Adoption Decision Making among Women Seeking Abortion

BackgroundLittle is known about how adoption factors into pregnancy decision making, particularly when abortion is unavailable.MethodsWe used data from the Turnaway Study, a longitudinal study of 956 women seeking abortion, including 231 women denied abortions owing to gestational limits. Through semiannual quantitative interviews, we assessed the frequency with which women denied abortion consider and choose adoption, and, among adoption participants, decision satisfaction. We compared differences in the demographic profiles of parenting and adoption participants using mixed effects regression models. We conducted in-depth interviews with 31 women who received or were denied wanted abortions, including 2 adoption participants, focused on understanding pregnancy decision making and feelings about their choice. Interviews were coded using inductive and deductive methods.ResultsMost women who received abortions were aware of but uninterested in adoption. A minority of women denied abortions (n = 231; 14%) were considering adoption at 1 week after denial. Of participants who gave birth (n = 161), most (91%) chose parenting. Parenting participants (n = 146) did not differ from adoption participants (n = 15) on measures of age, race, or poverty status, although adoption participants were somewhat less likely to be employed (20% vs. 43%; p = .1), and somewhat more likely to have completed high school (87% vs. 74%; p = .08). Although satisfaction with their decision was high among adoption participants, in-depth interviews revealed mixed emotions.ConclusionsAmong women motivated to avoid parenthood, as evidenced by abortion seeking, adoption is considered or chosen infrequently. Political promotion of adoption as an alternative to abortion is likely not grounded in the reality of women's decision making.     

How women anticipate coping after an abortion

BackgroundThere has been some study of women's emotional and psychological well-being after an abortion but no research into women's expectations, at the time of seeking an abortion, of how they will cope after the abortion.Study DesignWe abstracted counseling needs assessment forms of 5109 women who sought an abortion at a clinic in 2008.ResultsThe most common emotions that women anticipate feeling after their abortion are relieved (63%) and confident (52%). A significant minority anticipate feeling a little sad (24%) and a little guilty (21%); 3.4% anticipate poor coping. Women with fetal abnormalities, women who do not have high confidence in their decision, women who have spiritual concerns about abortion, women with a history of depression, women who feel that they were pushed into having an abortion and teenagers are more likely to anticipate poor coping postabortion.ConclusionsThe vast majority of women expect to cope well after their abortion. A small number make the decision to terminate their pregnancies even though they anticipate difficulty coping after the procedure.     

Factors Influencing Parental Involvement Among Minors Seeking an Abortion: A Qualitative Study

Objectives. We explored factors that influenced whether minors involved or excluded a parent when seeking an abortion.Methods. In the summer of 2010, we conducted interviews with 30 minors who sought an abortion in a state that did not require parental involvement at the time. Interviews were coded and analyzed following the principles of the grounded theory method.Results. The majority of minors involved a parent. Commonly cited factors were close or supportive parental relationships, a sense that disclosure was inevitable, a need for practical assistance, and compelled disclosure. Motivations for not wanting to involve a parent, although some minors ultimately did, included preservation of the parent–daughter relationship, fear or detachment, and preservation of autonomy.Conclusions. Minors were motivated to involve parents and other adults who were engaged in their lives at the time of the pregnancy, particularly those who supported them in obtaining an abortion. Motivations to exclude a parent were often based on particular family circumstances or experiences that suggested that involvement would not be helpful, might be harmful, or might restrict a minor’s ability to obtain an abortion.Nationally, nearly one third of pregnant women aged 18 years or younger seek an abortion.1 Currently, 38 states have parental involvement laws that require a parent provide consent or receive notification before a minor can access abortion. States do allow some exceptions in cases of abuse, assault, and medical emergencies.2 Courts have upheld parental involvement laws when an alternative for adolescents unable or unwilling to involve parents exists. In most states, this means a judge determines if the adolescent is sufficiently mature to waive parental involvement requirements, a process called “judicial bypass.” Although the majority of parental involvement laws have been in place since the 1990s, lawmakers have recently passed a new wave of legislation, including new parental involvement laws in states that lack them and stricter mandates for existing laws. Efforts to make parental involvement laws more restrictive include requiring parental consent instead of notification, mandating involvement of both parents, notarization of consent documents, heightened evidentiary requirements for judges to find a minor mature, and jurisdictional limitations on where minors can seek judicial bypass.3–5Previous studies, published in the 1980s and 1990s, found that parents were often involved in a minor’s decision regardless of the law. Those minors who did not wish to involve a parent often cited fear of negative parental reactions, lack of or fragile relationships with parents, and desire to avoid parental pressure in the decision-making process.6–10 The legal landscape has changed since these seminal studies, with a shift toward increasingly strict laws. There is limited current research exploring minors’ experiences and the factors influencing their decisions to involve or exclude parents when seeking an abortion.11States without parental involvement laws provide an opportunity to examine minors’ experiences involving adults in their abortion-seeking process in the absence of a legal requirement. In Illinois, the Parental Notice of Abortion Act was passed in 1995. The law requires physicians to give notice to an adult family member (defined as a parent, legal guardian, grandparent, or cohabiting step-parent) 48 hours before providing abortion services to a minor.12 However, because of legal challenges, the law was not implemented until August 2013. Previously, Illinois was the only state in the Midwest that did not enforce a parental involvement law. Our aim in this study was to explore the factors in abortion-seeking minors’ motivations regarding parental involvement. This snapshot before implementation of a new parental involvement law provided a rare opportunity to understand its potential impact.     

Comparing Website Identification for Crisis Pregnancy Centers and Abortion Clinics

BackgroundCrisis pregnancy centers (CPCs) seeking to dissuade women from abortion often appear in Internet searches for abortion clinics. We aimed to assess whether women can use screenshots from real websites to differentiate between CPCs and abortion clinics.MethodsWe conducted a cross-sectional, nationally representative online study of English- and Spanish-speaking women aged 18–49 years in the United States. We presented participants with screenshots from five CPCs and five abortion clinic websites and asked if they thought an abortion could be obtained at that center. We scored correct answers based on clinic type. Outcomes included ability to correctly identify CPCs and abortion clinics as well as risk factors for misidentification. The survey also included five questions about common abortion myths and a validated health literacy assessment.ResultsWe contacted 2,223 women, of whom 1,057 (48%) completed the survey and 1,044 (47%) were included in the analysis. The median score for correctly identifying CPCs as facilities not performing abortion was 2 out of 5 (Q1: 0, Q3: 4). The median score for correctly identifying abortion clinics as facilities performing abortion was 5 out of 5 (Q1: 3, Q3: 5). Those less likely to endorse abortion myths had higher odds of correctly identifying CPCs (adjusted odds ratio, 2.43; 95% confidence interval, 1.78–3.32). A low health literacy score was associated with decreased odds of correct identification of CPCs (adjusted odds ratio, 0.39; 95% confidence interval, 0.25–0.59).ConclusionsWebsites of CPCs were more difficult for women to correctly identify than those of abortion clinics. Women with limited knowledge about abortion and low health literacy may be particularly susceptible to misidentification of CPC websites.     

Travel for Abortion Services in Alabama and Delays Obtaining Care

BackgroundIn 2013, Alabama required women seeking abortion to have a consultation visit followed by a 24-hour waiting period. These requirements may adversely affect return for timely care among those traveling long distances for services.MethodsUsing de-identified billing data from two Alabama clinics for all abortion encounters in 2013, we calculated the distance traveled from women's residential zip code and the number of days between their in-person consultation and procedure visits. To assess the associations between distance traveled and return for an abortion visit and length of interval between visits, we used logistic and ordinal logistic regression, respectively.ResultsOf the 2,730 women attending a consultation visit, 58% traveled less than 25 miles one way to the clinic, 13% traveled 25 to 49 miles, 21% traveled 50 to 100 miles, and 8% traveled more than 100 miles. Overall, 19% of women did not return to either clinic for an abortion procedure after their consultation. Distance traveled was not associated with return for an abortion visit (odds ratio, 1.04; 95% confidence interval, 0.76–1.42). Among women who returned, 59% had less than 7 days, 29% had 7 to 13 days, and 12% had 14 or more days between their consultation and procedure visits. Compared with women traveling less than 25 miles, those traveling 50 to 100 miles had significantly longer intervals between visits (odds ratio, 1.25; 95% confidence interval, 1.01–1.56).ConclusionsAlthough most women returned for their abortion procedure, many traveling long distances had a week or more between visits. Because delays may limit women's options for affordable abortion care, evidence-based policies should be adopted to facilitate women's timely receipt of services.     

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.     

Tobacco Taxation and Its Prospective Impact on Disparities in Smoking Initiation and Progression Among Young Adults

PurposeLimited research exists on tobacco taxes and cigarette smoking initiation and progression, particularly across different sociodemographic groups in young adulthood. This project examines how cigarette pack price in late adolescence prospectively relates to smoking initiation and progression by 21 years of age, focusing on differences across demographics.MethodsData are from the longitudinal Monitoring the Future project (2001–2017). Monitoring the Future examines drug use behaviors with nationally representative samples of 12th graders annually. Subsamples of 12th graders are followed up longitudinally. We examined past 30-day cigarette smoking among baseline never smokers (N = 9,232) and daily smoking among youths who were not daily cigarette smokers at baseline (N = 15,141). Using logistic regression, we examined state-level cigarette pack price at a modal age of 18 years and smoking at follow-up ages 19–20 years; we used interaction terms to assess differences across sociodemographic groups (by gender, race/ethnicity, and parental education).ResultsFor each dollar increase in price at baseline, the odds of initiation by age 19–20 years were reduced by 12% (adjusted odds ratio = .88; 95% confidence interval = .78, .99) and the odds of progression to daily smoking were reduced by 16% (adjusted odds ratio = .84; 95% confidence interval = .76, .92). After adjusting for multiple testing, for both outcomes there were no statistically significant interactions between price and demographics.ConclusionsCigarette prices in late adolescence were associated with a prospective reduction in cigarette smoking initiation and progression among young adults, with limited differences across sociodemographic characteristics. Higher cigarette prices can prevent smoking initiation and progression; however, complementary interventions are needed to reduce initiation and progression among subgroups disproportionately affected by tobacco.     

Mandatory parental involvement in minors' abortions: effects of the laws in Minnesota, Missouri, and Indiana.

OBJECTIVES: This study examined the effects of parental involvement laws on the birth rate, in-state abortion rate, odds of interstate travel, and odds of late abortion for minors. METHODS: Poisson and logistic regression models fitted to vital records compared the periods before and after the laws were enforced. RESULTS: In each state, the in-state abortion rate for minors fell (relative to the rate for older women) when parental involvement laws took effect. Data offered no empirical support for the proposition that the laws drive up birth rates for minors. Although data were incomplete, the laws appeared to increase the odds of a minor's traveling out of state for her abortion. If one judges from the available data, minors who traveled out of state may have accounted for the entire observed decline in the in-state abortion rate, at least in Missouri. The laws appeared to delay minors' abortions past the eighth week, but probably not into the second trimester. CONCLUSIONS: Several empirical arguments used against and in support of parental involvement laws do not appear to be substantiated.     

Did parental involvement laws grow teeth? The effects of state restrictions on minors’ access to abortion

We compile data on the locations of abortion providers and enforcement of parental involvement laws to document dramatic increases in the distances minors must travel if they wish to obtain an abortion without involving a parent or judge: from 58 miles in 1992 to 454 in 2016. Using both double and triple-difference estimation strategies, we estimate the effects of parental involvement laws, allowing them to vary with the distances minors might travel to avoid them. Our results confirm previous findings that parental involvement laws did not increase teen births in the 1980s, and provide new evidence that in more recent decades they have increased teen birth by an average of 3 percent. The estimated effects are increasing in avoidance distance to the point that a confidential abortion is more than a day's drive away, and also are substantially larger in the poorest quartile of counties.     

A Prospective Cohort Study of the Effect of Receiving versus Being Denied an Abortion on Educational Attainment

BackgroundResearch on the effects of unintended childbearing has been limited in its ability to disentangle the direct effects of childbearing from common selection factors that predispose women to both unintended childbearing and lower educational attainment.MethodsUsing data from a 5-year prospective cohort study of 876 individuals seeking abortion care, some of whom were denied care because they presented beyond a facility's gestational age limit, we used discrete time survival models to estimate the hazard of graduating and dropping out among those enrolled in high school, college, or other type of school (n = 280). We also examined cluster-adjusted bivariable differences in degrees completed by receipt versus denial of a wanted abortion.ResultsParticipants denied an abortion who parented were equally likely to be in school as compared with women who received a wanted abortion (33 vs. 28%; p = .19); however, they were more likely to be seeking a high school diploma (40 vs. 24%; p = .05) than a higher degree. In adjusted models, there were no differences in the hazard of graduating (adjusted hazard ratio, 0.76; 95% confidence interval, 0.36–1.61) or dropping out (adjusted hazard ratio, 1.12; 95% confidence interval, 0.67–1.88) between those who were denied versus received an abortion. Among graduates, participants denied a wanted abortion less often completed a postsecondary degree (27%) compared with those who received a wanted abortion (71%; p = .002).ConclusionsUnintended childbirth was not associated with graduating or dropping out in this population, a finding that is at least partially explained by differences in degrees sought at the time of abortion seeking.     

The Impact of First-Person Abortion Stories on Community-Level Abortion Stigma: A Randomized Trial

ObjectiveWe aimed to assess the impact of first-person abortion stories on community-level abortion stigma.MethodsBetween November 2018 and March 2019, we recruited participants and analyzed data from a nationally representative, probability-based online panel of U.S. adults, randomized to watch three first-person abortion video stories (intervention, n = 460) or three nature videos (control, n = 426). We measured community-level abortion stigma using the Community Abortion Attitudes Scale, Reproductive Experiences and Events Scale, and Community Level Abortion Stigma Scale at baseline, immediately after video exposure, and 3 months later. We dichotomized stigma change scores as decreased stigma compared with no change or increased stigma. Bivariate and logistic regression analysis accounted for complex survey methodology and sample weighting.ResultsSample demographics reflected U.S. Census benchmarks (51% female, 68% White, 47% aged 18–44 years). Most participants (83.1%) completed the 3-month follow-up. Viewing the intervention videos was not associated with decreased stigma measured by Community Abortion Attitudes Scale or Community Level Abortion Stigma Scale immediately (odds ratio [OR], 0.80; 95% confidence interval [CI], 0.59–1.09; OR, 1.28; 95% CI, 0.93–1.75) or at the 3-month follow-up (OR, 0.86; 95% CI, 0.62–1.19; OR, 0.98; 95% CI, 0.70–1.37). Intervention exposure was associated with decreased stigma as measured by Reproductive Experiences and Events Scale immediately (OR, 1.74; 95% CI, 1.23–2.46); however, this association was not observed at the 3-month follow-up (OR, 0.98; 95% CI, 0.70–1.37).ConclusionsExposure to first-person video stories may not decrease community-level abortion stigma among U.S. adults.     

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.     

Parental consent for abortion and the judicial bypass option in Arkansas: effects and correlates

CONTEXT: In 2005, Arkansas changed its parental notification requirement for minors seeking an abortion to a parental consent law, under which a minor can obtain an abortion without consent after obtaining a judicial waiver. METHODS: Using state health department data on 7,463 abortions among 15–19‐year‐olds over the period 2001–2007, an analysis of abortion and second‐trimester abortion rates among Arkansas minors relative to rates among older teenagers evaluated the influence of the 2005 change in the law. Linear and logistic regression analyses estimated the changes in rates among different age‐groups, and assessed the likelihood of minors’ using the bypass procedure or having a second‐trimester abortion. RESULTS: No association was found between the change in the law and either the abortion rate or the second‐trimester abortion rate among minors in the state. Ten percent of all abortions among minors were obtained through the judicial bypass procedure, and minors aged 15 or younger who had an abortion were less likely than those aged 17 to get a waiver (odds ratio, 0.2). Minors who used the bypass option were less likely than those who obtained parental consent to have a second‐trimester abortion (0.5), and they terminated the pregnancy 1.1 weeks earlier, on average, than did minors who had gotten such consent. CONCLUSIONS: States that convert a parental notification statute to a parental consent statute are unlikely to experience a decrease in abortions among minors.     

Contraceptive Provision after Medication and Surgical Abortion

ObjectiveThis study sought to compare contraception provided to patients after medication and surgical abortion.Study DesignWomen who underwent first trimester induced abortion at a university-based urban clinic between May 2009 and May 2014 were identified. Medical records were reviewed to determine the method of contraception provided by the clinic to patients after medication and surgical abortion. Postabortal contraception was defined as any contraception administered or prescribed from our health system within 4 weeks of surgical abortion or mifepristone administration.ResultsWe reviewed 824 women who were 9 weeks gestational age or less and able to choose between medication and surgical termination of pregnancy. Overall, 587 (71.1%) had a surgical abortion and 237 (28.9%) had a medication abortion. Women who had surgical abortions were more likely to initiate long-acting reversible contraception (41.9% vs. 23.2%; p < .0001) and more likely to be provided with any type of contraception overall (83% vs. 64.6%; p < .0001). The overall follow-up rate after medication abortion was 71.7%.ConclusionsWomen who had surgical abortions had a greater odds of receiving long-acting reversible contraception than those who had medication abortions. Surgical abortion patients were also more likely to be provided contraception overall. Further prospective research is needed to determine the reasons for this difference and to ensure that all patients obtain the contraception that they desire.     

Minors' Behavioral Responses to Parental Involvement Laws: Delaying Abortion Until Age 18

CONTEXT : Prior research on the effect of laws mandating parental involvement in minors' abortions has failed to examine an important behavioral response to such laws: Older teenagers may delay an abortion until age 18; for some, this may mean terminating a pregnancy after the first trimester.
METHODS : Statewide data were obtained on abortions in Texas in 1997–2003. Analysis of relative rate ratios with narrowly defined comparison groups was used to evaluate the association between Texas's parental notification law and the occurrence of second-trimester abortions among minors who have responded to the law by delaying abortion until age 18.
RESULTS: : In the four years after the law went into effect, the proportion of abortions obtained at age 18 increased by six percentage points among minors who conceived at age 17 years and eight months, and by 13 points among those who did so at 17 years and nine months. As a result, the second-trimester abortion rate of these groups combined increased by 21%; by contrast, there was no evidence of an increase in this rate among younger minors, for whom delaying the abortion until age 18 was not feasible.
CONCLUSIONS : Some minors postpone abortion until the second or even third trimester of pregnancy to circumvent parental notification requirements. Given the greater costs of and medical risks associated with late-term abortions, policymakers should not ignore this behavior.     

Contraception After Surgical Abortion in Patients With Opioid Use Disorder

ObjectivesThis study describes the prevalence of medications for opioid use disorder (MOUD) among surgical abortion patients, evaluates long-acting reversible contraception (LARC) uptake after surgical abortion among patients on MOUD, and identifies predictors of immediate postabortion LARC uptake among individuals on MOUD.MethodsWe performed a secondary analysis of data from a retrospective observational cohort study of LARC uptake immediately after surgical abortion up to 21^0/7 weeks gestation at Planned Parenthood League of Massachusetts between October 2012 and April 2017. We estimated proportions and analyzed predictors of LARC uptake among women on MOUD using logistic regression analysis to control for possible confounders.ResultsDuring the study period, 26,858 patients had an abortion procedure; 768 (2.9%; 95% confidence interval, 2.7%–3.1%) used MOUD. In the primary study, controlling for demographic factors, MOUD was not an independent predictor of LARC uptake. In this analysis, patients on MOUD differed demographically from non-MOUD users and were significantly more likely to initiate a LARC method immediately after their procedure: 30.1% versus 25.3% (p = .002), including 22.7% who obtained an intrauterine device and 7.4% who obtained an implant. Among patients on MOUD, a prior live birth and public insurance predicted LARC uptake at the time of abortion.ConclusionWomen on MOUD had higher postabortion LARC uptake compared with those not on MOUD in a setting with easy access to postabortion LARC. Public insurance coverage for abortion was associated with LARC uptake among women on MOUD.     

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

BackgroundWidespread underreporting of abortion persists in survey data. The list experiment, a measurement tool designed to elicit truthful responses to sensitive questions, may alleviate underreporting.MethodsUsing The Statewide Survey of Women of Reproductive Age in Delaware and Maryland (n = 2,747), we estimate the prevalence of abortion in Maryland and Delaware using a double list experiment.ResultsWe find 21% (95% confidence interval [CI]: 16.8%–25.3%) of respondents aged 18 to 44 ever had an abortion and we identify disparities in abortion prevalence by age, race, education, income, marital status, and insurance status. Respondents who were Black (37.0%; 95% CI: 27.1%–46.8%), had less than a college degree (24.8%; 95% CI: 18.3%–31.3%), were in a cohabiting relationship (39.0%; 95% CI: 29.1%–48.9%), were living in households with incomes less than $50,000 (28.6%; 95% CI: 19.7%–37.5%), and were currently covered by Medicaid (42.8%; 95% CI: 27.6%–58.0%) were more likely than their counterparts to have ever had an abortion.ConclusionsList experiments yield estimates of abortion substantially higher than those obtained from direct questions. Findings demonstrate external validity through consistency with estimates from administrative data sources and gold standard abortion provider survey data.