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.     

Association between history of abortion and nonalcoholic fatty liver disease in middle-aged and elderly Chinese women

PurposeTo evaluate the possible relationship between self-reported history of abortion and nonalcoholic fatty liver disease (NAFLD) in middle-aged and elderly Chinese women.MethodsA cross-sectional study was performed in 5911 women aged 40 years or older in Jiading District, Shanghai, China. Reproductive histories, including miscarriage and induced abortion, were collected using a validated questionnaire by trained physicians. Abdominal B-mode ultrasound evaluation and serum liver enzymes levels were used in the diagnosis of NAFLD.ResultsThe percentage reporting history of abortion in women with NAFLD was higher than in those without NAFLD (72.4% vs. 69.3%, age-adjusted P = .001). Compared with women without a history of abortion, the fully adjusted odds ratio (OR) for NAFLD in those with a history of abortion was increased by 28% (OR, 1.28 and 95% confidence interval [CI], 1.06–1.55). Histories of miscarriage and induced abortion were also associated with increased risk of prevalent NAFLD in fully adjusted models (OR, 1.84 and 95% CI, 1.24–2.72; OR, 1.23 and 95% CI, 1.02–1.50, respectively).ConclusionsBoth miscarriage and induced abortion are associated with prevalent NAFLD in middle-aged and elderly Chinese women.     

Birth Control Sabotage as a Correlate of Women's Sexual Health Risk: An Exploratory Study

IntroductionTo explore associations between birth control sabotage, a form of reproductive coercion, and women's sexual risk among women attending family planning health centers. Data were collected from a 2017 cross-sectional online survey of 675 women who attended Connecticut Planned Parenthood centers. Participants reported birth control sabotage; sexual risk (i.e., inconsistent condom use during vaginal and anal sex in the past 6 months, lifetime sexually transmitted infection diagnosis, lifetime exchange sex [trading sex for money, drugs, or other goods], and multiple sexual partners in the past 6 months); and sociodemographics. Bivariate and multivariable logistic regression models were used to examine associations between birth control sabotage and women's sexual risk.ResultsOne in six women (16.4%; n = 111) reported experiencing birth control sabotage. Women who reported birth control sabotage had a greater odds of ever having an sexually transmitted infection (adjusted odds ratio, 2.18; 95% confidence interval, 1.31–3.60; p = .003), ever engaging in exchange sex (adjusted odds ratio, 2.77; 95% confidence interval, 1.17–6.53; p = .020), and having multiple sexual partners in the past 6 months (adjusted odds ratio, 1.96; 95% confidence interval, 1.21–3.18; p = .006).ConclusionsOur findings demonstrate increased engagement in sexual risk taking among women who reported birth control sabotage compared with women did not.     

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.     

The Association Between Postpartum Insurance Instability and Access to Postpartum Mental Health Services: Evidence From Colorado

IntroductionThe objective of this study was to assess the association between postpartum insurance instability and access to postpartum mental health services.MethodsWe used 2018–2019 Colorado Health eMoms survey data, which sampled mothers from the 2018 birth certificate files at 3–6 months and 12–14 months postpartum. Respondents were classified as stably insured or unstably insured based on postpartum insurance status at each time point. We examined postpartum insurance patterns and used logistic regression to assess the association between postpartum insurance instability and mental health care access.ResultsInsurance changes primarily occurred by 3–6 months postpartum. Of respondents with public coverage at childbirth, 33.2% experienced postpartum insurance changes compared with 9.5% with private coverage (p < .001). Respondents who were younger, had incomes of less than $50,000, and were of Hispanic ethnicity were more likely to experience unstable postpartum insurance. Respondents who experienced postpartum insurance instability had a lower odds of reporting that they discussed mental health at a postpartum check-up (adjusted odds ratio, 0.4; 95% confidence interval, 0.2–0.7; p < .01) and received postpartum mental health services (adjusted odds ratio, 0.4; 95% confidence interval, 0.2–0.9; p < .05).ConclusionsThe majority of postpartum insurance disruptions occurred among respondents with public coverage at childbirth and by 3–6 months postpartum. Respondents who experienced unstable coverage were more likely to have less access to postpartum mental health care. Policies that increase postpartum insurance stability, such as postpartum Medicaid extensions beyond 60 days, are needed to improve access to postpartum mental health services.     

Association of Provider Specialty With Abortion-Related Morbidity and Adverse Events Among Patients Having Procedural and Medication Abortions

ObjectiveSince abortion was legalized throughout the United States in 1973, states have passed restrictive abortion policies, including permitting only obstetrician-gynecologist physicians (OBGYNs) to provide abortions. We are unaware of any research that directly compares patient safety-related outcomes by physician specialty. In this study, we compared major and any abortion-related morbidity and adverse events in abortion care provided by physicians of other specialties versus OBGYNs.Study DesignUsing the IBM Watson Health MarketScan claims database, we identified privately insured individuals who had an induced abortion between January 1, 2011, and December 31, 2014. The primary outcome was major abortion-related morbidity or adverse events, and the secondary outcome was any abortion-related morbidity or adverse events occurring within 6 weeks of the abortion.ResultsThe study cohort included 34,764 patients who had 35,407 abortions—4,843 (13.7%) abortions provided by physicians of other specialties and 30,564 (86.3%) abortions provided by OBGYNs. Major and any abortion-related morbidity or adverse event occurred in 115 (0.3%) and 1,271 (3.6%) of 35,407 of abortions, respectively. In adjusted analyses, there was no statistically significant difference in major abortion-related morbidity or adverse events comparing physicians of other specialties versus OBGYNs (adjusted odds ratio, 1.02; 95% confidence interval, 0.59–1.75), and no statistically significant difference in any abortion-related morbidity or adverse events comparing physicians of other specialties versus OBGYNs (adjusted odds ratio, 0.91; 95% confidence interval, 0.77–1.09).ConclusionsThere were no differences in abortion-related morbidity or adverse events by physician specialty. Our findings do not support state laws limiting abortion care to OBGYN physicians.     

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.     

Congruence across Sexual Orientation Dimensions and Risk for Unintended Pregnancy among Adult U.S. Women

ObjectivesTo date, no studies have investigated whether sexual minority women (SMW) are more likely to experience unintended pregnancies compared with their heterosexual peers. The aim of this study was to explore whether adult SMW were more likely to have unintended pregnancies compared with heterosexual women, to examine the role of identity–attraction congruence in unintended pregnancy risk, and to evaluate possible mediators.MethodsData on pregnancies to women ages 18 to 44 were drawn from the 2006 through 2013 National Survey of Family Growth (n = 25,403). Weighted logistic regression models estimated the likelihood of reporting an unintended (rather than intended) pregnancy by identity–attraction congruence and the extent to which this association was mediated by sexual experiences with men, including age at first sex and number of sexual partners. Supplementary analyses addressed the issue of abortion underreporting.ResultsPregnancies to SMW were more likely to be unintended compared with pregnancies to heterosexual women (adjusted odds ratio, 1.26; 95% confidence interval, 1.08–1.46). This was driven by the elevated risk experienced by heterosexual-identified women with same-sex attractions, specifically (adjusted odds ratio, 1.28; 95% confidence interval, 1.08–1.51). Greater unintended pregnancy risk among these women was mediated by a greater number of male sex partners compared with heterosexual women.ConclusionsUnintended pregnancy risk among SMW has historically received little attention from scholars and clinicians. Future research should explore the specific conditions that put heterosexual-identified women with same sex attractions at increased risk for unintended pregnancy. Clinicians should consider these dynamics when screening patients for contraceptive counseling.     

Abortion referral patterns among generalist OB/GYNs and primary care practitioners: A qualitative study

ObjectiveAn informed, timely referral from a generalist practitioner has the potential to facilitate care for a patient seeking an abortion. However it is unclear what barriers, if any, generalist practitioners perceive in this process. The objective of this study was to qualitatively characterize abortion referral patterns among generalist practitioners.Study designWe conducted individual interviews with generalist practitioners practicing at Northwestern Medicine, encompassing four hospitals across the greater Chicago metropolitan area. The interview guide focused on abortion-related topics including: referral patterns, attitudes about providing referrals, and specifics of the abortion referral process. We analyzed the data for content and themes using an inductive approach.ResultsWe completed 37 interviews. Practitioners in all fields and practice sites were willing to provide abortion referrals. Practitioners perceived barriers in the referral process, with a lack of knowledge chief among them. Further, practitioners saw abortion referrals as more burdensome than other specialty referrals.ConclusionGeneralist practitioners are willing to provide abortion referrals, but perceive multiple barriers in the abortion referral process. Generalist practitioners can help to ensure their patients receive timely and quality abortion care if they feel prepared and empowered to assist with these referrals.     

Primary Cesarean Delivery Patterns among Women with Physical,Sensory, or Intellectual Disabilities

BackgroundLittle is known about the relationship between disability and mode of delivery. Prior research has indicated elevated risk of cesarean delivery among women with certain disabilities, but has not examined patterns across multiple types of disability or by parity.ObjectiveThis study sought to determine whether physical, sensory, or intellectual and developmental disabilities are independently associated with primary cesarean delivery.MethodsWe conducted a retrospective cohort study of all deliveries in California from 2000 to 2010 using linked birth certificate and hospital discharge data. We identified physical, sensory, and intellectual and developmental disabilities using International Classification of Diseases, 9th revision, clinical modification codes. We used logistic regression to examine the association of these disabilities and primary cesarean delivery, controlling for sociodemographic characteristics and comorbidities, and stratified by parity.ResultsIn our sample, 0.45% of deliveries (20,894/4,610,955) were to women with disabilities. A greater proportion of women with disabilities were nulliparous, had public insurance, and had comorbidities (e.g., gestational diabetes) compared with women without disabilities (p < .001 for all). The proportion of primary cesarean in women with disabilities was twice that in women without disabilities (32.7% vs. 16.3%; p < .001; adjusted odds ratio, 2.05; 95% confidence interval, 1.94–2.17). The proportion of deliveries by cesarean was highest among women with physical disabilities due to injuries compared with women without disabilities (57.8% vs. 16.3%; p < .001; adjusted odds ratio, 6.83; 95% confidence interval, 5.46–8.53).ConclusionsWomen across disability subgroups have higher odds of cesarean delivery, and there is heterogeneity by disability type. More attention is needed to this population to ensure better understanding of care practices that may impact maternal and perinatal outcomes.     

Concerns About the Cost of Contraception Among Young Women Attending Community College

IntroductionContraceptive use is lower among students attending community college than 4-year college students, which may be due to financial barriers to accessing contraceptives. This study examined insurance coverage, access to free or low-cost birth control, and concerns about contraceptive costs among women in community college.MethodsWe analyzed data from a study conducted at five community colleges in California and Oregon, which have expanded Medicaid coverage of family planning services for low-income individuals. Participants were students aged 18–25 years who self-identified as female, had vaginal sex, and were not pregnant or trying to become pregnant (N = 389). Multivariate analyses were conducted to examine concerns about the cost of contraception among these young women and how cost concerns varied by insurance coverage and access to free or low-cost birth control.ResultsNearly one-half of participants (49%) were concerned about the cost of contraception. In multivariate models, privately insured women had lower odds of being concerned about the cost of birth control than the uninsured (adjusted odds ratio, 0.42; 95% confidence interval, 0.22–0.83), yet women with public insurance had cost concerns similar to those of women without insurance. Women who reported they knew where to get free or low-cost birth control had lower odds of reporting cost concerns (adjusted odds ratio, 0.42; 95% confidence interval, 0.24–0.75), as did the few women enrolled in a state family planning program (adjusted odds ratio, 0.56; 95% confidence interval, 0.32–1.00).ConclusionsEven in states with publicly funded services for young people, concerns about the affordability of contraception were common among women, particularly the uninsured or publicly insured. Addressing students’ cost concerns is an important aspect of ensuring access to contraception during their pursuit of higher education.     

Patients' gender affected physicians' clinical decisions when presented with standardized patients but not for matching paper patients

ObjectiveTo compare physicians' treatment and referral decisions for total knee arthroplasty (TKA) for standardized patients with matching paper patients.Study Design and SettingSixty-seven physicians (38 family physicians and 29 orthopedic surgeons) performed blinded assessments of two standardized patients (one man and one woman) with moderate knee osteoarthritis and otherwise identical clinical scenarios differing only in gender, and consented to including their data. Standardized patients recorded physicians' recommendations (yes/no) to refer for, or perform, TKA. Sixty physicians provided their treatment recommendations to matching paper patients.ResultsRecommendation rates for both the male and the female standardized patients (67% and 32%, respectively) were lower compared with the matching paper patients (80% and 67%, respectively). Physicians were more likely to recommend TKA to a man than to a woman when presented with standardized patients (odds ratio, 4.2; 95% confidence interval [CI] = 2.4–7.3; P < 0.001). In contrast, patients' gender did not affect the same physicians' recommendations regarding referral for, or performing, TKA for the matching paper patients (odds ratio, 2.0; 95% CI = 0.9–4.6; P = 0.101).ConclusionUnlike their treatment recommendations for standardized patients, the same physicians' treatment and referral decisions for paper patients were not influenced by patients' gender, suggesting that paper patients are not a sensitive method of assessing physician bias.     

Is Depression Associated with Unhealthy Behaviors among Middle-Aged and Older Women with Hypertension or Heart Disease?

ObjectiveDepression is a common comorbidity in patients with cardiovascular conditions. This study aims to assess the association between comorbid depression and health-promoting behavior in middle-aged and older Australian women with hypertension or heart disease.MethodsData are from a subset of 45 and Up Study participants with diagnosed chronic illness (n = 1,925). Health behaviors including smoking status, alcohol consumption, and physical activity were assessed. Associations of depression with health behaviors in women with hypertension or heart disease were analyzed using unadjusted and adjusted (for chronic conditions and demographic measures) logistic regression models.ResultsA total of 666 women with hypertension and 220 women with heart disease were included in the analysis. In adjusted analyses, women with hypertension and comorbid depression were 2.36 (95% confidence interval, 1.02–5.46) times more likely to be risky or high-risk drinkers and 55% (adjusted odds ratio, 0.45; 95% confidence interval, 0.27–0.73) less likely to be highly physically active, compared with women without depression. Women with heart disease and comorbid depression were 65% (adjusted odds ratio, 0.35; 95% confidence interval, 0.12–0.95) less likely to be highly physically active, compared with women without depression.ConclusionsThis study provides the first data indicating that depression may be a barrier to health-promoting behavior in middle-aged and older women with hypertension or heart disease. Given that physical inactivity and risky alcohol consumption are important risk factors for aggravation of cardiologic conditions, health-promoting behaviors should be specifically targeted in the treatment of women with comorbid depression.     

Momentary Assessment of Social Context and Glucose Monitoring Adherence in Adolescents With Type 1 Diabetes

PurposeTo investigate the associations between momentary social context and glucose monitoring adherence in adolescents with type 1diabetes (T1D).MethodsFor 14 days, patients (14–18 years old, T1D duration >1 year) of a pediatric diabetes clinic carried handheld computers that prompted them to report their location, companionship, and attitudes toward companions at the times they usually checked their glucose, and again 30 minutes later to report whether they checked their glucose and, if not, why. Associations between social context factors and checking glucose (adherence) were analyzed using logistic generalized estimating equations and adjusted for age, sex, duration of T1D, and pump use.ResultsThirty-six participants (mean age 16.6 ± 1.5 years, mean duration of T1D 8.7 ± 4.4 years) completed 971 context and 1,210 adherence reports, resulting in 805 paired reports. Median signal response rate was 63%. The odds of checking glucose was higher when participants expressed very strong desire to blend in (adjusted odds ratio [AOR] = 2.30, 95% confidence interval 1.07–4.94, p = .03). Strong desire to impress others was associated with decreased likelihood of checking glucose (AOR = .52, 95% confidence interval .28–.97, p = .04.) Location, solitude, type of companion, and attitudes toward companions were not significantly associated with checking glucose.ConclusionsDesire to blend in may support glucose monitoring adherence and desire to impress others may impede this behavior in adolescents with T1D. Other dimensions of social context were not linked to checking glucose in this study.     

Are Illinois Contraceptive Providers Comfortable Providing Care to Adolescents? Results From a Statewide Provider Needs Assessment

ObjectivesLegislation allows adolescents to access comprehensive contraceptive care; however, provider practices remain unclear. We examined predictors of provider knowledge and comfort surrounding the provision of contraceptive care to adolescents.MethodsWe mailed a survey to Illinois contraceptive providers (n = 251). Study outcomes include 1) knowledge of adolescent consent laws, 2) comfort asking for time alone with adolescents, 3) comfort providing contraception to adolescents without parental consent, and 4) comfort providing long-acting reversible contraception (LARC) to adolescents without parental consent. Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs).ResultsMost providers are knowledgeable of consent laws (90%) and report being comfortable asking for time alone with adolescents (94%) and comfortable providing contraception to adolescents without parental consent (88%). Having a large proportion of patients who are eligible for family planning services was associated with increased comfort asking for time alone with adolescents (aOR, 7.03; 95% CI, 1.58–31.3) and providing contraception to adolescents (aOR, 4.0; 95% CI, 1.4–11.1). Only one-half (54%) were comfortable providing LARC methods to adolescents, with higher comfort among providers who: received more than 2 days of formal family planning training (aOR, 2.77; 95% CI, 1.2–6.2), specialized in obstetrics-gynecology (aOR, 5.64; 95% CI, 2.1–15.1), and had a patient population with more than 50% patients from minoritized racial/ethnic groups (aOR, 2.9; 95% CI, 1.2–6.6).ConclusionsAlthough knowledge of consent laws was high, gaps remain. Only one-half of our sample indicated comfort with the provision of LARC methods without parental consent. Additional efforts to increase provider comfort with all contraceptive methods and training on adolescent-centered practices may be required to meet the needs of adolescent patients.     

Evaluation of a Web-Based Asthma Management Intervention Program for Urban Teenagers: Reaching the Hard to Reach

PurposeAsthma interventions targeting urban adolescents are rare, despite a great need. Motivating adolescents to achieve better self-management of asthma is challenging, and the literature suggests that certain subgroups are more resistant than others. We conducted a school-based, randomized controlled trial (RCT) to evaluate Puff City, a Web-based, tailored asthma intervention, which included a referral coordinator, and incorporated theory-based strategies to target urban teens with characteristics previously found to be associated with lack of behavior change.MethodsTo identify eligible teens, we administered questionnaires on asthma diagnoses and symptoms to ninth through 12th graders of participating schools during a scheduled English class. We randomized eligible, consenting students to Puff City (treatment) or generic asthma education (control).ResultsWe randomized 422 students (98% African-American, mean age = 15.6 years). At 12-month follow-up, adjusted odds ratios (aORs) (95% confidence intervals) indicated intervention benefit for treatment teens for symptom-days and restricted activity days (analyzed as categorical variables) as aOR = .49 (.24–.79), p = .006 and .53 (.32–.86), p = .010, respectively. Among teens meeting baseline criteria for rebelliousness, treatment teens reported fewer symptom-days, symptom-nights, school absences, and restricted activity days: aOR = .30 (.11–.80), .29 (.14–.64), .40 (.20–.78), and .23 (.10–.55); all p < .05. Among teens reporting low perceived emotional support, treatment students reported only fewer symptom-days than controls: aOR = .23 (.06–.88), p = .031. We did not observe statistically significant differences in medical care use.ConclusionsResults suggest that a theory-based, tailored approach, with a referral coordinator, can improve asthma management in urban teens. Puff City represents a viable strategy for disseminating an effective intervention to high-risk and hard-to-reach populations.     

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.     

The Role of Parents and Partners in Minors' Decisions to Have an Abortion and Anticipated Coping After Abortion

PurposeDespite the prevalence of laws requiring parental involvement in minors' abortion, little is known about the effect of parental involvement on minors' abortion decision making and anticipated coping after abortion.MethodsWe analyzed data from medical charts and counseling needs assessment forms for 5,109 women accessing abortion services at a clinic in 2008, 9% (n = 476) of whom were minors aged 17 years and under. We examined differences in abortion characteristics, including parental and partner involvement, between minors and adults, and used multivariate logistic regression models to examine predictors of parental involvement and support, confidence in the decision, and anticipated poor coping among minors.ResultsMost minors reported that their mothers (64%) and partners (83%) were aware of their abortion. Younger age was associated with increased odds of maternal awareness and reduced odds of partner awareness. Compared with adults, minors were more likely to report external pressure to seek abortion (10% vs. 3%), and mothers were the most common source of pressure. Minors overall had high confidence in their decision and anticipated feeling a range of emotions post-abortion; minors who felt pressure to seek abortion were less likely to report having confidence in their decision (odds ratio = .1) and more likely to report anticipating poor coping (odds ratio = 5.6).ConclusionsMost minors involve parents and partners in their decision making regarding abortion, and find support from these individuals. For a minority, experiencing pressure or lack of support reduces confidence in their decision and increases their likelihood of anticipating poor coping after an abortion.     

Delayed Dysphagia May Be Sarcopenic Dysphagia in Patients After Stroke

ObjectiveIn many cases, swallowing function is impaired after the onset of stroke and gradually improves. However, delayed dysphagia has been reported in some post-stroke patients. Recently, several studies have reported that low muscle strength and decreased muscle mass cause dysphagia. This study aimed to investigate whether these conditions are associated with delayed dysphagia after stroke.DesignA multicenter prospective observational cohort study.Setting and ParticipantsParticipants included 165 patients with post-stroke dysphagia (mean age 79.1 ± 8.0 years, 53.3% women) admitted to rehabilitation wards for post-stroke rehabilitation.MethodsSwallowing function was assessed using the Functional Oral Intake Scale. Delayed dysphagia was defined as dysphagia that occurred more than 7 days after stroke onset. We used logistic regression to examine the independent association between low muscle strength and decreased muscle mass and delayed dysphagia development. Furthermore, we examined the relationship between improvement in dysphagia and delayed dysphagia.ResultsDelayed dysphagia was observed in 18 (10.9%) patients. The combination of severely low muscle strength and decreased muscle mass was independently associated with the development of delayed dysphagia (adjusted odds ratio: 4.423, 95% confidence interval: 1.400–13.974, P = .011). Delayed dysphagia had an adverse effect on the improvement of dysphagia during in-hospital rehabilitation (adjusted odds ratio: 0.278, 95% confidence interval: 0.078–0.986, P = .047).Conclusions and ImplicationsThe development of delayed dysphagia was influenced by a combination of severely low muscle strength and decreased muscle mass. Furthermore, delayed dysphagia adversely affects the improvement of dysphagia in patients with stroke and needs to be identified early. Identifying delayed dysphagia using the methods proposed in this study and incorporating early intervention may prevent or delay dependency conditions in this population.     

Smoking and subsequent human papillomavirus infection: a mediation analysis

PurposeSmoking is an established risk factor for a human papillomavirus (HPV) infection advancing to cervical precancer and cancer, but its role earlier in the natural history is less clear. Smoking is inversely associated with possessing HPV antibodies from a past infection suggesting that smoking may influence acquiring subsequent infections.MethodsIn a cohort of 1976 U.S. women, we evaluate whether reduced antibodies to HPV-16 is a mechanism for smoking's role on acquiring a subsequent HPV-16 infection, through the analytic technique of causal mediation analysis. We posit a causal model and estimate two counterfactually defined effects: a smoking impaired antibody-mediated indirect effect and a nonmediated direct effect representing all other potential mechanisms of smoking.ResultsCompared to never smokers, current smokers had increased odds of HPV-16 infection by the antibody-mediated indirect effect (odds ratio [OR] = 1.29; 95% confidence interval [CI]: 1.11, 1.73); the estimated direct effect was very imprecise (OR = 0.57; 95% CI, 0.26–1.13). We observed a stronger estimated indirect effect among women who smoked at least half a pack of cigarettes daily (OR = 1.61, 95% CI, 1.27–2.15) than among women who smoked less than that threshold (OR = 1.09; 95% CI, 0.94–1.44).ConclusionsThis is the first study to directly test the mechanism underlying smoking as an HPV cofactor. The results support current smoking as a risk factor earlier in the natural history of HPV and are consistent with the hypothesis that smoking increases the risk of a subsequent infection by reducing immunity.