Abortion Surveillance - United States, 2019

Economic analysis of foregoing Rh immunoglobulin for bleeding in pregnancy <12 weeks gestation

OBJECTIVES

To perform cost analyses of foregoing RhD blood type testing and administration of Rh immunoglobulin (RhIg) for bleeding in pregnancy at <12 weeks gestation in the United States.

STUDY DESIGN

We created a decision-analytic model comparing the current standard treatment pathway for patients who have threatened, spontaneous, or induced abortion in the United States, with a new pathway foregoing RhD testing and administration of RhIg for those who are RhD-negative at <12 weeks gestation, assuming that the risk of sensitization is 0%. We derived population and cost estimates from current literature and calculated the number needed to treat, and number needed to screen, to avoid one case of fatal hemolytic disease of the fetus and newborn. We performed sensitivity analyses assuming Rh-sensitization risks of 1.5% and 3% and varying the subsequent pregnancy rates from 44-100%.

RESULTS

The annual savings to healthcare payers in the United States of foregoing RhD testing and RhIg administration to RhD-negative patients with bleeding events at <12 weeks is $5.5 million/100,000 total pregnancies, assuming that the risk of sensitization is 0%. In the sensitivity analyses with sensitization risk 1.5% and subsequent pregnancy rate 84.3%, foregoing Rh testing and RhIg administration <12 weeks would save $2.8 million/100,000 pregnancies, with a corresponding number needed to treat of 7,322 and number needed to screen of 48,816. At a 3% sensitization rate, the current standard treatment pathway is the most economical.

CONCLUSIONS

There is an opportunity to save the United States healthcare payers as much as $5.5 million/100,000 pregnancies by withholding RhIg in specific situations and conserving it for use later in pregnancy.

IMPLICATIONS

Cost analyses support foregoing RhD blood type screening and RhIg administration at <12 weeks gestation if the sensitization rate is <3%. By de-implementing this low value care, payers in the United States can save as much as $5.5 million/100,000 pregnancies and conserve RhIg for use later in pregnancy.

Self-diagnosing the end of pregnancy after medication abortion

This qualitative study conducted between November 2020 and March 2021 in the US state of Mississippi examines the experiences of 25 people who obtained medication abortion at the state's only abortion facility. We conducted in-depth interviews with participants after their abortions until concept saturation was reached, and then analysed the content using inductive and deductive analysis. We assessed how people use embodied knowledge about their individual physical experiences such as pregnancy symptoms, a missed period, bleeding, and visual examinations of pregnancy tissue to identify the beginning and end of pregnancy. We compared this to how people use biomedical knowledge such as pregnancy tests, ultrasounds, and clinical examinations to confirm their self-diagnoses. We found that most people felt confident that they could identify the beginning and end of pregnancy through embodied knowledge, especially when combined with the use of home pregnancy tests that confirmed their symptoms, experiences, and visual evidence. All participants concerned about symptoms sought follow-up care at a medical facility, whereas people who felt confident of the successful end of the pregnancy did so less often. These findings have implications for settings of restricted abortion access that have limited options for follow-up care after medication abortion.

Abortion medical management between 14-16 weeks' amenorrhea after French legislation deadline extension

BACKGROUND

The National French Assembly promoted a law in 2022 allowing an extension of the period of abortion up to 16 week's amenorrhea. Medication protocols vary internationally, and there are no French data on medical management between 14- and 16-weeks' amenorrhea.

OBJECTIVE

To assess effectiveness and feasibility of a medical management abortion between 14 and 16 weeks of amenorrhea.

STUDY DESIGN

We retrospectively collected data from women undergoing medical abortion between 14 and 16 weeks' amenorrhea from April 2022 to April 2023 in Archet's University hospital, Nice, France. Medical protocol consisted in a single dose of oral mifepristone 600 mg and 36-48 h later, vaginal gemeprost 1 mg. Three hours after gemeprost, oral 400 µg of misoprostol were administered every three hours, to a maximum of three doses. Success was defined as fetal expulsion.

RESULTS

Thirty women were enrolled in the study. Twenty-nine (96.7 %) patients aborted successfully. The median dose of misoprostol required was 800 µg (400 µg -1200 µg) and the median induction-to-abortion interval after first prostaglandin administration was 7 h (5.5-11.6). One patient (3.3 %) didn't expulse the fetus after 3 doses of misoprostol. Nine patients (30.0 %) had additional surgical aspiration for retained product of conception within 24 h. We encountered one post-abortum hemorrhage controlled only with surgical intra uterine aspiration. We did not need complementary hemostatic procedure and we reported no immediate or late complication.

CONCLUSIONS

Medical abortion between 14 and 16 weeks of amenorrhea provides a noninvasive and effective management for a daycare mid trimester abortion in 96.7 % of cases, with a 36.7 % of risk of staying in hospital overnight and 30.0 % to have additional surgery for retained product of conception (RPOC).

Risk factors for delayed termination of pregnancy following increased nuchal translucency

OBJECTIVES

Termination of pregnancy after increased nuchal translucency (NT) is a common occurrence. This study aimed to identify characteristics of a cohort with a NT ≥3.0 mm who underwent a pregnancy termination ≥15 weeks compared with those who terminated <15 weeks.

METHODS

All NT ≥3.0 mm identified within our department over an 11-year period (2010-2021) (n = 689) were retrospectively examined and characteristics of the cohort of increased NTs ending in termination were further categorized.

RESULTS

There were 221 (32.1%) individuals with an increased NT (≥3 mm) who underwent a termination of pregnancy within our study period (2010-2021). Pregnancy termination occurred at a gestational age <15 weeks in 162 (73.3%) and ≥15 weeks in 59 individuals. Pregnant individuals without positive NIPT for aneuploidy were at a higher risk for a ≥15-week termination (p = 0.004). In 29% (17/59) of late terminations, there were additional imaging findings after the NT scan (ultrasound, echocardiogram, magnetic resonance imaging) that ultimately triggered the decision to pursue termination.

CONCLUSIONS

As the options for workup of an increased NT expand, potential delays in decision-making surrounding termination increase. This study identifies multiple reasons for delayed termination and proposes several approaches to care aimed at maximizing diagnostic information by imaging and diagnostic testing in an expedited manner.

Protect and Control: Coverture's Logics Across Welfare Policy and Abortion Law

In the aftermath of Dobbs v. Jackson Women's Health Organization, which overturned the federal constitutional right to abortion, states have begun to recriminalize the procedure. These abortion bans raise important questions about the political and social status of women and pregnant people in the United States. Moreover, restrictions in social welfare programs such as the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children and Temporary Assistance for Needy Families, which serve low-income pregnant people and parents, raise similar questions. The regulation and administration of all three are framed by race, class, and gender. To understand how these restrictions (a) claim to protect women but ultimately function to control, police, and surveil and (b) rely on imagined, stereotype-laden psychological states such as vulnerability, irresponsibility, or irrationality, we turn to the British Common Law doctrine of coverture, which subsumed a married woman's legal, financial, and political identities under her husband's. The American colonies, and later, states of the United States, drew from British Common Law to craft laws that regulated relationships between men and women. Taken together, this analysis can provide a more comprehensive accounting of the cumulative harms experienced by women, poor people, people of color, and pregnant people in today's health and social welfare landscape. We conclude with recommendations for psychologists and other mental health providers to address, in practice and advocacy, the ethical dilemmas and obligations raised by the reach of coverture's logics in people's lives.

Abortion Surveillance - United States, 2021

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

2021.

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 2021, a total of 48 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 47 reporting areas provided data each year during 2012-2021. 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 2020 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS).

Results

A total of 625,978 abortions for 2021 were reported to CDC from 48 reporting areas. Among 47 reporting areas with data each year during 2012-2021, in 2021, a total of 622,108 abortions were reported, the abortion rate was 11.6 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 204 abortions per 1,000 live births. From 2020 to 2021, the total number of abortions increased 5% (from 592,939 total abortions), the abortion rate increased 5% (from 11.1 abortions per 1,000 women aged 15-44 years), and the abortion ratio increased 4% (from 197 abortions per 1,000 live births). From 2012 to 2021, the total number of reported abortions decreased 8% (from 673,634), the abortion rate decreased 11% (from 13.1 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 1% (from 207 abortions per 1,000 live births).In 2021, women in their 20s accounted for more than half of abortions (57.0%). Women aged 20-24 and 25-29 years accounted for the highest percentages of abortions (28.3% and 28.7%, respectively) and had the highest abortion rates (19.7 and 19.4 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 3.6%, respectively) and had the lowest abortion rates (0.4 and 2.5 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 30-39 years.From 2020 to 2021, abortion rates increased among women aged 20-39 years, decreased among adolescents aged 15-19 years, and did not change among adolescents aged <15 years and women aged ≥40 years. Abortion rates decreased from 2012 to 2021 among all age groups, except women aged 30-34 years for whom it increased. The decrease in the abortion rate from 2012 to 2021 was highest among adolescents compared with any other age group. From 2020 to 2021, abortion ratios increased for women aged 15-24 years, decreased among adolescents aged <15 years and women aged ≥35 years and did not change for women aged 25-34 years. From 2012 to 2021, abortion ratios increased among women aged 15-29 years and decreased among adolescents aged <15 years and women aged ≥30 years. The decrease in abortion ratio from 2012 to 2021 was highest among women aged ≥40 years compared with any other age group.In 2021, the majority (80.8%) of abortions were performed at ≤9 weeks' gestation, and nearly all (93.5%) were performed at ≤13 weeks' gestation. During 2012-2021, the percentage of abortions performed at >13 weeks' gestation remained ≤8.7%. In 2021, the highest percentage of abortions were performed by early medication abortion at ≤9 weeks' gestation (53.0%), followed by surgical abortion at ≤13 weeks' gestation (37.6%), surgical abortion at >13 weeks' gestation (6.4%), and medication abortion at >9 weeks' gestation (3.0%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 66.6% of abortions were early medication abortions. In 2020, the most recent year for which PMSS data were reviewed for pregnancy-related deaths; six women died as a result of complications from legal induced abortion.

Interpretation

Among the 47 areas that reported data continuously during 2012-2021, overall decreases were observed during 2012-2021 in the total number, rate, and ratio of reported abortions; however, from 2020 to 2021, 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.

Changes in Induced Medical and Procedural Abortion Rates in a Commercially Insured Population, 2018 to 2022 : An Interrupted Time-Series Analysis

BACKGROUND

During the COVID-19 pandemic, access to in-person care was limited, and regulations requiring in-person dispensing of mifepristone for medical abortions were relaxed. The effect of the pandemic and accompanying regulatory changes on abortion use is unknown.

OBJECTIVE

To estimate changes in the incidence rate of induced medical and procedural abortions.

DESIGN

Serial cross-sectional study with interrupted time-series analyses.

SETTING

Commercially insured persons in the United States.

PARTICIPANTS

Reproductive-aged women.

INTERVENTION

Onset of the COVID-19 pandemic in March 2020 and subsequent regulatory changes affecting the in-person dispensing requirement for mifepristone.

MEASUREMENTS

Monthly age-adjusted incidence rates of medical and procedural abortions were measured among women aged 15 to 44 years from January 2018 to June 2022. Medical abortions were classified as in-person or telehealth. Linear segmented time-series regression was used to calculate changes in abortion rates after March 2020.

RESULTS

In January 2018, the estimated age-adjusted monthly incidence rate of abortions was 151 per million women (95% CI, 142 to 161 per million women), with equal rates of medical and procedural abortions. After March 2020, there was an immediate 14% decrease in the monthly incidence rate of abortions (21 per million women [CI, 7 to 35 per million women]; P = 0.004), driven by a 31% decline in procedural abortions (22 per million women [CI, 16 to 28 per million women]; P < 0.001). Fewer than 4% of medical abortions each month were administered via telehealth.

LIMITATION

Only abortions reimbursed by commercial insurance were measured.

CONCLUSION

The incidence rate of procedural abortions declined during the COVID-19 pandemic, and this lower rate persisted after other elective procedures rebounded to prepandemic rates. Despite removal of the in-person dispensing requirement for mifepristone, the use of telehealth for insurance-covered medical abortions remained rare. Amid increasing state restrictions, commercial insurers have the opportunity to increase access to abortion care, particularly via telehealth.

PRIMARY FUNDING SOURCE

Health Resources and Services Administration.

Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation: Jointly developed with the Society for Maternal-Fetal Medicine

The objective of this Clinical Recommendation is to review relevant literature and provide evidence-based recommendations for medication abortion between 14 0/7 and 27 6/7 weeks of gestation, with a focus on mifepristone-misoprostol and misoprostol-only regimens. We systematically reviewed PubMed articles published between 2008 and 2022 and reviewed reference lists of included articles to identify additional publications. See Search Strategy for more details. Several randomized trials of medication abortion between 14 0/7 and 27 6/7 weeks of gestation demonstrate that mifepristone 200 mg orally before misoprostol increases effectiveness (complete abortion at 24 or 48 hours) compared to misoprostol only. Studies continue to evaluate different doses, routes, and dosing intervals for misoprostol. If mifepristone is unavailable, several misoprostol regimens with individual doses of at least 200 mcg or more are effective. Adjunctive osmotic dilators are of limited benefit. It is important to individualize care, with consideration to reducing misoprostol dose in low-resource settings or at 24 0/7 weeks of gestation or later (or equivalent uterine size). Misoprostol in the setting of two or more previous cesarean sections is associated with increased risk of uterine rupture compared to one or none, but risk remains low. Most contraceptives can be started during or immediately following abortion. Appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks of gestation with appropriate backup within the confines of local regulations and licensure.

Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation: Jointly developed with the Society for Maternal-Fetal Medicine

The objective of this Clinical Recommendation is to review relevant literature and provide evidence-based recommendations for medication abortion between 14 0/7 and 27 6/7 weeks of gestation, with a focus on mifepristone-misoprostol and misoprostol-only regimens. We systematically reviewed PubMed articles published between 2008 and 2022 and reviewed reference lists of included articles to identify additional publications. See Search Strategy for more details. Several randomized trials of medication abortion between 14 0/7 and 27 6/7 weeks of gestation demonstrate that mifepristone 200 mg orally before misoprostol increases effectiveness (complete abortion at 24 or 48 hours) compared to misoprostol only. Studies continue to evaluate different doses, routes, and dosing intervals for misoprostol. If mifepristone is unavailable, several misoprostol regimens with individual doses of at least 200 mcg or more are effective. Adjunctive osmotic dilators are of limited benefit. It is important to individualize care, with consideration to reducing misoprostol dose in low-resource settings or at 24 0/7 weeks of gestation or later (or equivalent uterine size). Misoprostol in the setting of two or more previous cesarean sections is associated with increased risk of uterine rupture compared to one or none, but risk remains low. Most contraceptives can be started during or immediately following abortion. Appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks of gestation with appropriate backup within the confines of local regulations and licensure.

Abortion Bans and Resource Utilization for Congenital Heart Disease: A Decision Analysis

OBJECTIVE

To investigate the implications of potential national abortion ban scenarios on the incidence of neonatal single-ventricle cardiac defects.

METHODS

A decision tree model was developed to predict the incidence of neonatal single-ventricle cardiac defects and related outcomes in the United States under four theoretical national abortion bans: 1) abortion restrictions in existence immediately before the June 2022 Dobbs v Jackson Women's Health Organization Supreme Court decision, 2) 20 weeks of gestation, 3) 13 weeks of gestation, and 4) a complete abortion ban. The model included incidence of live births of neonates with single-ventricle cardiac defects, neonatal heart surgery (including heart transplant and extracorporeal membrane oxygenation [ECMO]), and neonatal death. Cohort size was based on national pregnancy incidence and different algorithm decision point probabilities were aggregated from the existing literature. Monte Carlo simulations were conducted with 10,000 iterations per model.

RESULTS

In the scenario before the Dobbs decision, an estimated 6,369,000 annual pregnancies in the United States resulted in 1,006 annual cases of single-ventricle cardiac defects. Under a complete abortion ban, the model predicted a 53.7% increase in single-ventricle cardiac defects, or an additional 9 cases per 100,000 live births. This increase would result in an additional 531 neonatal heart surgeries, 16 heart transplants, 77 ECMO utilizations, and 102 neonatal deaths annually. More restrictive gestational age-based bans are predicted to confer increases in cases of neonatal single-ventricle cardiac defects and related adverse outcomes as well.

CONCLUSION

Universal abortion bans are estimated to increase the incidence of neonatal single-ventricle cardiac defects, associated morbidity, and resource utilization. States considering limiting abortion should consider the implications on the resources required to care for increasing number of children that will be born with significant and complex medical needs, including those with congenital heart disease.

Self-Managed Medication Abortion: Implications for Clinical Practice

Medication abortion represents more than 50 percent of abortions in the United States (US). Since its approval in the US in 2000, the Food and Drug Administration (FDA) has progressively relaxed the prescribing requirements such that currently, no office visit, in-person dispensing, or ultrasound is required. Obtaining medication for abortion online without medical supervision or evaluation is also possible. This article reviews the complications of medication abortion by examining major studies and delineates the risks specific to self-managed abortion to inform clinicians in caring for women.

Summary

Medication abortion has become the most common abortion method in the United States. This document provides a detailed history of the relaxation requirements on medication abortion and reviews the major studies on medication abortion complications including a discussion of their limitations. Finally, the paper delineates the ease of access to medication abortion without a health care provider and the risks associated with self-managed abortion. This paper is intended to provide information for clinicians who likely will be encountering increasing number of patients with such complications.

Anesthetic Considerations for Second-Trimester Surgical Abortions

Although most abortion care takes place in the office setting, anesthesiologists are often asked to provide anesthesia for the 1% of abortions that take place later, in the second trimester. Changes in federal and state regulations surrounding abortion services may result in an increase in second-trimester abortions due to barriers to accessing care. The need for interstate travel will reduce access and delay care for everyone, given limited appointment capacity in states that continue to support bodily autonomy. Therefore, anesthesiologists may be increasingly involved in care for these patients. There are multiple, unique anesthetic considerations to provide safe and compassionate care to patients undergoing second-trimester abortion. First, a multiday cervical preparation involving cervical osmotic dilators and pharmacologic agents results in a time-sensitive, nonelective procedure, which should not be delayed or canceled due to risk of fetal expulsion in the preoperative area. In addition, a growing body of literature suggests that the older anesthesia dogma that all pregnant patients require rapid-sequence induction and an endotracheal tube can be abandoned, and that deep sedation without intubation is safe and often preferable for this patient population through 24 weeks of gestation. Finally, concomitant substance use disorders, preoperative pain from cervical preparation, and intraoperative management of uterine atony in a uterus that does not yet have mature oxytocin receptors require additional consideration.

Progesterone-mediated reversal of mifepristone-induced pregnancy termination in a rat model: an exploratory investigation

Globally, a substantial proportion of pregnancies end in induced (particularly medication) abortion. However, data also indicates a percentage of women who seek assistance in potentially reversing the medication abortion process. While previous literature has suggested the potential for progesterone-mediated reversal of mifepristone-induced abortion, this process has not been effectively investigated pre-clinically. Our study explored the potential reversal of mifepristone-induced pregnancy termination using progesterone in a rat model, following a clear initiation of pregnancy termination. Female Long-Evans rats were divided into three groups (n = 10-16/group): Pregnant control (M-P-), mifepristone-only/pregnancy termination (M+P-) and mifepristone + progesterone (M+P+). Drug/vehicle administration occurred on day 12 of gestation (first-trimester human equivalent). Rat weight was measured throughout gestation. Uterine blood, collected post-drug/vehicle administration, was analyzed spectrophotometrically to measure blood loss. Additionally, at the end of gestation (day 21), ultrasound was utilized to confirm pregnancy and measure fetal heart rate. Number of gestational sacs, uterine weights and diameters were obtained following tissue collection. Our results indicate that progesterone administration following initiation of mifepristone-induced pregnancy termination (indicated by weight loss and uterine bleeding) reversed the process in 81% of rats in the M+P+ group. Following the initial weight loss, these rats proceeded to gain weight at a similar rate to the M-P- group, in contrast to the continued decrease displayed by the M+P- group (and unsuccessful reversals). Moreover, while uterine blood loss was similar to that of the M+P- group (confirming pregnancy termination initiation), number of gestational sacs, uterine weights, diameters, approximate fetal weights and fetal heart rates were similar to the M-P- group. Thus, our results indicate a clear progesterone-mediated reversal of an initiated mifepristone-induced pregnancy termination in a rat model at first-trimester human equivalent, with resultant fully developed living fetuses at the end of gestation, clearly indicating the necessity for further pre-clinical investigation to assist in better informing the scientific/medical communities of the potential implications in humans.

WHEN REPRODUCTION IS NO LONGER AUTONOMOUS: FEELING RESPECTED BY MATERNITY CARE PROVIDERS MODERATES THE ASSOCIATION BETWEEN AUTONOMY IN DECISION MAKING AND BIRTH-RELATED PTSD SYMPTOMS IN A COMMUNITY SAMPLE OF POSTPARTUM BLACK WOMEN

Black individuals are at particularly high risk for birth-related posttraumatic stress disorder (PTSD) symptoms, in part due to a lack of opportunity to lead maternity care decisions. Maternal care providers need evidence-based ways to reduce pregnant persons' risk for birth-related PTSD symptoms despite reduced autonomy in decision making resulting from heightened restrictions on reproductive rights. We investigated whether a potential relation between autonomy in decision making and birth-related PTSD symptoms would be moderated by being mistreated or feeling respected by maternity care providers in a community sample of Black women (N = 52; Mage = 28.2 years, SDage = 5.7 years) seeking maternity care at a public hospital in the southeastern United States. At six weeks postpartum, participants completed measures assessing autonomy in decision making, current birth-related PTSD symptoms, number of mistreatment events, and feelings of respect from providers during pregnancy, childbirth, and the postpartum period. Autonomy in decision making was negatively correlated with birth-related PTSD symptoms, r=-.43, p < .01. An interaction between autonomy in decision making and mistreatment by providers was trending toward significance, B=-.23, SE=.14, p = .10. Autonomy in decision making and feeling respected by maternity care provider interacted to predict birth-related PTSD symptoms, B = .05, SE=.01, p < .01. Feeling respected by providers may buffer against the negative effects of lack of autonomy in decision making on birth-related PTSD symptoms, highlighting the importance of providers' ability to convey respect to pregnant patients when they cannot lead care decisions.

Dobbs Versus Jackson: Epilepsy, Reproductive Health, and Abortion

On June 24, 2022, Dobbs vs Jackson Women's Health Organization was decided by the Supreme Court effectively overturning the former precedent of Roe v. Wade. This ruling has direct consequences for the care of persons with epilepsy of childbearing potential. Now more than ever we need to provide informed and comprehensive care to our patients with epilepsy who are particularly vulnerable to the impact of this legislation on their reproductive decision-making. Important areas to understand include (1) the current state of affairs on abortion in the United States; (2) contraception options, their effectiveness, and interactions with anti-seizure medications (ASM); (3) teratogenic effects and adverse neurocognitive outcomes of ASMs; (4) folic acid supplementation; (5) the effect on perinatal and pediatric care; and (6) unique issues related to people of color.

Spontaneous and Complicated Therapeutic Abortion in the Emergency Department

Pregnancy-related emergency department visits are common in the United States. Although typically managed safely in the outpatient setting, patients with spontaneous abortion may also present with life-threatening hemorrhage or infection. Management strategies for spontaneous abortion are similarly wide-ranging from expectant management to emergent surgical intervention. Surgical management of complicated therapeutic abortion is similar to that of spontaneous abortion. The dramatic changes in the legal status of abortion in the United States may have significant influence on the incidence of complicated therapeutic abortion, and we encourage emergency physicians to familiarize themselves with the diagnosis and management of these conditions.

At-home urine pregnancy test assessment after mifepristone and misoprostol for undesired pregnancy of unknown location

OBJECTIVES

The ideal assessment after mifepristone and misoprostol for undesired pregnancy of unknown location (PUL) is unknown.

STUDY DESIGN

We prospectively followed patients at Planned Parenthood League of Massachusetts (2019-2021) with PUL who received immediate mifepristone and misoprostol with serial at-home urine pregnancy tests (UPT) and in-office serum HCGs.

RESULTS

Of 13 patients, 10 had a successful medication abortion. For those who completed UPTs (N = 9), all were negative by Day 14. Two abnormal pregnancies had positive UPTs on Day 14.

CONCLUSION

A negative UPT on Day 14 may help determine complete abortion after medication abortion for undesired PUL. A positive UPT on Day 14 warrants further evaluation.

IMPLICATION

Patients taking mifepristone and misoprostol in the setting of undesired PUL who cannot access serum testing may consider an at-home UPT to confirm complete abortion.

Abortion Policy in the United States: The New Legal Landscape and Its Threats to Health and Socioeconomic Well-Being

Policy Points The historic 2022 Supreme Court Dobbs v Jackson Women's Health Organization decision has created a new public policy landscape in the United States that will restrict access to legal and safe abortion for a significant proportion of the population. Policies restricting access to abortion bring with them significant threats and harms to health by delaying or denying essential evidence-based medical care and increasing the risks for adverse maternal and infant outcomes, including death. Restrictive abortion policies will increase the number of children born into and living in poverty, increase the number of families experiencing serious financial instability and hardship, increase racial inequities in socioeconomic security, and put significant additional pressure on under-resourced social welfare systems.

"Am I the Only One Who Feels Like This?": Needs Expressed Online by Abortion Seekers

In the United States, abortion is safe and common, but highly stigmatized and frequently targeted by legislation that aims to restrict access. Numerous obstacles impede access to abortion care, including logistical barriers like cost and transportation, limited clinic availability, and state-mandated waiting periods. Accurate abortion information can also be hard to access. To overcome these barriers, many people seeking abortion turn to anonymous online forums, including Reddit, for information and support. Examining this community provides a unique perspective on the questions, thoughts, and needs of people considering or undergoing an abortion. The authors web scraped 250 posts from subreddits that contain abortion-related posts, then coded deidentified posts using a combined deductive/inductive approach. The authors identified a subset of these codes in which users were giving/seeking information and advice on Reddit, then engaged in a targeted analysis of the needs expressed in these posts. Three interconnected needs emerged: (1) need for information, (2) need for emotional support, and (3) need for community around the abortion experience. In this study map the authors reflected these needs onto key social work practice areas and competencies; taken alongside support from social work's governing bodies, this research suggests that social workers would be beneficial additions to the abortion care workforce.

Obstetric and neonatal outcomes in people who acquired a spinal cord injury during pregnancy

OBJECTIVE

(s):The objectives of this study were to determine the obstetric and neonatal outcomes of people who acquired spinal cord injuries (SCI) during pregnancy.

METHODS

This is part of an international observational questionnaire examining pregnancy outcomes of people with SCI. The outcome measures included demographics, such as level of injury and American Spinal Injury Association (ASIA) scores, prenatal and postnatal complications, and neonatal outcomes.

RESULTS

Of 780 responses, 14 (1.79%) participants reported acquiring an SCI while pregnant. 64.2% (9/14) of injuries were due to trauma. Of 14 pregnancies, 1 person miscarried and 3 pregnancies were terminated. There were 11 live births. One participant had twins and 9 live births were singletons. Six participants delivered vaginally, 3 had cesarean delivery (CD) and 1 was unreported. The preterm birth (PTB) rate was 54.5% (6/11). Approximately 36% (4/11) of newborns were admitted to the neonatal intensive care unit (NICU). The average birthweight reported was 2409.7g (453.6-3458.6g). Forty percent (4/10) of participants reported experiencing postpartum blues or depression. Sixty percent (6/10) of participants breastfed for over 2 weeks.

CONCLUSION

(s):This is the largest known cohort to date of individuals acquiring SCI during pregnancy. The most common cause of SCI was motor vehicle accident. Complications included PTB and NICU admission. People who have an SCI during pregnancy are at risk for complications, however positive pregnancy and neonatal outcomes are possible. Absolute small numbers of this event limit the ability to assess incidence of outcomes.

OBJECTIF

Les objectifs de cette étude étaient de déterminer les issues obstétricales et néonatales des personnes ayant subi une lésion de la moelle épinière pendant la grossesse. MéTHODOLOGIE: L'étude fait partie d'un questionnaire d'observation international examinant les issues de grossesse de personnes atteintes d'une lésion de la moelle épinière. Les critères de jugement concernaient les caractéristiques démographiques, telles que le niveau de la lésion et les scores de l'American Spinal Injury Association (ASIA), les complications prénatales et postnatales ainsi que les issues néonatales. RéSULTATS: Des 780 réponses, 14 (1,79 %) participantes ont signalé avoir subi une lésion de la moelle épinière pendant leur grossesse. De ce nombre, 64,2 % (9/14) des lésions étaient dues à un trauma. Pour ces 14 grossesses, 1 personne a eu un avortement spontané et 3 grossesses ont été interrompues. Il y a eu 11 naissances vivantes issues de 1 grossesse gémellaire et de 9 grossesses monofœtales. Les accouchements se sont faits par voie vaginale dans 6 cas et par césarienne dans 3 cas, le mode d'accouchement n'ayant pas été déclaré pour 1 de ces naissances vivantes. Le taux de prématurité était de 54,5 % (6/11). Environ 36 % (4/11) des nouveau-nés ont été admis aux soins intensifs néonataux. Le poids moyen rapporté à la naissance était de 2 409,7 g (453,6-3 458,6 g). Quarante pour cent (4/10) des participantes ont signalé avoir souffert de dépression ou du blues du post-partum. Soixante pour cent (6/10) des participantes ont allaité pendant plus de 2 semaines.

CONCLUSION

Il s'agit de la plus importante cohorte connue à ce jour de personnes ayant subi une lésion de la moelle épinière pendant la grossesse. L'accident d'automobile était la plus importante cause de lésion de la moelle épinière. Les complications observées comprennent l'accouchement prématuré et l'admission aux soins intensifs néonataux. Quoique les personnes qui subissent une lésion de la moelle épinière pendant la grossesse soient à risque de complications, les issues obstétricales et néonatales positives sont possibles. Le faible nombre absolu de ces événements limite la capacité d'évaluer la fréquence des issues.

An Assessment of Perspectives and Concerns Among Research Participants of Childbearing Age Regarding the Health-Relatedness of Data, Online Data Privacy, and Donating Data to Researchers: Survey Study

BACKGROUND

The June 2022 US Supreme Court decision to ban abortion care in Dobbs v Jackson Women's Health Organization sparked ominous debate about the privacy and safety of women and families of childbearing age with digital footprints who actively engage in family planning, including abortion and miscarriage care.

OBJECTIVE

To assess the perspectives of a subpopulation of research participants of childbearing age regarding the health-relatedness of their digital data, their concerns about the use and sharing of personal data online, and their concerns about donating data from various sources to researchers today or in the future.

METHODS

An 18-item electronic survey was developed using Qualtrics and administered to adults (aged ≥18 years) registered in the ResearchMatch database in April 2021. Individuals were invited to participate in the survey regardless of health status, race, gender, or any other mutable or immutable characteristics. Descriptive statistical analyses were conducted using Microsoft Excel and manual queries (single layer, bottom-up topic modeling) and used to categorize illuminating quotes from free-text survey responses.

RESULTS

A total of 470 participants initiated the survey and 402 completed and submitted the survey (for an 86% completion rate). Nearly half the participants (189/402, 47%) self-reported to be persons of childbearing age (18 to 50 years). Most participants of childbearing age agreed or strongly agreed that social media data, email data, text message data, Google search history data, online purchase history data, electronic medical record data, fitness tracker and wearable data, credit card statement data, and genetic data are health-related. Most participants disagreed or strongly disagreed that music streaming data, Yelp review and rating data, ride-sharing history data, tax records and other income history data, voting history data, and geolocation data are health-related. Most (164/189, 87%) participants were concerned about fraud or abuse based on their personal information, online companies and websites sharing information with other parties without consent, and online companies and websites using information for purposes that are not explicitly stated in their privacy policies. Free-text survey responses showed that participants were concerned about data use beyond scope of consent; exclusion from health care and insurance; government and corporate mistrust; and data confidentiality, security, and discretion.

CONCLUSIONS

Our findings in light of Dobbs and other related events indicate there are opportunities to educate research participants about the health-relatedness of their digital data. Developing strategies and best privacy practices for discretion regarding digital-footprint data related to family planning should be a priority for companies, researchers, families, and other stakeholders.

Estimation of Multiyear Consequences for Abortion Access in Georgia Under a Law Limiting Abortion to Early Pregnancy

Importance

Following the US Supreme Court ruling in Dobbs v Jackson Women's Health Organization, Georgia's law limiting abortion to early pregnancy, House Bill 481 (HB481), was allowed to go into effect in July 2022.

Objectives

To estimate anticipated multiyear effects of HB481, which prohibits abortions after detection of embryonic cardiac activity, on abortion incidence in Georgia, and to examine inequities by race, age, and socioeconomic status.

Design, Setting, and Participants

This repeated cross-sectional analysis used abortion surveillance data from January 1, 2007, to December 31, 2017, to estimate future effects of HB481 on abortion care in Georgia, with a focus on the 2 most recent years of data (2016 and 2017). Abortion surveillance data were obtained from the 2007-2017 Georgia Department of Public Health's Induced Termination of Pregnancy files. Linear regression was used to estimate trends in abortions provided at less than 6 weeks' gestation and at 6 weeks' gestation or later in Georgia, and χ2 analyses were used to compare group differences by race, age, and educational attainment. Data were analyzed from July 26 to September 22, 2022.

Exposures

HB481, Georgia's law limiting abortion to early pregnancy.

Main Outcome and Measures

Weeks' gestation at abortion (<6 vs ≥6 weeks).

Results

From January 1, 2007, to December 31, 2017, there were 360 972 reported abortions in Georgia, with an annual mean (SD) of 32 816 (1812) abortions. Estimates from 2016 to 2017 suggest that 3854 abortions in Georgia (11.6%) would likely meet eligibility requirements for abortion care under HB481. Fewer abortions obtained by Black patients (1943 [9.6%] vs 1280 [16.2%] for White patients), patients younger than 20 years (261 [9.1%] vs 168 [15.0%] for those 40 years and older), and patients with fewer years of education (392 [9.2%] with less than a high school diploma and 1065 [9.6%] with a high school diploma vs 2395 [13.5%] for those with some college) would likely meet eligibility requirements under HB481.

Conclusions and Relevance

These findings suggest that Georgia's law limiting abortion to early pregnancy (HB481) would eliminate access to abortion for nearly 90% of patients in Georgia, and disproportionately harm patients who are Black, younger, and in lower socioeconomic status groups.

Patient concerns about accessing sexual and reproductive health services outside of primary care: A survey in rural and urban settings in the Pacific Northwest

OBJECTIVES

While primary care providers are a major source of sexual and reproductive health (SRH) services in the United States, particularly in rural areas, not all primary care settings offer a full range of SRH services. We aimed to understand primary care patient concerns regarding accessing SRH services, including abortion care, outside of their primary care clinic and if those concerns differed by urban or rural setting.

STUDY DESIGN

An anonymous survey was distributed over a 2-week period between December 2019 to March 2020 to all adult patients in four primary care clinics in Idaho, Washington, and Wyoming. The survey assessed patient concerns regarding accessing SRH services outside of their primary care clinic and their willingness to travel to access SRH services.

RESULTS

The overall response rate was 69% (745/1086). Over 85% of respondents identified at least one concern to seeking SRH services outside of a primary care setting, with cost, insurance coverage, length of wait time, and lack of an established relationship being the most frequently reported concerns. A majority of respondents were willing to travel a maximum of 1 hour for most SRH services. Respondents from rural-serving clinics were significantly more likely to be willing to travel longer amounts of time for medication abortion, aspiration abortion, and intrauterine device placement.

CONCLUSION

Our findings highlight that a majority of both urban and rural primary care patients have concerns regarding accessing SRH services outside of their primary care clinic and are unwilling to travel more than 1 hour to access most SRH services.

IMPLICATIONS

A majority of primary care patients have concerns regarding accessing SRH services outside of primary care settings. Health care policy changes should aim to strengthen the SRH services available in primary care settings to alleviate the burdens primary care patients face in accessing SRH services outside of their primary care clinic, particularly for rural populations.

Impact of the Great East Japan Earthquake on spontaneous abortion and induced abortion: A population-based cross-sectional and longitudinal study in the Fukushima Prefecture based on the census survey of the Fukushima maternity care facility and vital statistics

AIM

The 2011 Great East Japan Earthquake (GEJE) was a disaster leading to radiation exposure and psychological distress, particularly among pregnant women. However, it is not known how this affected the seasonal changes of pregnancy and childbirth. Therefore, this study investigated the impact of the GEJE in the Fukushima Prefecture on spontaneous and induced abortions with regard to seasonal variability.

METHODS

We used the data of vital statistics of live birth and stillbirth registry and the census survey of the Fukushima Maternity Care Facility. We calculated the spontaneous and induced abortion rate for 2011-2016 using two different methods (cross-sectional and longitudinal). We calculated the quartiles and outliers to determine the impact and duration of the GEJE. Periodicity was investigated using spectral density analysis. The data were analyzed for the entire Fukushima Prefecture and by region.

RESULTS

The spontaneous abortion rate did not show specific changes after the GEJE. Contrarily, the monthly analysis in the cross-sectional method, revealed specific increases in induced abortion rate during the year after the GEJE; in the longitudinal method, induced abortions increased among women who became pregnant within 1 year after the GEJE. Spontaneous abortion showed no specific periodicity, while induced abortion showed cycles of 6 and 12 months, with a particular increase in May each year.

CONCLUSIONS

The spontaneous abortion rate was not affected by the GEJE. The changes in the induced abortion rate after the disaster may have overlapped with the timing of the increased periodicity, and cannot be attributed solely to the GEJE.

"We had to put ourselves in their shoes": Experiences of Medical Students and ObGyn Residents with a Values Clarification Workshop on Abortion

Purpose

Values clarification workshops on abortion have been shown to increase support for abortion among healthcare workers. However, few studies have examined the impact of values clarification workshops on abortion among medical trainees. This study aimed to understand medical student and obstetrics and gynecology (ObGyn) residents' experiences with a virtual values clarification workshop on abortion.

Methods

Clerkship year medical students and ObGyn residents at four midwestern teaching hospitals were invited to be interviewed about their experiences in a virtual values clarification workshop on abortion from January 2021 through December 2021. A single interviewer conducted interviews via Zoom using a standardized interview guide. Participants were asked to provide feedback and discuss their experiences in the workshop. Four qualitatively trained evaluators coded the interview transcripts in NVivo, using an inductive approach to establish consensus codes then themes.

Results

This study interviewed 37 trainees, including 24 medical students and 13 ObGyn residents, as well as five facilitators, between November 2021 and February 2022. Three themes emerged in both trainee groups. First, participants found the workshops helped trainees clarify and understand their own views on abortion through thought exploration, peer validation, and reflection on their views' potential societal impacts. Second, through the workshop, participants reflected on others' opinions on abortion and better understood the spectrum of beliefs their peers held. Finally, participants found the workshops helped them explore and develop their professional identity as physicians-in-training, through practicing communication skills and building trust and mutual respect among peers.

Conclusions

Medical trainees found values clarification workshops on abortion to be valuable, helping them establish their own beliefs about abortion, contextualize these beliefs among their peers', and practice professionalism. These findings indicate that values clarification workshops can play a key role in helping medical trainees discuss abortion and prepare for their professional future.

Abortion-client religious identity and self-judgment in a setting with antiabortion protestors in Mississippi

OBJECTIVE

To assess abortion patients' self-judgment in a setting with antiabortion protestors.

METHODS

We analyzed data from a survey of 196 Mississippi abortion clients who interacted with antiabortion protestors, using ANOVA to compare feelings of self-judgment (measured on a 0-to-4 Likert-based scale) by religious identity. We assessed support for a law limiting protestor activity using a Χ² test.

RESULTS

The mean self-judgment score was 1.1 among respondents with no religious identity (n = 43), 1.4 among religious, not evangelical respondents (n = 95), and 1.5 among evangelical respondents (n = 58, p = 0.23). Most respondents (79%) supported a lawlimiting protestor activity.

DISCUSSION

Overall, self-judgment was low and support for a law limiting protestor access was high.

Trauma of abortion restrictions and forced pregnancy: urgent implications for acute care surgeons

In the aftermath of the Supreme Court's Dobbs vs. Jackson Women's Health decision, acute care surgeons face an increased likelihood of seeing patients with complications from both self-managed abortions and forced pregnancy in underserved areas of reproductive and maternity care throughout the USA. Acute care surgeons have an ethical and legal duty to provide care to these patients, especially in obstetrics and gynecology deserts, which already exist in much of the country and are likely to be exacerbated by legislation banning abortion. Structural inequities lead to an over-representation of poor individuals and people of color among patients seeking abortion care, and it is imperative to make central the fact that people of color who can become pregnant will be disproportionately affected by this legislation in every respect. Acute care surgeons must take action to become aware of and trained to treat both the direct clinical complications and the extragestational consequences of reproductive injustice, while also using their collective voices to reaffirm the right to abortion as essential healthcare in the USA.

Texas Senate Bill 8 significantly reduced travel to abortion clinics in Texas

The Dobbs v. Jackson decision by the United States Supreme Court has rescinded the constitutional guarantee of abortion across the United States. As a result, at least 13 states have banned abortion access with unknown effects. Using "Texas" SB8 law that similarly restricted abortions in Texas, we provide insight into how individuals respond to these restrictions using aggregated and anonymized human mobility data. We find that "Texas" SB 8 law reduced mobility near abortion clinics in Texas by people who live in Texas and those who live outside the state. We also find that mobility from Texas to abortion clinics in other states increased, with notable increases in Missouri and Arkansas, two states that subsequently enacted post-Dobbs bans. These results highlight the importance of out-of-state abortion services for women living in highly restrictive states.

Ethical Care for Patients with Self-Managed Abortion After Roe

ABSTRACT

The 2022 Supreme Court decision leaving the regulation of abortion to the states is sure to result in a complex regulatory environment for patients and nurses. In states where abortion is illegal, patients may self-manage abortions using medications they obtain through the mail or by other means. Nurses may care for these patients in multiple settings and may wonder about their own legal and ethical obligations. This article reviews patient privacy as it relates to self-managed abortion, ethical reporting requirements for nurses, and best practices for treating complications of self-managed abortion using a harm reduction framework, with a focus on protecting patients' rights. Recommendations for ethical patient care are also provided.

Does overruling Roe discriminate against women (of colour)?

On 24 July 2022, the landmark decision Roe v. Wade (1973), that secured a right to abortion for decades, was overruled by the US Supreme Court. The Court decision in Dobbs v. Jackson Women's Health Organisation severely restricts access to legal abortion care in the USA, since it will give the states the power to ban abortion. It has been claimed that overruling Roe will have disproportionate impacts on women of color and that restricting access to abortion contributes to or amounts to structural racism. In this paper, we consider whether restricting abortion access as a consequence of overruling Roe could be understood as discrimination against women of color (and women in general). We argue that banning abortion is indirectly discriminatory against women of color and directly (but neither indirectly, nor structurally) discriminatory against women in general.

Intimacy, Anonymity, and "Care with Nothing in the Way" on an Abortion Hotline

This essay is an ethnographic account of a volunteer, anonymous hotline of physicians and advanced practice providers who offer medical advice and guidance to those who are taking medications on their own to end their pregnancies. Attending to the phenomenology of caring on the Hotline reveals a new form of medical expertise at play, which we call "care with nothing in the way." By operating outside the State's scrutiny of abortion provision, the Hotline offers its volunteers a way to practice abortion care that aligns with their professional and political commitments and that distances them from the direct harm they see caused by the political, financial, and bureaucratic constraints of their clinical work. By delineating the structure of this new regime of care, these providers call into question the notion of the "good doctor." They radically re-frame widely shared assumptions about the tenets of the ideal patient-doctor relationship and engender a new form of intimacy-one based, ironically, out of anonymity and not the familiarity that is often idealized in the caregiving relationship. We suggest the implications of "care with nothing in the way" are urgent, not only in the context of increasing hostility to abortion rights, but also for a culture of medicine plagued by physician burnout.

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.

Estimated Travel Time and Spatial Access to Abortion Facilities in the US Before and After the Dobbs v Jackson Women's Health Decision

IMPORTANCE

Abortion facility closures resulted in a substantial decrease in access to abortion care in the US.

OBJECTIVES

To investigate the changes in travel time to the nearest abortion facility after the Dobbs v Jackson Women's Health Organization (referred to hereafter as Dobbs) US Supreme Court decision.

DESIGN, SETTING, AND PARTICIPANTS

Repeated cross-sectional spatial analysis of travel time from each census tract in the contiguous US (n = 82 993) to the nearest abortion facility (n = 1134) listed in the Advancing New Standards in Reproductive Health database. Census tract boundaries and demographics were defined by the 2020 American Community Survey. The spatial analysis compared access during the pre-Dobbs period (January-December 2021) with the post-Dobbs period (September 2022) for the estimated 63 718 431 females aged 15 to 44 years (reproductive age for this analysis) in the US (excluding Alaska and Hawaii).

EXPOSURES

The Dobbs ruling and subsequent state laws restricting abortion procedures. The pre-Dobbs period measured abortion access to all facilities providing abortions in 2021. Post-Dobbs abortion access was measured by simulating the closure of all facilities in the 15 states with existing total or 6-week abortion bans in effect as of September 30, 2022.

MAIN OUTCOMES AND MEASURES

Median and mean changes in surface travel time (eg, car, public transportation) to an abortion facility in the post-Dobbs period compared with the pre-Dobbs period and the total percentage of females of reproductive age living more than 60 minutes from abortion facilities during the pre- and post-Dobbs periods.

RESULTS

Of 1134 abortion facilities in the US (at least 1 in every state; 8 in Alaska and Hawaii excluded), 749 were considered active during the pre-Dobbs period and 671 were considered active during a simulated post-Dobbs period. Median (IQR) and mean (SD) travel times to pre-Dobbs abortion facilities were estimated to be 10.9 (4.3-32.4) and 27.8 (42.0) minutes. Travel time to abortion facilities in the post-Dobbs period significantly increased (paired sample t test P <.001) to an estimated median (IQR) of 17.0 (4.9-124.5) minutes and a mean (SD) of and 100.4 (161.5) minutes. In the post-Dobbs period, an estimated 33.3% (sensitivity interval, 32.3%-34.8%) of females of reproductive age lived in a census tract more than 60 minutes from an abortion facility compared with 14.6.% (sensitivity interval, 13.0%-16.9%) of females of reproductive age in the pre-Dobbs period.

CONCLUSIONS AND RELEVANCE

In this repeated cross-sectional spatial analysis, estimated travel time to abortion facilities in the US was significantly greater in the post-Dobbs period after accounting for the closure of abortion facilities in states with total or 6-week abortion bans compared with the pre-Dobbs period, during which all facilities providing abortions in 2021 were considered active.

Making a third-trimester abortion referral: Learning from patients

OBJECTIVES

Research on abortion referral practices has focused on referral to first-trimester abortion care. Research has not examined whether and how these recommendations apply to referrals for abortion later in pregnancy.

METHODS

We conducted a secondary analysis of semi-structured interviews with thirty third-trimester abortion patients of their experiences of referral from prenatal and/or pre-third-trimester abortion care. We used thematic coding to identify referral-related actions participants desired or wished providers would avoid.

RESULTS

Participants reported needs in referral for information that third-trimester abortion was a possibility and about third-trimester providers and funding resources. Several also reported a need for emotional support from the prenatal or abortion care provider who denied them abortion care.

CONCLUSIONS

Many factors important for first-trimester abortion referral are important in third-trimester abortion referral, but the specifics of third-trimester care (namely the paucity of clinics, need for travel, and possibility of strong emotional attachment to the pregnancy) require additional practice actions.

PRACTICE IMPLICATIONS

Providers can support their patients in need of third-trimester abortion care by proactively providing: information that third-trimester abortion is available; information on third-trimester providers and funding support (e.g., an abortion referral hotline); and clear, non-judgmental emotional support.

Abortion as Essential Health Care and the Critical Role Your Practice Can Play in Protecting Abortion Access

Few obstetrician-gynecologists (ob-gyns) provide abortion care, resulting in abortion being separated from other reproductive health care. This segregation of services disrupts the ob-gyn patient-clinician relationship, generates needless costs, delays access to abortion care, and contributes to stigma. General ob-gyns have both the skills and the knowledge to incorporate abortion into their clinical practices. In this way, they can actively contribute to the protection of abortion access now with the loss of federal protection for abortion under Roe v Wade . For those who live where abortion remains legal, now is the time to start providing abortions and enhancing your abortion-referral process. For all, regardless of state legislation, ob-gyns must be leaders in advocacy by facilitating abortion care-across state lines, using telehealth, or with self-managed abortion-and avoiding any contribution to the criminalization of those who seek or obtain essential abortion care. Our patients deserve a specialty-wide concerted effort to deliver comprehensive reproductive health care to the fullest extent.

The Intersection of Abortion and Criminalization: Abortion Access for People in Prisons

Most incarcerated women are of reproductive age, and more than a third of women will have an abortion during their reproductive years. Although women are the fastest growing population in Canadian prisons, no one has studied the effect of their incarceration on access to abortion services. Studies outside of Canada indicate rates of abortion are higher among people experiencing incarceration than in the general population, and that abortion access is often problematic. Although international standards for abortion care among incarcerated populations exist, there conversely appear to be no Canadian guidelines or procedures to facilitate unintended pregnancy prevention or management. Barriers to abortion care inequitably restrict people with unintended pregnancy from attaining education and employment opportunities, cause entrenchment in violent relationships, and prevent people from choosing to parent when they are ready and able. Understanding and facilitating equitable access to abortion care for incarcerated people is critical to address structural, gender-, and race-based reproductive health inequities, and to promote reproductive justice. There is an urgent need for research in this area to direct best practices in clinical care and support policies capable to ensure equal access to abortion care for incarcerated people.

Post-abortion Complications: A Narrative Review for Emergency Clinicians

An abortion is a procedure defined by termination of pregnancy, most commonly performed in the first or second trimester. There are several means of classification, but the most important includes whether the abortion was maternally “safe” (performed in a safe, clean environment with experienced providers and no legal restrictions) or “unsafe” (performed with hazardous materials and techniques, by person without the needed skills, or in an environment where minimal medical standards are not met). Complication rates depend on the procedure type, gestational age, patient comorbidities, clinician experience, and most importantly, whether the abortion is safe or unsafe. Safe abortions have significantly lower complication rates compared to unsafe abortions. Complications include bleeding, retained products of conception, retained cervical dilator, uterine perforation, amniotic fluid embolism, misoprostol toxicity, and endometritis. Mortality rates for safe abortions are less than 0.2%, compared to unsafe abortion rates that range between 4.7-13.2%. History and physical examination are integral components in recognizing complications of safe and unsafe abortions, with management dependent upon the diagnosis. This narrative review provides a focused overview of post-abortion complications for emergency clinicians.