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

Lifetime abortion incidence when abortion care is covered by Medicaid: Maryland versus five comparison states

OBJECTIVE

To estimate the association of Medicaid coverage of abortion care with cumulative lifetime abortion incidence among women insured by Medicaid.

DATA SOURCES AND STUDY SETTING

We use 2016-2019 (Pre-Dobbs) data from the Survey of Women studies that represent women aged 18-44 living in six U.S. states. One state, Maryland, has a Medicaid program that has long covered the cost of abortion care. The other five states, Alabama, Delaware, Iowa, Ohio, and South Carolina, have Medicaid programs that do not cover the cost of abortion care. Our sample includes 8972 women residing in the study states.

STUDY DESIGN

Our outcome, cumulative lifetime abortion incidence, is identified using an indirect survey method, the double list experiment. We use a multivariate regression of cumulative lifetime abortion on variables including whether women were Medicaid-insured and whether they were residing in Maryland versus in one of the other five states.

DATA COLLECTION/EXTRACTION METHODS

This study used secondary survey data.

PRINCIPAL FINDINGS

We estimate that Medicaid coverage of abortion care in Maryland is associated with a 37.0 percentage-point (95% CI: 12.3-61.4) higher cumulative lifetime abortion incidence among Medicaid-insured women relative to women not insured by Medicaid compared with those differences by insurance status in states whose Medicaid programs do not cover the cost of abortion care.

CONCLUSIONS

We found that Medicaid coverage of abortion care is associated with a much higher lifetime incidence of abortion among individuals insured by Medicaid. We infer that Medicaid coverage of abortion care costs may have a very large impact on the accessibility of abortion care for low-income women.

Individual changes in abortion knowledge and attitudes

RATIONALE

Policymakers need to know the abortion attitudes of those they represent. In addition, inaccurate knowledge of or negative attitudes toward abortion may lead to more abortion stigma, which may adversely affect abortion access and women's health.

OBJECTIVE

The first objective was to examine whether individual's abortion knowledge and attitudes changed during 2016-2020 in Delaware and Maryland. The second was to explore whether personally knowing someone who had an abortion in 2020 was associated with knowledge, attitudes, and changes in them from 2016 to 2020.

METHODS

Data were from the Delaware [Maryland] Survey of Women, a probability sample that was self-administered via web and mail (N = 1106). Women aged 18-44 from Delaware and Maryland were followed from 2016/2017 to 2019/2020. Outcomes were each two facets of abortion knowledge (perceived safety and perceived access) and abortion attitudes (acceptability and advocacy self-identification), and changes in these outcomes. The main predictor was whether women personally knew someone who had an abortion. Covariates included state, religiosity, pregnancy history, and sociodemographic factors. We used logistic models with inverse probability weights.

RESULTS

The percentage of respondents who changed between the first and third waves varied: 46% changed their views on safety and accessibility; 21% changed their views on acceptability; and 25% changed their advocacy self-identification. Knowing someone personally who had an abortion was associated with changing toward viewing abortion as very safe and towards pro-choice, and with not changing towards viewing abortion as wrong or identifying as pro-life.

CONCLUSIONS

These findings suggest abortion knowledge and attitudes are not fixed but change over time, and knowing someone who had an abortion or having an abortion oneself was associated with changing toward positive attitudes and accurate knowledge. Sharing one's abortion experience with others one knows may reduce negative attitudes and inaccurate knowledge regarding abortion.

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.