The Status of Women's Reproductive Rights and Adverse Birth Outcomes

BackgroundReproductive rights—the ability to decide whether and when to have children—shape women's socioeconomic and health trajectories across the life course. The objective of this study was to examine reproductive rights in association with preterm birth (PTB; <37 weeks) and low birth weight (LBW; <2,500g) across states in the United States.MethodsAnalysis included records for all live births in the United States in 2012 grouped by state. A reproductive rights composite index score was assigned to records from each state based on the following indicators for the year before birth (2011): mandatory sex education, expanded Medicaid eligibility for family planning services, mandatory parental involvement for minors seeking abortion, mandatory abortion waiting periods, public funding for abortion, and percentage of women in counties with abortion providers. Scores were ranked by tertile with the highest tertile reflecting states with strongest reproductive rights. We fit logistic regression models with generalized estimating equations to estimate the odds ratios and 95% confidence intervals for PTB and LBW associated with reproductive rights score controlling for maternal race, age, education, and insurance and state-level poverty.ResultsStates with the strongest reproductive rights had the lowest rates of LBW and PTB (7.3% and 10.6%, respectively) compared with states with more restrictions (8.5% and 12.2%, respectively). After adjustment, women in more restricted states experienced 13% to 15% increased odds of PTB and 6% to 9% increased odds of LBW compared with women in states with the strongest rights.ConclusionsState-level reproductive rights may influence likelihood of adverse birth outcomes among women residents.     

Abortion Knowledge Among Advanced Practice Clinicians in Colorado

IntroductionOur objective was to quantify abortion law and care knowledge among Colorado advanced practice clinicians.MethodsWe conducted a stratified random survey of advanced practice clinicians, oversampling women’s health and rural clinicians. We assessed sample characteristics, positions on abortion legality, and knowledge of abortion law and care. Mean knowledge scores were compared by sample characteristics. Survey responses were compared by provision of pregnancy options counseling and positions on abortion legality. Linear regression models were used to examine knowledge scores.ResultsA total of 513 participants completed the survey; the response rate was 21%. Abortion law knowledge questions (mean score, 1.7/7.0) ranged from 12% (physician-only law) to 45% (parental consent law) correct. For five of seven questions, “I don’t know” was the most frequently chosen response. Abortion care knowledge questions (mean score, 2.8/8.0) ranged from 19% (abortion prevalence) to 60% (no elevated risk of breast cancer) correct. For four of eight questions, “I don’t know” was the most frequently chosen response. Practicing in all other areas (e.g., family practice) was associated with lower abortion law and care knowledge than practicing in women’s health. Providing options counseling was positively associated with abortion knowledge (law, β = 0.44; 95% confidence interval [CI], 0.10–0.78; care, β = 0.52; 95% CI, 0.08–0.95). Compared with participants who believe abortion should be legal in all circumstances, those who believe abortion should be illegal in all circumstances had similar abortion law knowledge (β = ?0.03; 95% CI, ?0.65 to 0.59), but lower abortion care knowledge (β = ?1.85; 95% CI, ?2.34 to ?1.36).ConclusionsAbortion knowledge is low among Colorado advanced practice clinicians and education is needed.     

Does information about abortion safety affect Texas voters' opinions about restrictive laws? A randomized study

ObjectiveThe objective was to assess whether information about abortion safety and awareness of abortion laws affect voters' opinions about medically unnecessary abortion regulations.Study designBetween May and June 2016, we randomized 1200 Texas voters to receive or not receive information describing the safety of office-based abortion care during an online survey about abortion laws using simple random assignment. We compared the association between receiving safety information and awareness of recent restrictions and beliefs that ambulatory surgical center (ASC) requirements for abortion facilities and hospital admitting privileges requirements for physicians would make abortion safer. We used Poisson regression, adjusting for political affiliation and views on abortion.ResultsOf 1200 surveyed participants, 1183 had complete data for analysis: 612 in the information group and 571 in the comparison group. Overall, 259 (46%) in the information group and 298 (56%) in the comparison group believed that the ASC requirement would improve abortion safety (p=.008); 230 (41%) in the information group and 285 (54%) in the comparison group believed that admitting privileges would make abortion safer (p<.001). After multivariable adjustment, the information group was less likely to report that the ASC [prevalence ratio (PR): 0.82; 95% confidence interval (CI): 0.72–0.94] and admitting privileges requirements (PR: 0.76; 95% CI: 0.65–0.88) would improve safety. Participants who identified as conservative Republicans were more likely to report that the ASC (82%) and admitting privileges requirements (83%) would make abortion safer if they had heard of the provisions than if they were unaware of them (ASC: 52%; admitting privileges: 47%; all p<.001).ConclusionsInformational statements reduced perceptions that restrictive laws make abortion safer. Voters' prior awareness of the requirements also was associated with their beliefs.ImplicationsInformational messages can shift scientifically unfounded views about abortion safety and could reduce support for restrictive laws. Because prior awareness of abortion laws does not ensure accurate knowledge about their effects on safety, it is important to reach a broad audience through early dissemination of information about new regulations.     

It Is Time to Integrate Abortion Into Primary Care

The Roe v Wade decision made safe abortion available but did not change the reality that more than 1 million women face an unwanted pregnancy every year. Forty years after Roe v Wade, the procedure is not accessible to many US women.The politics of abortion have led to a plethora of laws that create enormous barriers to abortion access, particularly for young, rural, and low-income women. Family medicine physicians and advanced practice clinicians are qualified to provide abortion care.To realize the promise of Roe v Wade, first-trimester abortion must be integrated into primary care and public health professionals and advocates must work to remove barriers to the provision of abortion within primary care settings.THE 1973 ROE V WADE decision1 removed many legal obstacles to abortion and was a public health watershed. The availability of safe abortion services led to dramatically decreased rates of maternal morbidity and mortality in the United States,2 as in most countries that have removed legal impediments to abortion care.According to the most recent available data, approximately 1.2 million women obtain safe, legal abortions from skilled clinicians in the United States every year.3 The political debate over abortion has largely ignored the public health fact that the Roe v Wade decision did not create or change the need for abortion; legalization simply made abortion safe. Maternal death from unsafe abortion in the United States became a negligible statistic after 1973. Abortion is now one of the safest medical procedures available; only 0.3% of abortion patients experience a complication that requires hospitalization.4Unwanted pregnancy continues to be a reality of women’s lives. One in three women in the United States will seek an abortion before she is aged 45 years.3 For these women, restrictive laws driven by ideology, not science, are undermining the promise of Roe v Wade in many parts of the country. State restrictions—including waiting periods, parental consent requirements for minors, lack of insurance coverage or Medicaid coverage for abortion, and expensive and unnecessary building requirements for facilities that provide abortions—create almost insurmountable barriers to access, especially for rural, young, and low-income women. There are ever-increasing restrictions passed at the state and federal levels, and antiabortion activists have directed a relentless campaign of violence and harassment at clinics and clinicians who provide the service. Many medical residencies lack training opportunities, leading to a lack of skilled abortion providers. The cumulative result of these regulations, the harassment, and the lack of training is a shrinking number of sites that offer abortion services.Specialized abortion clinics performed 70% of all abortions in 2008,3 yet the hostile political climate those opposed to abortion have created is forcing the numbers of these clinics to decline every year. The number of abortion providers has declined dramatically, from 2908 in 1982 to 1787 in 2005. Eighty-seven percent of all US counties lacked an abortion provider in 2008; 35% of US women live in those counties.3Abortion services are concentrated in cities.3 Almost all nonmetropolitan counties (which is 97% of all US counties) lack an abortion provider.3 In eight states (Arkansas, Idaho, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, and Wyoming) there are abortion clinics in only one city in the entire state. The result of the shortage of providers is that although abortion is one of the most common medical procedures performed in the United States, in many areas of the country women must travel for hours and deal with long delays to get the reproductive health care they need.Primary care clinicians provide personalized continuous preventative health care to patients throughout their reproductive years. Physician assistants, nurse midwives, and nurse practitioners (collectively, advanced practice clinicians, or APCs) and family physicians provide the majority of well-woman care to patients throughout the country. The skills needed to provide abortions—including the ability to assess gestational age, provide counseling, provide medications, perform manual or electric vacuum aspiration, and conduct postabortion follow-up—are in the scope of practice of primary clinicians. Many primary care clinicians who specialize in women’s health have specialized training. They perform suturing, colposcopy, intrauterine device insertions, endometrial biopsy, and gynecological care; and prescribe medications for family planning. These skills are comparable to those required to perform a first-trimester abortion.The provision of first-trimester abortion care is clearly within the scope of practice of primary care clinicians. In fact, since 1973 physician assistants have provided abortions in Montana and Vermont. Beginning in the early 1990s, advocates and professional groups came together to begin state-by-state advocacy to clarify the laws and scope of practice issues and promote the involvement of APCs in abortion care. APCs have been legally recognized as competent to substitute for physicians in the performance of many tasks.5 Several studies6,7 have compared complication rates and patient satisfaction between abortions physicians provide and those APCs provide. These studies consistently show that APCs with the requisite skills, training, and experience are fully competent to provide medical and first-trimester surgical abortions safely. As a result of state-by-state advocacy, APCs are now providing medication abortion in 18 states. APCs provide aspiration abortions in Montana, New Hampshire, Oregon, and Vermont.Additionally, APCs are providing aspiration abortion in California through a five-year demonstration project (Health Workforce Pilot Project No. 171) under the auspices of the University of California, San Francisco. Nurse practitioners, certified nurse midwives, and physician assistants have been trained to provide first-trimester aspiration abortion, and the project is being carefully evaluated. To date, 41 APCs at sites across California have been trained through the project. Nearly 8000 patients have received abortion care from these trained nurse practitioners, certified nurse midwives, and physician assistants. The project has conducted a study to compare the outcomes of these early abortions that APCs performed to a comparable number that physicians performed. The data show similar rates of high patient satisfaction and low complications in both groups.8Nurse practitioners, certified nurse midwives, and physician assistants have been increasing their commitment to abortion care, and there has also been remarkable advocacy among family medicine physicians. Several organizations (e.g., the Reproductive Health Access Project and the Center for Reproductive Health Education in Family Medicine [RHEDI]) have worked to increase training in abortion procedures in family medicine residency programs and to increase advocacy among family medicine professional organizations. Family physicians currently provide abortions at many of the freestanding clinics around the United States. Studies have shown that abortion care that family doctors provide have low rates of complication9,10 and that many patients would prefer to get their abortion from their family physician.11As more primary care clinicians are being trained and expressing interest in providing abortions, new technologies are making it possible for women to diagnose and end their pregnancies earlier. Inexpensive and accurate pregnancy tests now allow many women to determine whether they are pregnant within two weeks after unprotected intercourse. Advances in ultrasound have made it possible to confirm a pregnancy very early on. These advances have contributed to women in the first trimester coming in earlier to end an unwanted pregnancy. Eighty-eight percent of women who have abortions get the procedure in the first 12 weeks of pregnancy, and 61.8% of women have their abortion before the ninth week.4 All these women could be treated in a primary care setting.Yet most of the primary care clinicians who currently provide abortions do so at freestanding abortion sites.3 Too often when a patient seeks an abortion from her primary care clinician at her medical home, she is referred to another health care provider,12 even though trained family medicine doctors, nurse practitioners, certified nurse midwives, and physician assistants can provide first-trimester abortions. Although there are certainly primary care clinicians who do not want to provide abortions to their patients, many qualified and trained clinicians are willing but unable to offer this care because of burdensome, politically motivated restrictions that are not derived from science, public health considerations, or good medicine.Family medicine practices and physicians and community health centers are key health access points for low-income and rural women. Community health centers are the medical and health care home for more than 20 million people nationally, and community health center patients are disproportionately low income, uninsured or publicly insured, and minority.13 If abortion care were available in these centers and in family medicine practices, more women would be able to end their unwanted pregnancies without having to travel hundreds of miles or face delays that push them into getting abortions later in their pregnancy.Unfortunately, most federally qualified community health centers do not offer abortion services because of the Hyde Amendment, a legislative provision barring the use of federal funds to pay for abortions. Additionally, many of the federally qualified community health centers rely on malpractice coverage from the federal government, which does not cover abortion care. Family doctors who want to provide early abortion care in their practices must purchase extremely expensive obstetrical coverage, even though many other procedures routinely performed in family medicine have a higher complication rate than do first-trimester abortion procedures. APCs face other barriers; in many states, APCs are prevented from providing abortions or are limited to providing only medication abortion because of laws promoted by those who seek to restrict abortion access and because of resistance to expanding the scope of APCs’ practice to include abortion care.14The World Health Organization recently issued technical and policy guidelines for safe abortion worldwide. The guidelines state,

Both vacuum aspiration and medical abortion can be provided at the primary care level on an outpatient basis and do not require advanced technical knowledge or skills, expensive equipment such as ultrasound, or a full complement of hospital staff (e.g., anaesthesiologist). 15

The United States needs to step up to the World Health Organization standard. Health care reform has identified the importance of promoting high-quality, continuous, accessible, and cost-effective care in primary care settings. It is time for the promise of legal abortion to be available to every woman in the United States, rural or urban, low-income or middle class. Public health professionals and advocates must work together to find strategies to expand access to abortion by removing restrictions on the primary care clinicians who are trained and willing to provide the service. Forty years after Roe v Wade, it is time to integrate first-trimester abortion into primary care.     

Provision of abortion and other reproductive health services among former Midwest Access Project trainees

Objective

The Midwest Access Project (MAP) offers opt-in training to students, residents and practicing clinicians in reproductive health care including abortion. We surveyed MAP alumni to identify current practice characteristics and assess predictors of reproductive health service provision.

Abortion Law Around the World: Progress and Pushback

There is a global trend toward the liberalization of abortion laws driven by women’s rights, public health, and human rights advocates. This trend reflects the recognition of women’s access to legal abortion services as a matter of women’s rights and self-determination and an understanding of the dire public health implications of criminalizing abortion.Nonetheless, legal strategies to introduce barriers that impede access to legal abortion services, such as mandatory waiting periods, biased counseling requirements, and the unregulated practice of conscientious objection, are emerging in response to this trend. These barriers stigmatize and demean women and compromise their health.Public health evidence and human rights guarantees provide a compelling rationale for challenging abortion bans and these restrictions.According to the most recent research, the legal framework in 68 countries worldwide currently prohibits abortion entirely or permits it only to save a woman’s life. Conversely, 60 countries allow a woman to decide whether to terminate a pregnancy. A further 57 countries permit abortion to protect a woman’s life and health, and an additional 14 permit abortion for socioeconomic motives.1 These figures indicate that roughly 39% of the world’s population lives in countries with highly restrictive laws governing abortion.2Following World War II, abortion was highly restricted throughout most of the world.3 Since the 1950s, when the liberalization of abortion laws began in Eastern and Central Europe, an unmistakable global trend toward easing legal restrictions on abortion has ensued. The landmark decision of Roe v. Wade in the United States can be seen against the backdrop of liberalization of abortion laws in the developed world through the 1960s and 1970s.4 Between 1950 and 1985, nearly all industrialized countries—and several others—liberalized their abortion laws.5 Furthermore, since 1994, when 179 countries committed to preventing unsafe abortion under the International Conference on Population and Development Programme of Action, more than 25 countries have liberalized their abortion laws. During the same period, only a handful have tightened legal restrictions on abortion.6Despite some notable exceptions,7 nearly all countries in the global north and central and eastern Asia currently have liberal abortion laws, authorizing the service without restrictions as to reason during certain gestational limits or on broad grounds, such as for socioeconomic reasons. By contrast, countries in the global south generally have restrictive abortion laws on the books, with abortion criminalized except for limited circumstances, such as if a woman’s health or life is at risk, or in cases of rape, incest, or fetal impairment.8The legal framework for abortion in a given country can be derived from multiple sources, including statutes enacted by legislatures, regulations created by administrative agencies, and court decisions. Many of these laws and policies apply concurrently. Although abortion is a medical procedure, it has historically been addressed in penal codes and characterized as a crime. Penal codes generally set out criminal sanctions for the abortion provider and in some instances also for the woman undergoing the abortion. However, these same penal codes normally recognize exceptions under which performing an abortion does not carry any criminal penalties.9The liberalization of abortion laws using legal means has generally been achieved by amending criminal bans to specify certain circumstances in which there is no legal penalty for abortion. Thus, countries in the first wave of liberalization, in Central and Eastern Europe, saw the introduction of specific circumstances in which abortion carried no criminal sanction.10 In addition, although most countries (including those with liberal abortion laws) still maintain penal code provisions delineating the circumstances in which abortion is a crime, penal code provisions have been increasingly replaced or supplemented by public health codes, court decisions, and other regulations and laws addressing the provision of reproductive health care.11 In 2010, for example, Spain (one of the few European countries that had maintained a restrictive abortion law) enacted a law on sexual and reproductive health that eliminated a penal code provision punishing women for illegally procuring abortions and recognized their right to abortion without restrictions as to reason during certain gestational limits and thereafter on specific grounds.12Active campaigning from the women’s rights, public health, and human rights fields has worked to considerable effect,13 with achievements in law reform reflecting both the recognition of the dire public health implications of criminalizing abortion and the identification of women’s access to lawful termination of a pregnancy as a question of women’s rights and self-determination. Concurrently, international standards on the protection of women’s reproductive rights and their application to abortion have developed considerably.14 This trend persists despite the recent emergence of an increasingly organized and vehement opposition that seeks to restrict abortion laws and impose barriers to women’s access to abortion globally.Despite the overall global trend of easing legal restrictions on abortion, legal strategies have emerged to introduce new types of barriers that impede women’s access to legal abortion services. An increasingly global and coordinated movement—which pronatalist and religious concerns have fueled in direct response to the worldwide trend toward abortion law liberalization—has instigated such strategies. Although in some countries progressive or retrogressive steps can be classified simply, in others political tugs-of-war have led to measures that pull the specific elements of the legal status of abortion back and forth. Retrogressive steps have been added that introduce new barriers to abortion access rather than altering the overall legal status of abortion, making the achievement of broader reform unrealistic because of the political context or established legal framework.In Poland, for example, a liberal abortion law in place until the fall of the Soviet Union was restricted in 1993.15 In 1996, the law was again liberalized, but subsequent efforts, through amendments to the law and a ruling from the constitutional court, again restricted the law.16 The Polish parliament narrowly rejected a bill that would have introduced an absolute ban on abortion in 2011.17Strategies to restrict abortion access have increasingly focused on introducing procedural barriers, through law or policy, that limit the availability of abortion services. Such barriers—introduced primarily in countries with liberal abortion laws, including the United States and Central and Eastern Europe countries—include mandatory and biased counseling requirements,18 waiting periods,19 third-party consent and notification requirements,20 limitations on the range of abortion options (e.g., restrictions on medical abortion, including specific bans on misoprostol21), and limitations on abortion funding.Currently, 26 US states have a waiting period, which is normally 24 hours,22 and nine states require counseling that provides inaccurate information about negative mental health consequences of abortion.23 In 2011, the Russian parliament established a mandatory waiting period for abortions and considered several other procedural barriers to abortion.24 In 2009, the Slovak Republic introduced several procedural barriers to abortion access, including a mandatory counseling requirement, a 48-hour waiting period, and the extension of the parental consent requirement to all minors25 when previously it had applied only to girls younger than 16 years.26A further impediment to abortion access results from the unregulated conscientious objection of health care providers and others. The right to refuse to perform services because of moral or religious objections is governed by national laws that vary in the scope of limits of conscientious objection and that invite differing interpretations.27 Although insufficient research has been conducted into the prevalence of unregulated conscientious objection, case law and limited research shows that it is increasingly invoked in countries where opposition to recent liberalization is strong (e.g., Colombia)28 and where there are attempts to reverse the legalization of abortion (e.g., Poland).29 A growing body of jurisprudence delineates the justifiable limits on the exercise of conscientious objection in this context, including when pharmacists, nurses, judges, and health care institutions invoke it.30     

Estimating the lifetime incidence of induced abortion and understanding abortion practices in a Northeastern Tanzania community through a household survey

ObjectivesAll Tanzanian abortion estimates rely on health facility data that do not take into account completely the incidence of abortion. This papers aims to estimate the lifetime incidence of induced abortion in Arusha, Tanzania via direct and double list-experiment methods using community data and evaluate outcomes and behaviors of women who had an abortion.MethodsFrom January to May 2018, a face-to-face interview survey was conducted on a representative sample of sexually active women (n = 3658) living in Arusha, Tanzania. Participants were selected in a three-stage random process and questions were asked about reproductive history, contraceptive use, and health seeking behaviors. A direct question and double list-experiment was used to estimate lifetime incidence of abortion.ResultsLifetime abortion incidence was 3% using the direct question compared to 7.7% using the double list-experiment method. However, post-estimation tests revealed a key study design violation thus invalidating list the experiment estimate. We find that 45% of women received their abortion outside the formal health care system, the most frequent method used was manyono pill (traditional medicine), and only 50% of women who experienced abortion complications sought treatment.ConclusionsWe provide another example of the performance of list experiment in measuring abortion incidence. Nearly half of reported abortions took place outside of the formal health system highlighting the substantial underestimation while using facility data to measure abortion. Seeking health care for potential complications was low despite post-abortion care services being free and legal in Tanzania.ImplicationsUsing administrative data to estimate lifetime incidence of abortion is inaccurate as we found half of our sample received abortions outside a health facility. Women should be encouraged to seek post-abortion care, when needed.     

未婚流产女青年对医疗保健服务满意度与需求现况分析

目的:了解未婚人工流产女青年对医疗机构服务的满意度和服务需求,为探索青少年友好服务相关措施提供依据。方法:采用匿名问卷调查形式对在医院计划生育门诊接受人工流产手术的未婚女青年1 225例进行调查。结果:①服务满意度:对服务人员的满意度比对候诊时间和就诊环境高,达60%;20岁以下者对就诊环境满意度(45.60%)比20～24岁满意度(50.00%)低,20～24岁组对候诊时间的满意度(37.40%)比20岁以下的(45.60%)低;9.0%未婚人工流产女青年认为医务人员对其存在歧视或者态度冷淡。②需求:对性生殖健康知识最希望了解的前三位为:怀孕与避孕、性生理保健及人工流产后保健;③服务:对于流产希望获得的相关服务主要为人工流产后保健指导、避孕指导、心理咨询指导等;对服务的希望是获得保护隐私(65.96%),性保健知识宣教(36.49%),工作人员友好(35.27%)等。结论:未婚女青年对目前人工流产服务的环境、候诊时间的满意度相对较低,对接受人工流产的相关服务内涵及要求相对较高,提示需要建立满足青春期性生殖保健的友好服务模式。     

U.S. Women's Knowledge of Reproductive Biology

BackgroundHaving accurate knowledge of reproductive biology can help women to improve their general, sexual, and reproductive health and assert their sexual and reproductive rights.MethodsThis cross-sectional study examined knowledge of three topics (age-related fertility decline, egg supply, fertile period) among a national probability sample of 1,779 nonsterilized, English-speaking women (aged 18–29 years) in the U.S. general population. Using bivariate and multivariable regressions, we assessed associations between knowledge of these topics and individual characteristics.ResultsMost respondents were unmarried (63%), childless (78%), and intended to have children (65%); 51% did not know whether they would have difficulty conceiving, and 44% had discussed fertility-related topics with a health care provider. More respondents knew the age of marked fertility decline (62%) than the fertile period (59%) or that ovaries do not continuously produce new eggs (45%); 22% knew all three topics, and 13% knew none. In multivariable analysis, knowledge was positively associated (p < .001) with education, income, and having regular periods. Black and Asian respondents and those for whom religion was very important were less likely (all p values < .01) than White and nonreligious respondents to know all three topics. Knowledge was unrelated to relationship status, parity, childbearing intentions, receipt of fertility-related counseling or services, self-perceived infertility risk, or health status; the relationship with Hispanic ethnicity approached but did not reach significance (p = .08).ConclusionsYoung U.S. women have incomplete knowledge of aspects of their reproductive biology; these knowledge gaps could increase their risk of adverse health and reproductive outcomes. Policy-, provider-, and client-level interventions are warranted to address these knowledge gaps.     

Interest in Medication and Aspiration Abortion Training among Colorado Nurse Practitioners,Nurse Midwives,and Physician Assistants

ObjectivesWe examined advanced practice clinicians’ (APCs: nurse practitioners [NPs], certified nurse midwives [CNMs], physician assistants) interest in training to provide medication and aspiration abortion in Colorado, where abortion provision by APCs is legal.MethodsWe surveyed a stratified random sample of APCs, oversampling women's health (CNMs/women's health nurse practitioners [WHNPs]) and rural APCs. We examined prevalence and predictors of interest in abortion training using weighted χ² tests.ResultsOf 512 participants (21% response), the weighted sample is 50% NPs, 41% physician assistants, and 9% CNMs/WHNPs; 55% provide primary care. Only 12% are aware they can legally provide abortion. A minority of participants disagree that medication abortion (15%) or aspiration abortion (25%) should be in APC scope of practice. Almost one-third (29%) are interested in medication abortion training and 16% are possibly interested; interest is highest among CNMs/WHNPs (52%) (p < .01). Interest in aspiration abortion training is 15% with another 11% who are possibly interested; interest is highest among CNMs/WHNPs (34%) (p < .01). There are no significant differences in abortion training interest by rural practice location or by receipt of abortion education in graduate school. Participants not interested in medication and aspiration abortion training cited abortion being outside their specialty practice scope (44% and 38%, respectively) and religious or personal objections (42% and 34%). Among clinicians interested in medication abortion training, 33% believe their clinical facility is likely to allow them to provide this service, compared with 16% for aspiration abortion.ConclusionsInterest in abortion training among Colorado APCs is substantial. However, facility barriers to abortion provision must be addressed to increase abortion access with APCs.     

Twenty Years of the Ryan Residency Training Program in Abortion and Family Planning

ObjectiveTo summarize the effects of routine, opt-out abortion and family planning residency training on obstetrics and gynecology (ob-gyn) residents’ clinical skills in uterine evacuation and intentions to provide abortion care after residency.MethodsData from ob-gyn residency programs supported during the first 20 years of the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning were analyzed. Postrotation surveys assessed residents’ training experiences and acquisition of abortion care skills. Residency program director surveys assessed benefits of the training to residents and the academic department from the educators’ perspectives.ResultsA total of 2775 residents in 89 ob-gyn programs completed postrotation surveys for a response rate of 72%. During the rotation, residents – including those who only partially participated – gained exposure to and skills in first- and second-trimester abortion care. Sixty-one percent intended to provide abortion care in their postresidency practice. More than 90% of residency program directors (97.5% response rate) reported that training improved resident competence in abortion and contraception care and 81.3% reported that the training increased their own program's appeal to residency applicants.ConclusionOver 20 years, the Ryan Program has supported programs to integrate abortion training to give ob-gyn residents the skills and inspiration to provide comprehensive reproductive health care, including uterine evacuation and abortion care, in future practice. Residency program directors noted that this integrated training meets resident applicants’ expectations.ImplicationsRyan Program residents are trained to competence and are prepared, both clinically and in their professional attitudes, to care for women's reproductive health.     

Characterization of U.S. State Laws Requiring Health Care Provider Reporting of Perinatal Substance Use

BackgroundState policies pertaining to health care provider reporting of perinatal substance use have implications for provider screening and referral behavior, patients’ care seeking and access to prenatal substance use disorder treatment, and pregnancy and birth outcomes.ObjectivesThis study sought to characterize specific provisions enacted in state statutes pertaining to mandates that health care providers report perinatal substance use, and to determine the proportion of births occurring in states with such laws.MethodsWe conducted a systematic content analysis of statutes in all U.S. states that mentioned reporting by health care providers of substance use by pregnant women or infants exposed to substances in utero; inter-rater reliability was high. We calculated the number of states, and proportion of U.S. births occurring in states, with processes for mandatory reporting of perinatal substance use to authorities, and substance use disorder treatment provision for individuals who are reported.ResultsTwenty states (corresponding with 31% of births) had laws requiring health care providers to report perinatal substance use to child protective authorities, and four states (18% of births) had laws requiring reporting only when a health care provider believed the substance use was associated with child maltreatment. About one-half of states (13) with any reporting law had a provision promoting substance use disorder treatment in the perinatal period.ConclusionsFindings inform the ongoing debate about how health policies may be used to reduce the population burden of perinatal substance use.     

Connecting Knowledge about Abortion and Sexual and Reproductive Health to Belief about Abortion Restrictions: Findings from an Online Survey

BackgroundThe objective of this research was to examine individuals' knowledge about abortion in the context of their knowledge about other sexual and reproductive health (SRH) issues, including contraception, abortion, pregnancy, and birth.MethodsDuring August 2012, we administered an online questionnaire to a randomly selected sample of 639 men and women of reproductive age (18–44 years) in the United States.FindingsRespondents reported the highest levels of perceived knowledge about SRH in general (81%), followed by pregnancy and birth (53%), contraception (48%), and abortion (35%); knowledge of specific items within each of these areas paralleled this pattern. Respondents who believe that abortion should be allowed in at least some circumstances were more likely to be correct regarding the safety and consequences of contraception and abortion. Characteristics associated with higher levels of knowledge regarding abortion-related issues included having higher levels of knowledge about non–abortion-related SRH issues and having less restrictive abortion beliefs.ConclusionsWomen and men are not well-informed about the relative safety and consequences of SRH-related experiences. Many overestimate their knowledge, and personal beliefs about abortion restrictions may influence their knowledge about the safety and consequences of abortion and contraception. Providers of SRH services should provide comprehensive evidence-based information about the risks and consequences of SRH matters during consultations, particularly in the case of abortion providers serving women who hold more restrictive abortion beliefs.     

Spousal caregivers’ experiences of participation in everyday life when living in shifting contexts

Abstract

Background: To promote health and well-being, and to meet the desires of the growing elderly population to age in place, elderly spousal caregivers need adequate support such as respite care services. More knowledge is needed about elderly spousal caregivers’ experiences in relation to participation, which is an aspect of health that remains relatively unexplored for this group.

Aim: To explore and describe how elderly spousal caregivers experience and discuss participation in everyday life when living in shifting contexts due to the use of respite care.

Method: A grounded theory approach was used during data generation and analysis, which involved repeated focus group interviews with 12 spousal caregivers.

Results: Complexity and ambiguity was understood to imbue participation in everyday life. Being in charge of everyday life was challenging for spousal caregivers, and created a need for personal time. Respite care and home care service gave them time, although when interacting with social contexts other issues arose that influenced their own recovery.

Conclusions: A holistic ‘situation centered’ approach that focuses on the elderly couple’s life story and needs might capture a wider perspective and enable adequate support that influences their health, well-being, and participation in everyday life.