes in relationship status, contraceptive use, and other dimensions of deliberate fertility control in understanding trends in the non-marital fertile pregnancy rate between 2004 and 2014. We use data from several cycles of the National Survey of Family Growth to identify relationship and contraceptive use status at the time of conception for pregnancies that resulted or were likely to result in live births (i.e., fertile pregnancies), and focus our analysis on non-Hispanic Black women in their twenties. We find that changes in relationship status and sexual activity did not contribute to the decline in fertile pregnancy rates, nor did changes in the distribution of contraceptive method use. Instead, changing fertile pregnancy rates within contraceptive use categories, including among those who report using no method of contraception, account for the observed trend. Though contraceptive method mix is an insufficient explanation for recent trends, our results suggest that considering the sources of within-method variation in fertile pregnancy rates over time is key to understanding declines in non-marital births, and that some women not using contraception likely engaged in a form of deliberate fertility control not captured by the National Survey of Family Growth.

Disparities in the Incidence of Ectopic Pregnancy in a Large Health Care System in California, 2010-2019

IntroductionEctopic pregnancy leads to reproductive health morbidity, including greater risk of another ectopic pregnancy, infertility, and, in rare cases, mortality. Information on trends in the incidence of ectopic pregnancy in the last decade is limited. MethodsA population-based cross-sectional study of women aged 15-44 years enrolled at Kaiser Permanente Northern and Southern California 2010-2019 was conducted. Electronic health records were used to identify ectopic pregnancies. The crude ectopic pregnancy incidence per 1000 pregnancies (live births, induced abortions, and ectopic pregnancies) and 95% confidence interval (CI) was estimated per study year, overall, and stratified by age group. The age-adjusted incidence and 95% CI was estimated per study year, overall, and stratified by race/ethnicity. Temporal trend was assessed using Poisson regression. ResultsThere were 15,537 ectopic pregnancies among 979,027 pregnancies. The overall age-adjusted ectopic pregnancy incidence was 15.8 per 1000 pregnancies, 95% CI: 15.6, 16.1. The annual incidence increased from 15.2, 95% CI: 14.4, 16.1, in 2010 to 16.4, 95% CI: 15.6, 17.2, in 2019 (p < 0.001). The overall incidence was highest among women aged 40-44 years (24.2, 95% CI: 22.7, 25.6) and non-Hispanic Black women (21.9, 95% CI: 21.0, 22.8); compared to 30-34-year-old (16.2, 95% CI: 15.7, 16.6) and non-Hispanic White (14.6, 95% CI: 14.1, 15.0) women, respectively. DiscussionThe increase in ectopic pregnancy incidence during the studied period was largely driven by increasing incidence in younger women. However, disparities in the incidence by age and race/ethnicity persisted. ConclusionEctopic pregnancy remains a significant source of reproductive health morbidity, especially for older ( >40 years) and non-Hispanic Black women.

Unintended pregnancy resolution among parous women in twelve low- and middle-income countries

Around 40% of pregnancies worldwide are unintended and a half of those are terminated. Yet, few international comparisons of unintended pregnancy resolution (choosing birth or abortion) exist. This study analysed how parous women's pregnancy intentions and abortion decisions are associated with their reproductive histories and country contexts using twelve Demographic and Health Surveys representing four context groups: post-Soviet/communist and Asian countries with liberal abortion legislation, and Asian and Latin American countries with restrictive abortion legislation. Similarities were found across contexts: preference to have children of both sexes, space births, stop childbearing after reaching desired family size and an increased likelihood of unintended pregnancy when using less-effective contraceptive methods versus none. Contextual factors most clearly associated with reports of unintended pregnancy resolution were type of abortion legislation and living in post-Soviet/communist contexts. Women's propensity to report abortions and unintended pregnancy varied by context and the decision-making processes for pregnancy versus fertility management were different.

Who are the women who relinquish infants for adoption? Domestic adoption and contemporary birth motherhood in the United States

INTRODUCTION

The social context of pregnancy decision-making has changed in recent decades in the United States (US), but little research has examined how these changes manifest in the context of infant adoption.

METHODS

To create an updated profile of US birth mothers, this analysis uses demographic data collected and aggregated from six adoption agencies, with information on 8658 private adoptions that occurred between 2011 and 2020.

RESULTS

Based on this sample, birth mothers today are older and more racially and ethnically diverse than counterparts in previous generations; a majority have other had children and a substantial proportion were parenting other children at the time of relinquishment. They report living on low incomes and, when considered with other measures (e.g., employment, health insurance, homelessness), seem to lack the economic resources that would give them meaningful power over the options available to themselves and their children. Most birth mothers contact agencies late in their pregnancies or after delivery, at a point when abortion care is likely inaccessible or unavailable. An important minority of birth mothers will relinquish more than one infant for adoption over the course of their reproductive lives.

CONCLUSION

Given the underlying shift in the demographic profile of women who relinquish infants, it is likely that the underlying circumstances that lead to adoption have also diverged. More research is needed into how women make decisions about adoption; such research carries implications for how best to support women's decision-making and ensure access to needed services throughout pregnancy and beyond.

The Missing Baby Bust: The Consequences of the COVID-19 Pandemic for Contraceptive Use, Pregnancy, and Childbirth Among Low-Income Women

Multiple episodes in US history demonstrate that birth rates fall in response to recessions. However, the 2020 COVID-19 recession differed from earlier periods in that employment and access to contraception and abortion fell, as reproductive health centers across the country temporarily closed or reduced their capacity. This paper exploits novel survey and administrative data to examine how reductions in access to reproductive health care during 2020 affected contraceptive efficacy among low-income women. Accounting for 2020's reductions in access to contraception and the economic slowdown, our results predict a modest decline in births of 1.1 percent in 2021 for low-income women. Further accounting for reductions in access to abortion implies that birth rates may even rise for low-income women. These results also suggest that already economically disadvantaged families disproportionately affected by the COVID-19 economy will experience a large increase in unplanned births.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11113-022-09703-9.

Qualitative Data Sharing: Participant Understanding, Motivation, and Consent

Expectations to share data underlying studies are increasing, but research on how participants, particularly those in qualitative research, respond to requests for data sharing is limited. We studied research participants' willingness to, understanding of, and motivations for data sharing. As part of a larger qualitative study on abortion reporting, we conducted interviews with 64 cisgender women in two states in early 2020 and asked for consent to share de-identified data. At the end of interviews, we asked participants to reflect on their motivations for agreeing or declining to share their data. The vast majority of respondents consented to data sharing and reported that helping others was a primary motivation for agreeing to share their data. However, a substantial number of participants showed a limited understanding of the concept of "data sharing." Additional research is needed on how to improve participants' understanding of data sharing and thus ensure fully informed consent.

Contraceptive Consistency and Poverty after Birth

Unplanned pregnancies in the U.S. disproportionately occur among poor, less educated, and minority women, but it is unclear whether poverty following a birth is itself an outcome of this pregnancy planning status. Using the National Longitudinal Survey of Youth 1997 (n=2,101) and National Survey of Family Growth (n=778), we constructed two-year sequences of contraceptive use before a birth that signal an unplanned versus a planned birth. We regressed poverty in the year of the birth both on this contraceptive-sequence variable and on sociodemographic indicators including previous employment and poverty status in the year before the birth, race/ethnicity, education, partnership status, birth order, and family background. Compared to sequences indicating a planned birth, sequences of inconsistent use and non-use of contraception were associated with a higher likelihood of poverty following a birth, both before and after controlling for sociodemographic variables, and before and after additionally controlling for poverty status before the birth. In pooled-survey estimates with all controls included, having not used contraception consistently is associated with a 42% higher odds of poverty after birth. The positive association of poverty after birth with contraceptive inconsistency or non-use, however, is limited to women with low to medium educational attainment. These findings encourage further exploration into relationships between contraceptive access and behavior and subsequent adverse outcomes for the mother and her children.

An Assessment of Third-Party Reporting of Close Ties to Measure Sensitive Behaviors: The Confidante Method to Measure Abortion Incidence in Ethiopia and Uganda

Indirect estimation techniques are important tools for measuring sensitive and stigmatized behaviors. This includes third‐party reporting methods, which have become increasingly common in the field of abortion measurement, where direct survey approaches notoriously lead to underreporting. This paper provides the first in‐depth assessment of one of the most widely used of these techniques in the field of abortion measurement: the confidante method. We outline six key assumptions behind the confidante method and describe how violations of these assumptions can bias resulting estimates. Using data from modules added to the performance monitoring for action surveys in Uganda and Ethiopia in 2018, we compute one‐year abortion incidence estimates using the confidante method. We also perform a validation check, using the method to estimate intrauterine device /implant use. Our results revealed implementation problems in both settings. Several of the method's foundational assumptions were violated, and efforts to adjust for these violations either failed or only partially addressed the resulting bias. Our validation check also failed, resulting in a gross overestimate of intrauterine device/implant use. These results have implications more broadly for the potential biases that can be introduced in using third‐party reporting of close ties to measure other sensitive or stigmatized behaviors.

State-Level Variation in Abortion Stigma and Women and Men's Abortion Underreporting in the USA

Abortion is highly stigmatized in most settings and severely underreported in demographic surveys. In the USA, variation in the context of abortion between states may influence respondents’ exposure to abortion stigma and create geographic variation in their likelihood of disclosing abortion in surveys. We used restricted geographic data from the 2006–2010 and 2011–2015 National Survey of Family Growth (NSFG) to investigate the association between abortion reporting in the USA and state-level structural factors that may influence respondents’ experience of abortion stigma. At the aggregate level, we compared the weighted number of abortions women reported in the NSFG to abortion counts derived from abortion provider censuses and test for variation in underreporting by state-level structural measures. At the individual level, we tested if state-level structural factors were associated with less reporting of abortion in the face-to-face (FTF) survey mode than the more confidential audio computer-assisted self-interviewing mode (ACASI) of the NSFG. We found that at the aggregate level, there were no differences in reporting by the state-level measures. At the individual level, about 40% of women and men who reported an abortion in their ACASI did not fully report in the FTF interview; however, there were few differences by any state-level factors. This study documents that abortion stigma plagues the quality of reporting in the USA for both women and men, regardless of which state they live in. Survey improvements to reduce abortion underreporting are needed.

Estimating Prevalence of Abortion Using List Experiments: Findings from a Survey of Women in Delaware and Maryland

BACKGROUND

Widespread underreporting of abortion persists in survey data. The list experiment, a measurement tool designed to elicit truthful responses to sensitive questions, may alleviate underreporting.

METHODS

Using The Statewide Survey of Women of Reproductive Age in Delaware and Maryland (n = 2,747), we estimate the prevalence of abortion in Maryland and Delaware using a double list experiment.

RESULTS

We find 21% (95% confidence interval [CI]: 16.8%-25.3%) of respondents aged 18 to 44 ever had an abortion and we identify disparities in abortion prevalence by age, race, education, income, marital status, and insurance status. Respondents who were Black (37.0%; 95% CI: 27.1%-46.8%), had less than a college degree (24.8%; 95% CI: 18.3%-31.3%), were in a cohabiting relationship (39.0%; 95% CI: 29.1%-48.9%), were living in households with incomes less than $50,000 (28.6%; 95% CI: 19.7%-37.5%), and were currently covered by Medicaid (42.8%; 95% CI: 27.6%-58.0%) were more likely than their counterparts to have ever had an abortion.

CONCLUSIONS

List experiments yield estimates of abortion substantially higher than those obtained from direct questions. Findings demonstrate external validity through consistency with estimates from administrative data sources and gold standard abortion provider survey data.

The Impact of Abortion Underreporting on Pregnancy Data and Related Research

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Reducing underreporting of abortion in surveys: Results from two test applications of the list experiment method in Malawi and Senegal

BACKGROUND

Accurately measuring abortion incidence poses many challenges. The list experiment is a method designed to increase the reporting of sensitive or stigmatized behaviors in surveys, but has only recently been applied to the measurement of abortion. To further test the utility of the list experiment for measuring abortion incidence, we conducted list experiments in two countries, over two time periods.

MATERIALS AND METHODS

The list experiment is an indirect method of measuring sensitive experiences that protects respondent confidentiality by hiding individual responses to a binary sensitive item (i.e., abortion) by combining this response with answers to other non-sensitive binary control items. Respondents report the number of list items that apply to them, not which ones. We conducted a list experiment to measure cumulative lifetime incidence of abortion in Malawi, and separately to measure cumulative five-year incidence of abortion in Senegal, among cisgender women of reproductive age.

RESULTS

Among 810 eligible respondents in Malawi, list experiment results estimated a cumulative lifetime incidence of abortion of 0.9% (95%CI: 0.0, 7.6). Among 1016 eligible respondents in Senegal, list experiment estimates indicated a cumulative five-year incidence of abortion of 2.8% (95%CI: 0.0, 10.4) which, while lower than anticipated, is seven times the proportion estimated from a direct question on abortion (0.4%).

CONCLUSIONS

Two test applications of the list experiment to measure abortion experiences in Malawi and Senegal likely underestimated abortion incidence. Future efforts should include context-specific formative qualitative research for the development and selection of list items, enumerator training, and method delivery to assess if and how these changes can improve method performance.

Termination of pregnancy data completeness and feasibility in population-based surveys: EN-INDEPTH study

BACKGROUND

Termination of pregnancy (TOP) is a common cause of maternal morbidity and mortality in low- and middle-income countries. Population-based surveys are the major data source for TOP data in LMICs but are known to have shortcomings that require improving. The EN-INDEPTH multi-country survey employed a full pregnancy history approach with roster and new questions on TOP and Menstrual Restoration. This mixed methods paper assesses the completeness of responses to questions eliciting TOP information from respondents and reports on practices, barriers, and facilitators to TOP reporting.

METHODS

The EN-INDEPTH study was a population-based cross-sectional study. The Full Pregnancy History arm of the study surveyed 34,371 women of reproductive age between 2017 and 2018 in five Health and Demographic Surveillance System (HDSS) sites of the INDEPTH network: Bandim, Guinea-Bissau; Dabat, Ethiopia; IgangaMayuge, Uganda; Kintampo, Ghana; and Matlab, Bangladesh. Completeness and time spent in answering TOP questions were evaluated using simple tabulations and summary statistics. Exact binomial 95% confidence intervals were computed for TOP rates and ratios. Twenty-eight (28) focus group discussions were undertaken and analysed thematically.

RESULTS

Completeness of responses regarding TOP was between 90.3 and 100.0% for all question types. The new questions elicited between 2.0% (1.0-3.4), 15.5% (13.9-17.3), and 11.5% (8.8-14.7) lifetime TOP cases over the roster questions from Dabat, Ethiopia; Matlab, Bangladesh; and Kintampo, Ghana, respectively. The median response time on the roster TOP questions was below 1.3 minutes in all sites. Qualitative results revealed that TOP was frequently stigmatised and perceived as immoral, inhumane, and shameful. Hence, it was kept secret rendering it difficult and uncomfortable to report. Miscarriages were perceived to be natural, being easier to report than TOP. Interviewer techniques, which were perceived to facilitate TOP disclosure, included cultural competence, knowledge of contextually appropriate terms for TOP, adaptation to interviewee's individual circumstances, being non-judgmental, speaking a common language, and providing detailed informed consent.

CONCLUSIONS

Survey roster questions may under-represent true TOP rates, since the new questions elicited responses from women who had not disclosed TOP in the roster questions. Further research is recommended particularly into standardised training and approaches to improving interview context and techniques to facilitate TOP reporting in surveys.