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Sariahmed K, Christine PJ, Wang J, Prifti C, Sabharwal M, LaRochelle M. Medication and procedural abortion uptake during a period of increasing abortion hostility. Soc Sci Med 2024; 356:117151. [PMID: 39068874 DOI: 10.1016/j.socscimed.2024.117151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 07/13/2024] [Accepted: 07/16/2024] [Indexed: 07/30/2024]
Abstract
Hundreds of state-level abortion restrictions were implemented in the US between 2010 and 2020. Medication abortion was being widely adopted during this same period. Understanding the impact of health policies and political climate will improve the delivery of and access to reproductive healthcare in a period of rapid change. To measure the association between state abortion hostility and mifepristone and procedural abortion rates, we conducted a state-level repeated cross-sectional study using 2010-2020 employer-sponsored insurance claims data from Merative MarketScan. The exposure of interest was a 13-point state-level abortion hostility score based on the presence of policies which either reduce or protect access to abortion. Outcomes of interest were annual mifepristone and procedural abortion claims per 100,000 enrollees. We used a linear mixed model adjusting for urbanicity, age group, and year. We assessed whether temporal trends in abortion claims were modified by state abortion hostility by interacting year with two measurements of abortion hostility: baseline score in 2010 and change from baseline score. We found that median state-level mifepristone claims increased from 20 to 37 per 100,000 included enrollees; meanwhile, median procedural abortions claims decreased from 69 to 20 per 100. For mifepristone, every unit increase in a state's baseline abortion hostility score was associated with 7.5 (CI, -12 to -3.6) fewer mifepristone claims per 100,000 in 2010. For states with baseline hostility and change scores of zero, we did not observe a significant time trend over the 11 year study period. For every unit increase in baseline hostility, the time trend changed by 0.5 fewer claims (CI, -0.8 to -0.2) per 100,000 per year. States with higher baseline abortion hostility had fewer overall abortions, less uptake of mifepristone abortions, and slower decline in procedural abortions between 2010 and 2020. Changes in hostility from new restrictions during this time period did not significantly impact claims. Advocates for abortion access must simultaneously attend to individual abortion policies and the overall political climate. Updated research on the relationship between political climate and the evolving clinical landscape of abortion care is needed to inform this work.
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Affiliation(s)
- Karim Sariahmed
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA.
| | - Paul J Christine
- Section of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, USA
| | - Jiayi Wang
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Christine Prifti
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Mallika Sabharwal
- Department of Family Medicine, Boston Medical Center, Boston, MA, USA
| | - Marc LaRochelle
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA
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Requena M, Stanek M. Differential rates of induced abortion in Spain: educational attainment and age among native and immigrant women. GACETA SANITARIA 2024; 38:102419. [PMID: 39128445 DOI: 10.1016/j.gaceta.2024.102419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/21/2024] [Accepted: 07/10/2024] [Indexed: 08/13/2024]
Abstract
OBJECTIVE Analyzing the variations in induced abortion (IA) rates across different subpopulations in Spain based on country of origin, while considering educational and age composition. METHOD Using 2021 Voluntary Termination of Pregnancy register and 2021 Spanish Census microdata, we calculated crude IA rates and age-specific abortion rates. We used age-standardized IA rates (ASIAR) to account for the confounding effect of age composition. We compared seven subpopulations residing in Spain, taking into account simple ages and educational levels aggregated into four categories. RESULTS Immigrant women, especially those from Sub-Saharan and Latin American countries, consistently had higher IA rates compared to native Spanish women. According to age-specific IA rates, university-educated women had considerably fewer abortions than women with other education levels at any age. Age-standardized rates stratified by migratory origin revealed that native Spanish women with primary education or less had higher IA rates than their immigrant counterparts. There was a clear non-linear, association between educational level and IA rates among immigrants. The highest propensity for IA was found among secondary school graduates, while university graduates had the lowest IA rate. CONCLUSIONS The study demonstrated that variability in sociodemographic characteristics had an impact on IA rates. Young women with middle educational attainment and immigrant background had a higher likelihood of undergoing IA in Spain. The relationship between educational level and IA rates was complex, with variations observed among different groups and changes over time.
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Affiliation(s)
- Miguel Requena
- Grupo de Estudios "Población y Sociedad", Departamento de Sociología II, Universidad Nacional de Educación a Distancia, Spain
| | - Mikolaj Stanek
- Departamento de Sociología y Comunicación, Universidad de Salamanca, Salamanca, Spain.
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Mackinnon Krems J, Grossman D, Ehrenreich K, Ralph L. Money and place: Quantifying the types of obstacles associated with seeking an abortion after 10 weeks' gestation, 2019-2020. Contraception 2024; 136:110476. [PMID: 38679274 DOI: 10.1016/j.contraception.2024.110476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 04/19/2024] [Accepted: 04/23/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVES Identify factors associated with presenting for abortion after 10 weeks' gestation in a large, geographically diverse sample. STUDY DESIGN From October 2019 to March 2020, we surveyed 1089 patients seeking abortion at seven U.S. facilities. We identified four domains of barriers: geographic, financial, logistical/personal, and legislative. Using multivariable logistic regression, we investigated the relationship between each domain and presenting for abortion after 10 weeks' gestation, overall and stratified by state policy landscape. RESULTS One-third of participants reported geographic (33.0%), financial (33.3%), and logistical/personal (31.4%) barriers; fewer (4.8%) reported legislative barriers. One-third (30.8%) traveled over 50 miles to the clinic. One-quarter (25.2%) presented after 10 weeks' gestation. In multivariable analyses, financial barriers (adjusted odds ratio [aOR] = 1.49, 95% confidence interval [CI] = 1.06-2.09), geographic barriers (aOR = 2.05, 95% CI = 1.44-2.90), and difficulty meeting basic expenses (aOR = 1.47, 95% CI = 1.15-1.89) were associated with presenting after 10 weeks' gestation across the seven clinics. Among participants accessing care at clinics in states with supportive abortion policies (n = 178), geographic barriers remained significantly associated with presenting after 10 weeks' gestation. CONCLUSIONS In a large, geographically diverse sample, financial and geographic barriers were associated with presenting after the threshold for medication abortion. In supportive states, the association with geographic barriers persisted. Cost and geographic barriers are increasing as more states restrict abortion post-Dobbs, highlighting the urgent need to expand financial and travel support. IMPLICATIONS People seeking abortion faced barriers before the Dobbs decision. Now, post-Dobbs, restrictions to abortion have only increased, making barriers to care even more threatening. Providing access to financial resources and transportation for people seeking abortion and expanding telehealth medication for abortion is now even more important.
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Affiliation(s)
- Jennifer Mackinnon Krems
- Joint Medical Program, University of California San Francisco and University of California Berkeley, San Francisco and Berkeley, CA, USA.
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health, Department of Obstetrics Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, CA, USA
| | - Katherine Ehrenreich
- Advancing New Standards in Reproductive Health, Department of Obstetrics Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, CA, USA
| | - Lauren Ralph
- Advancing New Standards in Reproductive Health, Department of Obstetrics Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, CA, USA
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Samples S, Gandhi R, Woo J, Patel A. Ethical Considerations in Fetal Cardiology. J Cardiovasc Dev Dis 2024; 11:172. [PMID: 38921672 PMCID: PMC11204861 DOI: 10.3390/jcdd11060172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 06/27/2024] Open
Abstract
Fetal cardiology has evolved over the last 40 years and changed the timing of diagnosis and counseling of congenital heart disease, decision-making, planning for treatment at birth, and predicting future surgery from the postnatal to the prenatal period. Ethical issues in fetal cardiology transect multiple aspects of biomedical ethics including improvement in prenatal detection and diagnostic capabilities, access to equitable comprehensive care that preserves a pregnant person's right to make decisions, access to all reproductive options, informed consent, complexity in shared decision-making, and appropriate use of fetal cardiac interventions. This paper first reviews the literature and then provides an ethical analysis of accurate and timely diagnosis, equitable delivery of care, prenatal counseling and shared decision-making, and innovation through in utero intervention.
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Affiliation(s)
- Stefani Samples
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Rupali Gandhi
- Division of Pediatric Cardiology, Advocate Christ Children’s Hospital, Oak Lawn, IL 60453, USA
- Section of Cardiology, Department of Pediatrics, Comer Children’s Hospital, University of Chicago, Chicago, IL 60637, USA
| | - Joyce Woo
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Angira Patel
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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Escobar VAP, Wyant WA, Debs LH, Jamshidi A, Kiehna EN, McCrea HJ. Evaluating the potential role of determinants of health on encephalocele patient outcomes - a combined retrospective study and systematic review. Childs Nerv Syst 2024; 40:1751-1763. [PMID: 38347306 DOI: 10.1007/s00381-024-06312-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 01/30/2024] [Indexed: 05/23/2024]
Abstract
INTRODUCTION To evaluate the outcomes and demographics of encephalocele patients who were born and received treatment in our neonatal ICU and conduct a PRISMA literature review. METHODS An Institutional Review Board (IRB)-approved retrospective cohort study was undertaken to investigate the results of treating encephalocele patients at Jackson Memorial Hospital (JMH) from 1998 to 2022. The study focused on assessing outcomes and the impact of maternal socioeconomic factors, such as religion, age, and education, along with the timing of diagnosis, in connection with a systematic review. RESULTS A total of 20 encephalocele patients were identified (13 females and 7 males), with 15 having available medical records for review. Most of these cases involved occipital encephaloceles (73.3%). Maternal ages at the time of delivery ranged from 15 to 42 years, with a mean age of 27.3 years. The average gestational age at birth was 37 weeks. Ten cases had a prenatal diagnosis documented, occurring between 12 and 24.5 weeks of gestation. Three of the surviving patients had records of prenatal counseling that included discussions about termination. No infections were reported. Among the 15 cases, 11 patients (73.3%) were alive at the last follow-up, with a mean age at follow-up of 4.12 years, ranging from 6 weeks to 15 years post-birth. Hydrocephalus was noted in 26.7%. Only 1 mother had completed high school. Most mothers were either on Medicaid (9 patients) or uninsured (3 patients), with only 3 having commercial insurance. Religious affiliations varied among the mothers, with 14 out of 15 identifying with a particular religion. The systematic review identified 22 articles from various countries, with 11 articles meeting the inclusion criteria for qualitative analysis. These articles revealed potential maternal risk factors for encephaloceles, including low-nutrient diets, inadequate folic acid intake, young maternal age, advanced maternal age, low socioeconomic status, and limited educational attainment. CONCLUSIONS In the twenty-first century, there is a positive trend in the survival rates of children born with encephalocele. However, maternal factors such as low socioeconomic status and limited educational attainment remain prominent, affecting their ability to access timely prenatal care and impacting follow-up medical care for these children.
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Affiliation(s)
- Victoria A Pinilla Escobar
- Department of Neurological Surgery, University of Miami Miller School of Medicine/Jackson Health System, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - W Austin Wyant
- Department of Neurological Surgery, University of Miami Miller School of Medicine/Jackson Health System, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - Luca H Debs
- Department of Neurological Surgery, Augusta University Medical Center, Augusta, GA, USA
| | - Aria Jamshidi
- Department of Neurological Surgery, University of Miami Miller School of Medicine/Jackson Health System, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - Erin N Kiehna
- Department of Neurological Surgery, Novant Health, Charlotte, NC, USA
| | - Heather J McCrea
- Department of Neurological Surgery, University of Miami Miller School of Medicine/Jackson Health System, 1095 NW 14th Terrace, Miami, FL, 33136, USA.
- Department of Pediatrics, University of Miami Miller School of Medicine/Jackson Health System, Miami, FL, USA.
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Preiksaitis C, Saxena M, Zhang J, Henkel A. Prevalence and Characteristics of Emergency Department Visits by Pregnant People: An Analysis of a National Emergency Department Sample (2010-2020). West J Emerg Med 2024; 25:436-443. [PMID: 38801052 PMCID: PMC11112670 DOI: 10.5811/westjem.60461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 10/05/2023] [Accepted: 01/09/2024] [Indexed: 05/29/2024] Open
Abstract
Introduction The number and characteristics of pregnant patients presenting to the emergency department (ED) has not been well described. Our objective in this study was to determine the prevalence and characteristics of pregnant patients presenting to EDs in the US between 2010-2020. Methods We completed a retrospective, cross-sectional study of patient encounters at hospital-based EDs in the US from 2010-2020. Using the ED subsample of the National Hospital Ambulatory Medical Care Survey (NHAMCS) we identified ED visits for female patients aged 15-44 years. We defined a subsample of these as visits for pregnant patients using discharge diagnosis codes specific to pregnancy. We compared this population of pregnant patient visits to those for non-pregnant patients and computed point estimates for nationally weighted values. Multivariable linear regression was used to determine factors independently associated with pregnant patient visits. Results The 2010-2020 NHAMCS dataset included 255,963 ED visits. Of these visits 59,080 were for female patients 15-44 years old, and 6,068 of those visits were for pregnant patients. Pregnant patients accounted for 3% (95% confidence interval [CI] 2.7-3.2) of all ED visits and 8.6% (95% CI 8-9.3) of all visits among female patients 15-44 years. Weighting to a national sample, this equates to 2.77 million pregnant patients presenting for ED visits annually. Pregnant patients were more likely to be Black, Hispanic, or to use public insurance. Conclusion Pregnant patients make up a significant number of ED visits annually and are more likely to be people of color or publicly insured. Interventions to address the effects of changing abortion legislation on emergency medicine practice may benefit from consideration that certain populations of pregnant people are more likely to present to the ED for care.
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Affiliation(s)
- Carl Preiksaitis
- Stanford University School of Medicine, Department of Emergency Medicine, Stanford, California
| | - Monica Saxena
- Stanford University School of Medicine, Department of Emergency Medicine, Stanford, California
| | - Jiaqi Zhang
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Stanford, California
| | - Andrea Henkel
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Stanford, California
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Riley T, Fiastro AE, Benson LS, Khattar A, Prager S, Godfrey EM. Abortion Provision and Delays to Care in a Clinic Network in Washington State After Dobbs. JAMA Netw Open 2024; 7:e2413847. [PMID: 38809551 PMCID: PMC11137636 DOI: 10.1001/jamanetworkopen.2024.13847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/24/2024] [Indexed: 05/30/2024] Open
Abstract
Importance The Supreme Court decision Dobbs v Jackson Women's Health Organization (Dobbs) overturned federal protections to abortion care and altered the reproductive health care landscape. Thus far, aggregated state-level data reveal increases in the number of abortions in states where abortion is still legal, but there is limited information on delays to care and changes in the characteristics of people accessing abortion in these states after Dobbs. Objective To examine changes in abortion provision and delays to care after Dobbs. Design, Setting, and Participants Retrospective cohort study of all abortions performed at an independent, high-volume reproductive health care clinic network in Washington state from January 1, 2017, to July 31, 2023. Using an interrupted time series, the study assessed changes in abortion care after Dobbs. Exposure Abortion care obtained after (June 24, 2022, to July 31, 2023) vs before (January 1, 2017, to June 23, 2022) Dobbs. Main Outcome and Measure Primary outcomes included weekly number of abortions and out-of-state patients and weekly average of gestational duration (days) and time to appointment (days). Results Among the 18 379 abortions during the study period, most were procedural (13 192 abortions [72%]) and funded by public insurance (11 412 abortions [62%]). The mean (SD) age of individuals receiving abortion care was 28.5 (6.44) years. Following Dobbs, the number of procedural abortions per week increased by 6.35 (95% CI, 2.83-9.86), but then trended back toward pre-Dobbs levels. The number of out-of-state patients per week increased by 2 (95% CI, 1.1-3.6) and trends remained stable. The average gestational duration per week increased by 6.9 (95% CI, 3.6-10.2) days following Dobbs, primarily due to increased gestations of procedural abortions. The average gestational duration among out-of-state patients did not change following Dobbs, but it did increase by 6 days for in-state patients (5.9; 95% CI, 3.2-8.6 days). There were no significant changes in time to appointment. Conclusions and Relevance These findings provide a detailed picture of changes in abortion provision and delays to care after Dobbs in a state bordering a total ban state. In this study, more people traveled from out of state to receive care and in-state patients sought care a week later in gestation. These findings can inform interventions and policies to improve access for all seeking abortion care.
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Affiliation(s)
- Taylor Riley
- Department of Epidemiology, University of Washington, Seattle
| | - Anna E. Fiastro
- Department of Family Medicine, University of Washington, Seattle
| | - Lyndsey S. Benson
- Department of Obstetrics and Gynecology, University of Washington, Seattle
| | | | - Sarah Prager
- Department of Obstetrics and Gynecology, University of Washington, Seattle
| | - Emily M. Godfrey
- Department of Family Medicine, University of Washington, Seattle
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McMahon HV, Serrano L, Vyavahare T, Hairston I, Ayala S, Jah Z, Hailstorks T, Diallo DD, Mosley EA. My Health in My Hands: Improving Medication Abortion Knowledge and Closing Disparities with a Community-Led Media Intervention. Health Equity 2024; 8:138-142. [PMID: 38435024 PMCID: PMC10908321 DOI: 10.1089/heq.2023.0210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 03/05/2024] Open
Abstract
Purpose Inaccurate beliefs about medication abortion (MA) are common. This study evaluated pilot data from a community-led media intervention designed to increase MA knowledge among Black and Latinx women in Georgia. Methods Participants (N=855) viewed the intervention video and completed pre-post surveys. Data were analyzed using linear and logistic regression. Results Knowledge scores significantly increased from 3.88/5.00 to 4.47/5.00. Participants who were Native American, Asian and Pacific Islander, multiracial, Black, <20 years old, and living in Georgia scored below the sample mean at baseline; however, nearly all disparities disappeared after intervention exposure. Conclusions This intervention effectively increased MA knowledge and narrowed racial/ethnic, age-based, and geographic disparities.
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Affiliation(s)
- Hayley V. McMahon
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- The Center for Reproductive Health Research in the Southeast (RISE), Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Leslie Serrano
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- The Center for Reproductive Health Research in the Southeast (RISE), Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | | | - Sequoia Ayala
- The Raben Group, Washington, District of Columbia, USA
| | - Zainab Jah
- National Birth Equity Collaborative, New Orleans, Louisiana, USA
| | - Tiffany Hailstorks
- The Center for Reproductive Health Research in the Southeast (RISE), Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Elizabeth A. Mosley
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- The Center for Reproductive Health Research in the Southeast (RISE), Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Center for Innovative Research on Gender Health Equity, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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McMahon HV, McMahon BD. Automating untruths: ChatGPT, self-managed medication abortion, and the threat of misinformation in a post- Roe world. Front Digit Health 2024; 6:1287186. [PMID: 38419805 PMCID: PMC10900507 DOI: 10.3389/fdgth.2024.1287186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/26/2024] [Indexed: 03/02/2024] Open
Abstract
Background ChatGPT is a generative artificial intelligence chatbot that uses natural language processing to understand and execute prompts in a human-like manner. While the chatbot has become popular as a source of information among the public, experts have expressed concerns about the number of false and misleading statements made by ChatGPT. Many people search online for information about self-managed medication abortion, which has become even more common following the overturning of Roe v. Wade. It is likely that ChatGPT is also being used as a source of this information; however, little is known about its accuracy. Objective To assess the accuracy of ChatGPT responses to common questions regarding self-managed abortion safety and the process of using abortion pills. Methods We prompted ChatGPT with 65 questions about self-managed medication abortion, which produced approximately 11,000 words of text. We qualitatively coded all data in MAXQDA and performed thematic analysis. Results ChatGPT responses correctly described clinician-managed medication abortion as both safe and effective. In contrast, self-managed medication abortion was inaccurately described as dangerous and associated with an increase in the risk of complications, which was attributed to the lack of clinician supervision. Conclusion ChatGPT repeatedly provided responses that overstated the risk of complications associated with self-managed medication abortion in ways that directly contradict the expansive body of evidence demonstrating that self-managed medication abortion is both safe and effective. The chatbot's tendency to perpetuate health misinformation and associated stigma regarding self-managed medication abortions poses a threat to public health and reproductive autonomy.
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Affiliation(s)
- Hayley V. McMahon
- Department of Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, GA, United States
- The Center forReproductive Health Research in the Southeast, Emory University Rollins School of Public Health, Atlanta, GA, United States
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Chen R, Gordon M, Chervenak F, Coverdale J. Addressing Moral Distress After Dobbs v. Jackson Women's Health Organization : A Professional Virtues-Based Approach. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2024; 99:12-15. [PMID: 37816216 DOI: 10.1097/acm.0000000000005476] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
ABSTRACT The June 2022 U.S. Supreme Court decision in Dobbs v. Jackson Women's Health Organization abolished federal protections for reproductive choice. In states where subsequent legislation has restricted or banned access to abortion services, physicians and trainees are prevented from providing ethically justified evidence-based care when patients with previable pregnancies are seeking an abortion. Pregnant patients' vulnerabilities, stress, and the undue burden that they experience when prevented from acting in accordance with their reproductive decision-making can evoke negative emotional consequences, including moral distress in clinicians. Moral distress occurs when clinicians feel a moral compulsion to act a certain way but cannot do so because of external constraints, including being hindered by state laws that curtail practicing in line with professional standards on reproductive health care. Moral distress has the potential to subvert prudent clinical judgment. The authors provide recommendations for managing moral distress in these circumstances based on the professional virtues. The fundamental professional virtues of integrity, compassion, self-effacement, self-sacrifice, and humility inform the management of moral distress and how to respond thoughtfully and compassionately, without over-identification or indifference to the plight of patients denied abortions. The authors also discuss the role of academic leaders and medical educators in cultivating a virtue-based professional culture at the forefront of clinical and educational processes in a post- Dobbs world.
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Kheyfets A, Dhaurali S, Feyock P, Khan F, Lockley A, Miller B, Cohen L, Anwar E, Amutah-Onukagha N. The impact of hostile abortion legislation on the United States maternal mortality crisis: a call for increased abortion education. Front Public Health 2023; 11:1291668. [PMID: 38115843 PMCID: PMC10728320 DOI: 10.3389/fpubh.2023.1291668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 11/15/2023] [Indexed: 12/21/2023] Open
Abstract
The growing restrictive abortion policies nationwide and the Supreme Court decision on Dobbs v. Jackson Women's Health Organization place increasing barriers to abortion access in the United States. These restrictions disproportionately affect low-income people of color, immigrants, and non-English speakers, and have the potential to exacerbate already existing racial inequities in maternal and neonatal outcomes. The United States is facing a Black maternal health crisis where Black birthing people are more than twice as likely to experience maternal mortality and severe maternal morbidity compared to White birthing people. Restrictions creating geographic, transportation, and financial barriers to obtaining an abortion can result in increased rates of maternal death and adverse outcomes across all groups but especially among Black birthing people. Restrictive abortion laws in certain states will decrease already limited training opportunities in abortion care for medical professionals, despite the existing abortion provider shortage. There is an immediate need for federal legislation codifying broad abortion care access into law and expanding access to abortion training across medical education. This commentary explores the impact of restrictive abortion laws on the Black maternal health crisis through multiple pathways in a logic model. By identifying current barriers to abortion education in medical school and residency, we created a list of action items to expand abortion education and access.
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Affiliation(s)
- Anna Kheyfets
- Tufts University School of Medicine, Boston, MA, United States
- Center for Black Maternal Health and Reproductive Justice, Tufts University School of Medicine, Boston, MA, United States
| | - Shubhecchha Dhaurali
- Center for Black Maternal Health and Reproductive Justice, Tufts University School of Medicine, Boston, MA, United States
| | - Paige Feyock
- Center for Black Maternal Health and Reproductive Justice, Tufts University School of Medicine, Boston, MA, United States
- University of Michigan School of Medicine, Ann Arbor, MI, United States
| | - Farinaz Khan
- Collective Energy for Nurturing Training in Reproductive and Sexual Health (CENTRS Health), Albuquerque, NM, United States
| | - April Lockley
- Collective Energy for Nurturing Training in Reproductive and Sexual Health (CENTRS Health), Albuquerque, NM, United States
| | - Brenna Miller
- Center for Black Maternal Health and Reproductive Justice, Tufts University School of Medicine, Boston, MA, United States
| | - Lauren Cohen
- Center for Black Maternal Health and Reproductive Justice, Tufts University School of Medicine, Boston, MA, United States
| | - Eimaan Anwar
- Center for Black Maternal Health and Reproductive Justice, Tufts University School of Medicine, Boston, MA, United States
| | - Ndidiamaka Amutah-Onukagha
- Tufts University School of Medicine, Boston, MA, United States
- Center for Black Maternal Health and Reproductive Justice, Tufts University School of Medicine, Boston, MA, United States
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Kortsmit K, Nguyen AT, Mandel MG, Hollier LM, Ramer S, Rodenhizer J, Whiteman MK. Abortion Surveillance - United States, 2021. MORBIDITY AND MORTALITY WEEKLY REPORT. SURVEILLANCE SUMMARIES (WASHINGTON, D.C. : 2002) 2023; 72:1-29. [PMID: 37992038 PMCID: PMC10684357 DOI: 10.15585/mmwr.ss7209a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
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.
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Hwang CS, Kesselheim AS, Sarpatwari A, Huybrechts KF, Brill G, Rome BN. Changes in Induced Medical and Procedural Abortion Rates in a Commercially Insured Population, 2018 to 2022 : An Interrupted Time-Series Analysis. Ann Intern Med 2023; 176:1508-1515. [PMID: 37871317 DOI: 10.7326/m23-1609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023] Open
Abstract
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.
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Affiliation(s)
- Catherine S Hwang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (C.S.H., A.S.K., A.S., K.F.H., G.B., B.N.R.)
| | - Aaron S Kesselheim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (C.S.H., A.S.K., A.S., K.F.H., G.B., B.N.R.)
| | - Ameet Sarpatwari
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (C.S.H., A.S.K., A.S., K.F.H., G.B., B.N.R.)
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (C.S.H., A.S.K., A.S., K.F.H., G.B., B.N.R.)
| | - Gregory Brill
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (C.S.H., A.S.K., A.S., K.F.H., G.B., B.N.R.)
| | - Benjamin N Rome
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (C.S.H., A.S.K., A.S., K.F.H., G.B., B.N.R.)
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Smith MH, Broscoe M, Chakraborty P, Hill J, Hood R, McGowan M, Bessett D, Norris AH. COVID-19 and abortion in the Ohio River Valley: A case study of Kentucky, Ohio, and West Virginia. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2023; 55:178-191. [PMID: 37571959 DOI: 10.1363/psrh.12244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Abstract
INTRODUCTION During early stages of COVID-19 in the United States, government representatives in Kentucky, Ohio, and West Virginia restricted or threatened to restrict abortion care under elective surgery bans. We examined how abortion utilization changed in these states. METHODOLOGY We examined COVID-19 abortion-related state policies implemented in March and April 2020 using publicly available sources. We analyzed data on abortions by method and gestation and experiences of facility staff, using a survey of 14 facilities. We assessed abortions that took place in February-June 2020 and February-June 2021. RESULTS In February-June 2020 the monthly average abortion count was 1916; 863 (45%) were medication abortions and 229 (12%) were ≥14 weeks gestation. Of 1959 abortions performed across all three states in April 2020, 1319 (67%) were medication abortions and 231 (12%) were ≥14 weeks gestation. The shift toward medication abortion that took place in April 2020 was not observed in April 2021. Although the total abortion count in the three-state region remained steady, West Virginia had the greatest decline in total abortions, Ohio experienced a shift from instrumentation to medication abortions, and Kentucky saw little change. Staff reported increased stress from concerns over health and safety and increased scrutiny by the state and anti-abortion protesters. DISCUSSION Although abortion provision continued in this region, policy changes restricting abortion in Ohio and West Virginia resulted in a decrease in first trimester instrumentation abortions, an overall shift toward medication abortion care, and an increase in stress among facility staff during the early phase of COVID-19.
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Affiliation(s)
- Mikaela H Smith
- Division of Epidemiology, College of Public Health, Ohio State University, Columbus, Ohio, USA
| | - Molly Broscoe
- Department of Sociology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Payal Chakraborty
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jessie Hill
- Case Western Reserve University School of Law, Cleveland, Ohio, USA
| | - Robert Hood
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Michelle McGowan
- Biomedical Ethics Research Program, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
- Department of Women's, Gender & Sexuality Studies, University of Cincinnati, Cincinnati, Ohio, USA
| | - Danielle Bessett
- Department of Sociology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alison H Norris
- Division of Epidemiology, College of Public Health, Ohio State University, Columbus, Ohio, USA
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Hartwig SA, Youm A, Contreras A, Mosley EA, McCloud C, Goedken P, Carroll E, Lathrop E, Cwiak C, Hall KS. "The right thing to do would be to provide care… and we can't": Provider experiences with Georgia's 22-week abortion ban. Contraception 2023; 124:110059. [PMID: 37160176 DOI: 10.1016/j.contraception.2023.110059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVES In 2015, the Georgia (US) legislature implemented a gestational limit, or "ban" on abortion at or beyond 22 weeks from the last menstrual period. In this study, we qualitatively examined abortion provider perspectives on the ban's impact on abortion care access and provision. STUDY DESIGN Between May 2018 and September 2019, we conducted in-depth individual interviews with 20 abortion providers (clinicians, staff, and administrators) from four clinics in Georgia. Interviews explored perceptions of and experiences with the ban and its effects on abortion care. Team members coded transcripts to 100% agreement using an iterative, group consensus process, and conducted a thematic analysis. RESULTS Participants reported strict adherence to the ban and also its negative consequences: additional labor plus service-delivery restrictions, legally constructed risks for providers, intrusion into the provider-patient relationship, and impact of limited services felt by patients and, thus, providers. Participants commonly mentioned disparities in the ban's impact and viewed the ban as disproportionately affecting people of color, those experiencing financial insecurity, and those with underlying medical conditions. Nonetheless, participants described a clear, unrelenting commitment to providing quality patient-centered care and dedication to and satisfaction in their work. CONCLUSIONS Georgia's ban operates as legislative interference, adversely affecting the provision of quality, patient-centered abortion care, despite providers' resilience and commitment. These experiences in Georgia have timely and clear implications for the entire country following the Supreme Court's decision to overturn Roe v Wade, thus reducing care access and increasing negative health and social consequences and inequities for patients and communities on a national scale. IMPLICATIONS Our findings from Georgia (US) indicate an urgent need for coordinated efforts to challenge the Dobbs v Jackson Women's Health Organization decision and for proactive policies that protect access to later abortion care. Research that identifies strategies for supporting providers and patients faced with continuing restrictive legal environments is warranted.
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Affiliation(s)
- Sophie A Hartwig
- Center for Reproductive Health Research in the Southeast (RISE), Atlanta, GA, USA; Emory University, Rollins School of Public Health, Atlanta, GA, USA.
| | - Awa Youm
- Center for Reproductive Health Research in the Southeast (RISE), Atlanta, GA, USA; Emory University, Rollins School of Public Health, Atlanta, GA, USA
| | - Alyssa Contreras
- Center for Reproductive Health Research in the Southeast (RISE), Atlanta, GA, USA; Emory University, Rollins School of Public Health, Atlanta, GA, USA
| | - Elizabeth A Mosley
- Center for Reproductive Health Research in the Southeast (RISE), Atlanta, GA, USA; Emory University, Rollins School of Public Health, Atlanta, GA, USA
| | - Candace McCloud
- Center for Reproductive Health Research in the Southeast (RISE), Atlanta, GA, USA; Emory University, Rollins School of Public Health, Atlanta, GA, USA
| | - Peggy Goedken
- Emory University, School of Medicine, Department of Gynecology and Obstetrics, Atlanta, GA, USA
| | - Erin Carroll
- Center for Reproductive Health Research in the Southeast (RISE), Atlanta, GA, USA; University of Alabama at Birmingham, Department of Health Care Organization and Policy, Birmingham, AL, USA
| | - Eva Lathrop
- Center for Reproductive Health Research in the Southeast (RISE), Atlanta, GA, USA; Emory University, Rollins School of Public Health, Atlanta, GA, USA; Emory University, School of Medicine, Department of Gynecology and Obstetrics, Atlanta, GA, USA
| | - Carrie Cwiak
- Center for Reproductive Health Research in the Southeast (RISE), Atlanta, GA, USA; Emory University, Rollins School of Public Health, Atlanta, GA, USA; Emory University, School of Medicine, Department of Gynecology and Obstetrics, Atlanta, GA, USA
| | - Kelli Stidham Hall
- Center for Reproductive Health Research in the Southeast (RISE), Atlanta, GA, USA; Emory University, Rollins School of Public Health, Atlanta, GA, USA; Emory University, School of Medicine, Department of Gynecology and Obstetrics, Atlanta, GA, USA
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Weitz TA, O'Donnell J. The Challenges in Measurement for Abortion Access and Use in Research Post-Dobbs. Womens Health Issues 2023:S1049-3867(23)00101-9. [PMID: 37225646 DOI: 10.1016/j.whi.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/26/2023]
Affiliation(s)
- Tracy A Weitz
- Department of Sociology and Center on Health, Risk, and Society, American University, Washington, DC.
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Zhu Y, Bateman BT, Hernandez-Diaz S, Gray KJ, Straub L, Reimers RM, Manning-Geist B, Yoselevsky E, Taylor LG, Ouellet-Hellstrom R, Ma Y, Qiang Y, Hua W, Huybrechts KF. Validation of claims-based algorithms to identify non-live birth outcomes. Pharmacoepidemiol Drug Saf 2023; 32:468-474. [PMID: 36420643 PMCID: PMC10906136 DOI: 10.1002/pds.5574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Perinatal epidemiology studies using healthcare utilization databases are often restricted to live births, largely due to the lack of established algorithms to identify non-live births. The study objective was to develop and validate claims-based algorithms for the ascertainment of non-live births. METHODS Using the Mass General Brigham Research Patient Data Registry 2000-2014, we assembled a cohort of women enrolled in Medicaid with a non-live birth. Based on ≥1 inpatient or ≥2 outpatient diagnosis/procedure codes, we identified and randomly sampled 100 potential stillbirth, spontaneous abortion, and termination cases each. For the secondary definitions, we excluded cases with codes for other pregnancy outcomes within ±5 days of the outcome of interest and relaxed the definitions for spontaneous abortion and termination by allowing cases with one outpatient diagnosis only. Cases were adjudicated based on medical chart review. We estimated the positive predictive value (PPV) for each outcome. RESULTS The PPV was 71.0% (95% CI, 61.1-79.6) for stillbirth; 79.0% (69.7-86.5) for spontaneous abortion, and 93.0% (86.1-97.1) for termination. When excluding cases with adjacent codes for other pregnancy outcomes and further relaxing the definition, the PPV increased to 80.6% (69.5-88.9) for stillbirth, 86.6% (80.5-91.3) for spontaneous abortion and 94.9% (91.1-97.4) for termination. The PPV for the composite outcome using the relaxed definition was 94.4% (92.3-96.1). CONCLUSIONS Our findings suggest non-live birth outcomes can be identified in a valid manner in epidemiological studies based on healthcare utilization databases.
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Affiliation(s)
- Yanmin Zhu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Brian T. Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kathryn J. Gray
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Loreen Straub
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca M. Reimers
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Beryl Manning-Geist
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth Yoselevsky
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lockwood G. Taylor
- Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rita Ouellet-Hellstrom
- Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Yong Ma
- Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Yandong Qiang
- Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Wei Hua
- Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - Krista F. Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Aguilar GA, Lundsberg LS, Stanwood NL, Gariepy AM. Exploratory study of race- or ethnicity-based discrimination among patients receiving procedural abortion care. Contraception 2023; 120:109949. [PMID: 36641096 DOI: 10.1016/j.contraception.2023.109949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Explore relationships of race and ethnicity with experiences of race- or ethnicity-based discrimination during abortion care. STUDY DESIGN English- or Spanish-speaking individuals aged 18 to 50 completed cross-sectional, self-administered online surveys within 30 days of procedural abortion at 5 Northeastern U.S. reproductive health clinics from June 2020 toFebruary 2021. We considered any affirmative response on the Discrimination in Medical Settings (DMS) scale evidence of race- or ethnicity-based discrimination. We performed bivariate analyses and logistic regression examining discrimination among Black non-Latinx, Latinx any race, Other race non-Latinx compared to White non-Latinx participants. We assessed associations between discrimination and healthcare quality and satisfaction. RESULTS Participants (n = 163) averaged 27(±6) years and self-identified as Black non-Latinx (36.2%), White non-Latinx (28.8%), Latinx of any race (27.0%), and Other non-Latinx (8.0%). Most were publicly insured (52.8%) and <14 weeks gestation (90.8%).Overall, 15.3% reported race- or ethnicity-based discrimination during abortion care with Black non-Latinx more likely to report discrimination (23.7%; OR 7.00, 95% CI 1.50-32.59), while Latinx any race (15.9%, OR 4.26, 95% CI 0.83-21.74) and Other race non-Latinx participants (15.4%, OR 4.09, 95% CI 0.52-32.35) demonstrated statistically nonsignificant trend toward increased odds of discrimination compared to White non-Latinx (4.3%). Discrimination was associated with negative perceptions of: time with physician (p = 0.03), patient care involvement (p < 0.05), physician communication (p = 0.01), care quality (p = 0.02), and care satisfaction (p < 0.01). CONCLUSION Racially minoritized participants were more likely to report race- or ethnicity-based discrimination during abortion care; Black non-Latinx reported highest odds of discrimination compared to White non-Latinx. Discrimination was associated with unfavorable healthcare quality measures. IMPLICATIONS Race- or ethnicity-based discrimination during abortion care is disproportionately reported by racially minoritized populations, especially Black individuals, compared to White non-Latinx individuals. Discrimination is significantly associated with negative experiences of care. Future work should verify findings in different regions and larger studies, and design and test discrimination-reduction interventions.
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Affiliation(s)
- Gabriela A Aguilar
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, United States.
| | - Lisbet S Lundsberg
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, United States
| | - Nancy L Stanwood
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, United States
| | - Aileen M Gariepy
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, United States
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Kimport K, Rasidjan MP. Exploring the emotional costs of abortion travel in the United States due to legal restriction. Contraception 2023; 120:109956. [PMID: 36634729 DOI: 10.1016/j.contraception.2023.109956] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Pregnant people have traveled across state and national borders for the purpose of abortion since at least the 1960s. Scholarship has robustly documented the financial and logistical costs associated with travel, but less work has examined the emotional costs of abortion travel. We investigate whether abortion travel has emotional costs and, if so, how they come about. STUDY DESIGN We conducted in-depth interviews with 30 women who had to travel across state borders in the United States for abortion care because of their gestation. We analyzed findings thematically. RESULTS Interviewees described having to travel to obtain abortion care as emotionally burdensome, causing distress, stress, anxiety, and shame. Because they had to travel, they were compelled to disclose their abortion to others and obtain care in an unfamiliar place and away from usual networks of support, which engendered emotional costs. Additionally, travel induced feelings of shame and exclusion because it stemmed from a law-based denial of in-state abortion care, which some experienced as marking them as deviant or abnormal. CONCLUSIONS People who have to travel for abortion care experience emotional costs alongside financial and logistical costs. The circumstances of that travel-specifically, being forced to travel because of legal restriction and service unavailability-are foundational to the ensuing emotional burdens. Findings add to the emerging literature on how laws and other structures produce the stigmatization of abortion at interpersonal and individual levels. IMPLICATIONS With abortion bans following the overturning of the right to abortion and existing gestational limits in the US, more people will have to travel for abortion care. Attention to the emotional costs of abortion travel can help providers understand what their patients may be experiencing when they present for care.
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Affiliation(s)
- Katrina Kimport
- Advancing New Standards in Reproductive Health, University of California, San Francisco, Oakland, CA, United States.
| | - Maryani Palupy Rasidjan
- Advancing New Standards in Reproductive Health, University of California, San Francisco, Oakland, CA, United States
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Lands M, Carpenter E, Valley T, Jacques L, Higgins J. "Am I the Only One Who Feels Like This?": Needs Expressed Online by Abortion Seekers. SOCIAL WORK 2023; 68:103-111. [PMID: 36795036 PMCID: PMC10074479 DOI: 10.1093/sw/swad011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/13/2022] [Accepted: 05/12/2022] [Indexed: 06/18/2023]
Abstract
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.
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Affiliation(s)
- Madison Lands
- MSW, MPH, is research program manager, Collaborative for Reproductive Equity, Department of Obstetrics and Gynecology, University of Wisconsin-Madison, 1010 Mound Street, Madison, WI 75371, USA
| | - Emma Carpenter
- PhD, MSW, is postdoctoral fellow, Population Research Center, University of Texas at Austin, Austin, TX, USA
| | - Taryn Valley
- MA, is an MD-PhD student, Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Laura Jacques
- MD, is assistant professor, Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Jenny Higgins
- PhD, MPH, is professor, Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
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Bergman ME, Gaskins VA, Allen T, Cheung HK, Hebl M, King EB, Sinclair RR, Siuta RL, Wolfe C, Zelin AI. The Dobbs Decision and the Future of Occupational Health in the US. OCCUPATIONAL HEALTH SCIENCE 2023; 7:1-37. [PMID: 36843836 PMCID: PMC9940085 DOI: 10.1007/s41542-023-00143-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/30/2022] [Accepted: 01/02/2023] [Indexed: 02/25/2023]
Abstract
Access to abortion care has a profound impact on women's ability to participate in the workforce. In the US, restrictions on abortion care have waxed and waned over the years, including periods when abortion was broadly permitted across the nation for most pregnant people for a substantial proportion of pregnancy and times when restrictions varied across states, including states where abortion is banned for nearly all reasons. Additionally, access to abortion care has always been a reproductive justice issue, with some people more able to access this care than others even when it is structurally available. In June 2022, the US Supreme Court handed down the Dobbs v. Jackson Women's Health Organization, returning to states the ability to determine restrictions on abortion, including near-total bans on abortion. In this anthology, ten experts share their perspectives on what the Dobbs decision means for the future, how it will exacerbate existing, well-researched issues, and likely also create new challenges needing investigation. Some contributions are focused on research directions, some focus on implications for organizations, and most include both. All contributions share relevant occupational health literature and describe the effects of the Dobbs decision in context.
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Smith MH, McGowan M, Chakraborty P, Hood RB, Field MP, Bessett D, Norwood C, Norris AH. Kentucky's abortion landscape, 2010 to 2019: an analysis of pre- Dobbs abortion disparities in a rural, restrictive state. LANCET REGIONAL HEALTH. AMERICAS 2023; 19:100441. [PMID: 36852333 PMCID: PMC9958464 DOI: 10.1016/j.lana.2023.100441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 01/13/2023] [Accepted: 01/19/2023] [Indexed: 02/17/2023]
Abstract
Background Since 2010, many US states have passed laws restricting abortion providers' ability to provide care. Such legislation has no demonstrated health benefits and creates inequitable barriers for patients. Methods To examine how Kentucky's abortion policies coincided with facility closures and abortion utilisation, we conducted a review of state abortion policies from 2010 to 2019 using newspapers and websites. We calculated abortion rates (abortions per 1000 women ages 15-44) by state of residence and provision for Kentucky, the South, and the US using data from the CDC and Kentucky Department of Health. We calculated percentages leaving and from out-of-state, and analysed abortions by race, pregnancy duration, and method. Findings Of 17 policies passed between 2010 and 2019, ten were enacted, including 20-week and telemedicine bans. One of Kentucky's two abortion facilities closed in 2017. The pooled average abortion rate in Kentucky (4.1) and for Kentuckians (5.8) was lower than national averages (11.8 and 11.1). An average of 38% of Kentuckians left their state for care, compared to 7% nationally. In 2019, the abortion rate in Kentucky was 5.8 times higher for Black patients than White patients (compared to 4.8 times nationally). The majority (62%) of abortions in Kentucky took place at 7-13 weeks' gestation. Interpretation Abortions in Kentucky were less frequent than in the South and US. The larger Black-White abortion rate gap reflects race- and class-based structural inequities in healthcare. Without federal protections, abortion access in Kentucky will continue waning. Funding This study was supported by a philanthropic foundation that makes grants anonymously.
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Affiliation(s)
- Mikaela H. Smith
- Division of Epidemiology, The Ohio State University, College of Public Health, Columbus, OH, USA,Corresponding author.
| | - Michelle McGowan
- Biomedical Ethics Research Program, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA,Department of Women's, Gender & Sexuality Studies, University of Cincinnati, Cincinnati, OH, USA
| | - Payal Chakraborty
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Robert B. Hood
- Department of Epidemiology, Emory University, Rollins School of Public Health, Atlanta, GA, USA
| | | | - Danielle Bessett
- Department of Sociology, University of Cincinnati, Cincinnati, OH, USA
| | - Carolette Norwood
- Department of Sociology and Criminology, Howard University, Washington, DC, USA
| | - Alison H. Norris
- Division of Epidemiology, The Ohio State University, College of Public Health, Columbus, OH, USA
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Congy J, Bouyer J, de La Rochebrochard E. Low-income women and use of prescribed contraceptives in the context of full health insurance coverage in France, 2019. Contraception 2023; 121:109976. [PMID: 36758736 DOI: 10.1016/j.contraception.2023.109976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/23/2023] [Accepted: 01/30/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVE Major socioeconomic differences in contraceptive use are observed in high-income countries. Cost is often cited as a main factor to explain these differences but other barriers may also exist. Our aim was to compare prescribed contraceptive use among low-income and non-low-income women in a national context of full health insurance coverage. STUDY DESIGN In the French national health insurance database, we selected all women (14.8 million) aged 15-49 years living in France in 2019. We compared the prevalence of use of each prescribed contraceptive between low-income and non-low-income women: oral contraceptives, copper intrauterine devices (IUDs), the levonorgestrel intrauterine system (LNG-IUS), and implants. RESULTS In the study population, 11% had a low income. Fewer low-income women used prescribed contraceptives than non-low-income women (36% vs. 46%, p < 0.001). When using a contraceptive, low-income women used a different method: at 20-24 years old, they used less oral contraceptives (60% vs. 77%, p < 0.001) and more implants (22% vs. 9%, p < 0.001), while at 40-44 years, they used less levonorgestrel intrauterine systems (18% vs. 30%, p < 0.001). CONCLUSIONS Even in a national context of free access to medical care for low-income women, they use less and different prescribed contraceptives than non-low-income women. These results could reflect barriers other than financial cost to the use of prescribed contraceptives by low-income women. IMPLICATIONS Financial barriers need to be removed in order to increase contraceptive use. However, this may not be sufficient and further research should explore barriers that low-income women may encounter in accessing and choosing their contraception.
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Affiliation(s)
- Juliette Congy
- Institut National d'Etudes Démographiques, Ined, Sexual and Reproductive Health and Rights Unit - UR14, 9 cours des Humanités, Aubervilliers, France.
| | - Jean Bouyer
- Institut National d'Etudes Démographiques, Ined, Sexual and Reproductive Health and Rights Unit - UR14, 9 cours des Humanités, Aubervilliers, France; Université Paris-Saclay, UVSQ, Inserm, CESP, 16 avenue Paul Vaillant Couturier, Villejuif, France
| | - Elise de La Rochebrochard
- Institut National d'Etudes Démographiques, Ined, Sexual and Reproductive Health and Rights Unit - UR14, 9 cours des Humanités, Aubervilliers, France; Université Paris-Saclay, UVSQ, Inserm, CESP, 16 avenue Paul Vaillant Couturier, Villejuif, France
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24
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Carpenter E, Gyuras H, Burke KL, Czarnecki D, Bessett D, McGowan M, White K. Seeking abortion care in Ohio and Texas during the COVID-19 pandemic. Contraception 2023; 118:109896. [PMID: 36240904 PMCID: PMC9554324 DOI: 10.1016/j.contraception.2022.09.134] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/27/2022] [Accepted: 09/30/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Political and public health responses to the COVID-19 pandemic changed provision of abortion care and exacerbated existing barriers. We aimed to explore experiences of individuals seeking abortion care in 2 abortion-restrictive states in the United States where state policies and practice changes disrupted abortion provision during the pandemic. STUDY DESIGN We conducted 22 semistructured interviews in Texas (n = 10) and Ohio (n = 12) to assess how state executive orders limiting abortion, along with other public health guidance and pandemic-related service delivery changes, affected individuals seeking abortion care. We included individuals 18 years and older who contacted a facility for abortion care between March and November 2020. We coded and analyzed interview transcripts using both inductive and deductive approaches. RESULTS Participants reported obstacles to obtaining their preferred timing and method of abortion. These obstacles placed greater demands on those seeking abortion and resulted in delays in obtaining care for as long as 11 weeks, as well as some being unable to obtain an abortion at all. CONCLUSIONS Political and public health responses to the COVID-19 pandemic - exacerbated pre-pandemic barriers and existing restrictions and constrained options for people seeking abortion in Ohio and Texas. Delays were consequential for all participants, regardless of their ultimate ability to obtain an abortion. IMPLICATIONS During the COVID-19 pandemic, state executive orders and clinic practices exacerbated already constrained access to care. Findings highlight the importance of protecting timely care and the full range of abortion methods. Findings also preview barriers individuals seeking abortion may encounter in states that restrict or ban abortion.
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Affiliation(s)
- Emma Carpenter
- Texas Policy Evaluation Project, University of Texas-Austin, Austin, TX, United States; Population Research Center, University of Texas at Austin, Austin, TX, United States; Department of Women's, Gender & Sexuality Studies, University of Cincinnati, Cincinnati, OH, United States.
| | - Hillary Gyuras
- Department of Women's, Gender & Sexuality Studies, University of Cincinnati, Cincinnati, OH, United States; Ohio Policy Evaluation Network, University of Cincinnati, The Ohio State University, Columbus, Cincinnati OH, United States; College of Public Health, The Ohio State University, Columbus, OH, United States
| | - Kristen L Burke
- Texas Policy Evaluation Project, University of Texas-Austin, Austin, TX, United States; Population Research Center, University of Texas at Austin, Austin, TX, United States; Department of Women's, Gender & Sexuality Studies, University of Cincinnati, Cincinnati, OH, United States
| | - Danielle Czarnecki
- Department of Women's, Gender & Sexuality Studies, University of Cincinnati, Cincinnati, OH, United States; Ohio Policy Evaluation Network, University of Cincinnati, The Ohio State University, Columbus, Cincinnati OH, United States; Department of Sociology, University of Cincinnati, Cincinnati, OH, United States
| | - Danielle Bessett
- Department of Women's, Gender & Sexuality Studies, University of Cincinnati, Cincinnati, OH, United States; Ohio Policy Evaluation Network, University of Cincinnati, The Ohio State University, Columbus, Cincinnati OH, United States; Department of Sociology, University of Cincinnati, Cincinnati, OH, United States
| | - Michelle McGowan
- Department of Women's, Gender & Sexuality Studies, University of Cincinnati, Cincinnati, OH, United States; Ohio Policy Evaluation Network, University of Cincinnati, The Ohio State University, Columbus, Cincinnati OH, United States; Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States; Ethics Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Kari White
- Texas Policy Evaluation Project, University of Texas-Austin, Austin, TX, United States; Population Research Center, University of Texas at Austin, Austin, TX, United States; Department of Women's, Gender & Sexuality Studies, University of Cincinnati, Cincinnati, OH, United States; Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX, United States
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Rizzolo K, Faucett A, Kendrick J. Implications of Antiabortion Laws on Patients with Kidney Disease in Pregnancy. Clin J Am Soc Nephrol 2023; 18:276-278. [PMID: 36754012 PMCID: PMC10103201 DOI: 10.2215/cjn.0000000000000027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
- Katherine Rizzolo
- Department of Renal Medicine and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Allison Faucett
- Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jessica Kendrick
- Department of Renal Medicine and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Samuels-Kalow ME, Agrawal P, Rodriguez G, Zeidan A, Love JS, Monette D, Lin M, Cooper RJ, Madsen TE, Dobiesz V. Post-Roe emergency medicine: Policy, clinical, training, and individual implications for emergency clinicians. Acad Emerg Med 2022; 29:1414-1421. [PMID: 36268814 PMCID: PMC9772035 DOI: 10.1111/acem.14609] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/27/2022] [Accepted: 10/18/2022] [Indexed: 12/24/2022]
Abstract
In June 2022, the United States Supreme Court decision Dobbs v. Jackson Women's Health Organization overturned Roe v. Wade, removing almost 50 years of precedent and enabling the imposition of a wide range of state-level restrictions on abortion access. Historical data from the United States and internationally demonstrate that the removal of safe abortion options will increase complications and the health risks to pregnant patients. Because the emergency department is a critical access point for reproductive health care, emergency clinicians must be prepared for the policy, clinical, educational, and legal implications of this change. The goal of this paper, therefore, is to describe the impact of the reversal of Roe v. Wade on health equity and reproductive justice, the provision of emergency care education and training, and the specific legal and reproductive consequences for emergency clinicians. Finally, we conclude with specific recommended policy and advocacy responses for emergency medicine clinicians.
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Affiliation(s)
- Margaret E Samuels-Kalow
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pooja Agrawal
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Giovanni Rodriguez
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amy Zeidan
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jennifer S Love
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Derek Monette
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle Lin
- Department of Emergency Medicine, Stanford University, Palo Alto, California, USA
| | - Richelle J Cooper
- Department of Emergency Medicine, University of California Los Angeles, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Tracy E Madsen
- Department of Emergency Medicine, Alpert Medial School of Brown University, Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Valerie Dobiesz
- Department of Emergency Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Mosley EA, Ayala S, Jah Z, Hailstorks T, Hairston I, Rice WS, Hernandez N, Jackson K, Scales M, Gutierrez M, Goode B, Filippa S, Strader S, Umbria M, Watson A, Faruque J, Raji A, Dunkley J, Rogers P, Ellison C, Suarez K, Diallo DD, Hall KS. " I don't regret it at all. It's just I wish the process had a bit more humanity to it … a bit more holistic": a qualitative, community-led medication abortion study with Black and Latinx Women in Georgia, USA. Sex Reprod Health Matters 2022; 30:2129686. [PMID: 36368036 PMCID: PMC9664998 DOI: 10.1080/26410397.2022.2129686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Traditional family planning research has excluded Black and Latinx leaders, and little is known about medication abortion (MA) among racial/ethnic minorities, although it is an increasingly vital reproductive health service, particularly after the fall of Roe v. Wade. Reproductive justice (RJ) community-based organisation (CBO) SisterLove led a study on Black and Latinx women's MA perceptions and experiences in Georgia. From April 2019 to December 2020, we conducted key informant interviews with 20 abortion providers and CBO leaders and 32 in-depth interviews and 6 focus groups (n = 30) with Black and Latinx women. We analysed data thematically using a team-based, iterative approach of coding, memo-ing, and discussion. Participants described multilevel barriers to and strategies for MA access, wishing that "the process had a bit more humanity … [it] should be more holistic." Barriers included (1) sociocultural factors (intersectional oppression, intersectional stigma, and medical experimentation); (2) national and state policies; (3) clinic- and provider-related factors (lack of diverse clinic staff, long waiting times); and (4) individual-level factors (lack of knowledge and social support). Suggested solutions included (1) social media campaigns and story-sharing; (2) RJ-based policy advocacy; (3) diversifying clinic staff, offering flexible scheduling and fees, community integration of abortion, and RJ abortion funds; and (4) social support (including abortion doulas) and comprehensive sex education. Findings suggest that equitable MA access for Black and Latinx communities in the post-Roe era will require multi-level intervention, informed by community-led evidence production; holistic, de-medicalised, and human rights-based care models; and intersectional RJ policy advocacy.
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Affiliation(s)
- Elizabeth A. Mosley
- Affiliated Faculty Member, Center for Reproductive Health Research in the Southeast, Emory University Rollins School of Public Health Atlanta, GA, USA,Assistant Professor, Center for Innovative Research on Gender Health Equity, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. Correspondence:
| | - Sequoia Ayala
- Director of Policy and Advocacy, SisterLove, Inc., Atlanta, GA, USA
| | - Zainab Jah
- Research Director, SisterLove, Inc., Atlanta, GA, USA
| | - Tiffany Hailstorks
- Assistant Professor, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Indya Hairston
- Community-Based Research Program Manager, SisterLove, Inc., Atlanta, GA, USA
| | - Whitney S. Rice
- Assistant Professor, Center for Reproductive Health Research in the Southeast, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | | | - Kwajelyn Jackson
- Executive Director, Feminist Women’s Health Center, Atlanta, GA, USA
| | - Marieh Scales
- MPH Student, Emory University Rollins School of Public Health, Atlanta, GA, USA,Research Intern, SisterLove, Inc., Atlanta, GA, USA
| | - Mariana Gutierrez
- MPH Student, Emory University Rollins School of Public Health, Atlanta, GA, USA,Research Intern, SisterLove, Inc., Atlanta, GA, USA
| | - Bria Goode
- MPH Student, Emory University Rollins School of Public Health, Atlanta, GA, USA,Research Intern, SisterLove, Inc., Atlanta, GA, USA
| | - Sofia Filippa
- MPH Student, Emory University Rollins School of Public Health, Atlanta, GA, USA,Research Intern, SisterLove, Inc., Atlanta, GA, USA
| | - Shani Strader
- MPH Student, Emory University Rollins School of Public Health, Atlanta, GA, USA,Research Intern, SisterLove, Inc., Atlanta, GA, USA
| | - Mariana Umbria
- Research Intern, SisterLove, Inc., Atlanta, GA, USA,MPH Student, Georgia State University School of Public Health, Atlanta, GA, USA
| | - Autumn Watson
- MPH Student, Emory University Rollins School of Public Health, Atlanta, GA, USA,Research Intern, SisterLove, Inc., Atlanta, GA, USA
| | - Joya Faruque
- MPH Student, Emory University Rollins School of Public Health, Atlanta, GA, USA,Research Intern, SisterLove, Inc., Atlanta, GA, USA
| | - Adeola Raji
- Research Intern, SisterLove, Inc., Atlanta, GA, USA,MPH Student, Georgia State University School of Public Health, Atlanta, GA, USA
| | - Janae Dunkley
- MPH Student, Emory University Rollins School of Public Health, Atlanta, GA, USA,Research Intern, SisterLove, Inc., Atlanta, GA, USA
| | - Peyton Rogers
- MPH Student, Emory University Rollins School of Public Health, Atlanta, GA, USA,Research Intern, SisterLove, Inc., Atlanta, GA, USA
| | - Celeste Ellison
- MPH Student, Emory University Rollins School of Public Health, Atlanta, GA, USA,Research Intern, SisterLove, Inc., Atlanta, GA, USA
| | - Kheyanna Suarez
- MPH Student, Emory University Rollins School of Public Health, Atlanta, GA, USA,Research Intern, SisterLove, Inc., Atlanta, GA, USA
| | | | - Kelli S. Hall
- Founding Director, Center for Reproductive Health Research in the Southeast, Emory University Rollins School of Public Health, Atlanta, GA, USA,Associate Professor, Columbia University Mailman School of Public Health, New York, NY, USA
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Dickey MS, Mosley EA, Clark EA, Cordes S, Lathrop E, Haddad LB. "They're forcing people to have children that they can't afford": a qualitative study of social support and capital among individuals receiving an abortion in Georgia. Soc Sci Med 2022; 315:115547. [PMID: 36427479 DOI: 10.1016/j.socscimed.2022.115547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 11/12/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022]
Abstract
Abortion is common but highly stigmatized in the United States, and the overturning of Roe v. Wade severely restricted abortion access in many states across the nation. Data reveal that maternal morbidity and mortality are already increasing, and research suggests existing inequities in abortion access across racial/ethnic and socioeconomic groups will be exacerbated. Research has shown that social support (perceived and received aid from one's social network) and social capital (resources accessed through those social connections) can improve access to health services and decrease barriers to care. Given the escalating barriers to abortion, including longer travel distances, it is imperative to better understand the roles of social support and social capital within abortion access, especially for people living on lower incomes and people of color. Our team conducted in-depth interviews with post-abortion patients (n = 18) from an urban abortion clinic in Georgia in 2019 and 2020, shortly after a six-week gestational age abortion limit had been passed but before it was enacted. We examined how people described their social support and social capital - or lack thereof - when making decisions about their pregnancy and their ability to access abortion. We found that social support and social capital - economic support in particular - were key facilitators of both abortion access and parenting, but participants often experienced barriers to economic support within their social networks due to poverty, unstable partnerships, structural inequality, and abortion stigma. Women experienced constraints to their reproductive autonomy, wherein they had no alternatives but abortion. Our findings suggest that increased economic support and de-stigmatization of abortion are needed to improve reproductive autonomy. Our findings also indicate that restricting and outlawing abortion services is significantly detrimental to the well-being of pregnant people, their families and networks, and their communities by perpetuating cycles of poverty and deepening socioeconomic and racial/ethnic inequities.
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Affiliation(s)
- Madison S Dickey
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA, 30322, USA.
| | - Elizabeth A Mosley
- The Center for Reproductive Health Research in the Southeast (RISE), Rollins School of Public Health, Emory University, 250 East Ponce De Leon Avenue, Decatur, GA, 30030, USA
| | - Elizabeth A Clark
- Emory University School of Medicine, Department of Gynecology and Obstetrics, 49 Jesse Hill Jr Drive, Atlanta, GA, 30303, USA
| | - Sarah Cordes
- Emory University School of Medicine, Department of Gynecology and Obstetrics, 49 Jesse Hill Jr Drive, Atlanta, GA, 30303, USA
| | - Eva Lathrop
- Emory University School of Medicine, Department of Gynecology and Obstetrics, 49 Jesse Hill Jr Drive, Atlanta, GA, 30303, USA
| | - Lisa B Haddad
- Emory University School of Medicine, Department of Gynecology and Obstetrics, 49 Jesse Hill Jr Drive, Atlanta, GA, 30303, USA; The Population Council, Center for Biomedical Research, 1230 York Avenue, New York, NY, 10065, USA
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Kortsmit K, Nguyen AT, Mandel MG, Clark E, Hollier LM, Rodenhizer J, Whiteman MK. Abortion Surveillance - United States, 2020. MORBIDITY AND MORTALITY WEEKLY REPORT. SURVEILLANCE SUMMARIES (WASHINGTON, D.C. : 2002) 2022; 71:1-27. [PMID: 36417304 PMCID: PMC9707346 DOI: 10.15585/mmwr.ss7110a1] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Katherine Kortsmit
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Antoinette T Nguyen
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Michele G Mandel
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Elizabeth Clark
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Lisa M Hollier
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Jessica Rodenhizer
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Maura K Whiteman
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
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Bridwell R, Long B, Montrief T, Gottlieb M. Post-abortion Complications: A Narrative Review for Emergency Clinicians. West J Emerg Med 2022; 23:919-925. [DOI: 10.5811/westjem.2022.8.57929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/23/2022] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Rachel Bridwell
- Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington
| | - Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
| | - Tim Montrief
- Jackson Memorial Health System, Department of Emergency Medicine, Miami, Florida
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
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Diakiese BM, Féron V. [Induced abortion and COVID-19 : What changed with the pandemic in 2020]. Rev Epidemiol Sante Publique 2022; 70:277-285. [PMID: 36123204 PMCID: PMC9452417 DOI: 10.1016/j.respe.2022.06.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/24/2022] [Accepted: 06/01/2022] [Indexed: 12/02/2022] Open
Abstract
Contexte L'année 2020 a été marquée par la pandémie du SARS-CoV2 dont les mesures de gestion ont fortement perturbé l'organisation de la société en général et particulièrement l'organisation du système de soins. Cette étude avait pour objectif d'analyser l’évolution des indicateurs des interruptions volontaires de grossesse (IVG) dans la région parisienne au cours de l'année 2020 et d'analyser particulièrement ce qui a changé au cours du premier confinement. Méthode Les données issues du Système national des données de santé (SNDS) ont été analysées pour comparer les indicateurs de 2020 à ceux de 2016–2019. En 2020, les indicateurs ont été étudiés mensuellement. L’âge des femmes, la méthode utilisée pour interrompre la grossesse, le terme de la grossesse au moment de l'IVG et le département de résidence de la femme ont été analysés. Résultats Après cinq années consécutives d'augmentation du taux de recours à l'IVG, l'année 2020 a été marquée par un recul du nombre d'IVG (50 615), soit une baisse de 5,6 % par rapport à 2019 (53 601). Le taux de recours est passé de 17,3 IVG/1000 femmes de 15–49 ans en 2019 à 16,3 ‰ en 2020. Ce recul a été observé dans les quatre semaines ayant suivi le premier confinement. Il concernait plus particulièrement les IVG réalisées à l'hôpital et les IVG des femmes jeunes (< 25 ans). En 2020, les proportions des IVG médicamenteuses et des IVG instrumentales sous anesthésie locale ont augmenté comparativement aux quatre années précédant la crise sanitaire. Par ailleurs, on a dénombré moins d'IVG tardives en 2020 (IVG sur grossesse > 12 semaines d'aménorrhée). Cette analyse met également en évidence une baisse du nombre de naissances dans les huit à neuf mois ayant suivi le premier confinement. Discussion et conclusion La crise liée à la COVID-19 a entraîné d'autres conséquences sanitaires non imputables directement au virus. En termes de reproduction, la crise sanitaire, particulièrement le premier confinement, est associée à un recul des conceptions se traduisant par une baisse du nombre de grossesses, qu'elles soient désirées ou non, avec comme conséquence une baisse de recours à l'IVG dans les semaines suivant le premier confinement et un recul de la natalité dans les neuf mois suivants.
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Affiliation(s)
- B Matulonga Diakiese
- Observatoire régional de santé Île-de-France, 75015, Paris, France; Institut Paris Région, 75015, Paris, France.
| | - V Féron
- Observatoire régional de santé Île-de-France, 75015, Paris, France; Institut Paris Région, 75015, Paris, France
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Mosley EA, Ayala S, Jah Z, Hailstorks T, Dixon Diallo D, Hernandez N, Jackson K, Hairston I, Hall KS. Community-led research for reproductive justice: Exploring the SisterLove Georgia Medication Abortion project. Front Glob Womens Health 2022; 3:969182. [PMID: 36033920 PMCID: PMC9412101 DOI: 10.3389/fgwh.2022.969182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/26/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction While reproductive injustice indicators are improving globally, they are worsening in the United States particularly for Black and other marginalized communities. Eugenics and obstetric violence against low-income and communities of color create well-founded distrust of sexual and reproductive health (SRH). Transformational, reparative ways of conducting SRH research are needed. Proposed principles of community-led research for reproductive justice Drawing on our collective experience as reproductive justice leaders, SRH researchers, and clinicians, we propose the following principles of community-led research for reproductive justice: 1) Center the marginalized community members most affected by SRH inequities as leaders of research; 2) Facilitate equitable, collaborative partnership through all phases of SRH research; 3) Honor multiple ways of knowing (experiential, cultural, empirical) for knowledge justice and cross-directional learning across the team; 4) Build on strengths (not deficits) within the community; 5) Implement the tenets of reproductive justice including structural-level analysis and the human rights framework; 6) Prioritize disseminating useful findings to community members first then to other audiences; 7) Take action to address social and reproductive injustices. SisterLove's community-led georgia medication abortion project We offer the community-led Georgia Medication Abortion (GAMA) Project by reproductive justice organization SisterLove from 2018-2022 as a case study to demonstrate these principles along with the strengths and challenges of reproductive justice research. Discussion Community-led reproductive justice research offers innovative and transformational methods for truly advancing SRH in an era of increasing policy restrictions and decreasing access to care. Yet existing funding, research administrative, and publishing systems will require structural change.
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Affiliation(s)
- Elizabeth A. Mosley
- Center for Reproductive Health Research in the Southeast (RISE), Emory University School of Public Health, Atlanta, GA, United States
| | | | - Zainab Jah
- SisterLove, Inc., Atlanta, GA, United States
- National Birth Equity Collaborative, Washington, DC, United States
| | - Tiffany Hailstorks
- Center for Reproductive Health Research in the Southeast (RISE), Emory University School of Public Health, Atlanta, GA, United States
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, United States
| | | | - Natalie Hernandez
- Center for Maternal Health Equity, Morehouse School of Medicine, Atlanta, GA, United States
| | | | | | - Kelli S. Hall
- Center for Reproductive Health Research in the Southeast (RISE), Emory University School of Public Health, Atlanta, GA, United States
- Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, NY, United States
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Corpuz JS, Simmonds K. Empowering the Nurse Practitioner With the Reproductive Justice Framework. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Watson K. The Ethics of Access: Reframing the Need for Abortion Care as a Health Disparity. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:22-30. [PMID: 35621314 DOI: 10.1080/15265161.2022.2075976] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The majority of U.S. abortion patients are poor women, and Black and Hispanic women. Therefore, this article encourages bioethicists and equity advocates to consider whether the need for abortion care should be considered a health disparity, and if yes, whether framing it this way would increase the ability of poor women and women of color to get the medical care they need. In order to engage with these critical questions, bioethicists must avoid abortion exceptionalism and respect patients as moral agents. Centering the conscience of pregnant people shifts our analysis away from the ethics of the act of abortion, and toward the ethics of access to abortion care. Because the Supreme Court is on the brink of shifting the question of abortion's legality to state legislatures, this is the moment for all bioethicists to clarify and strengthen their thinking, writing, and teaching in abortion ethics.
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Kheyfets A, Miller B, Amutah-Onukagha N. Implications for racial inequities in maternal health if Roe v Wade is lost. Lancet 2022; 400:9-11. [PMID: 35659035 DOI: 10.1016/s0140-6736(22)01024-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/30/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Anna Kheyfets
- MOTHER Lab, Tufts University School of Medicine, Boston, MA 02111, USA.
| | - Brenna Miller
- MOTHER Lab, Tufts University School of Medicine, Boston, MA 02111, USA
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Brown K, Plummer M, Bell A, Combs M, Gates-Burgess B, Mitchell A, Sparks M, McLemore MR, Jackson A. Black Women's Lived Experiences of Abortion. QUALITATIVE HEALTH RESEARCH 2022; 32:1099-1113. [PMID: 35537214 DOI: 10.1177/10497323221097622] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
In this study, we aim to understand abortion in the context of structural racism and reproductive injustice. We designed this study using Reproductive Justice and Public Health Critical Race Praxis frameworks. We conducted in-depth semi-structured interviews with self-identified Black women over the age of 18 who have had an abortion. The primary identified theme is that "choice" around abortion is a privilege that is not always available to Black women. Participants discussed domains of experience around abortion. The domains were (1) community experience and intergenerational wisdom, (2) personal experience and beliefs, (3) the process of accessing abortion, and (4) reflecting on abortion experience and recovery. Understanding the ways in which reproductive injustices and structural racism constrict choices is critical to providing abortion care. Abortion care should seek to honor the experiences of Black women, trust in the expertise that Black women have in our own bodies, and work to provide Reproductive-Justice-informed care.
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Affiliation(s)
- Katherine Brown
- Department of Obstetrics, Gynecology, & Reproductive Sciences, 8785University of California, San Francisco, CA, USA
- Bixby Center for Global Reproductive Health, University of California, San Francisco, San Francisco, CA
| | - Melissa Plummer
- Department of Obstetrics and Gynecology, 2348Massachusetts General Hospital, Boston, MA, USA
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Arielle Bell
- School of Nursing, 8785University of California, San Francisco, CA, USA
| | - Maya Combs
- School of Nursing, 8785University of California, San Francisco, CA, USA
| | | | | | - Marshawna Sparks
- School of Nursing, 8785University of California, San Francisco, CA, USA
| | - Monica R McLemore
- Bixby Center for Global Reproductive Health, University of California, San Francisco, San Francisco, CA
- Family Healthcare Nursing Department, 8785University of California, San Francisco, CA, USA
| | - Andrea Jackson
- Department of Obstetrics, Gynecology, & Reproductive Sciences, 8785University of California, San Francisco, CA, USA
- Bixby Center for Global Reproductive Health, University of California, San Francisco, San Francisco, CA
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Fulcher IR, Onwuzurike C, Goldberg AB, Cottrill AA, Fortin J, Janiak E. The impact of the COVID-19 pandemic on abortion care utilization and disparities by age. Am J Obstet Gynecol 2022; 226:819.e1-819.e15. [PMID: 35114184 PMCID: PMC8802456 DOI: 10.1016/j.ajog.2022.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/08/2022] [Accepted: 01/24/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND A variety of state-level restrictions were placed on abortion care in response to the COVID-19 pandemic, leading to drops in utilization and delays in time to abortion. Other pandemic-related factors also may have impacted receipt of abortion care, potentially exacerbating existing barriers to care. Massachusetts is an ideal setting to study the impact of these other pandemic-related factors on abortion care utilization because there was no wide-scale abortion policy change in response to the pandemic. OBJECTIVE This study aimed to evaluate the impact of the COVID-19 pandemic on abortion care utilization and disparities in utilization by patient age in Massachusetts. STUDY DESIGN Using the electronic medical records from all abortions that occurred at the Planned Parenthood League of Massachusetts from May 1, 2017 through December 31, 2020 (N=35,411), we performed time series modeling to estimate monthly changes in the number of abortions from the expected counts during the COVID-19 pandemic. We also assessed if legal minors (<18 years) experienced delays in time to abortion, based on gestational age at procedure, and whether minors were differentially impacted by the pandemic. RESULTS There were 1725 less abortions than expected, corresponding to a 20% drop, from March 2020 to December 2020 (95% prediction interval, -2025 to -1394) with 888 less (20% reduction) abortions among adults, 792 (20% reduction) less among young adults, and 45 (27% reduction) among minors. Adults and young adults experienced significant reductions in the number of abortions beginning in March 2020, whereas decreases among minors did not begin until July 2020. The rate of abortions occurring ≥12 weeks gestational age was unchanged during the COVID-19 pandemic among minors (adjusted rate ratio, 0.92; 95% confidence interval, 0.55-1.51) and among adults (adjusted rate ratio, 0.92; 95% confidence interval, 0.78-1.09). Young adults had a lower rate of second trimester abortion during the pandemic (adjusted rate ratio, 0.79; 95% confidence interval, 0.66-0.95). CONCLUSION Despite uninterrupted abortion service provision, abortion care utilization decreased markedly in Massachusetts during the pandemic. There was no evidence of an increase in second trimester abortions in any age group. Further research is needed to determine if a decline in the pregnancy rate or other factors, such as financial and travel barriers, fear of infection, or privacy concerns, may have contributed to this decline.
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Affiliation(s)
- Isabel R Fulcher
- Harvard Data Science Initiative, Cambridge, MA; Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA.
| | - Chiamaka Onwuzurike
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA
| | - Alisa B Goldberg
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA; Planned Parenthood League of Massachusetts, Boston, MA
| | - Alischer A Cottrill
- Planned Parenthood League of Massachusetts, Boston, MA; Harvard T.H. Chan School of Public Health, Boston, MA
| | | | - Elizabeth Janiak
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA; Planned Parenthood League of Massachusetts, Boston, MA
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Natarajan M, Wilkins-Yel KG, Sista A, Anantharaman A, Seils N. Decolonizing Purity Culture: Gendered Racism and White Idealization in Evangelical Christianity. PSYCHOLOGY OF WOMEN QUARTERLY 2022. [DOI: 10.1177/03616843221091116] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purity culture is a phenomenon promulgated by evangelical Christianity that teaches strict adherence to sexual abstinence prior to heterosexual marriage. Extant research illuminated the ways these teachings have harmed women by normalizing the oppression of their bodies, restricting sexual agency, teaching a shame response to pleasure, and perpetuating rape culture. Notably, these studies have centered white women’s experiences, and to date, there is a dearth of literature examining how these teachings uniquely impact Women of Color. There remains a paucity of research about the ways in which purity culture has perpetuated colonial and Eurocentric values that have systematically oppressed Women of Color. Framed by critical race feminism and intersectionality, we examined the lived experiences of nine Women of Color impacted by evangelical purity culture, revealing the nuanced ways in which gendered racism and white idealization influenced participants’ alliance to and embodiment of their intersecting racialized and gendered identities. With the insights gleaned from this study, we encourage readers to (a) raise their consciousness about the insidious mechanisms through which purity culture and the religious right operate and (b) actively dismantle forms of internalized oppression through radical acts of healing, and systematically through disrupting the perpetuation of purity culture rhetoric.
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Affiliation(s)
- Madison Natarajan
- Department of Counseling and School Psychology, University of Massachusetts Boston, Boston, MA, USA
| | - Kerrie G. Wilkins-Yel
- Department of Counseling and School Psychology, University of Massachusetts Boston, Boston, MA, USA
| | - Anushka Sista
- Department of Counseling and School Psychology, University of Massachusetts Boston, Boston, MA, USA
| | - Aashika Anantharaman
- Department of Counseling and School Psychology, University of Massachusetts Boston, Boston, MA, USA
| | - Natalie Seils
- Department of Public Policy and Public Affairs, University of Massachusetts Boston, Boston, MA, USA
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Wolfe T, van der Meulen Rodgers Y. Abortion During the COVID-19 Pandemic: Racial Disparities and Barriers to Care in the USA. SEXUALITY RESEARCH & SOCIAL POLICY : JOURNAL OF NSRC : SR & SP 2022; 19:541-548. [PMID: 33777258 PMCID: PMC7983965 DOI: 10.1007/s13178-021-00569-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/15/2021] [Indexed: 05/06/2023]
Abstract
This article draws on first-hand experience as well as scholarly research to illuminate how COVID-19 has impacted an already-embattled medical service in the USA, subsequently affecting the reproductive health and experiences of diverse individuals navigating an unfamiliar health and economic environment. COVID-19's introduction into a landscape of abortion restrictions has intensified the barriers that providers and communities already face, with disproportionate impacts on Black and Hispanic abortion seekers. Relaxing existing restrictions on medication abortions and telemedicine delivery models may be one way to ease the tension between keeping people home and getting them the treatment they need.
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Affiliation(s)
- Taida Wolfe
- Department of Women’s, Gender, and Sexuality Studies, Rutgers University, 162 Ryders Lane, New Brunswick, NJ 08901 USA
| | - Yana van der Meulen Rodgers
- Department of Women’s, Gender, and Sexuality Studies, Rutgers University, 162 Ryders Lane, New Brunswick, NJ 08901 USA
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Moseson H, Fix L, Gerdts C, Ragosta S, Hastings J, Stoeffler A, Goldberg EA, Lunn MR, Flentje A, Capriotti MR, Lubensky ME, Obedin-Maliver J. Abortion attempts without clinical supervision among transgender, nonbinary and gender-expansive people in the United States. BMJ SEXUAL & REPRODUCTIVE HEALTH 2022; 48:e22-e30. [PMID: 33674348 PMCID: PMC8685648 DOI: 10.1136/bmjsrh-2020-200966] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/09/2021] [Accepted: 02/15/2021] [Indexed: 06/01/2023]
Abstract
BACKGROUND Transgender, nonbinary and gender-expansive (TGE) people face barriers to abortion care and may consider abortion without clinical supervision. METHODS In 2019, we recruited participants for an online survey about sexual and reproductive health. Eligible participants were TGE people assigned female or intersex at birth, 18 years and older, from across the United States, and recruited through The PRIDE Study or via online and in-person postings. RESULTS Of 1694 TGE participants, 76 people (36% of those ever pregnant) reported considering trying to end a pregnancy on their own without clinical supervision, and a subset of these (n=40; 19% of those ever pregnant) reported attempting to do so. Methods fell into four broad categories: herbs (n=15, 38%), physical trauma (n=10, 25%), vitamin C (n=8, 20%) and substance use (n=7, 18%). Reasons given for abortion without clinical supervision ranged from perceived efficiency and desire for privacy, to structural issues including a lack of health insurance coverage, legal restrictions, denials of or mistreatment within clinical care, and cost. CONCLUSIONS These data highlight a high proportion of sampled TGE people who have attempted abortion without clinical supervision. This could reflect formidable barriers to facility-based abortion care as well as a strong desire for privacy and autonomy in the abortion process. Efforts are needed to connect TGE people with information on safe and effective methods of self-managed abortion and to dismantle barriers to clinical abortion care so that TGE people may freely choose a safe, effective abortion in either setting.
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Affiliation(s)
| | - Laura Fix
- Ibis Reproductive Health, Cambridge, Massachusetts, USA
| | | | | | - Jen Hastings
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California, USA
| | - Ari Stoeffler
- Ibis Reproductive Health, Cambridge, Massachusetts, USA
| | - Eli A Goldberg
- Department of Family Medicine, The Robert Larner, M.D. College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Mitchell R Lunn
- Department of Nephrology, Stanford University School of Medicine, Stanford, California, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
- The PRIDE Study, Stanford University, Stanford, California, USA
| | - Annesa Flentje
- The PRIDE Study, Stanford University, Stanford, California, USA
- Department of Community Health Systems, University of California San Francisco, San Francisco, California, USA
- Alliance Health Project, Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Matthew R Capriotti
- The PRIDE Study, Stanford University, Stanford, California, USA
- Department of Psychology, San Jose State University, San Jose, California, USA
| | - Micah E Lubensky
- The PRIDE Study, Stanford University, Stanford, California, USA
- Department of Community Health Systems, University of California San Francisco, San Francisco, California, USA
| | - Juno Obedin-Maliver
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
- The PRIDE Study, Stanford University, Stanford, California, USA
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
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Stallings EB, Isenburg JL, Heinke D, Sherman SL, Kirby RS, Lupo PJ. Co-occurrence of congenital anomalies by maternal race/ethnicity among infants and fetuses with Down syndrome, 2013-2017: A U.S. population-based analysis. Birth Defects Res 2021; 114:57-61. [PMID: 34951159 DOI: 10.1002/bdr2.1975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/23/2021] [Accepted: 11/29/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Individuals with Down syndrome (DS) have a higher prevalence of additional congenital anomalies, especially cardiovascular defects, compared to the general population. Several reports have indicated that the prevalence of DS among live births varies by race and ethnicity within the United States. We aim to examine variations in co-occurring congenital anomalies by maternal race/ethnicity among infants and fetuses diagnosed with DS born during 2013-2017. METHODS State birth defect surveillance systems (N = 12) submitted data on infants and fetuses diagnosed with DS born during 2013-2017. We calculated the prevalence of co-occurring major and minor congenital anomalies, by organ system, and four selected cardiovascular birth defects, all stratified by maternal race/ethnicity. RESULTS Among 5,836 cases of DS, 79.7% had one or more co-occurring congenital anomalies. There was a higher percentage of co-occurring congenital anomalies among infants and fetuses born to Hispanic mothers. The lowest percentage of co-occurring congenital anomalies, including three out of the four individual cardiovascular conditions examined, was among infants/fetuses born to non-Hispanic American Indian/Alaska Native mothers. CONCLUSIONS We describe differences in DS co-occurrence with additional congenital anomalies among maternal racial/ethnic groups. These data may help focus future research on differences among racial/ethnic groups in the diagnosis and reporting of co-occurring congenital anomalies in infants/fetuses diagnosed with DS.
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Affiliation(s)
- Erin B Stallings
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jennifer L Isenburg
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Dominique Heinke
- Massachusetts Department of Public Health, Center for Birth Defects Research and Prevention, Boston, Massachusetts, USA
| | - Stephanie L Sherman
- Department of Human Genetics, Emory School of Medicine, Atlanta, Georgia, USA
| | - Russell S Kirby
- College of Public Health, University of South Florida, Tampa, Florida, USA
| | - Philip J Lupo
- Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
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Association of State Gestational Age Limit Abortion Laws With Infant Mortality. Am J Prev Med 2021; 61:787-794. [PMID: 34364724 PMCID: PMC8608731 DOI: 10.1016/j.amepre.2021.05.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/27/2021] [Accepted: 05/11/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION A growing number of state legislatures have passed laws that restrict access to abortion care after a specified gestational age (gestational age limit laws). The impact of these laws on maternal and child population health outcomes and inequities is unknown. The objective of this study is to determine whether states that implement gestational age limit laws experience subsequent changes in rates of infant mortality. METHODS Using U.S. population‒based data from the National Center for Health Statistics Linked Infant Birth-Death Files (2005-2017), difference-in-differences models were estimated using multivariable linear regressions to compare the trends in infant mortality (all-cause and cause-specific rates) in states with gestational age limit laws with the trends in states without such laws. Models stratified by maternal racial/ethnic group explored racial heterogeneity in the law's impact. Data were analyzed in 2020. RESULTS This study included 16,232,133 births in states that enacted a gestation age limit abortion law and 36,472,309 births in states that did not from 2005 to 2017. In difference-in-difference analyses, gestational age limit laws were associated with 0.23 excess infant deaths per 1,000 live births (95% CI=0.09, 0.37, p<0.01). In cause-specific analyses, gestational age limit laws were associated with 0.10 additional infant deaths owing to congenital anomalies per 1,000 live births (95% CI=0.03, 0.17, p=0.01). Associations between gestational age limit laws and infant mortality in models stratified by maternal racial/ethnic group were not statistically significant. CONCLUSIONS On the basis of data from 2005 to 2017, states that enacted gestational age limit abortion laws subsequently experienced increased infant mortality rates.
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Kortsmit K, Mandel MG, Reeves JA, Clark E, Pagano HP, Nguyen A, Petersen EE, Whiteman MK. Abortion Surveillance - United States, 2019. MORBIDITY AND MORTALITY WEEKLY REPORT. SURVEILLANCE SUMMARIES (WASHINGTON, D.C. : 2002) 2021; 70:1-29. [PMID: 34818321 PMCID: PMC8654281 DOI: 10.15585/mmwr.ss7009a1] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Katherine Kortsmit
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Michele G Mandel
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Jennifer A Reeves
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Elizabeth Clark
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - H Pamela Pagano
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Antoinette Nguyen
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Emily E Petersen
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Maura K Whiteman
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
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di Giacomo E, Pessina R, Santorelli M, Rucco D, Placenti V, Aliberti F, Colmegna F, Clerici M. Therapeutic termination of pregnancy and women's mental health: Determinants and consequences. World J Psychiatry 2021; 11:937-953. [PMID: 34888166 PMCID: PMC8613757 DOI: 10.5498/wjp.v11.i11.937] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 07/27/2021] [Accepted: 09/14/2021] [Indexed: 02/06/2023] Open
Abstract
The therapeutic termination of pregnancy (TToP) is an induced abortion following a diagnosis of medical necessity. TToP is applied to avoid the risk of substantial harm to the mother or in cases of fetal unviability. This type of induced abortion is provided after the second semester of gestation if fetal illness or the pregnancy cause physical danger or pathological mental distress to the mother. Socio-cultural and economic determinants could influence the desire for children and family planning in couples, as well as the use of effective contraception and the choice to perform an induced abortion. Also, pre-existing mental health problems could affect the decision between carrying on a problematic pregnancy or having TToP. Furthermore, the TToP is a reproductive event with an important traumatic burden, but also with an intrinsic therapeutic effect and it can produce different psychological and psychopathological effects on women and couples. The aim of this review is to evaluate what demographic, reproductive and psychopathological determinants are involved in the choice of undergoing a TToP in women. Also, we will examine both positive and negative consequences of this procedure on women's mental health, underlying which factors are related to a worse outcome in order to provide the best clinical support to vulnerable groups.
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Affiliation(s)
- Ester di Giacomo
- School of Medicine and Surgery, University Milan Bicocca, Monza 20900, Lombardy, Italy
- Department of Psychiatric, ASST Monza, Monza 20900, Lombardy, Italy
| | - Rodolfo Pessina
- Psychiatric Residency Training Program, University Milan Bicocca, Monza 20900, Lombardy, Italy
| | - Mario Santorelli
- Psychiatric Residency Training Program, University Milan Bicocca, Monza 20900, Lombardy, Italy
| | - Daniele Rucco
- PhD Program in Psychology, Linguistics and Cognitive Neuroscience, University Milan Bicocca, Milano 20126, Lombardy, Italy
| | - Valeria Placenti
- Psychiatric Residency Training Program, University of Genova, Genova 16126, Liguria, Italy
| | - Francesca Aliberti
- Psychiatric Residency Training Program, University Milan Bicocca, Monza 20900, Lombardy, Italy
| | | | - Massimo Clerici
- School of Medicine and Surgery, University Milan Bicocca, Monza 20900, Lombardy, Italy
- Department of Psychiatric, ASST Monza, Monza 20900, Lombardy, Italy
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Mosley EA, Redd SK, Hartwig SA, Narasimhan S, Lemon E, Berry E, Lathrop E, Haddad L, Rochat R, Cwiak C, Hall KS. Racial and Ethnic Abortion Disparities Following Georgia's 22-Week Gestational Age Limit. Womens Health Issues 2021; 32:9-19. [PMID: 34711498 DOI: 10.1016/j.whi.2021.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 08/18/2021] [Accepted: 09/23/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Georgia's 2012 House Bill 954 (HB954) prohibiting abortions after 22 weeks from last menstrual period (LMP) has been associated with a significant decrease in abortions after 22 weeks. However, the policy's effects by race or ethnicity remain unexplored. We investigated whether changes in abortion numbers and ratios (per 1,000 live births) in Georgia after HB954 varied by race or ethnicity. METHODS Using Georgia Department of Public Health induced terminations of pregnancy data from 2007 to 2017, we examined changes in number of abortions and abortion ratios (per 1,000 live births) by race and ethnicity following HB954 implementation. RESULTS After full implementation of HB954 in 2015, the number of abortions and abortion ratios at or after 22 weeks (from last menstrual period) decreased among White (bNumber = -261.83, p < .001; bRatio = -3.31, p < .001), Black (bNumber = -416.17, p < .001; bRatio = -8.84, p < .001), non-Hispanic (bNumber = -667.00, p = .001; bRatio = -5.82, p < .001), and Hispanic (bNumber = -56.25, p = .002; bRatio = -2.44, p = .002) people. However, the ratio of abortions before 22 weeks increased for Black people (bLessThan22Weeks = 44.06, p = .028) and remained stable for White (bLessThan22Weeks = -6.78, p = .433), Hispanic (bLessThan22Weeks = 21.27, p = .212), and non-Hispanic people (bLessThan22Weeks = 26.93, p = .172). CONCLUSION The full implementation of HB954 had differential effects by race/ethnicity and gestational age. Although abortion at 22 weeks or more decreased for all groups, abortion at less than 22 weeks increased among Black people. Additional research should elucidate the possible causes, consequences, and reactions to differential effects of abortion restrictions by race and ethnicity.
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Affiliation(s)
- Elizabeth A Mosley
- Georgia State University, School of Public Health, Mark Chaffin Center for Healthy Development, Atlanta, Georgia; Emory University, Rollins School of Public Health, Atlanta, Georgia; Center for Reproductive Health Research in the Southeast (RISE), Atlanta, Georgia.
| | - Sara K Redd
- Emory University, Rollins School of Public Health, Atlanta, Georgia; Center for Reproductive Health Research in the Southeast (RISE), Atlanta, Georgia
| | - Sophie A Hartwig
- Emory University, Rollins School of Public Health, Atlanta, Georgia; Center for Reproductive Health Research in the Southeast (RISE), Atlanta, Georgia
| | - Subasri Narasimhan
- Emory University, Rollins School of Public Health, Atlanta, Georgia; Center for Reproductive Health Research in the Southeast (RISE), Atlanta, Georgia
| | - Emily Lemon
- Emory University, Rollins School of Public Health, Atlanta, Georgia; Center for Reproductive Health Research in the Southeast (RISE), Atlanta, Georgia
| | - Erin Berry
- Center for Reproductive Health Research in the Southeast (RISE), Atlanta, Georgia; Emory University, School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia
| | - Eva Lathrop
- Emory University, Rollins School of Public Health, Atlanta, Georgia; Center for Reproductive Health Research in the Southeast (RISE), Atlanta, Georgia; Emory University, School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia
| | - Lisa Haddad
- Center for Reproductive Health Research in the Southeast (RISE), Atlanta, Georgia; Emory University, School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia
| | - Roger Rochat
- Emory University, Rollins School of Public Health, Atlanta, Georgia; Center for Reproductive Health Research in the Southeast (RISE), Atlanta, Georgia; Emory University, School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia
| | - Carrie Cwiak
- Emory University, Rollins School of Public Health, Atlanta, Georgia; Center for Reproductive Health Research in the Southeast (RISE), Atlanta, Georgia; Emory University, School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia
| | - Kelli Stidham Hall
- Emory University, Rollins School of Public Health, Atlanta, Georgia; Center for Reproductive Health Research in the Southeast (RISE), Atlanta, Georgia
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Redd SK, Rice WS, Aswani MS, Blake S, Julian Z, Sen B, Wingate M, Hall KS. Racial/ethnic and educational inequities in restrictive abortion policy variation and adverse birth outcomes in the United States. BMC Health Serv Res 2021; 21:1139. [PMID: 34686197 PMCID: PMC8532280 DOI: 10.1186/s12913-021-07165-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/12/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND To examine racial/ethnic and educational inequities in the relationship between state-level restrictive abortion policies and adverse birth outcomes from 2005 to 2015 in the United States. METHODS Using a state-level abortion restrictiveness index comprised of 18 restrictive abortion policies, we conducted a retrospective longitudinal analysis examining whether race/ethnicity and education level moderated the relationship between the restrictiveness index and individual-level probabilities of preterm birth (PTB) and low birthweight (LBW). Data were obtained from the 2005-2015 National Center for Health Statistics Period Linked Live Birth-Infant Death Files and analyzed with linear probability models adjusted for individual- and state-level characteristics and state and year fixed-effects. RESULTS Among 2,250,000 live births, 269,253 (12.0%) were PTBs and 182,960 (8.1%) were LBW. On average, states had approximately seven restrictive abortion policies enacted from 2005 to 2015. Black individuals experienced increased probability of PTB with additional exposure to restrictive abortion policies compared to non-Black individuals. Similarly, those with less than a college degree experienced increased probability of LBW with additional exposure to restrictive abortion policies compared to college graduates. For all analyses, inequities worsened as state environments grew increasingly restrictive. CONCLUSION Findings demonstrate that Black individuals at all educational levels and those with fewer years of education disproportionately experienced adverse birth outcomes associated with restrictive abortion policies. Restrictive abortion policies may compound existing racial/ethnic, socioeconomic, and intersecting racial/ethnic and socioeconomic perinatal and infant health inequities.
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Affiliation(s)
- Sara K Redd
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA, 30322, USA.
- Center for Reproductive Health Research in the Southeast (RISE), Emory University, 1518 Clifton Rd NE, Atlanta, GA, 30322, USA.
| | - Whitney S Rice
- Center for Reproductive Health Research in the Southeast (RISE), Emory University, 1518 Clifton Rd NE, Atlanta, GA, 30322, USA
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Monica S Aswani
- Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, 1719 9th Ave. S, Birmingham, AL, 35233, USA
| | - Sarah Blake
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA, 30322, USA
- Center for Reproductive Health Research in the Southeast (RISE), Emory University, 1518 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Zoë Julian
- Independent Clinician Scholar, Atlanta, GA, 30322, USA
| | - Bisakha Sen
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, 1665 University Blvd, Birmingham, AL, 35233, USA
| | - Martha Wingate
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, 1665 University Blvd, Birmingham, AL, 35233, USA
| | - Kelli Stidham Hall
- Center for Reproductive Health Research in the Southeast (RISE), Emory University, 1518 Clifton Rd NE, Atlanta, GA, 30322, USA
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA, 30322, USA
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, 722 West 168th St, New York, NY, 10032, USA
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Kissling A, Jackson HM. Estimating Prevalence of Abortion Using List Experiments: Findings from a Survey of Women in Delaware and Maryland. Womens Health Issues 2021; 32:33-40. [PMID: 34556399 DOI: 10.1016/j.whi.2021.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 08/16/2021] [Accepted: 08/19/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Widespread underreporting of abortion persists in survey data. The list experiment, a measurement tool designed to elicit truthful responses to sensitive questions, may alleviate underreporting. METHODS Using The Statewide Survey of Women of Reproductive Age in Delaware and Maryland (n = 2,747), we estimate the prevalence of abortion in Maryland and Delaware using a double list experiment. RESULTS We find 21% (95% confidence interval [CI]: 16.8%-25.3%) of respondents aged 18 to 44 ever had an abortion and we identify disparities in abortion prevalence by age, race, education, income, marital status, and insurance status. Respondents who were Black (37.0%; 95% CI: 27.1%-46.8%), had less than a college degree (24.8%; 95% CI: 18.3%-31.3%), were in a cohabiting relationship (39.0%; 95% CI: 29.1%-48.9%), were living in households with incomes less than $50,000 (28.6%; 95% CI: 19.7%-37.5%), and were currently covered by Medicaid (42.8%; 95% CI: 27.6%-58.0%) were more likely than their counterparts to have ever had an abortion. CONCLUSIONS List experiments yield estimates of abortion substantially higher than those obtained from direct questions. Findings demonstrate external validity through consistency with estimates from administrative data sources and gold standard abortion provider survey data.
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Affiliation(s)
- Alexandra Kissling
- University of Maryland-College Park, Population Research Center, College Park, Maryland.
| | - Heide M Jackson
- University of Maryland-College Park, Population Research Center, College Park, Maryland
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Swartz JJ, Rowe C, Truong T, Bryant AG, Morse JE, Stuart GS. Comparing Website Identification for Crisis Pregnancy Centers and Abortion Clinics. Womens Health Issues 2021; 31:432-439. [PMID: 34266709 DOI: 10.1016/j.whi.2021.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/21/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Crisis pregnancy centers (CPCs) seeking to dissuade women from abortion often appear in Internet searches for abortion clinics. We aimed to assess whether women can use screenshots from real websites to differentiate between CPCs and abortion clinics. METHODS We conducted a cross-sectional, nationally representative online study of English- and Spanish-speaking women aged 18-49 years in the United States. We presented participants with screenshots from five CPCs and five abortion clinic websites and asked if they thought an abortion could be obtained at that center. We scored correct answers based on clinic type. Outcomes included ability to correctly identify CPCs and abortion clinics as well as risk factors for misidentification. The survey also included five questions about common abortion myths and a validated health literacy assessment. RESULTS We contacted 2,223 women, of whom 1,057 (48%) completed the survey and 1,044 (47%) were included in the analysis. The median score for correctly identifying CPCs as facilities not performing abortion was 2 out of 5 (Q:1 0, Q:3 4). The median score for correctly identifying abortion clinics as facilities performing abortion was 5 out of 5 (Q:1 3, Q:3 5). Those less likely to endorse abortion myths had higher odds of correctly identifying CPCs (adjusted odds ratio, 2.43; 95% confidence interval, 1.78-3.32). A low health literacy score was associated with decreased odds of correct identification of CPCs (adjusted odds ratio, 0.39; 95% confidence interval, 0.25-0.59). CONCLUSIONS Websites of CPCs were more difficult for women to correctly identify than those of abortion clinics. Women with limited knowledge about abortion and low health literacy may be particularly susceptible to misidentification of CPC websites.
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Affiliation(s)
- Jonas J Swartz
- Division of Women's Community and Population Health, Department of OBGYN, Duke University Medical Center, Durham, North Carolina; Division of Family Planning, Department of OBGYN, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Carly Rowe
- Division of Family Planning, Department of OBGYN, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Tracy Truong
- Department of Biostatistics & Bioinformatics, Duke University of Medical Center, Dueham, North Carolina
| | - Amy G Bryant
- Division of Family Planning, Department of OBGYN, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jessica E Morse
- Division of Family Planning, Department of OBGYN, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Gretchen S Stuart
- Division of Family Planning, Department of OBGYN, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Racial and Ethnic Disparities in Receipt of Sexual Health Care and Education Among A Nationally Representative Sample of Adolescent Females. J Racial Ethn Health Disparities 2021; 9:1422-1429. [PMID: 34160820 DOI: 10.1007/s40615-021-01079-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/21/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE(S) The USA has a high rate of adolescent pregnancy, with non-Hispanic (NH) Black and Hispanic women disproportionately affected. We sought to investigate the presence of racial/ethnic disparities in the receipt of sexual health (SRH) care and education and whether such disparities contribute to differences in sexual health outcomes for youth. STUDY DESIGN We conducted a cross-sectional study of females aged 15-21 years who participated in the National Survey of Family Growth from 2008 to 2015. Multivariable logistic regression was used to measure the association between race/ethnicity and SRH outcomes after adjustment for potential confounders. Models were developed to measure whether receipt of SRH care and education served as an effect modifier on SRH outcomes. RESULTS The sample included 4316 participants, representing 33.5 million females. Almost half (47.2%) received birth control services in the last 12 months; NH-Blacks (aOR 0.7 [0.5, 0.9]) and Hispanics (aOR 0.6 [0.5, 0.8]) were less likely to have obtained birth control services than NH-whites. Hispanics (aOR 1.5 [1.2, 1.9]) had a higher likelihood of receipt of condom education than NH-whites. We found that disparities in SRH outcomes were slightly mitigated after adjustment for access to SRH care and education. CONCLUSIONS We identified racial/ethnic disparities in sexual health outcomes and in SRH and education; however, SRH care and education can mitigate some of these differences in sexual behaviors and outcomes. Racial/ethnic differences in sexual health outcomes may be at least partially related to the differential receipt of sexual health care and education and deserve further investigation.
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Rayment-Jones H, Dalrymple K, Harris J, Harden A, Parslow E, Georgi T, Sandall J. Project20: Does continuity of care and community-based antenatal care improve maternal and neonatal birth outcomes for women with social risk factors? A prospective, observational study. PLoS One 2021; 16:e0250947. [PMID: 33945565 PMCID: PMC8096106 DOI: 10.1371/journal.pone.0250947] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 04/17/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Social factors associated with poor childbirth outcomes and experiences of maternity care include minority ethnicity, poverty, young motherhood, homelessness, difficulty speaking or understanding English, migrant or refugee status, domestic violence, mental illness and substance abuse. It is not known what specific aspects of maternity care work to improve the maternal and neonatal outcomes for these under-served, complex populations. METHODS This study aimed to compare maternal and neonatal clinical birth outcomes for women with social risk factors accessing different models of maternity care. Quantitative data on pregnancy and birth outcome measures for 1000 women accessing standard care, group practice and specialist models of care at two large, inner-city maternity services were prospectively collected and analysed using multinominal regression. The level of continuity of care and place of antenatal care were used as independent variables to explore these potentially influential aspects of care. Outcomes adjusted for women's social and medical risk factors and the service attended. RESULTS Women who received standard maternity care were significantly less likely to use water for pain relief in labour (RR 0.11, CI 0.02-0.62) and have skin to skin contact with their baby shortly after birth (RR 0.34, CI 0.14-0.80) compared to the specialist model of care. Antenatal care based in the hospital setting was associated with a significant increase in preterm birth (RR 2.38, CI 1.32-4.27) and low birth weight (RR 2.31, CI 1.24-4.32), and a decrease in induction of labour (RR 0.65, CI 0.45-0.95) compared to community-based antenatal care, this was despite women's medical risk factors. A subgroup analysis found that preterm birth was increased further for women with the highest level of social risk accessing hospital-based antenatal care (RR 3.11, CI1.49-6.50), demonstrating the protective nature of community-based antenatal care. CONCLUSIONS This research highlights how community-based antenatal care, with a focus on continuity of carer reduced health inequalities and improved maternal and neonatal clinical outcomes for women with social risk factors. The findings support the current policy drive to increase continuity of midwife-led care, whilst adding that community-based care may further improve outcomes for women at increased risk of health inequalities. The relationship between community-based models of care and neonatal outcomes require further testing in future research. The identification of specific mechanisms such as help-seeking and reduced anxiety, to explain these findings are explored in a wider evaluation.
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Affiliation(s)
- Hannah Rayment-Jones
- Department of Women and Children’s Health, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
| | - Kathryn Dalrymple
- Department of Women and Children’s Health, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
| | - James Harris
- Clinical Research Facility, Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
| | - Angela Harden
- School of Health Sciences, City University of London, London, United Kingdom
| | - Elidh Parslow
- St Mary’s Hospital, Imperial College NHS Trust, London, United Kingdom
| | - Thomas Georgi
- School of Population Health & Environmental Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
| | - Jane Sandall
- Department of Women and Children’s Health, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
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