Abortion pills on TV: An exploratory study of the associations between abortion plotline viewership and beliefs regarding in-clinic and self-managed medication abortion

OBJECTIVES

Entertainment television is an influential source of health information, including about reproductive health. We investigated the association between exposure to television plotlines about medication abortion on audience awareness and beliefs about medication abortion.

STUDY DESIGN

We administered a national cross-sectional online survey from December 2021 to January 2022 with a probability-based sample of people assigned female at birth. We asked respondents to select plotlines they had seen from a list of seven that portrayed medication abortion. Among the 3425 people who responded to plotline items, 3340 responded to our outcome measures. Using weighed multivariable analyses, we examined adjusted relationships between exposure to specific types of abortion plotlines and awareness of and beliefs about medication abortion medical safety.

RESULTS

We found that audience exposure to medication abortion plotlines in which the medication abortion was obtained from a clinic and portrayed as safe was associated with greater awareness of medication abortion compared to nonexposure (RR: 1.68; 95% CI: 1.17, 2.40). Exposure to plotlines that portrayed MA or self-managed MA as safe was associated with audience beliefs that medication abortion is safe.

CONCLUSIONS

This study demonstrates that the content of abortion plotlines and exposure to accurate information may be connected to audience awareness of and beliefs about abortion.

IMPLICATIONS

In a climate of misinformation about abortion, audience exposure to medically accurate television plotlines about medication abortion may be an effective way to increase awareness of medication abortion and influence beliefs about medication abortion safety.

Abortion and mental health outcomes: A systematic review and meta-analysis

This is a protocol for a systematic review and meta-analysis of research on mental health outcomes of abortion. Does abortion increase the risk of adverse mental health outcomes? That is the central question for this review. Our review aims to inform policy and practice by locating, critically appraising, and synthesizing empirical evidence on associations between abortion and subsequent mental health outcomes. Given the controversies surrounding this topic and the complex social, political, legal, and ideological contexts in which research and reviews on abortion are conducted, it is especially important to conduct this systematic review and meta-analysis with comprehensive, rigorous, unbiased, and transparent methods. We will include a variety of study designs to enhance understanding of studies' methodological strengths and weaknesses and to identify potential explanations for conflicting results. We will follow open science principles, providing access to our methods, measures, and results, and making data available for re-analysis.

Mail-Order Pharmacy Dispensing of Mifepristone for Medication Abortion After In-Person Screening

Importance

Before 2021, the US Food and Drug Administration required mifepristone to be dispensed in person, limiting access to medication abortion.

Objective

To estimate the effectiveness, acceptability, and feasibility of dispensing mifepristone for medication abortion using a mail-order pharmacy.

Design, Setting, and Participants

This prospective cohort study was conducted from January 2020 to May 2022 and included 11 clinics in 7 states (5 abortion clinics and 6 primary care sites, 4 of which were new to abortion provision). Eligible participants were seeking medication abortion at 63 or fewer days' gestation, spoke English or Spanish, were age 15 years or older, and were willing to take misoprostol buccally. After assessing eligibility for medication abortion through an in-person screening, mifepristone and misoprostol were prescribed using a mail-order pharmacy. Patients had standard follow-up care with the clinic. Clinical information was collected from medical records. Consenting participants completed online surveys about their experiences 3 and 14 days after enrolling. A total of 540 participants were enrolled; 10 withdrew or did not take medication. Data were analyzed from August 2022 to December 2023.

Intervention

Mifepristone, 200 mg, and misoprostol, 800 µg, prescribed to a mail-order pharmacy and mailed to participants instead of dispensed in person.

Main Outcomes and Measures

Proportion of patients with a complete abortion with medications only, reporting satisfaction with the medication abortion, and reporting timely delivery of medications.

Results

Clinical outcome information was obtained and analyzed for 510 abortions (96.2%) among 506 participants (median [IQR] age, 27 [23-31] years; 506 [100%] female; 194 [38.3%] Black, 88 [17.4%] Hispanic, 141 [27.9%] White, and 45 [8.9%] multiracial/other individuals). Of these, 436 participants (85.5%; 95% CI, 82.2%-88.4%) received medications within 3 days. Complete abortion occurred after medication use in 499 cases (97.8%; 95% CI, 96.2%-98.9%). There were 24 adverse events (4.7%) for which care was sought for medication abortion symptoms; 3 patients (0.6%; 95% CI, 0.1%-1.7%) experienced serious adverse events requiring hospitalization (1 with blood transfusion); however, no adverse events were associated with mail-order dispensing. Of 477 participants, 431 (90.4%; 95% CI, 87.3%-92.9%) indicated that they would use mail-order dispensing again for abortion care, and 435 participants (91.2%; 95% CI, 88.3%-93.6%) reported satisfaction with the medication abortion. Findings were similar to those of other published studies of medication abortion with in-person dispensing.

Conclusions and Relevance

The findings of this cohort study indicate that mail-order pharmacy dispensing of mifepristone for medication abortion was effective, acceptable to patients, and feasible, with a low prevalence of serious adverse events. This care model should be expanded to improve access to medication abortion services.

Interest in and Support for Alternative Models of Medication Abortion Provision Among Patients Seeking Abortion in the United States

INTRODUCTION

Medication abortion is safe and effective, but restrictions still limit patients from accessing this method. Alternative models of medication abortion provision, namely advance provision, over-the-counter (OTC), and online, could help improve access to care for some, although there is limited evidence about abortion patients' interest in these models.

METHODS

Between 2017 and 2019, we administered a cross-sectional survey to abortion patients at 45 clinics across 15 U.S. states to explore their interest in and support for advance provision, OTC, and online abortion access. We assessed relationships between sociodemographic characteristics and interest in and support for each model using bivariate logistic regressions and present perceived advantages and disadvantages of each model, as described by a subset of participants.

RESULTS

Among 1,965 people enrolled, 1,759 (90%) initiated the survey. Interest in and support for advance provision was highest (72% and 82%, respectively), followed by OTC (63% and 72%) and online access (57% and 70%). In bivariate analyses, non-Hispanic Black and Asian/Pacific Islander respondents expressed lower interest and support for the online model and Alaska Native/Native American respondents expressed higher interest in an OTC model, as compared with white respondents. Among 439 participants naming advantages and disadvantages of each model, the most common advantages included convenience and having the abortion earlier. The most common disadvantages were not seeing a provider first and possibly taking pills incorrectly.

CONCLUSIONS

Although most abortion patients expressed interest in and support for alternative models of medication abortion provision, variation in support across race/ethnicity highlights a need to ensure that abortion care service models meet the needs and preferences of all patients, particularly people from historically underserved populations.

Effectiveness and safety of telehealth medication abortion in the USA

Telehealth abortion has become critical to addressing surges in demand in states where abortion remains legal but evidence on its effectiveness and safety is limited. California Home Abortion by Telehealth (CHAT) is a prospective study that follows pregnant people who obtained medication abortion via telehealth from three virtual clinics operating in 20 states and Washington, DC between April 2021 and January 2022. Individuals were screened using a standardized no-test protocol, primarily relying on their medical history to assess medical eligibility. We assessed effectiveness, defined as complete abortion after 200 mg mifepristone and 1,600 μg misoprostol (or lower) without additional intervention; safety was measured by the absence of serious adverse events. We estimated rates using multivariable logistic regression and multiple imputation to account for missing data. Among 6,034 abortions, 97.7% (95% confidence interval (CI) = 97.2-98.1%) were complete without subsequent known intervention or ongoing pregnancy after the initial treatment. Overall, 99.8% (99.6-99.9%) of abortions were not followed by serious adverse events. In total, 0.25% of patients experienced a serious abortion-related adverse event, 0.16% were treated for an ectopic pregnancy and 1.3% abortions were followed by emergency department visits. There were no differences in effectiveness or safety between synchronous and asynchronous models of care. Telehealth medication abortion is effective, safe and comparable to published rates of in-person medication abortion care.

Failure of the Law to Grant Access to Legal Abortion in Chile

Introduction

In 2017, Chile decriminalized abortion on three grounds: (i) if the pregnant person's life is at risk, (ii) fetal nonviability, and (iii) rape or incest. This multicase study explores the experiences of pregnant people legally entitled to but denied access to legal abortion in Chile.

Methods

Through a snowball sampling approach, we recruited adult Chilean residents who sought, were eligible for, and were denied a legal abortion after September 2017. We conducted semistructured interviews with participants to explore their experiences in seeking and being denied legal abortions. We recorded and transcribed the interviews, then coded and analyzed the transcriptions to identify common themes.

Results

We identified four women who met the eligibility criteria. The interviews revealed five common themes in their experiences: (i) disparate levels of social support in accessing abortion, (ii) abundant access barriers, (iii) forced pregnancy, (iv) abortion stigma, and (v) a failure of the law to provide access to abortion.

Discussion and Health Equity Implications

Although the 2017 law expanded legal access to abortion in Chile, significant barriers remain. Compounded with social stigma, and the socioeconomic disparities in abortion access, pregnant people continue to face insurmountable obstacles in obtaining legal abortions, even when their lives are at risk and the pregnancy is not viable. The state must prioritize equity of access to legal abortions. Future studies should continue to explore the challenges people face accessing legal abortion care to inform strategies to ensure people are able to obtain the quality care that they are legally entitled to.

Is legal recreational cannabis associated with cannabis use during pregnancy, beliefs about safety, and perceived community stigma?

BACKGROUND

Among pregnant and recently pregnant people we investigated whether legal recreational cannabis is associated with pregnancy-related cannabis use, safety beliefs, and perceived community stigma.

METHODS

In 2022, we surveyed 3571 currently and recently pregnant English- or Spanish-speaking adults in 37 states. Primary outcomes included cannabis use during pregnancy and two continuous scale measures of beliefs about safety and perceived community stigma. Using generalized linear models and mixed effects ordinal logistic regression with random effects for state, we assessed associations between legal recreational cannabis and outcomes of interest, controlling for state-level and individual-level covariates and specifying appropriate functional form.

RESULTS

Those who reported cannabis use during pregnancy were more likely to believe it is safe and to perceive community stigma compared to those who did not report use during pregnancy. Legal recreational cannabis was not associated with cannabis use during pregnancy, continuation or increase in use, frequency of use, or safety beliefs. Legal recreational cannabis was associated with lower perceived community stigma (coefficient: -0.07, 95% CI: -0.13, -0.01), including among those who reported use during (coefficient = -0.22, 95% CI: -0.40, -0.04) and prior to but not during (coefficient = -0.19, 95% CI: -0.37, -0.01) pregnancy.

CONCLUSION

Findings do not support concerns that legal recreational cannabis is associated with cannabis use during pregnancy or beliefs about safety. Legal recreational cannabis may be associated with lower community stigma around cannabis use during pregnancy, which could have implications for pregnant people's disclosure of use and care-seeking behavior.

Support for criminalization of self-managed abortion (SMA): A national representative survey

OBJECTIVE

Since the U.S. Supreme Court eliminated the federal right to abortion, there is a heightened need to understand public opinion about the criminalization of people who attempt to end their pregnancies outside the formal healthcare setting, referred to as self-managed abortion (SMA). We assessed U.S. attitudes about whether three forms of SMA should be legal, reported or punished: 1) using abortion pills obtained outside the healthcare system, 2) using other medications, drugs, herbs, or by drinking alcohol, and 3) using traumatic methods (inserting an object in their body or hitting their stomach).

METHODS

From December 2021 to January 2022, we administered a national probability-based online survey to English- and Spanish-speaking people assigned female (AFAB, ages 15-49) or male at birth (AMAB, ages 18-49) regarding their attitudes about criminalizing SMA, using Ipsos' KnowledgePanel. We estimated weighted proportions and conducted multivariable regression analyses to identify characteristics associated with support for SMA legality and punishment (reporting to authorities, paying a fine or going to jail).

RESULTS

A total of 7,016 AFAB and 360 AMAB completed the survey. People were less likely (p < .05) to agree that SMA using abortion pills should be illegal (34% of AFAB and 43% of AMAB) than other forms of SMA (36-48%), although over one-fifth were unsure (AFAB, 20-23% and AMAB, 24-27%). People were less likely to agree SMA using abortion pills should be criminalized than SMA using other drugs, medications, herbs, alcohol or by using traumatic methods. In multivariable analyses, AMAB and Christian religion were associated with agreeing that SMA using abortion pills should be illegal; people who identified as Hispanic/Latinx ethnicity and experienced medical mistreatment were less likely to agree SMA with medication abortion pills should be illegal.

CONCLUSIONS

Public support for criminalizing SMA is complex and varied by SMA method and form of punishment.

Association Between Facility and Clinician Characteristics and Family Planning Services Provided During U.S. Outpatient Care Visits

INTRODUCTION

Recent guidelines from the Centers for Disease Control and Prevention emphasize the importance of access to comprehensive family planning services and recommend patient-centered contraceptive counseling be incorporated into routine primary care visits for reproductive-age individuals. This study aims to describe family planning service provision in outpatient care settings and assess differences by facility and clinician characteristics.

METHODS

Using National Ambulatory Medical Care Survey data, a nationally representative survey of outpatient care visits, we assessed family planning service provision by facility location, facility type, physician specialty, types of clinicians seen, and whether the patient was seen by their primary care provider. We used random intercept logistic regression with robust standard errors, adjusting for patient characteristics, and state and year fixed effects.

RESULTS

The analytic sample included 53,489 patient visits with reproductive-age (15-49 years) individuals between 2011 and 2019. Family planning services were provided at 8% of total sampled visits and were more likely to be provided in urban compared with rural areas (adjusted odds ratio, 1.45; p = .02) and at community health centers compared with private physician practices (adjusted odds ratio, 1.74; p = .00). Family planning services were also more likely to be provided when the patient saw a physician assistant or nurse compared with only a physician. After controlling for observed covariates, measures of between-clinician heterogeneity indicate wide variation in which clinicians provided family planning services.

CONCLUSIONS

Family planning services were more likely to be provided in urban areas, at community health centers, and when patients received team-based care. The wide variation between clinicians suggests a need to better incorporate family planning services into primary care and other outpatient settings to meet patient needs and preferences.

Access to Reproductive Health Services Among People With Disabilities

Importance

People with disabilities face inequitable access to reproductive health (RH) services, yet the national prevalence of barriers to access experienced across disability types and statuses is unknown.

Objective

To assess the national prevalence of barriers to RH access experienced by people with disabilities.

Design, Setting, and Participants

This cross-sectional study analyzed results of an online probability-based national survey of RH experiences that was conducted from December 2021 to January 2022. The national sample consisted of English- and Spanish-speaking panel members of a market research firm. Panelists were invited to participate in a survey on their RH experiences and opinions. These participants were aged 15 to 49 years and assigned female at birth (AFAB). Weighted proportions were estimated, and bivariable and multivariable regression analyses were performed to assess associations between disability status and barriers to accessing RH services.

Exposure

Using 5 of the 6 Washington Group Short Set on Functioning items, 8 dichotomous disability indicators were created: (1) vision, (2) hearing, (3) mobility, (4) activities of daily living, (5) communication, (6) overall disability status (a lot or more difficulty functioning in ≥1 domain), (7) some difficulty functioning (below the disability threshold; some or more difficulty functioning in ≥1 domain), and (8) multiple disabilities (a lot or more difficulty functioning in ≥2 domains).

Main Outcomes and Measures

Number and types of barriers (logistical, access, cost, privacy, and interpersonal relationship) to accessing RH services in the past 3 years.

Results

After exclusion, the final sample included 6956 people AFAB, with a mean (SD) age of 36.0 (8.3) years. Of these participants, 8.5% (95% CI, 7.6%-9.5%) met the disability threshold. Participants with disabilities compared with those without disabilities were disproportionately more likely to be non-Hispanic Black (18.8% [95% CI, 14.4%-24.1%] vs 13.2% [95% CI, 11.9%-14.5%]) or Hispanic or Latinx (completed survey in English: 18.1% [95% CI, 14.0%-23.0%] vs 14.6% [95% CI, 13.3%-16.0%]; completed survey in Spanish: 8.9% [95% CI, 6.2%-12.8%] vs 6.2% [95% CI, 5.4%-7.1%]) individuals, to identify as LGBTQAI (lesbian, gay, bisexual, transgender, queer [or questioning], asexual [or allied], intersex; 16.4% [95% CI, 12.3%-21.6%] vs 11.8% [95% CI, 10.6%-13.1%]), to live below the federal poverty level (27.3% [95% CI, 22.3%-32.8%] vs 10.7% [95% CI, 9.7%-11.9%]), and to ever experienced medical mistreatment (49.6% [95% CI, 43.7%-55.5%] vs 36.5% [95% CI, 34.8%-38.2%]). Among those who had ever tried to access RH services (n = 6027), people with disabilities vs without disabilities were more likely to experience barriers (69.0% [95% CI, 62.9%-74.5%] vs 43.0% [95% CI, 41.2%-44.9%]), which were most often logistical (50.7%; 95% CI, 44.2%-57.2%) and access (49.9%; 95% CI, 43.4%-56.4%) barriers. The disability domains with the highest proportion of people who experienced 3 or more barriers in the past 3 years included activities of daily living (75.3%; 95% CI, 61.1%-85.6%), communication (65.1%; 95% CI, 49.5%-78.1%), and multiple (59.9%; 95% CI, 45.6%-72.7%) disabilities.

Conclusions and Relevance

This cross-sectional study found large disparities in access to RH services among people AFAB with disabilities. Findings indicated a need to alleviate barriers to RH care, including improving the transportation infrastructure and reinforcing patient-centered approaches that engender inclusivity in health care settings.

Awareness of medication abortion among a nationally representative U.S. sample, 2021-2022

OBJECTIVES

Assess public awareness of medication abortion in the U.S.

STUDY DESIGN

We conducted a cross-sectional survey in 2021-2022 with a probability-based sample, calculating the prevalence of medication abortion awareness and assessing its associations with participant characteristics using multivariable logistic regression.

RESULTS

A total of 45% of adults (7201/16,113) and 49% of eligible 15-17-year-old females (175/358) invited completed the survey. In all, 64% of 6992 participants assigned female at birth, and 57% of 360 participants assigned male reported awareness of medication abortion. Race, age, education, poverty level, religion, sexual identity, abortion history, and attitudes toward abortion legality were associated with differences in awareness.

CONCLUSIONS

Medication abortion awareness differs by participant groups and is critical for expanding abortion access.

IMPLICATIONS

Tailored health information for groups with less awareness of medication abortion may help spread knowledge of the method and how to access it.

Association of Mandatory Warning Signs for Cannabis Use During Pregnancy With Cannabis Use Beliefs and Behaviors

Importance

As states have legalized recreational cannabis use, some have enacted policies mandating point-of-sale warning signs with information on harms of using cannabis during pregnancy. While research has found such warning signs are associated with increased adverse birth outcomes, reasons why are unclear.

Objective

To examine whether exposure to cannabis warning signs is associated with cannabis-related beliefs, stigma, and use.

Design, Setting, and Participants

This cross-sectional study used data from a population-based online survey conducted from May to June 2022. Participants included pregnant and recently pregnant (within past 2 years) members of the national probability KnowledgePanel and nonprobability samples in all US states and Washington, the District of Columbia, where recreational cannabis is legal. Data were analyzed from July 2022 to April 2023.

Exposure

Living in 1 of 5 states with a warning signs policy.

Main Outcomes and Measures

Outcomes of interest were self-reported beliefs (linear) that cannabis use during pregnancy is not safe, should be punished, and is stigmatized and cannabis use during pregnancy (dichotomous). Regressions, accounting for survey weights and clustering by state, examined associations of warning signs with cannabis-related beliefs and use.

Results

A total of 2063 pregnant or recently pregnant people (mean [SD] weighted age, 32 [6] years) completed the survey, and 585 participants (weighted, 17%) reported using cannabis during their pregnancy. Among people who used cannabis during their pregnancy, living in a warning signs state was associated with beliefs that cannabis use during pregnancy was safe (β = -0.33 [95% CI, -0.60 to -0.07]) and that people who used cannabis during pregnancy should not be punished (β = -0.40 [95% CI, -0.73 to -0.07]). Among people who did not use cannabis before or during pregnancy, living in a warning signs state was associated with beliefs that use was not safe (β = 0.34 [95% CI, 0.17 to 0.51]), that people should be punished for use (β = 0.35 [95% CI, 0.24 to 0.47]), and that use was stigmatized (β = 0.35 [95% CI, 0.07 to 0.63]). Warning signs policies were not associated with use (adjusted odds ratio, 1.11 [95% CI, 0.22 to 5.67]).

Conclusions and Relevance

In this cross-sectional study of warning signs and cannabis-related use and beliefs, warning signs policies were not associated with reduced cannabis use during pregnancy or with people who used cannabis believing use during pregnancy was less safe but were associated with greater support for punishment and stigma among people who did not use cannabis.

Accuracy of Self-assessment of Gestational Duration Among Adolescents Seeking Abortion Using Information in Addition to Date of Last Menstrual Period

This diagnostic study evaluates whether using additional information beyond the date of last menstrual period is associated with improved accuracy of self-assessed gestational duration among adolescents seeking abortion.

Changes in the Frequency and Type of Barriers to Reproductive Health Care Between 2017 and 2021

Importance

Previous research has documented individual-level barriers to reproductive health services, but few studies have examined national trends.

Objective

To determine whether the number and type of barriers to reproductive health care experienced by US women of reproductive age changed from 2017 to 2021.

Design, Setting, and Participants

This cross-sectional study used serial survey data, weighted to be nationally representative, collected in August 2017 and December 2021 from members of Ipsos's KnowledgePanel who were aged 18 to 49 years and assigned female at birth.

Exposures

Having experienced barriers to reproductive health care over the past 3 years.

Main Outcomes and Measures

The primary outcome was number and type of barriers to reproductive health care services, including Papanicolaou tests or birth control, experienced in the past 3 years. Increases in barriers to reproductive health care were measured using multivariable linear regressions adjusted for age, race and ethnicity, education level, employment status, metropolitan area, geographic region, household income, and language (English vs Spanish).

Results

Of 29 496 KnowledgePanel members invited, 7022 (mean [SD] age, 33.9 [9.0] years) and 6841 (mean [SD] age, 34.2 [8.6] years) completed the 2017 and 2021 surveys (50% and 45% response rates, respectively). Among 12 351 participants who indicated that they had ever tried accessing reproductive health services, 35.9% (95% CI, 34.8%-37.0%) were aged 30 to 39 years; 5.5% (95% CI, 4.9%-6.2%) were Asian or Pacific Islander, 13.7% (95% CI, 12.8%-14.6%) were Black, 19.1% (95% CI, 18.1%-20.1%) were Hispanic, 58.2% (95% CI, 57.0%-59.5%) were White, and 3.5% (95% CI, 3.1%-4.0%) were multiracial or of other race or ethnicity; and 11.7% (95% CI, 11.0%-12.5%) were living below 100% of the federal poverty level. Covariate distribution was similar across years. In bivariable analyses, participants were more likely to report experiencing a given barrier in the past 3 years in 2021 than in 2017 for all but 2 barriers. More people experienced 3 or more barriers in 2021 (18.6%; 95% CI, 17.3%-20.0%) than in 2017 (16.1%; 95% CI, 14.9%-17.4%) (P = .008). In multivariable analyses, the mean number of barriers increased significantly from 1.09 (95% CI, 1.02-1.14) in 2017 to 1.29 (95% CI, 1.22-1.37) (P < .001) in 2021. Participants who were aged 25 to 29 years (0.42; 95% CI, 0.37-0.47), identified as Hispanic (0.41; 95% CI, 0.38-0.45), had no high school diploma or General Educational Development test (0.62; 95% CI, 0.53-0.72), lived below 100% of the federal poverty level (0.65; 95% CI, 0.55-0.73), and took the survey in Spanish (0.87; 95% CI, 0.73-1.01) saw the greatest increases in mean number of barriers between 2017 and 2021.

Conclusions and Relevance

The study findings suggest that barriers to reproductive health care increased between 2017 and 2021, with the largest increases observed among individuals from historically disadvantaged populations. Efforts are needed to ensure that reproductive health care access remains a priority.

Unwanted abortion disclosure and social support in the abortion decision and mental health symptoms: A cross-sectional survey

OBJECTIVES

To assess the extent of unwanted abortion disclosure and levels of social support in the abortion decision and their association with depression, anxiety, and stress.

STUDY DESIGN

From January to June 2019, we surveyed people presenting for abortion at four clinics in California, New Mexico, and Illinois regarding their experiences accessing abortion. We used multivariable regression to examine associations between unwanted abortion disclosure and social support in the abortion decision, and symptoms of depression, anxiety and stress.

RESULTS

Among 1092 people approached, 784 (72% response rate) eligible individuals initiated the survey, and 746 responded to the unwanted abortion disclosure item and were included in analyses. Over one-quarter (27%) told someone they would have preferred not to tell about their decision, mostly due to obstacles getting to the appointment-time to appointment (46%), travel distance (33%), and costs (32%). Three-quarters (74%, n=546) had at least one person in their life who supported the abortion decision "very much"; 20% had someone who supported the decision "not at all." In adjusted analyses, unwanted abortion disclosure was associated with more symptoms of depression (B = 0.62, 95% confidence interval: 0.28, 0.95), anxiety (B = 1.79; 95% CI: 0.76, 2.82) and stress (B = 1.80, 95% CI: 0.64, 1.72). People also had more symptoms of depression and stress when one or more person (B = 0.64; 95% CI: 0.27, 1.02 and B = 0.75, 95% CI: 0.15, 1.35, respectively) or the man involved in the pregnancy (B = 0.67, 95% CI: 0.16, 1.18 and B = 0.96, 95% CI: 0.13, 1.78, respectively) supported their decision "not at all" (vs "very much" support).

CONCLUSION

Being forced to disclose the abortion decision due to logistical and cost constraints may be harmful to people's mental health.

IMPLICATIONS

Logistical burdens such as travel, time to access care, and costs needed to access abortion may force people seeking abortion to involve others who are unsupportive in the abortion decision having negative implications for their mental health.

Development of a Spanish-language drug facts label prototype for a combination mifepristone and misoprostol medication abortion product

OBJECTIVE

To develop a Spanish-language drug facts label prototype for medication abortion.

STUDY DESIGN

We translated a drug facts label prototype for medication abortion and conducted cognitive video interviews with reproductive age native Spanish speakers to assess and improve its readability.

RESULTS

Thirty-eight people ages 15 to 48 completed cognitive interviews, found the drug facts label easy to understand and suggested minor improvements.

CONCLUSION

Conducting cognitive interviews with native Spanish speakers is a helpful tool to improve readability of a translated label.

IMPLICATIONS

This drug facts label can help to ensure that Spanish speakers have access to easy-to-understand instructions of how to take medication abortion without clinical supervision.

Abortion terminology preferences: a cross-sectional survey of people accessing abortion care

BACKGROUND

Abortion stigma likely affects the terminology abortion patients, providers and the public use or avoid using to refer to abortion care. Knowing the terminology people seeking abortion prefer could help inform the language used in clinical interactions and improve patients' experiences with abortion care. However, research in the U.S. has not examined patients' preferences in this area or whether terminology preferences vary by participant characteristics, in the way that experiences of stigma vary across different contexts and communities. This study aims to describe preferred terminology among people presenting for abortion care and to explore the pregnancy-related characteristics associated with these preferences.

METHODS

We surveyed abortion patients about their experiences accessing abortion care, including preferred terms for the procedure. Respondents could mark more than one term, suggest their own term, or indicate no preference. We recruited people ages 15-45 seeking abortion from four U.S. abortion facilities located in three states (California, Illinois, and New Mexico) from January to June 2019. We used descriptive statistics and multivariable multinomial logistic regression to explore associations between respondents' pregnancy-related characteristics and their preferred terminology.

RESULTS

Among the 1092 people approached, 784 (77%) initiated the survey and 697 responded to the terminology preference question. Most participants (57%, n = 400) preferred only one term. Among those participants, "abortion" (43%) was most preferred, followed by "ending a pregnancy" (29%), and "pregnancy termination" (24%). In adjusted multivariable models, participants who worried "very much" that other people might find out about the abortion (29%) were significantly more likely than those who were "not at all" worried (13%) to prefer "ending a pregnancy" over having no preference for a term (adjusted relative risk ratio: 2.68, 95% Confidence Interval: 1.46-4.92).

CONCLUSIONS

People seeking abortion have varied preferences for how they want to refer to their abortions, in particular if they anticipate abortion stigma. Findings can be useful for clinicians and researchers so that they can be responsive to people's preferences during clinical interactions and in the design and conduct of abortion research.

Intimate relationships after receiving versus being denied an abortion: A 5-year prospective study in the United States

CONTEXT

When an individual seeking an abortion cannot obtain one, carrying that pregnancy to term may affect both her relationship with the man involved in the pregnancy and her prospects for new intimate relationships. We aimed to assess the impact of receiving versus being denied a wanted abortion on women's intimate relationships, up to 5 years after seeking an abortion in the United States.

METHODS

Using mixed-effects regression models, we compared relationship outcomes among women who presented for abortion care just under facilities' gestational age limits ("Near-limit abortion patients," n = 452) with those who presented just over, were denied an abortion ("Turnaways," n = 146) at 30 US facilities.

RESULTS

At 1 week post-abortion seeking, the predicted probability of being in a relationship with the man involved in the pregnancy was 58%, gradually declining to 27% at 5 years with no significant differences between those who received and those who were denied an abortion. However, from 2 to 5 years post-abortion seeking, participants who were denied an abortion had double the odds (aOR = 2.01, 95% CI: 1.09-3.69) of being in a poor intimate relationship, with a predicted probability of being in a poor relationship of 14% among those denied an abortion compared with 9% among those who received one (p < 0.05).

CONCLUSIONS

Carrying an unwanted pregnancy to term does not increase the chance of being in an intimate relationship with the man involved in the pregnancy but may have negative implications for the quality of future relationships up to 5 years post-abortion seeking.

Relationship between mandatory warning signs for cannabis use during pregnancy policies and birth outcomes in the Western United States

As U.S. states legalize recreational cannabis, some enact policies requiring Mandatory Warning Signs for cannabis during pregnancy (MWS-cannabis). While previous research has found MWS for alcohol during pregnancy (MWS-alcohol) associated with increases in adverse birth outcomes, research has not examined effects of MWS-cannabis. This study uses Vital Statistics birth certificate data from June 2015 - June 2017 in seven western states and policy data from NIAAA's Alcohol Policy Information System and takes advantage of the quasi-experiment created by Washington State's enactment of MWS-cannabis in June 2016, while nearby states did not. Outcomes are birthweight, low birthweight, gestation, and preterm birth. Analyses use a Difference-in-Difference approach and compare changes in outcomes in Washington to nearby states in the process of legalizing recreational cannabis (Alaska, California, Nevada) and, as a secondary analysis, nearby states continuing to criminalize recreational cannabis (Idaho, Montana, Wyoming). Birthweight was -7.03 g lower (95% CI -10.06, -4.00) and low birthweight 0.3% higher (95% CI 0.0, 0.6) when pregnant people were exposed to MWS-cannabis than when pregnant people were not exposed to MWS-cannabis, both statistically significant (p = 0.005 and p = 0.041). Patterns for gestation, -0.014 weeks earlier (95% CI -0.038, 0.010) and preterm birth 0.2% higher (95% CI -0.2, 0.7), were similar, although not statistically significant (p = 0.168 and 0.202). The direction of findings was similar in secondary analyses, although statistical significance varied. Similar to MWS-alcohol, enacting MWS-cannabis is associated with an increase in adverse birth outcomes. The idea that MWS-cannabis provide a public health benefit is not evidence-based.

A cross-sectional study examining consideration of self-managed abortion among people seeking facility-based care in the United States

Introduction

With increasing restrictions on abortion across the United States, we sought to understand whether people seeking abortion would consider ending their pregnancy on their own if unable to access a facility-based abortion.

Methods

From January to June 2019, we surveyed patients seeking abortion at 4 facilities in 3 US states. We explored consideration of self-managed abortion (SMA) using responses to the question: “Would you consider ending this pregnancy on your own if you are unable to obtain care at a health care facility?” We used multivariable Poisson regression to assess associations between individual sociodemographic, pregnancy and care-seeking characteristics and prevalence of considering SMA. In bivariate Poisson models, we also explored whether consideration of SMA differed by specific obstacles to abortion care.

Results

One-third (34%) of 741 participants indicated they would definitely or probably consider ending the pregnancy on their own if unable to obtain care at a facility. Consideration of SMA was higher among those who reported no health insurance (adjusted prevalence ratio [aPR] = 1.66; 95% Confidence Interval [CI] 1.12–2.44), described the pregnancy as unintended (aPR = 1.53; 95% CI 1.08–2.16), were seeking abortion due to concerns about their own physical or mental health (aPR = 1.50, 95% CI 1.02, 2.20), or experienced obstacles that delayed their abortion care seeking (aPR = 2.26, 95% CI 1.49, 3.40). Compared to those who would not consider SMA, participants who would consider SMA expressed higher difficulty finding an abortion facility (35 vs. 27%, p = 0.019), figuring out how to get to the clinic (29 vs 21%, p = 0.021) and needing multiple clinic visits (23 vs 17%, p = 0.044).

Conclusions.

One in three people seeking facility-based abortion would consider SMA if unable to obtain abortion care at a facility. As abortion access becomes increasingly restricted in the US, SMA may become more common. Future research should continue to monitor people’s consideration and use of SMA and ensure that they have access to safe and effective methods.

Accuracy of self-assessment of gestational duration among people seeking abortion

BACKGROUND

Mifepristone, used together with misoprostol, is approved by the United States Food and Drug Administration for medication abortion through 10 weeks' gestation. Although in-person ultrasound is frequently used to establish medication abortion eligibility, previous research demonstrates that people seeking abortion early in pregnancy can accurately self-assess gestational duration using the date of their last menstrual period.

OBJECTIVE

In this study, we establish the screening performance of a broader set of questions for self-assessment of gestational duration among a sample of people seeking abortion at a wide range of gestations.

STUDY DESIGN

We surveyed patients seeking abortion at 7 facilities before ultrasound and compared self-assessments of gestational duration using 11 pregnancy dating questions with measurements on ultrasound. For individual pregnancy dating questions and combined questions, we established screening performance focusing on metrics of diagnostic accuracy, defined as the area under the receiver operating characteristic curve, sensitivity (or the proportion of ineligible participants who correctly screened as ineligible for medication abortion), and proportion of false negatives (ie, the proportion of all participants who erroneously screened as eligible for medication abortion). We tested for differences in sensitivity across individual and combined questions using McNemar's test, and for differences in accuracy using the area under the receiver operating curve and Sidak adjusted P values.

RESULTS

One-quarter (25%) of 1089 participants had a gestational duration of >70 days on ultrasound. Using the date of last menstrual period alone demonstrated 83.5% sensitivity (95% confidence interval, 78.4-87.9) in identifying participants with gestational durations of >70 days on ultrasound, with an area under the receiver operating characteristic curve of 0.82 (95% confidence interval, 0.79-0.85) and a proportion of false negatives of 4.0%. A composite measure of responses to questions on number of weeks pregnant, date of last menstrual period, and date they got pregnant demonstrated 89.1% sensitivity (95% confidence interval, 84.7-92.6) and an area under the receiver operating curve of 0.86 (95% confidence interval, 0.83-0.88), with 2.7% of false negatives. A simpler question set focused on being >10 weeks or >2 months pregnant or having missed 2 or more periods had comparable sensitivity (90.7%; 95% confidence interval, 86.6-93.9) and proportion of false negatives (2.3%), but with a slightly lower area under the receiver operating curve (0.82; 95% confidence interval, 0.79-0.84).

CONCLUSION

In a sample representative of people seeking abortion nationally, broadening the screening questions for assessing gestational duration beyond the date of the last menstrual period resulted in improved accuracy and sensitivity of self-assessment at the 70-day threshold for medication abortion. Ultrasound assessment for medication abortion may not be necessary, especially when requiring ultrasound could increase COVID-19 risk or healthcare costs, restrict access, or limit patient choice.

Mail-order pharmacy dispensing of mifepristone for medication abortion after in-person clinical assessment

OBJECTIVE(S)

To estimate the effectiveness, acceptability, and feasibility of medication abortion with mifepristone dispensed by a mail-order pharmacy after in-person clinical assessment.

STUDY DESIGN

This is an interim analysis of an ongoing prospective cohort study conducted at five sites. Clinicians assessed patients in clinic and, if they were eligible for medication abortion and ≤ 63 days' gestation, electronically sent prescriptions for mifepristone 200 mg orally and misoprostol 800 mcg buccally to a mail-order pharmacy, which shipped medications for next-day delivery. Participants completed surveys three and 14 days after enrollment, and we abstracted medical chart data.

RESULTS

Between January 2020 and April 2021 we enrolled 240 participants and obtained clinical outcome information for 227 (94.6%); 3 reported not taking either medication. Of those with abortion outcome information (N = 224), 216 (96.4%) completed day-3 and 212 (94.6%) day-14 surveys. Of the 224 that took medications, none reported taking past 70 days' gestation, and complete medication abortion occurred for 217 participants (96.9%, 95% CI 93.7%-98.7%). Most received medications within three days (82.1%, 95% CI 76.5%-86.9%). In the day-3 survey, 95.4% (95% CI 91.7%-97.8%) reported being very (88.4%) or somewhat (6.9%) satisfied with receiving medications by mail. In the day-14 survey, 89.6% (95% CI 84.7%-93.4%) said they would use the mail-order service again if needed. Eleven (4.9%, 95% CI 2.5%-8.6%) experienced adverse events; two were serious (one blood transfusion, one hospitalization), and none were related to mail-order pharmacy dispensing.

CONCLUSIONS

Medication abortion with mail-order pharmacy dispensing of mifepristone appears effective, feasible, and acceptable to patients.

IMPLICATIONS

The in-person dispensing requirement for mifepristone, codified in the drug's Risk Evaluation and Mitigation Strategy, should be removed.

Timing of pregnancy discovery among women seeking abortion. Contraception 2021;104:642-647. [PMID: 34363842 DOI: 10.1016/j.contraception.2021.07.110]

OBJECTIVE

Little is known about the incidence and causes of delay in recognition of pregnancy. Delay in pregnancy recognition is associated with later presentation for abortion and exacerbates the burdens in accessing care. Using Turnaway study data, this study assessed the prevalence of later pregnancy recognition among a sample of people who obtained or were denied a wanted abortion.

STUDY DESIGN

The Turnaway Study included telephone interviews of 956 women who sought an abortion in the first trimester or just over or under the gestational limit of one of 30 abortion facilities across the United States and in-depth interviews with 31 who completed 5 years of surveys. We describe women's experiences discovering pregnancy and conducted multivariate analyses assessing factors associated with later pregnancy discovery (after 13 weeks since last menstrual period [LMP]).

RESULTS

Most women seeking second trimester abortions recognized their pregnancy more than 8 weeks after their LMP; more than 1 in 5 recognized pregnancy after 20 weeks. In interviews, women explained that recognition was delayed because of a lack of pregnancy symptoms or concurrence of other conditions with symptoms similar to pregnancy. According to multivariate analyses, women who had never given birth (adjusted odds ratio [aOR] = 1.71; 95% confidence interval [CI]: 1.24, 2.35) and those who used hormonal contraceptives in the month of conception (aOR = 1.83; 95% CI: 1.35, 2.47) were more likely to discover pregnancy after 13 weeks.

CONCLUSION

Laws imposing gestational limits will make abortion unavailable to people who discover pregnancy after the limit. Such bans are likely to disproportionately affect people using contraceptive methods to prevent pregnancy and those who have never given birth.

IMPLICATIONS

Some pregnant people have few pregnancy symptoms and/or have conditions with symptoms similar to pregnancy, such as irregular periods or chronic pain. Gestational limits to abortion are likely to disproportionately affect people who recognize pregnancy later in pregnancy, particularly those without prior pregnancy experiences and who are using contraception.

Pharmacists' knowledge, perspectives, and experiences with mifepristone dispensing for medication abortion

BACKGROUND

The U.S. Food and Drug Administration (FDA) restricts dispensing of mifepristone for medication abortion to certified health care providers at clinical facilities, thus prohibiting pharmacist dispensing. Allowing mifepristone dispensing by pharmacists could improve access to medication abortion.

OBJECTIVE

To assess the feasibility of pharmacists dispensing mifepristone to patients who have undergone evaluation for eligibility and counseling for medication abortion by a clinician.

METHODS

Before providing a study training on medication abortion, we administered baseline surveys to pharmacists who participated in a multisite mifepristone-dispensing intervention. The survey assessed medication abortion knowledge-using a 15-item score-and perceptions about the benefits and challenges of the model. We administered follow-up surveys in the study's final month that also assessed the pharmacists' satisfaction and experiences with mifepristone dispensing. To investigate the association of the study intervention with the pharmacists' knowledge, perceptions, and experiences dispensing mifepristone, we conducted multivariable linear regression analyses using generalized estimating equation models, accounting for clustering by individual.

RESULTS

Among the 72 pharmacists invited from 6 pharmacies, 47 (65%) completed the baseline surveys, and 56 (78%) received training. At the study's end (mean 18 months later), 43 of the 56 pharmacists who received training (77%) completed the follow-up surveys. At follow-up, 36 (83%) respondents were very or somewhat satisfied with mifepristone dispensing, and 24 (56%) reported experiencing no challenges dispensing mifepristone. Four (6%) of the 72 pharmacists invited objected to participating in mifepristone dispensing. In regression analyses, average knowledge scores, perceived ease of implementation, and level of support for the pharmacist-dispensing model were higher at follow-up (P < 0.001).

CONCLUSION

Most pharmacists were willing to be trained, dispensed mifepristone with few challenges when given the opportunity, were satisfied with the model, and had higher knowledge levels at follow-up. Our findings support removal of FDA's restriction on pharmacist dispensing of mifepristone.

"It's Worked Well for Me": Young Women's Reasons for Choosing Lower-Efficacy Contraceptive Methods

STUDY OBJECTIVE

To understand the diverse reasons why some young women choose contraceptive methods that are less effective at preventing pregnancy, including condoms, withdrawal, and emergency contraception pills, even when more effective contraceptive methods are made available to them.

DESIGN

In-depth interviews with young women at family planning clinics in July-November 2016. Interview data were thematically coded and analyzed using an iterative approach.

SETTING

Two youth-serving family planning clinics serving predominantly Latinx and African American communities in the San Francisco Bay Area, California.

PARTICIPANTS

Twenty-two young women ages 15-25 years who recently accessed emergency contraception to prevent pregnancy.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Young women's experiences using different methods of contraception, with specific attention to methods that are less effective at preventing pregnancy.

RESULTS

Young women reported having previously used a range of higher- and lower-efficacy contraceptive methods. In interviews, they described affirmative values that drive their decision to use lower-efficacy methods, including: a preference for flexibility and spontaneity over continual contraceptive use, an emphasis on protecting one's body, and satisfaction with the method's effectiveness at preventing pregnancy. Some young women described using a combination of lower-efficacy methods to reduce their pregnancy risk.

CONCLUSION

Young women make contraceptive decisions on the basis of preferences and values that include, but are not limited to, effectiveness at preventing pregnancy. These reasons are salient in their lives and need to be recognized as valid by sexual health care providers to ensure that young women receive ongoing high-quality care.

"I'll just deal with this on my own": a qualitative exploration of experiences with self-managed abortion in the United States

Background

A growing body of evidence indicates that some people seek options to terminate a pregnancy without medical assistance, but experiences doing so have largely been documented only among people accessing a clinic-based abortion. We aim to describe self-managed abortion (SMA) experiences of people recruited outside of clinics, including their motivations for SMA, pregnancy confirmation and decision-making processes, method choices, and clinical outcomes.

Methods

In 2017, we conducted 14 in-depth interviews with self-identified females of reproductive age who recently reported in an online survey administered to Ipsos’ KnowledgePanel that, since 2000, they had attempted SMA while living in the United States. We asked participants about their reproductive histories, experiences seeking reproductive health care, and SMA experiences. We used an iterative process to develop codes and analyzed transcripts using thematic content analysis methods.

Results

Motivations and perceptions of effectiveness varied by whether participants had confirmed the pregnancy prior to SMA. Participants who confirmed their pregnancies chose SMA because it was convenient, accessible, and private. Those who did not test for pregnancy were motivated by a preference for autonomy and felt empowered by the ability to try something on their own before seeking facility-based care. Participants prioritized methods that were safe and available, though not always effective. Most used herbs or over-the-counter medications; none used self-sourced abortion medications, mifepristone and/or misoprostol. Five participants obtained facility-based abortions and one participant decided to continue the pregnancy after attempting SMA. The remaining eight reported being no longer pregnant after SMA. None of the participants sought care for  SMA complications; one participant saw a provider to confirm abortion completion.

Conclusions

There are many types of SMA experiences. In addition to those who pursue SMA as a last resort (after facing barriers to facility-based care) or as a first resort (because they prefer homeopathic remedies), our findings show that some individuals view SMA as a potential interim step worth trying after suspecting pregnancy and before accessing facility-based care. These people in particular would benefit from a medication abortion product available over the counter, online, or in the form of a missed-period pill.

Some people in the United States (US) attempt to end a pregnancy on their own without medical supervision. What we know about this experience comes from studies focused on people who go to clinics. In this study, we conducted 14 interviews with self-identified women ages 18–49 who recently reported attempting to end a pregnancy on their own and who were recruited outside of the clinic setting. We asked participants about their fertility histories, experiences seeking reproductive health care, and experiences ending a pregnancy without medical assistance. Those who took a pregnancy test and then chose to end the pregnancy on their own did so because it was convenient, accessible, and private. Those who did not test for pregnancy felt empowered by the ability to try something on their own before seeking facility-based care. All participants prioritized methods that were safe and available, though not always effective. After they attempted to end the pregnancy on their own, five participants accessed abortion care in facilities, one decided to continue the pregnancy, and eight were no longer pregnant. Our findings show that, in addition to people who end a pregnancy on their own as a last resort (after facing barriers to facility-based care) or as a first resort (because of preferences for homeopathic methods), a third group values having an interim step to try after suspecting pregnancy and before accessing facility-based care. These people would particularly benefit from a medication abortion product available over the counter, online, or in the form of a missed-period pill.

Pre-Abortion Informed Consent Through Telemedicine vs. in Person: Differences in Patient Demographics and Visit Satisfaction

PURPOSE

Utah law requires patients to have a face-to-face "informed consent" visit at least 72 hours prior to abortion. Planned Parenthood Association of Utah (PPAU) offers this visit via telemedicine as an alternative to an in-person visit, which can require burdensome travel. This novel study identifies factors associated with using telemedicine for informed consent, patients' reasons for using it, and experiences with it, compared to in-person informed consent.

METHODS

In 2017 and 2018, patients 18 years and older seeking abortion at PPAU completed a self-administered online survey about their experiences with the informed consent visit. We used linear and logistic regression models to compare participants' demographic characteristics by informed consent visit type, and descriptive statistics to describe reasons for using each visit type and experiences with the visit. Multivariable logistic regression models examined associations between visit type and satisfaction.

RESULTS

Responses from 166 telemedicine patients and 217 in-person informed consent patients indicate that telemedicine participants would have had to travel significantly further than in-person participants traveled to attend the visit at the clinic (mean of 65 miles versus 21 miles, p < .001). In multivariable analyses, telemedicine participants had higher odds of being "very satisfied" with the visit (aOR, 2,89; 95% CI: 1.93-4.32) and "very comfortable" asking questions during the visit (aOR, 3.76; 95% CI: 2.58-5.49), compared to participants who attended in-person visits.

CONCLUSIONS

Telemedicine offers a convenient, acceptable option for mandated pre-abortion informed consent visits and reduces the burden of additional travel and associated barriers for some patients, particularly those who live further away from clinics.

The Role of Health Care Providers in Young Women's Attitudes about and Willingness to Use Emergency Contraceptive Pills

BACKGROUND

Emergency contraceptive pills (ECPs) are an underused resource among adolescent and young adult women who have unprotected sex. This analysis examines young women's attitudes about and willingness to use ECPs, with particular attention to their experiences with health care providers.

METHODS

Sexually active young women (ages 15-25, assigned female at birth, N = 212) completed a self-administered survey at 10 family planning clinics in the San Francisco Bay Area. Participants reported attitudes about ECP effectiveness, safety, effect on sex drive, and whether it should not be taken often, and their willingness to use ECPs in the next 3 months. The predictors of interest were past and current contraceptive experiences with health care providers. Data were analyzed through descriptive statistics and multivariable logistic regression analyses controlling for sociodemographic characteristics, prior contraceptive use, pregnancy history, and pregnancy intentions.

RESULTS

Most young women agreed that ECPs are effective at preventing pregnancy (75%) and safe to use (71%); few reported that they reduce sex drive (11%). Yet, the majority (62%) believed ECPs should not be taken often and only 35% reported willingness to use ECPs. In multivariable analyses, more positive health care experiences were associated with more positive attitudes about ECP safety, less concern that ECPs should not be taken often, and greater willingness to use ECPs (p < .05).

CONCLUSIONS

Health care providers play an important role in the acceptance and provision of ECPs, especially for young women who prefer ECPs over other contraceptive methods. In particular, providers can use the contraceptive visit as an opportunity to destigmatize repeat ECP use.

Reasons for and Logistical Burdens of Judicial Bypass for Abortion in Illinois

PURPOSE

Minors seeking abortion in states with parental involvement requirements can obtain judicial bypass (JB) as an alternative. Research on minors' reasons for choosing bypass and the logistical obstacles associated with bypass is limited, yet needed to assess potential burdens introduced by mandated parental involvement.

METHODS

Using data from all minors represented in JB proceedings by the Illinois Judicial Bypass Coordination Project in 2017 and 2018, we present descriptive statistics summarizing minors' demographic characteristics, reasons for seeking bypass, individuals involved in decision-making, and distances traveled and time elapsed to attend the court hearing.

RESULTS

Most minors obtaining bypass (n = 150) agreed to participate (n = 128). Just more than half (55%) were aged 17 years and lived with one parent (54%). A minority were already parenting (5%) and/or lived with someone besides a parent or on their own (16%). The reasons for bypass included concern about being forced to continue the pregnancy (50%), fear of being kicked out of their home and/or cut off financially (41%), having no/minimal relationship with parents (15%), and fear of physical/emotional abuse (13%). Minors traveled an average of 24 miles one-way (range 1-270 miles) to a courthouse for their hearing. On average, 6.4 days elapsed between contacting the Judicial Bypass Coordination Project and the hearing.

CONCLUSIONS

Judicial bypass can offer young people an opportunity to retain autonomy in decision-making, potentially avoiding abuse and other negative outcomes. However, even in a state with a well-organized network of attorneys, JB contributes 1 week to minors' abortion-seeking timeline and necessitates traveling long distances.

Abortion method preference among people presenting for abortion care

OBJECTIVE

To explore abortion method preference, interpersonal and cultural factors associated with preference, and whether, among people with a preference for medication abortion, those presenting past 10 weeks gestation had experienced more obstacles to care.

METHODS

In 2019, we invited people aged 15 to 45 years presenting to 4 U.S. abortion clinics to complete a self-administered, anonymous iPad survey prior to seeing the health care provider. Questions focused on their pregnancy, including self-reported gestational age and experiences accessing abortion care, including abortion method preference. We used multivariate logistic regression to assess associations between worry about perceived pregnancy-related stigma or abortion-related health myths and abortion method preference.

RESULTS

The majority (784 [77%]) of those approached (1092) initiated the survey and 712 responded to the preference question. Most (597 [84%]) preferred a method: 246 (41%) preferred medication abortion and 351 (59%) an in-clinic procedure. About one-third (110 [32%]) of those preferring medication abortions exceeded 10 weeks gestation and 83% (n = 91) had experienced delay-causing obstacles to care. In multivariate analyses, we found a greater odd of preference for medication abortion over in-clinic procedure among those very worried about people's reaction to the pregnancy (adjusted OR [aOR] 1.95, 95% CI 1.16-3.28), judgment from God or religion (aOR 1.93, 95% CI 1.17-3.19) and abortion affecting mental health (aOR 2.51, 95% CI 1.45-4.34) or ability to get pregnant later (aOR 1.80, 95% CI: 1.09-2.97).

CONCLUSIONS

Many people seeking abortion have a method preference; delayed presentation to care may impede ability to obtain desired method. Pregnancy-related stigma and misinformation are associated with preference for medication abortion.

IMPLICATIONS STATEMENT

Pregnancy-related stigma and misinformation, such as health and safety myths promulgated by state-mandated abortion counseling, may motivate preference for medication abortion. Abortion access obstacles may impede individuals' ability to obtain their preferred method. Removing barriers to clinic access may enhance people's ability to obtain their preferred abortion method.

Chilean Medical and Midwifery Faculty's Views on Conscientious Objection for Abortion Services

CONTEXT

In 2017, Chile reformed its abortion law to allow the procedure under limited circumstances. Exploring the views of Chilean medical and midwifery faculty regarding abortion and the use of conscientious objection (CO) at the time of reform can inform how these topics are being taught to the country's future health care providers.

METHODS

Between March and September 2017, 30 medical and midwifery school faculty from universities in Santiago, Chile were interviewed; 20 of the faculty taught at secular universities and 10 taught at religiously affiliated universities. Faculty perspectives on CO and abortion, the scope of CO, and teaching about CO and abortion were analyzed using a grounded theory approach.

RESULTS

Most faculty at secular and religiously affiliated universities supported the rights of clinicians to refuse to provide abortion care. Secular-university faculty generally thought that CO should be limited to specific providers and rejected the idea of institutional CO, whereas religious-university faculty strongly supported the use of CO by a broad range of providers and at the institutional level. Only secular-university faculty endorsed the idea that CO should be regulated so that it does not hinder access to abortion care.

CONCLUSIONS

The broader support for CO in abortion among religious-university faculty raises concerns about whether students are being taught their ethical responsibility to put the needs of their patients above their own. Future research should monitor whether Chile's CO regulations and practices are guaranteeing people's access to abortion care.

Developing and validating the Psychosocial Burden among people Seeking Abortion Scale (PB-SAS)

While there is a large body of research demonstrating that having an abortion is not associated with adverse mental health outcomes, less research has examined which factors may contribute to elevated levels of mental health symptoms at the time of abortion seeking. This study aims to develop and validate a new tool to measure dimensions of psychosocial burden experienced by people seeking abortion in the United States. To develop scale items, we reviewed the literature including existing measures of stress and anxiety and conducted interviews with experts in abortion care and with patients seeking abortion. Thirty-five items were administered to 784 people seeking abortion at four facilities located in three U.S. states. We used exploratory factor analysis (EFA) to reduce items and identify key domains of psychosocial burden. We assessed the predictive validity of the overall scale and each sub-scale, by assessing their associations with validated measures of perceived stress, anxiety, and depression using multivariable linear regression models. Factor analyses revealed a 12-item factor solution measuring psychosocial burden seeking abortion, with four subdomains: structural challenges, pregnancy decision-making, lack of autonomy, and others' reactions to the pregnancy. The alpha reliability coefficients were acceptable for the overall scale (α = 0.83) and each subscale (ranging from α = 0.82-0.85). In adjusted analyses, the overall scale was significantly associated with stress, anxiety and depression; each subscale was also significantly associated with each mental health outcome. This new scale offers a practical tool for providers and researchers to empirically document the factors associated with people's psychological well-being at the time of seeking an abortion. Findings suggest that the same restrictions that claim to protect people from mental health harm may be increasing people's psychosocial burden and contributing to adverse psychological outcomes at the time of seeking abortion.

The Fine Line Between Informing and Coercing: Community Health Center Clinicians' Approaches to Counseling Young People About IUDs

CONTEXT

While community health centers (CHCs) are meeting increased demand for contraceptives, little is known about contraceptive counseling in these settings. Understanding how clinicians counsel about IUDs in CHCs, including whether they address or disregard young people's preferences and concerns during counseling, could improve contraceptive care.

METHODS

As part of a training program, 20 clinicians from 11 San Francisco Bay Area CHC sites who counsel young people about contraception were interviewed by telephone in 2015 regarding their IUD counseling approaches. An iterative grounded theory approach was used to analyze interview transcripts and identify salient themes related to clinicians' contraceptive counseling, IUD removal practices and efforts to address patient concerns regarding side effects.

RESULTS

Most clinicians offered comprehensive contraceptive counseling and method choice. While several clinicians viewed counseling as an opportunity to empower their patients to make contraceptive decisions without pressure, they also described a tension between guiding young people toward higher-efficacy methods and respecting patients' choices. Many clinicians engaged in what could be considered coercive practices by trying to dissuade patients from removals within a year of placement and offering to treat or downplay side effects.

CONCLUSIONS

Providers try to promote their young patients' autonomous decision making, but their support for high-efficacy methods can result in coercive practices. More training is needed to ensure that providers employ patient-centered counseling approaches, including honoring patient requests for removals.

Prevalence of Self-Managed Abortion Among Women of Reproductive Age in the United States

IMPORTANCE

Increasing evidence indicates that people are attempting their own abortions outside the formal health care system. However, population-based estimates of experience with self-managed abortion (SMA) are lacking.

OBJECTIVE

To estimate the prevalence of SMA attempts among the general US population.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey study was fielded August 2 to 17, 2017 among English- and Spanish- speaking, self-identified female panel members from the GfK web-based KnowledgePanel. Women ages 18 to 49 years were approached to complete a 1-time survey. Data were analyzed from September 22, 2017, to March 26, 2020.

MAIN OUTCOMES AND MEASURES

SMA was defined as "some women may do something on their own to try to end a pregnancy without medical assistance. For example, they may get information from the internet, a friend, or family member about pills, medicine, or herbs they can take on their own, or they may do something else to try to end the pregnancy." SMA was assessed using the question, "Have you ever taken or used something on your own, without medical assistance, to try to end an unwanted pregnancy?" Participants reporting SMA were asked about methods used, reasons, and outcomes. Factors associated with SMA experience, including age, race/ethnicity, socioeconomic status, nativity, reproductive health history, and geography, were assessed. Projected lifetime SMA prevalence was estimated using discrete-time event history models, adjusting for abortion underreporting.

RESULTS

Among 14 151 participants invited to participate, 7022 women (49.6%) (mean [SE] age, 33.9 [9.0] years) agreed to participate. Among these, 57.4% (95% CI, 55.8%-59.0%) were non-Hispanic White, 20.2% (95% CI, 18.9%-21.5%) were Hispanic, and 13.3% (95% CI, 12.1%-14.5%) were non-Hispanic Black; and 15.1% (95% CI, 14.1%-16.3%) reported living at less than 100% federal poverty level (FPL). A total of 1.4% (95% CI, 1.0%-1.8%) of participants reported a history of attempting SMA while in the US. Projected lifetime prevalence of SMA adjusting for underreporting of abortion was 7.0% (95% CI, 5.5%-8.4%). In bivariable analyses, non-Hispanic Black (prevalence ratio [PR], 3.16; 95% CI, 1.48-6.75) and Hispanic women surveyed in English (PR, 3.74; 95% CI, 1.78-7.87) were more likely than non-Hispanic White women to have attempted SMA. Women living below 100% of the FPL were also more likely to have attempted SMA compared with those at 200% FPL or greater (PR, 3.43; 95% CI, 1.83-6.42). At most recent SMA attempt, 20.0% (95% CI, 10.9%-33.8%) of respondents used misoprostol, 29.2% (95% CI, 17.5%-44.5%) used another medication or drug, 38.4% (95% CI, 25.3%-53.4%) used herbs, and 19.8% (95% CI, 10.0%-35.5%) used physical methods. The most common reasons for SMA included that it seemed faster or easier (47.2% [95% CI, 33.0%-61.8%]) and the clinic was too expensive (25.2% [95% CI, 15.7%-37.7%]). Of all attempts, 27.8% (95% CI, 16.6%-42.7%) of respondents reported they were successful; the remainder reported they had subsequent facility-based abortions (33.6% [95% CI, 21.0%-49.0%]), continued the pregnancy (13.4% [95% CI, 7.4%-23.1%]), had a miscarriage (11.4% [95% CI, 4.2%-27.5%]), or were unsure (13.3% [95% CI, 6.8%-24.7%]). A total of 11.0% (95% CI, 5.5%-21.0%) of respondents reported a complication.

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that approximately 7% of US women reported having attempted SMA in their lifetime, commonly with ineffective methods. These findings suggest that surveys of SMA experience among patients at abortion clinics may capture only one-third of SMA attempts. People's reasons for attempting SMA indicate that as abortion becomes more restricted, SMA may become more common.

Fertility intentions and recent births among US abortion patients

OBJECTIVE

To examine fertility intentions among abortion patients and the potential of abortion for avoiding short birth intervals.

STUDY DESIGN

We used national data from a sample of more than 8000 individuals obtaining abortions in the United States in 2014. We created a measure of fertility intentions based on prior births and responses to an item asking about future childbearing expectations. We identify respondents who reported having a birth in the last 12 months as at risk of a short birth interval. We used simple logistic regression to assess for differences in these measures according to key demographic variables.

RESULTS

Most commonly, 39% of patients intended to have (more) children, with similar proportions wanting to delay a first birth (20%) or postpone a second or higher order birth (19%). Some 31% of abortion patients had completed childbearing; they had one or more prior births and did not want to have any more children. Similar proportions of respondents were not sure if they wanted to have children (16%) or did not want to have any children (15%). Among abortion patients who had children, 14% had had a birth in the prior year. We estimate that as many as 77,800 short birth intervals were averted in 2014 because individuals had access to abortion.

CONCLUSIONS

These findings support the view that abortion allows individuals to plan and space their births according to their reproductive life plans and intentions.

IMPLICATIONS

Access to abortion may help thousands of individuals in the United States avoid short birth intervals, potentially leading to improvements in maternal and child health.

"Obviously there is a conflict between confidentiality and what you are required to do by law": Chilean university faculty and student perspectives on reporting unlawful abortions

BACKGROUND AND OBJECTIVES

While Chile recently decriminalized abortion in cases of rape, lethal fetal anomaly, and to save a woman's life, most abortions are still criminalized. We assessed medical and midwifery school faculty and students' views on punishing and reporting people involved in unlawful abortion, and their understanding of their obligation to protect patient confidentiality and to report unlawful abortions.

METHODS

We interviewed 30 medical and midwifery school clinician faculty from seven public, private, secular and Catholic-affiliated universities, all located in the metropolitan region of Santiago, Chile. Medical (n = 239) and midwifery (n = 79) students at these same seven universities completed an online survey. We coded faculty interview transcripts, and analyzed codes related to maintaining patient confidentiality and reporting unlawful abortion. We summarized student views related to reporting and imprisoning people involved in unlawful abortion, and used general estimating equation (GEE) models to identify the factors associated with support for criminalization.

RESULTS

Faculty and students generally did not support reporting or imprisoning anyone involved in an unlawful abortion and believed that protecting patient information takes precedence over reporting. Yet, faculty described pressures to report in the public sector and several cases where they or their colleagues were involved in reports. Most students somewhat/strongly agreed (78%) that patient information concerning an unlawful abortion should be kept confidential; 35% strongly/somewhat agreed that a clinician involved in an unlawful surgical abortion should be imprisoned, and 18% agreed that the woman involved should be imprisoned, with students from secular universities being significantly less likely to support reporting and punishing people involved in unlawful abortion, than students from Catholic universities.

DISCUSSION

There is a need to clarify clinicians' ethical obligations in abortion care, in particular in Catholic universities, so that they can ensure that their patients have access to high quality confidential health care services.