Providing quality family planning services to LGBTQIA individuals: a systematic review

Pathways to parenthood among transgender men and gender diverse people assigned female or intersex at birth in the United States: analysis of a Cross-Sectional 2019 Survey

Objective

To assess pathways to parenthood, pregnancy outcomes, future pregnancy desire, and fertility counseling experiences among a cross-sectional sample of transgender men and gender diverse individuals assigned female or intersex at birth in the United States.

Methods

Participants were recruited from The Population Research in Identity and Disparities for Equality (PRIDE) Study and the general public. Eligible participants for this analysis were able to read and understand English, assigned female or intersex at birth, US residents, 18+ years old, and identified as transgender, nonbinary, or gender diverse. We analyzed responses to close-ended survey questions, overall and stratified by gender identity, race/ethnicity, and testosterone use. We also qualitatively assessed open-text responses on fertility counseling.

Results

Among the 1694 participants, median age was 27 years (range: 18-72), 12% had ever been pregnant, and 12% were parents. Carrying a pregnancy where the individual was the egg source (36%) was the most common pathway to parenthood. Individuals with an exclusively binary gender identity (ie, transgender man or man) more often reported becoming parents through adoption than individuals with gender diverse identities (19% vs 12%). A third of individuals did not receive fertility counseling prior to initiating testosterone; individuals who exclusively reported nonbinary identities were recommended to investigate fertility preservation options less often (36%) compared to transgender men (50%).

Conclusion

Transgender men and gender diverse individuals who were assigned female or intersex at birth build their families through a variety of pathways, including pregnancy, stepparenting, and adoption. Clinicians should avoid making assumptions about reproductive desires in these populations based on gender identities or testosterone use and should provide consistent fertility counseling prior to and after hormone initiation.

Holistic Sexual-Reproductive Healthcare Services and Needs for Queer Individuals: Healthcare Providers' Perspectives

There are ongoing debates and controversies about whether genderqueer individuals have specific sexual-reproductive healthcare services and needs (SRHSNs). This study intended to identify and explore queer-specific SRHSNs among healthcare providers (HCPs) in Gauteng Province, South Africa. This was an exploratory sequential mixed-methods study, and this article focuses on the qualitative findings of that investigation. Thirty-three HCPs were purposively sampled, and semi-structured one-on-one interviews were used to collect data between September and November 2023. The data were analyzed using thematic content analysis (TCA). The results of this study revealed nine main themes: a crucial need for inclusive healthcare facilities; a need for psychological, counseling, and therapeutic support in sexual and reproductive healthcare; access to sexual-reproductive education and integrating support; suggested reproductive health services for queer sexual wellness; improved accessibility and particular queer reproductive healthcare; optimizing services related to human immunodeficiency virus (HIV), pre-exposure prophylaxis (PrEP) access, and sexually transmitted illness (STI) treatment; genderqueer persons' parenthood aspirations and empowerment; the safe availability of intimacy tools; and navigation transitions. A holistic and inclusive healthcare approach that fits psychological support, comprehensive sexual-reproductive education, and specialized services to accommodate the unique needs of queer individuals should be implemented and made easily accessible.

Contraceptive use in patients with gender dysphoria who were assigned female at birth receiving care at a specialty gender-affirming clinic

BACKGROUND

The Centers for Disease Control and Prevention (CDC) recommend that all patients, regardless of gender identity or sexual orientation, should be offered family planning and contraceptive options without assumptions of sexual behaviors and pregnancy risk. Current research on family planning services for lesbian, gay, bisexual, transgender, and queer or questioning patients is limited, but patients who are sexual or gender minorities are at increased risk for unintended pregnancy.

OBJECTIVES

The objective of this study was to describe contraceptive use in patients assigned female at birth with gender dysphoria at a gender-affirming primary care clinic.

METHODS

A retrospective descriptive study was conducted. Patients were included if they were 18 to 44 years old, received care at University of New Mexico Truman Health Services in 2019, were diagnosed with gender dysphoria, and were assigned female at birth. Patients were excluded if they had never developed female reproductive organs. Data were collected from the electronic medical records. Potential differences in contraceptive use based on demographic characteristics, having a family planning discussion, and having a contraceptive use discussion were analyzed using chi-square analyses. Potential predictors of contraceptive use were identified using exploratory forward conditional logistic regression and univariate logistic regression analyses.

RESULTS

A total of 163 patients were included; average age was 26.6 years; 71% identified as male, 5% identified as masculine, and 25% identified as nonbinary. Most patients (92%) were prescribed masculinizing therapy (testosterone). Forty-five (28%) patients had documented contraception use; the most common form was permanent contraception (76%). Most patients (68%) did not have any documented contraindications to contraception based on CDC US Medical Eligibility Criteria for contraceptive use. Of 113 patients with a documented sexual orientation, 45 patients (40%) reported having sex with persons who have a penis; only 13 (29%) of those patients had a documented form of contraception. Family planning discussions were documented for 82% of patients. Family planning discussions that specifically addressed contraception were documented in only 49% of patients. However, the odds of a patient having a documented use of contraception was 9.26 times higher when family planning discussions specifically addressed contraception.

CONCLUSION

Documented contraception use was low in people assigned female at birth of childbearing age receiving care at a gender-affirming clinic. Due to increased risks of unintended pregnancy in this population and the teratogenic nature of testosterone, family planning discussion should also include discussions related to contraception, as this was associated with increased contraception use. Additional research is needed to address potential barriers to contraception use in this population.

"Where do I go? Who do I go to?": BRCA Previvors, genetic counselors and family planning

Objective

We sought to understand BRCA previvors' perceptions of communication with genetic counselors and other healthcare providers.

Methods

We conducted 16 qualitative interviews and utilized thematic analysis to develop patterns present in the narratives of previvors.

Results

Interviews with previvors suggest genetic counselors and other providers often make assumptions about previvors' family planning and treatment needs based on perceived gender, age, and sexual orientation.

Conclusion

BRCA patients require individualized attention when planning for their future and making healthcare decisions and we argue that implementing patient-centered care practices into the communication process can provide a higher quality of care.

Innovation

This study offers an innovative lens through which scholars and healthcare providers may examine the experiences of BRCA previvors as they seek adequate care. Asking previvors to explain their perceptions of conversations with genetic counselors and healthcare providers offers insight into the communicative process of seeking care rather than the health outcomes of the care itself. Our findings suggest biases among providers related to gender, age, and sexual orientation are concerning elements of family planning communication that potentially interrupt previvors' abilities to express their care needs in a safe environment. We argue for an increased awareness of, and advocacy for, more inclusive conversations regarding treatment and family planning decisions.

Understanding ethical challenges of family planning interventions in sub-Saharan Africa: a scoping review

Background

Improving the design of family planning (FP) interventions is essential to advancing gender equality, maternal health outcomes, and reproductive autonomy for both men and women. While progress has been made towards applying a rights-based approach to FP interventions in sub-Saharan Africa, the ethical implications of FP interventions has been underreported and underexplored. Several ethical challenges persist related to measuring success, choice, and target population.

Methods

We conducted a scoping review to understand if and how FP interventions published between 2000 and 2020 within sub-Saharan Africa address the ethical challenges raised within the literature. We identified a total of 1,652 papers, of which 40 were included in the review.

Results

Our review demonstrated that the majority of family planning interventions in sub-Saharan Africa place a strong emphasis, on measuring success through quantitative indicators such as uptake of modern contraception methods among women, specifically those that are married and visiting healthcare centres. They also tend to bias the provision of family planning by promoting long-acting reversible contraception over other forms of contraception methods potentially undermining individuals' autonomy and choice. The interventions in our review also found most interventions exclusively target women, not recognising the importance of gender norms and social networks on women's choice in using contraception and the need for more equitable FP services.

Conclusion

The results of this review highlight how FP interventions measured success through quantitative indicators that focus on uptake of modern contraception methods among women. Utilising these measures makes it difficult to break away from the legacy of FP as a tool for population control as they limit the ability to incorporate autonomy, choice, and rights. Our results are meant to encourage members of the global family planning community to think critically about the ethical implications of their existing interventions and how they may be improved. More public health and policy research is required to assess the effect of applying the new indicators with the FP community as well as explicitly outlining monitoring and evaluation strategies for new interventions to allow for programme improvement and the dissemination of lessons learned.

Women's Perspectives on a Reproductive Health Services Screening Question: An Alternative to Pregnancy Intention Screening

Background

Current efforts to integrate reproductive health care into primary care in the United States involve assessing pregnancy intentions and reproductive goals, which are often not meaningful or attainable for some. Alternatively, we designed a reproductive health services-based screening question: "Can I help you with any reproductive health services today, such as preventing pregnancy or planning a healthy pregnancy?" In this study, we describe women's interpretations of this question as part of a larger study, exploring perspectives on reproductive health care quality in primary care.

Materials and Methods

We utilized a third-party research firm to recruit New York women of reproductive age (18-45), who visited a primary care provider in the past year. We conducted five focus groups and eight interviews (N = 30). Semistructured guides queried participants on interpretations of the screening question and preferences for raising reproductive health concerns during a primary care visit. We employed inductive thematic analysis.

Results

Participants interpreted the question as offering contraception or pregnancy counseling and care, although younger participants also understood it as offering sexual and reproductive health services broadly. Participants also connected the question with discussions about their ability to conceive. Some participants described experiences with provider assumptions and implicit bias. Tensions emerged around accepting primary care as a setting for reproductive health due to a perceived lack of specialized training.

Conclusions

Participants interpreted the screening question as intended, indicating face validity. Primary care settings should increase patients' awareness of reproductive health service availability, such as by routinely introducing a services-based screening question.

Abortion Surveillance - United States, 2020

Problem/Condition

CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States.

Period Covered

2020.

Description of System

Each year, CDC requests abortion data from the central health agencies for the 50 states, the District of Columbia, and New York City. For 2020, a total of 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2011-2020. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2019 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS).

Results

A total of 620,327 abortions for 2020 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2011-2020, in 2020, a total of 615,911 abortions were reported, the abortion rate was 11.2 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 198 abortions per 1,000 live births. From 2019 to 2020, the total number of abortions decreased 2% (from 625,346 total abortions), the abortion rate decreased 2% (from 11.4 abortions per 1,000 women aged 15-44 years), and the abortion ratio increased 2% (from 195 abortions per 1,000 live births). From 2011 to 2020, the total number of reported abortions decreased 15% (from 727,554), the abortion rate decreased 18% (from 13.7 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 9% (from 217 abortions per 1,000 live births).In 2020, women in their 20s accounted for more than half of abortions (57.2%). Women aged 20-24 and 25-29 years accounted for the highest percentages of abortions (27.9% and 29.3%, respectively) and had the highest abortion rates (19.2 and 19.0 abortions per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.7%, respectively) and had the lowest abortion rates (0.4 and 2.6 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios were highest among adolescents (aged ≤19 years) and lowest among women aged 25-39 years.Abortion rates decreased from 2011 to 2020 among all age groups. The decrease in abortion rate was highest among adolescents compared with any other age group. From 2019 to 2020, abortion rates decreased or did not change for all age groups. Abortion ratios decreased from 2011 to 2020 for all age groups, except adolescents aged 15-19 years and women aged 25-29 years for whom abortion ratios increased. The decrease in abortion ratio was highest among women aged ≥40 years compared with any other age group. From 2019 to 2020, abortion ratios decreased for adolescents aged <15 years and women aged ≥35 and increased for women 15-34 years.In 2020, 80.9% of abortions were performed at ≤9 weeks' gestation, and nearly all (93.1%) were performed at ≤13 weeks' gestation. During 2011-2020, the percentage of abortions performed at >13 weeks' gestation remained consistently low (≤9.2%). In 2020, the highest percentage of abortions were performed by early medical abortion at ≤9 weeks' gestation (51.0%), followed by surgical abortion at ≤13 weeks' gestation (40.0%), surgical abortion at >13 weeks' gestation (6.7%), and medical abortion at >9 weeks' gestation (2.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 63.9% of abortions were early medical abortions. In 2019, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, four women died as a result of complications from legal induced abortion.

Interpretation

Among the 48 areas that reported data continuously during 2011-2020, overall decreases were observed during 2011-2020 in the total number, rate, and ratio of reported abortions. From 2019 to 2020, decreases also were observed in the total number and rate of reported abortions; however, a 2% increase was observed in the total abortion ratio.

Public Health Action

Abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Reproductive health in transgender and gender diverse individuals: A narrative review to guide clinical care and international guidelines

Background

Hormonal treatments and surgical interventions practiced with the aim to affirm gender identity in transgender and gender diverse patients may impact their future reproductive ability, family building, and family planning options. Whereas it is recommended by international guidelines to discuss the potential risks of infertility and to present fertility preservation (FP) options to transgender individuals and their families prior to initiating any of these treatments, many barriers still remain. Further, transgender and gender diverse individuals often experience barriers to accessing contraception, abortion, pre-conception care, and comprehensive perinatal care.

Aims

In this review we summarize the current literature on reproductive healthcare issues reported in transgender people including fertility issues, fertility preservation (FP), contraception, pregnancy and lactation and perinatal health.

Methods

A narrative literature search of major databases (Pubmed, Medline, PsycInfo, Google Scholar, Web of Science) was conducted. Given the paucity and heterogeneity of studies, summative review tactics were not available. The literature was critically reviewed by international experts in the field with focus on the impact of gender-affirming medical interventions on future fertility, current FP options and reproductive health issues in transgender people.

Results

The current literature supports that transgender and gender diverse individuals may wish to have genetically related children in the future, rendering the issue of FP relevant to this patient group. The cryopreservation of mature gametes is an efficacious option for FP for post-pubertal adolescents and adults. It is recommended to discuss these options at time of planning for gender-affirming hormonal therapy (GAHT) or engaging with other gender-affirming procedures that can limit future fertility. Discontinuation of GAHT may allow individuals to undergo FP later, but data are limited and there is the concern of symptoms and consequences of stopping GAHT. For pre-pubertal and early pubertal children, FP options are limited to the cryopreservation of gonadal tissue. At present the tissue can become functional only after re-transplantation, which might be undesirable by transgender individuals in the future. Preconception counseling, prenatal surveillance, perinatal support, contraceptive, and pregnancy termination related healthcare need to be meaningfully adapted for this patient population, and many knowledge gaps remain.

Discussion

Specialized FP reproductive healthcare for transgender and gender diverse individuals is in early evolution. Research should be conducted to examine effects of medical interventions on fertility, timing of FP, gamete preservation and outcome of the fertility treatments. Strategies to inform and educate transgender and gender diverse patients can lead to optimization of reproductive care and counseling and decision making of FP for this population.

Transmasculine Persons' Experiences of Encounters with Health Care Professionals Within Reproductive, Perinatal, and Sexual Health in Sweden: A Qualitative Interview Study

Purpose: Transmasculine persons may experience stigma, which increases the risk of psychological distress. They may need reproductive, perinatal, and sexual health care; however, qualitative studies addressing transgender individuals' experiences are scarce. This study aimed at interpreting and describing the experiences of transmasculine persons in encounters with health care professionals (HCPs) within reproductive, perinatal, and sexual health care.

Methods: Nine qualitative semi-structured online interviews were conducted via email with transmasculine persons, and data were analyzed by using Braun and Clarke's thematic analysis.

Results: Two themes were identified. The first theme is normalization and confirmation of the gender identity. This theme comprises the knowledge and experience that these transmasculine persons are facing. The verbal approach from the HCPs was important as well as could be addressed with a non-binary approach. The second theme is Respect in an especially exposed situation. This theme shows the great importance of being involved in the care and at the same time being met with openness and empathy. There must be good prospects of being able to preserve dignity.

Conclusion: Transmasculine persons are in an exposed position in reproductive, perinatal, and sexual health care. The encounters in health care could be negatively affected if HCPs show inadequate knowledge or express gender stereotypical attitudes. A good encounter is characterized by respect, preserved integrity, involvement in the care, and an open attitude toward gender variations.

Women's experiences with person-centered family planning care: Differences by sociodemographic characteristics

Objective

Person-centered contraceptive care is associated with positive reproductive health outcomes. Our objective was to analyze patients’ ratings on the newly developed Person-Centered Contraceptive Counseling scale (PCCC) to provide distributions for a nationally representative population and to assess differences by sociodemographic characteristics.

Study design

Using data from 2017 to 2019 National Survey of Family Growth (NSFG), we analyzed ratings across the four PCCC items among 2242 women who received contraceptive counseling in the past year. Items measured patients’ reports of how providers respected them, let them describe their contraceptive preferences, took their preferences seriously, and adequately informed them about their options. We studied each PCCC item individually as well as the combined scale, distinguishing between ratings of “excellent” versus lower ratings. Bivariate and multivariate logistic regression models assessed how patients’ characteristics (age, race/ethnicity and English proficiency, sexual orientation, income, and parity) and provider type were associated with the likelihood of experiencing person-centered care.

Results

The majority of women (59%–69%) reported that their family planning provider was “excellent” across the four PCCC items and just over half (51%) reported “excellent” on all items. In multivariate analyses, having a lower income, Black race, non-heterosexual identity, and Hispanic ethnicity combined with low English proficiency were associated with lower PCCC ratings.

Conclusions

In a nationally representative sample, the PCCC captured variation in women's experiences with person-centered family planning care by sociodemographic characteristics. Findings highlight the need for contraceptive counseling that centers on clients’ preferences and experiences, particularly for patients who belong to groups experiencing health inequities.

Implications

Person-centered care is a key component of high-quality family planning services. This analysis highlights sociodemographic disparities in person-centered care by analyzing PCCC ratings. Findings show the value of this new health care performance measure and affirm the need for family planning care that centers individuals' preferences and lived experiences.

Mapping the scientific literature on reproductive health among transgender and gender diverse people: a scoping review

We conducted a scoping review to map the extent, range and nature of the scientific research literature on the reproductive health (RH) of transgender and gender diverse assigned female at birth and assigned male at birth persons. A research librarian conducted literature searches in Ovid MEDLINE®, Ovid Embase, the Cochrane Library, PubMed, Google Scholar, Gender Studies Database, Gender Watch, and Web of Science Core Collection. The results were limited to peer-reviewed journal articles published between 2000 and 2018 involving human participants, written in English, pertaining to RH, and including disaggregated data for transgender and gender diverse people. A total of 2197 unique citations with abstracts were identified and entered into Covidence. Two independent screeners performed a title and abstract review and selected 75 records for full-text review. The two screeners independently extracted data from 37 eligible articles, which were reviewed, collated, summarised, and analysed using a numerical summary and thematic analysis approach. The existing scientific research literature was limited in terms of RH topics, geographic locations, study designs, sampling and analytical strategies, and populations studied. Research is needed that: focuses on the full range of RH issues; includes transgender and gender diverse people from the Global South and understudied and multiply marginalised subpopulations; is guided by intersectionality; and uses intervention, implementation science, and community-based participatory research approaches. Further, programmes, practices, and policies that address the multilevel barriers to RH among transgender and gender diverse people addressed in the existing scientific literature are warranted.

Contraceptive technology research & development: a call for inclusion of trans and gender diverse individuals assigned female at birth

OBJECTIVE

Increased research efforts over the past decade provide a more in-depth understanding of the diverse fertility desires and family planning needs of trans and gender diverse individuals assigned female at birth (TGD AFAB). Despite this increased understanding and unmet need, global health researchers and contraceptive product developers have yet to include TGD AFAB individuals and considerations of their needs in the product development process, marginalising this historically underrepresented population. The aim of this perspective is to present the case for inclusion of TGD AFAB individuals in contraceptive research.

MAIN OUTCOMES

This perspective summarises the most recent literature characterising contraceptive access and use within TGD AFAB populations as well as the barriers to use. Furthermore, this perspective offers insight into how novel contraceptive technologies in the research and development pipeline could potentially appeal to TGD AFAB populations and recommends steps product developers can make towards being more inclusive.

CONCLUSIONS

With current research efforts in contraceptive product development aimed at expanding the method mix to appeal to a more diverse population of potential users, it behoves product developers to be more inclusive of TGD AFAB individuals in the development process and consider them as stakeholders of an expanded contraceptive method mix.

Abortion Surveillance - United States, 2019

Problem/Condition

CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States.

Period Covered

2019.

Description of System

Each year, CDC requests abortion data from the central health agencies for 50 states, the District of Columbia, and New York City. For 2019, 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2010–2019. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15–44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2018 were assessed as part of CDC’s Pregnancy Mortality Surveillance System (PMSS).

Results

A total of 629,898 abortions for 2019 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2010–2019, in 2019, a total of 625,346 abortions were reported, the abortion rate was 11.4 abortions per 1,000 women aged 15–44 years, and the abortion ratio was 195 abortions per 1,000 live births. From 2018 to 2019, the total number of abortions increased 2% (from 614,820 total abortions), the abortion rate increased 0.9% (from 11.3 abortions per 1,000 women aged 15–44 years), and the abortion ratio increased 3% (from 189 abortions per 1,000 live births). From 2010 to 2019, the total number of reported abortions, abortion rate, and abortion ratio decreased 18% (from 762,755), 21% (from 14.4 abortions per 1,000 women aged 15–44 years), and 13% (from 225 abortions per 1,000 live births), respectively.

In 2019, women in their 20s accounted for more than half of abortions (56.9%). Women aged 20–24 and 25–29 years accounted for the highest percentages of abortions (27.6% and 29.3%, respectively) and had the highest abortion rates (19.0 and 18.6 abortions per 1,000 women aged 20–24 and 25–29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.7%, respectively) and had the lowest abortion rates (0.4 and 2.7 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios in 2019 were highest among adolescents (aged ≤19 years) and lowest among women aged 25–39 years. Abortion rates decreased from 2010 to 2019 for all women, regardless of age. The decrease in abortion rate was highest among adolescents compared with any other age group. From 2018 to 2019, abortion rates decreased or did not change among women aged ≤24 years; however, the abortion rate increased among those aged ≥25 years. Abortion ratios also decreased or did not change from 2010 to 2019 for all age groups, except adolescents aged <15 years. The decrease in abortion ratio was highest among women aged ≥40 years compared with any other age group. From 2018 to 2019, abortion ratios increased for all age groups, except adolescents aged <15 years.

In 2019, 79.3% of abortions were performed at ≤9 weeks’ gestation, and nearly all (92.7%) were performed at ≤13 weeks’ gestation. During 2010–2019, the percentage of abortions performed at >13 weeks’ gestation remained consistently low (≤9.0%). In 2019, the highest proportion of abortions were performed by surgical abortion at ≤13 weeks’ gestation (49.0%), followed by early medical abortion at ≤9 weeks’ gestation (42.3%), surgical abortion at >13 weeks’ gestation (7.2%), and medical abortion at >9 weeks’ gestation (1.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks’ gestation), 53.7% of abortions were early medical abortions. In 2018, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, two women died as a result of complications from legal induced abortion.

Interpretation

Among the 48 areas that reported data continuously during 2010–2019, overall decreases were observed during 2010–2019 in the total number, rate, and ratio of reported abortions; however, from 2018 to 2019, 1%–3% increases were observed across all measures.

Public Health Action

Abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies.

Fertility health information seeking among sexual minority women

OBJECTIVE

To qualitatively explore and describe fertility information-seeking experiences of sexual minority women (SMW) couples using assisted reproduction.

DESIGN

Qualitative thematic analysis of 30 semistructured, in-depth individual and dyadic interviews with SMW couples.

SETTING

Video conferencing.

PATIENT(S)

Twenty self-identified lesbian, bisexual, and queer women comprising 10 same-sex cisfemale couples (10 gestational and 10 nongestational partners) using assisted reproduction technology in the United States.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

We describe how SMW came to learn about ways to achieve pregnancy through information seeking, acquisition, appraisal, and use.

RESULT(S)

Analysis revealed three primary themes. First, uncertainty and information scarcity: SMW have basic knowledge about how to conceive but uncertainty persists due to information scarcity regarding how same-sex couples navigate assisted reproduction. Second, women attempt to collect fragmented information from disparate sources. The participants discussed a mixture of formal and informal, online, textual (books), and in-person seeking, finding, and synthesizing information that ranged from reliable to unreliable and from accurate to inaccurate. Finally, persistent heteronormative communication focused on the needs and conditions of male-female couples who experienced subfertility or infertility, rather than barriers related to social constraints and the absence of gametes that SMW sought to overcome.

CONCLUSION(S)

These findings support and extend existing evidence that has focused primarily on online fertility information seeking. Our findings suggest that shifts in fundamental assumptions about who seeks assisted reproductive support and why, together with improvements in fertility-related health communication, may result in more inclusive care for this population.

Contraceptive Care Disparities Among Sexual Orientation Identity and Racial/Ethnic Subgroups of U.S. Women: A National Probability Sample Study

Background: Sexual minority women may use contraception for various reasons but face notable barriers to contraceptive care, including stigma and discrimination. However, studies examining sexual orientation disparities in contraceptive care have largely relied on nonprobability samples of predominately White women and may thus not be generalizable to U.S. women overall or Black and Latina women in particular. Materials and Methods: Using data from the 2006 to 2017 National Survey of Family Growth, a large national probability sample of U.S. women 15-44 years of age (N = 25,473), we used multivariable logistic regression to estimate adjusted odds ratios for receiving a contraceptive method or prescription and contraceptive counseling from a health care provider in the past year among sexual orientation identity and racial/ethnic subgroups of heterosexual, bisexual, and lesbian White, Black, and Latina women relative to White heterosexual women. Results: Among women overall, 33.9% had received contraception and 18.3% had obtained contraceptive counseling. Black (odds ratio [OR] = 0.73, 95% confidence interval [CI]: 0.65-0.82) and Latina (OR = 0.73, 95% CI: 0.64-0.82) heterosexual women, White (OR = 0.80, 95% CI: 0.65-0.99) and Black (OR = 0.43, 95% CI: 0.32-0.58) bisexual women, and White (OR = 0.23, 95% CI: 0.13-0.43), Black (OR = 0.19, 95% CI: 0.09-0.40), and Latina (OR = 0.08, 95% CI: 0.03-0.22) lesbian women had significantly lower adjusted odds of receiving contraception compared with White heterosexual women. White (OR = 0.36, 95% CI: 0.15-0.85), Black (OR = 0.42, 95% CI: 0.18-0.98), and Latina (OR = 0.22, 95% CI: 0.09-0.53) lesbian women also had significantly lower adjusted odds of obtaining contraceptive counseling relative to White heterosexual women. Conclusions: Policies, programs, and practices that facilitate access to person-centered contraceptive care among marginalized sexual orientation identity and racial/ethnic subgroups of U.S. women are needed to promote reproductive health equity.

Sexual Health Information Sources, Needs, and Preferences of Young Adult Sexual Minority Cisgender Women and Non-Binary Individuals Assigned Female at Birth

BACKGROUND

Young adult sexual minority women (SMW) have unique sexual health needs and higher rates of some poor sexual health outcomes compared to their heterosexual peers. Unequal access to relevant sexual health information may contribute to sexual orientation disparities in sexual health among women, but research on sexual health communication among SMW is sparse.

METHODS

In-depth interviews conducted in 2016-2017 investigated sexual health communication in a sample of 29 racially/ethnically diverse cisgender women and non-binary individuals assigned female at birth who were between 19 and 36 years of age and identified as a sexual minority. Data were analyzed using a thematic analysis approach that involved inductive and deductive coding to identify themes.

RESULTS

Three broad themes were identified: 1) sources of sexual health information; 2) sexual health information needs; and 3) preferences for sexual health information delivery. Participants discussed and critiqued the Internet, other mass media, health care providers, school-based sex education, family, and peers/partners as sources of sexual health information. Participants expressed a need for customized, non-heteronormative information pertaining to sexually transmitted infection risk and prevention. They preferred receiving information from health care providers, the Internet, and other mass media, and some also suggested school-based sex education and peer education as methods for delivering information.

CONCLUSIONS

Participants expressed clear desires for relevant, high-quality sexual health information delivered through a variety of channels, especially the Internet, other mass media, and health care providers.

POLICY IMPLICATIONS

Findings call for policies that improve provision of sexual health information through health care providers, online resources, and school-based sex education.

Abortion experiences and preferences of transgender, nonbinary, and gender-expansive people in the United States

Background

Transgender, nonbinary, and gender-expansive people who were assigned female or intersex at birth experience pregnancy and have abortions. Scarce data have been published on individual abortion experiences or preferences of this understudied population.

Objective

This study aimed to fill existing evidence gaps on the abortion experiences and preferences of transgender, nonbinary, and gender-expansive people in the United States to inform policies and practices to improve access to and quality of abortion care for this population.

Study Design

In 2019, we recruited transgender, nonbinary, and gender-expansive people who were assigned female or intersex at birth at the age of ≥18 years from across the United States to participate in an online survey about sexual and reproductive health recruited through The Population Research in Identities and Disparities for Equality Study and online postings. We descriptively analyzed closed- and open-ended survey responses related to pregnancy history, abortion experiences, preferences for abortion method, recommendations to improve abortion care for transgender, nonbinary, and gender-expansive people, and respondent sociodemographic characteristics.

Results

Most of the 1694 respondents were <30 years of age. Respondents represented multiple gender identities and sexual orientations and resided across all 4 United States Census Regions. Overall, 210 respondents (12%) had ever been pregnant; these 210 reported 433 total pregnancies, of which 92 (21%) ended in abortion. For respondents’ most recent abortion, 41 (61%) were surgical, 23 (34%) were medication, and 3 (5%) were another method (primarily herbal). Most recent abortions took place at ≤9 weeks’ gestation (n=41, 61%). If they were to need an abortion today, respondents preferred medication abortion over surgical abortion in a 3:1 ratio (n=703 vs n=217), but 514 respondents (30%) did not know which method they would prefer. The reasons for medication abortion preference among the 703 respondents included a belief that it is the least invasive method (n=553, 79%) and the most private method (n=388, 55%). To improve accessibility and quality of abortion care for transgender, nonbinary, and gender-expansive patients, respondents most frequently recommended that abortion clinics adopt gender-neutral or gender-affirming intake forms, that providers use gender-neutral language, and that greater privacy be incorporated into the clinic.

Conclusion

These data contribute substantially to the evidence base on individual experiences of and preferences for abortion care for transgender, nonbinary, and gender-expansive people. Findings can be used to adapt abortion care to better include and affirm the experiences of this underserved population.

Abortion Surveillance - United States, 2018

PROBLEM/CONDITION

CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States.

PERIOD COVERED

2018.

DESCRIPTION OF SYSTEM

Each year, CDC requests abortion data from the central health agencies for 50 states, the District of Columbia, and New York City. For 2018, 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2009-2018. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2017 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS).

RESULTS

A total of 619,591 abortions for 2018 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2009-2018, in 2018, a total of 614,820 abortions were reported, the abortion rate was 11.3 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 189 abortions per 1,000 live births. From 2017 to 2018, the total number of abortions and abortion rate increased 1% (from 609,095 total abortions and from 11.2 abortions per 1,000 women aged 15-44 years, respectively), and the abortion ratio increased 2% (from 185 abortions per 1,000 live births). From 2009 to 2018, the total number of reported abortions, abortion rate, and abortion ratio decreased 22% (from 786,621), 24% (from 14.9 abortions per 1,000 women aged 15-44 years), and 16% (from 224 abortions per 1,000 live births), respectively. In 2018, women in their 20s accounted for more than half of abortions (57.7%). In 2018 and during 2009-2018, women aged 20-24 and 25-29 years accounted for the highest percentages of abortions; in 2018, they accounted for 28.3% and 29.4% of abortions, respectively, and had the highest abortion rates (19.1 and 18.5 per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.6%, respectively) and had the lowest abortion rates (0.4 and 2.6 per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios in 2018 and throughout 2009-2018 were highest among adolescents (aged ≤19 years) and lowest among women aged 25-39 years. Abortion rates decreased from 2009 to 2018 for all women, regardless of age. The decrease in abortion rate was highest among adolescents compared with women in any other age group. From 2009 to 2013, the abortion rates decreased for all age groups and from 2014 to 2018, the abortion rates decreased for all age groups, except for women aged 30-34 years and those aged ≥40 years. In addition, from 2017 to 2018, abortion rates did not change or decreased among women aged ≤24 and ≥40 years; however, the abortion rate increased among women aged 25-39 years. Abortion ratios also decreased from 2009 to 2018 among all women, except adolescents aged <15 years. The decrease in abortion ratio was highest among women aged ≥40 years compared with women in any other age group. The abortion ratio decreased for all age groups from 2009 to 2013; however, from 2014 to 2018, abortion ratios only decreased for women aged ≥35 years. From 2017 to 2018, abortion ratios increased for all age groups, except women aged ≥40 years. In 2018, approximately three fourths (77.7%) of abortions were performed at ≤9 weeks' gestation, and nearly all (92.2%) were performed at ≤13 weeks' gestation. In 2018, and during 2009-2018, the percentage of abortions performed at >13 weeks' gestation remained consistently low (≤9.0%). In 2018, the highest proportion of abortions were performed by surgical abortion at ≤13 weeks' gestation (52.1%), followed by early medical abortion at ≤9 weeks' gestation (38.6%), surgical abortion at >13 weeks' gestation (7.8%), and medical abortion at >9 weeks' gestation (1.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 50.0% of abortions were early medical abortions. In 2017, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, two women were identified to have died as a result of complications from legal induced abortion.

INTERPRETATION

Among the 48 areas that reported data continuously during 2009-2018, decreases were observed during 2009-2017 in the total number, rate, and ratio of reported abortions, and these decreases resulted in historic lows for this period for all three measures. These decreases were followed by 1%-2% increases across all measures from 2017 to 2018.

PUBLIC HEALTH ACTION

The data in this report can help program planners and policymakers identify groups of women with the highest rates of abortion. Unintended pregnancy is a major contributor to induced abortion. Increasing access to and use of effective contraception can reduce unintended pregnancies and further reduce the number of abortions performed in the United States.

Stakeholder Perceptions and Experiences Regarding Access to Contraception and Abortion for Transgender, Non-Binary, and Gender-Expansive Individuals Assigned Female at Birth in the U.S

Sexual and reproductive health (SRH) care often excludes the needs and experiences of transgender, non-binary, and gender-expansive (TGE) individuals. This study aimed to collect diverse stakeholder perspectives on barriers and facilitators to contraception and abortion for TGE individuals assigned female at birth (AFAB), assess knowledge and attitudes about unintended pregnancy prevention in these populations, and identify recommendations for improving SRH services for people of all genders. Between October 2017 and January 2018, we conducted 27 in-depth interviews with SRH stakeholders, including five TGE individuals who had obtained contraception or abortion care, and 22 clinicians, researchers, and advocates experienced in transgender healthcare. We iteratively developed a codebook and conducted thematic analysis to capture the spectrum of perspectives across interviews. Stakeholders reported a range of barriers to contraception and abortion access for TGE people AFAB, including inability to afford services, lack of gender-affirming clinicians, difficulty obtaining insurance coverage, and misconceptions about fertility and unplanned pregnancy risk. Deterrents to care-seeking included gendered healthcare environments, misgendering, and discrimination. Stakeholders described provider knowledge gaps and a perceived lack of medical education relevant to the SRH needs of TGE people. Recommendations included using gender-inclusive language and gender-affirming patient education materials and improving provider training on gender-affirming SRH care. Stakeholders identified substantial barriers to high-quality contraception and abortion care for TGE AFAB people in the U.S. They recommended specific interventions at the provider and institutional levels to improve experiences with care for TGE people and ensure broader access to gender-affirming SRH services.

The Imperative for Transgender and Gender Nonbinary Inclusion: Beyond Women's Health

We describe barriers to clinical care and research participation unique to transgender and gender nonbinary people and offer concrete suggestions for creating more inclusive environments.

We aim to make evident that solely referencing cisgender women in the context of sexual and reproductive health—particularly pregnancy planning and care—excludes a diverse group of transgender and gender nonbinary people who have sexual and reproductive health needs and experiences that can be similar to but also unique from those of cisgender women. We call on clinicians and researchers to ensure that all points of sexual and reproductive health access, research, sources of information, and care delivery comprehensively include and are accessible to people of all genders. We describe barriers to sexual and reproductive health care and research participation unique to people of marginalized gender identities, provide examples of harm resulting from these barriers, and offer concrete suggestions for creating inclusive, accurate, and respectful care and research environments—which will lead to higher quality health care and science for people of all genders.

Contraceptive Beliefs, Decision Making and Care Experiences Among Transmasculine Young Adults: A Qualitative Analysis

CONTEXT

Transmasculine people-that is, individuals who were assigned female at birth and have a male or masculine gender identity-can experience unintended pregnancy. Yet research on contraception among transmasculine individuals is extremely limited.

METHODS

Participants were recruited online; from community-based organizations, health centers and student groups; and by chain referral. From purposive sampling, 21 transmasculine individuals aged 18-29 who resided in the greater Boston area and had had, in the last five years, a sexual partner who was assigned male at birth were selected for in-depth interviews. All interviews were conducted in person between February and May 2018 in Boston, and transcripts were analyzed using a thematic analysis approach involving inductive and deductive coding to identify themes and subthemes.

RESULTS

Most participants believed that contraceptive use was necessary to effectively prevent pregnancy among transmasculine individuals. Their beliefs and decisions regarding contraception occurred in the context of a lack of information about contraception among transmasculine people, especially those using testosterone. Many individuals chose a contraceptive method on the basis of whether it mitigated their gender dysphoria or stopped menstruation, and said they preferred condoms and implants because these methods provided fewer reminders of their natal anatomy and were not perceived as interfering with testosterone use. Gender bias, discrimination and stigma in patient-provider interactions and health care settings negatively influenced participants' contraceptive care experiences.

CONCLUSIONS

Health care providers and facilities should provide transmasculine people with tailored contraceptive information and care that address their specific gender-affirmation needs and contraceptive preferences in safe, inclusive and supportive clinical settings.

Sexual Minority Women and Contraceptive Use: Complex Pathways Between Sexual Orientation and Health Outcomes

Compared with their heterosexual peers, sexual minority women (SMW; e.g., queer, bisexual, lesbian, pansexual) have an elevated risk for unintended pregnancy.A team of social science and clinical researchers qualitatively documented the multilevel pathways leading to this disparity, particularly the contexts of contraceptive use. From August 2017 to April 2018, we conducted focus groups and interviews with young adult cisgender SMW in 3 cities: Chicago, Illinois; Madison, Wisconsin; and Salt Lake City, Utah.Most participants reported experience with both penile-vaginal intercourse and contraception. However, they faced several queer-specific barriers to preventing unwanted pregnancy, including a comparative lack of self-concept as contraceptive users, fear of stigma from both queer and health care communities, use of less-effective methods because of infrequent penile-vaginal intercourse and a sense that longer-acting methods were "overkill," and previous experiences of discrimination such as homophobia and gender-based violence. However, participants also reported ways that contraception could align with queer identity, including both taking advantage of noncontraceptive benefits and framing contraception as sex- and queer-positive. These facilitators can inform future efforts to help SMW better meet their pregnancy prevention needs.

Abortion Surveillance - United States, 2016

PROBLEM/CONDITION

Since 1969, CDC has conducted abortion surveillance to document the number and characteristics of women obtaining legal induced abortions in the United States.

PERIOD COVERED

2016.

DESCRIPTION OF SYSTEM

Each year, CDC requests abortion data from the central health agencies of 52 reporting areas (the 50 states, the District of Columbia, and New York City). The reporting areas provide this information voluntarily. For 2016, data were received from 48 reporting areas. Abortion data provided by these 48 reporting areas for each year during 2007-2016 were used in trend analyses. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively.

RESULTS

A total of 623,471 abortions for 2016 were reported to CDC from 48 reporting areas. Among these 48 reporting areas, the abortion rate for 2016 was 11.6 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 186 abortions per 1,000 live births. From 2015 to 2016, the total number of reported abortions decreased 2% (from 636,902), the abortion rate decreased 2% (from 11.8 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 1% (from 188 abortions per 1,000 live births). From 2007 to 2016, the total number of reported abortions decreased 24% (from 825,240), the abortion rate decreased 26% (from 15.6 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 18% (from 226 abortions per 1,000 live births). In 2016, all three measures reached their lowest level for the entire period of analysis (2007-2016). In 2016 and throughout the period of analysis, women in their 20s accounted for the majority of abortions and had the highest abortion rates. In 2016, women aged 20-24 and 25-29 years accounted for 30.0% and 28.5% of all reported abortions, respectively, and had abortion rates of 19.1 and 17.8 abortions per 1,000 women aged 20-24 and 25-29 years, respectively. By contrast, women aged 30-34, 35-39, and ≥40 years accounted for 18.0%, 10.3%, and 3.5% of all reported abortions, respectively, and had abortion rates of 11.6, 6.9, and 2.5 abortions per 1,000 women aged 30-34, 35-39, and ≥40 years, respectively. From 2007 to 2016, the abortion rate decreased among women in all age groups. In 2016, adolescents aged <15 and 15-19 years accounted for 0.3% and 9.4% of all reported abortions, respectively, and had abortion rates of 0.4 and 6.2 abortions per 1,000 adolescents aged <15 and 15-19 years, respectively. From 2007 to 2016, the percentage of abortions accounted for by adolescents aged 15-19 years decreased 43%, and the abortion rate decreased 56%. This decrease in abortion rate was greater than the decreases for women in any older age group. In contrast to the percentage distribution of abortions and abortion rates by age, abortion ratios in 2016 and throughout the entire period of analysis were highest among adolescents and lowest among women aged 25-39 years. Abortion ratios decreased from 2007 to 2016 for women in all age groups. In 2016, almost two-thirds (65.5%) of abortions were performed at ≤8 weeks' gestation, and nearly all (91.0%) were performed at ≤13 weeks' gestation. Fewer abortions were performed between 14 and 20 weeks' gestation (7.7%) or at ≥21 weeks' gestation (1.2%). During 2007-2016, the percentage of abortions performed at >13 weeks' gestation remained consistently low (8.2%-9.0%). Among abortions performed at ≤13 weeks' gestation, the percentage distributions of abortions by gestational age were highest among those performed at ≤6 weeks' gestation (35.0%-38.4%). In 2016, 27.9% of all abortions were performed by early medical abortion (a nonsurgical abortion at ≤8 weeks' gestation), 59.9% were performed by surgical abortion at ≤13 weeks' gestation, 8.8% were performed by surgical abortion at >13 weeks' gestation, and 3.4% were performed by medical abortion at >8 weeks' gestation; all other methods were uncommon (0.1%). Among those that were eligible for early medical abortion on the basis of gestational age (i.e., performed at ≤8 weeks' gestation), 41.9% were completed by this method. In 2016, women with one or more previous live births accounted for 59.0% of abortions, and women with no previous live births accounted for 41.0%. Women with one or more previous induced abortions accounted for 43.1% of abortions, and women with no previous abortions accounted for 56.9%. Deaths of women associated with complications from abortion are assessed as part of CDC's Pregnancy Mortality Surveillance System. In 2015, the most recent year for which data were reviewed for abortion-related deaths, two women were identified to have died as a result of complications from legal induced abortion and for one additional death, it was unknown whether the abortion was induced or spontaneous.

INTERPRETATION

Among the 48 areas that reported data every year during 2007-2016, decreases in the total number, rate, and ratio of reported abortions resulted in historic lows for the period of analysis for all three measures of abortion.

PUBLIC HEALTH ACTION

The data in this report can help program planners and policymakers identify groups of women with the highest rates of abortion. Unintended pregnancy is the major contributor to induced abortion. Increasing access to and use of effective contraception can reduce unintended pregnancies and further reduce the number of abortions performed in the United States.

Abortion Surveillance - United States, 2015

PROBLEM/CONDITION

Since 1969, CDC has conducted abortion surveillance to document the number and characteristics of women obtaining legal induced abortions in the United States.

PERIOD COVERED

2015.

DESCRIPTION OF SYSTEM

Each year, CDC requests abortion data from the central health agencies of 52 reporting areas (the 50 states, the District of Columbia, and New York City). The reporting areas provide this information voluntarily. For 2015, data were received from 49 reporting areas. Abortion data provided by these 49 reporting areas for each year during 2006-2015 were used in trend analyses. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively.

RESULTS

A total of 638,169 abortions for 2015 were reported to CDC from 49 reporting areas. Among these 49 reporting areas, the abortion rate for 2015 was 11.8 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 188 abortions per 1,000 live births. From 2014 to 2015, the total number of reported abortions decreased 2% (from 652,639), the abortion rate decreased 2% (from 12.1 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 2% (from 192 abortions per 1,000 live births). From 2006 to 2015, the total number of reported abortions decreased 24% (from 842,855), the abortion rate decreased 26% (from 15.9 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 19% (from 233 abortions per 1,000 live births). In 2015, all three measures reached their lowest level for the entire period of analysis (2006-2015). In 2015 and throughout the period of analysis, women in their 20s accounted for the majority of abortions and had the highest abortion rates; women aged ≥30 years accounted for a smaller percentage of abortions and had lower abortion rates. In 2015, women aged 20-24 and 25-29 years accounted for 31.1% and 27.6% of all reported abortions, respectively, and had abortion rates of 19.9 and 17.9 abortions per 1,000 women aged 20-24 and 25-29 years, respectively. In contrast, women aged 30-34, 35-39, and ≥40 years accounted for 17.7%, 10.0%, and 3.5% of all reported abortions, respectively, and had abortion rates of 11.6, 7.0, and 2.5 abortions per 1,000 women aged 30-34, 35-39, and ≥40 years, respectively. From 2006 to 2015, the abortion rate decreased among women in all age groups. In 2015, adolescents aged <15 and 15-19 years accounted for 0.3% and 9.8% of all reported abortions, respectively, and had abortion rates of 0.5 and 6.7 abortions per 1,000 adolescents aged <15 and 15-19 years, respectively. From 2006 to 2015, the percentage of abortions accounted for by adolescents aged 15-19 years decreased 41%, and their abortion rate decreased 54%. This decrease in abortion rate was greater than the decreases for women in any older age group. In contrast to the percentage distribution of abortions and abortion rates by age, abortion ratios in 2015 and throughout the entire period of analysis were highest among adolescents and lowest among women aged 25-39 years. Abortion ratios decreased from 2006 to 2015 for women in all age groups. In 2015, almost two thirds (65.4%) of abortions were performed at ≤8 weeks' gestation, and nearly all (91.1%) were performed at ≤13 weeks' gestation. Few abortions were performed between 14 and 20 weeks' gestation (7.6%) or at ≥21 weeks' gestation (1.3%). During 2006-2015 the percentage of all abortions performed at >13 weeks' gestation remained consistently low (≤9.0%). Among abortions performed at ≤13 weeks' gestation, a shift occurred toward earlier gestational ages, with the percentage performed at ≤6 weeks' gestation increasing 11%. In 2015, 24.6% of all abortions were performed by early medical abortion (a nonsurgical abortion at ≤8 weeks' gestation), 64.3% were performed by surgical abortion at ≤13 weeks' gestation, and 8.8% were performed by surgical abortion at >13 weeks' gestation; all other methods were uncommon (≤2.2%). Among those that were eligible for early medical abortion on the basis of gestational age (i.e., performed at ≤8 weeks' gestation), 35.8% were completed by this method. In 2015, women with one or more previous live births accounted for 59.3% of abortions, and women with no previous live births accounted for 40.7%. Women with one or more previous induced abortions accounted for 43.6% of abortions, and women with no previous abortion accounted for 56.3%. Women with three or more previous births accounted for 14.2% of abortions, and women with three or more previous abortions accounted for 8.2% of abortions. Deaths of women associated with complications from abortion for 2015 are being assessed as part of CDC's Pregnancy Mortality Surveillance System. In 2014, the most recent year for which data were available, six women were identified to have died as a result of complications from legal induced abortion.

INTERPRETATION

Among the 49 areas that reported data every year during 2006-2015, decreases in the total number, rate, and ratio of reported abortions resulted in historic lows for the period of analysis for all three measures of abortion.

PUBLIC HEALTH ACTION

The data in this report can help program planners and policymakers identify groups of women with the highest rates of abortion. Unintended pregnancy is the major contributor to induced abortion. Increasing access to and use of effective contraception can reduce unintended pregnancies and further reduce the number of abortions performed in the United States.