Society for Maternal-Fetal Medicine Special Statement: A critical examination of abortion terminology as it relates to access and quality of care

Accuracy and Misleadingness of Anatomical and Embryological Statements in State-Level Abortion Ban Legislation in the United States

OBJECTIVE

In the last 15 years, the United States has seen a surge in anti-abortion legislation enacted at the state level. Many of these pieces of legislation utilize anatomical and embryological details to justify the necessity of abortion bans. In this study, we evaluated the level to which these statements are accurate and/or misleading, if at all, as determined by experts in anatomy and embryology.

METHODS

Experts evaluated statements of anatomical and embryological fact included in Legislative Findings (or equivalent) sections of state-level abortion ban legislation passed between January 2016 and January 2023 on their level of accuracy and misleadingness. We investigated 56 pieces of legislation from 23 states, which resulted in 57 testable statements common to 13 pieces of legislation across 12 states. Forty-one experts in anatomy and embryology rated each statement from 1 (completely inaccurate/misleading) to 5 (completely accurate/non-misleading).

RESULTS

Mean accuracy for all 57 statements was 3.0 ± 1.2 (range: 1.4-4.3) and the overall level of misleadingness was 2.5 ± 1.2 (range: 1.3-3.8).

CONCLUSION

All 57 statements were significantly different from a null expectation of completely accurate and completely non-misleading. Statements made about anatomy and embryology aim to justify abortion bans but contain, to varying extents, inaccurate and misleading information, thereby contributing to the detrimental effects of restrictive abortion legislation on the health and well-being of pregnancy-capable people.

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

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

Abortion

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

The association between abortion training and obstetrics and gynecology resident competence and intention to provide abortion care before Dobbs

OBJECTIVE

To assess the role of abortion training in fourth-year obstetrics and gynecology (OBGYN) residents' abortion care competence and practice intentions before the Dobbs decision.

STUDY DESIGN

This is a planned secondary analysis of survey data of fourth-year U.S. OBGYN residents. Abortion training was defined as 'routine' if automatically included in schedules, ''optional'' if not scheduled but available, and ''not available''. Self-assessed competence was defined as feeling prepared to independently provide care. Participants were asked about their competence and post-residency intentions to provide specific aspects of pregnancy loss and induced abortion care.

RESULTS

Of 1241 fourth-year residents, 885 (71%) completed the questions of interest. For each skill, more residents with routine training reported competence compared to those with less comprehensive training. More residents with routine training reported intentions to include abortion care in practice (422, 79%) compared to residents with optional (171, 66%) or no training (51, 55%), p < 0.001). Residents with routine training were nearly six times more likely to intend to provide medication abortion post-residency compared to residents without training; more residents in all groups reported intentions to provide care for pregnancy loss compared to abortion.

CONCLUSIONS

Pre-Dobbs, residents with routine abortion training had greater self-assessed competence in abortion care than those with optional or no training and were more likely to intend to provide this after residency. Given the evolving impacts of the 2022 reversal of Roe v Wade, residency training programs must work to ensure routine access to legally permissible abortion training as routine training is associated with intention to provide fundamental, reproductive healthcare.

IMPLICATIONS

Routine training in abortion care during OBGYN residency is associated with higher competence and intention to provide post-residency - availability of this training Is severely compromised in restricted states post-Dobbs.

Threatened Periviable Delivery and Abortion: Clinical Considerations

Periviable delivery, or a pregnancy at risk of delivery between 20 0/7 and 25 6/7 weeks gestational, is an uncommon event with profound physical, psychological, and financial impact. Neonatal outcomes can be hard to predict and with the changing legal landscape around abortion access, management options may be compromised. Dynamic maternal and fetal factors make a cohesive and supportive care team critical for optimal care. Management of threatened periviable delivery in a post-Roe United States may prioritize fetal outcomes regardless of threat to maternal health due to legal restrictions.

"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.

Fetal anomaly diagnosis and termination of pregnancy in Ireland: a service evaluation following implementation of abortion services in 2019

BACKGROUND

Approximately 3% of pregnancies are diagnosed with a fetal anomaly, of which a proportion is fatal or life-limiting. The introduction of legislation for termination of pregnancy in Ireland in 2019 for conditions "likely to lead to the death of the fetus" made termination of pregnancy for "fatal fetal anomaly" an option for pregnant women in Ireland.

OBJECTIVE

This study examined all cases of termination of pregnancy performed for major fetal anomaly over the first 3 years of service implementation, including cases that did not meet the legal criteria, resulting in women traveling outside Ireland for abortion care.

STUDY DESIGN

A retrospective service evaluation of tertiary fetal medicine clinics in 2 tertiary maternity hospitals between 2019 and 2021 was undertaken. We compared pregnancies of patients diagnosed with fatal fetal anomaly who underwent termination of pregnancy in Ireland with those of patients who did not meet the legal criteria and hence traveled outside Ireland for termination of pregnancy.

RESULTS

Overall, 139 pregnancies met the inclusion criteria; 83 (59.7%) patients had termination of pregnancy in the tertiary maternity hospital (local), and 56 (40.3%) traveled abroad, mainly to the United Kingdom. Demographic characteristics were similar between the 2 groups, as was gestation at diagnosis and delivery. All cases where termination of pregnancy was local were discussed at fetal medicine multidisciplinary meetings, as opposed to 34% of cases of patients who ultimately traveled outside Ireland for termination of pregnancy. The most common indication (25/83; 30.1%) for local termination of pregnancy was trisomy 18, followed by anencephaly. Traveling to obtain abortion care was mainly due to diagnosis of trisomy 21 (30/56; 53.6%), followed by other multiple structural anomalies/syndromes deemed locally as not meeting the legal criteria.

CONCLUSION

Legislation for termination of pregnancy for fetal anomaly, restricted to fatal diagnoses, is difficult to implement, requires significant multidisciplinary input, and can lead to limited services for pregnancies diagnosed with major fetal anomalies. Our findings emphasize the impact of legislative barriers to abortion care for fetal anomaly and the need for policies and services that support women's access to termination of pregnancy for fetal anomaly.