Abortion Surveillance Research Articles

Quantitative and qualitative assessment of the bovine abortion surveillance system in France

Bovine abortion is the main clinical sign of bovine brucellosis, a disease of which France has been declared officially free since 2005. To ensure the early detection of any brucellosis outbreak, event-driven surveillance relies on the mandatory notification of bovine abortions and the brucellosis testing of aborting cows. However, the under-reporting of abortions appears frequent. Our objectives were to assess the aptitude of the bovine abortion surveillance system to detect each and every bovine abortion and to identify factors influencing the system's effectiveness. We evaluated five attributes defined by the U.S. Centers for Disease Control with a method suited to each attribute: (1) data quality was studied quantitatively and qualitatively, as this factor considerably influences data analysis and results; (2) sensitivity and representativeness were estimated using a unilist capture–recapture approach to quantify the surveillance system's effectiveness; (3) acceptability and simplicity were studied through qualitative interviews of actors in the field, given that the surveillance system relies heavily on abortion notifications by farmers and veterinarians. Our analysis showed that (1) data quality was generally satisfactory even though some errors might be due to actors’ lack of awareness of the need to collect accurate data; (2) from 2006 to 2011, the mean annual sensitivity – i.e. the proportion of farmers who reported at least one abortion out of all those who detected such events – was around 34%, but was significantly higher in dairy than beef cattle herds (highlighting a lack of representativeness); (3) overall, the system's low sensitivity was related to its low acceptability and lack of simplicity. This study showed that, in contrast to policy-makers, most farmers and veterinarians perceived the risk of a brucellosis outbreak as negligible. They did not consider sporadic abortions as a suspected case of brucellosis and usually reported abortions only to identify their cause rather than to reject brucellosis. The system proved too complex, especially for beef cattle farmers, as they may fail to detect aborting cows at pasture or have difficulties catching them for sampling. By investigating critical attributes, our evaluation highlighted the surveillance system's strengths and needed improvements. We believe our comprehensive approach can be used to assess other event-driven surveillance systems. In addition, some of our recommendations on increasing the effectiveness of event-driven brucellosis surveillance may be useful in improving the notification rate for suspected cases of other exotic diseases.

Was the French clinical surveillance system of bovine brucellosis influenced by the occurrence and surveillance of other abortive diseases?

The bovine brucellosis clinical surveillance system implemented in France aims to detect early any case of bovine brucellosis, a disease of which the country has been declared free since 2005. It relies on the mandatory notification of every bovine abortion. Following the spread of the Schmallenberg virus (SBV) in France in 2012 and 2013, and the implementation in 2012 of a clinical surveillance programme of Q fever based on abortion notifications in ten pilot départements, our objective was to study whether these two events influenced the brucellosis clinical surveillance system. The proportion of notifying farmers was analyzed over each semester from June 1, 2009 to June 30, 2013 according to the size and production type of herds, SBV status of départements and the implementation of the Q fever surveillance. Our analysis showed a slight increase in the proportion of notifying farmers as départements became infected by SBV, and after the implementation of Q fever surveillance (during the first semester of 2013). These variations might be explained by an increase in abortion occurrence (congenital deformities in newborns, due to SBV) and/or by an increase in farmers’ and veterinarians’ awareness (due to the spread of SBV and the implementation of the Q fever surveillance). These results highlight the difficulties in interpreting variations in the proportion of notifying farmers as a consequence of an increase in abortion occurrence. As bovine abortion surveillance can play an important role in the early warning for several diseases, there is a need to explore other ways to monitor abortions in cattle, such as syndromic surveillance using the dates of artificial insemination or calving data.

Trends in use of medical abortion in the United States: reanalysis of surveillance data from the Centers for Disease Control and Prevention, 2001–2008

BackgroundWith changing patterns and increasing use of medical abortion in the United States, it is important to have accurate statistics on the use of this method regularly available. This study assesses the accuracy of medical abortion data reported annually to the Centers for Disease Control and Prevention (CDC) and describes trends over time in the use of medical abortion relative to other methods. Study DesignThis analysis included data reported to CDC for 2001–2008. Year-specific analyses included all states that monitored medical abortion for a given year, while trend analyses were restricted to states that monitored medical abortion continuously from 2001 to 2008. Data quality and completeness were assessed by (a) examining abortions reported with an unspecified method type within the gestational age limit for medical abortion (med-eligible abortions) and (b) comparing the percentage of all abortions and med-eligible abortions reported to CDC as medical abortions with estimates based on published mifepristone sales data for the United States from 2001 to 2007. ResultsDuring 2001–2008, the percentage of med-eligible abortions reported to CDC with an unspecified method type remained low (1.0%–2.2%); CDC data and mifepristone sales estimates for 2001–2007 demonstrated strong agreement [all abortions: intraclass correlation coefficient (ICC)=0.983; med-eligible abortions: ICC=0.988]. During 2001–2008, the percentage of abortions reported to CDC as medical abortions increased (p<.001 for all abortions and for med-eligible abortions). Among states that reported medical abortions for 2008, 15% of all abortions and 23% of med-eligible abortions were reported as medical abortions. ConclusionCDC's Abortion Surveillance System provides an important annual data source that accurately describes the use of medical abortion relative to other methods in the United States.

Regression Analysis and Causal Inference: Cause for Concern?

Norman A. Constantine is senior scientist and director, Center for Research on Adolescent Health and Development, Public Health Institute, Oakland, CA, and clinical professor of community health and human development, School of Public Health, University of California, Berkeley. Regular readers of Perspectives on Sexual and Reproductive Health may have noticed a preference among published authors for regression analysis as their primary methodology. In fact, last year, a substantial majority of this journal’s articles employed some form of regression analysis, predominantly logistic regression. Such methodological dominance—which is by no means unique to this journal—supports the need for a critical review of the common uses and misuses of these types of analyses, and a careful examination of the validity threats and issues associated with the claims, conclusions and recommendations that typically result. When used appropriately, regression analysis can be a powerful tool: It allows one to statistically model the relationship between a dependent (outcome) variable and a set of independent (predictor) variables. Linear regression is used with continuous dependent variables, such as number of sex partners or infant birth weight, while logistic regression is used with dichotomous dependent variables, such as a history of pregnancy or STD infection. Both forms of regression allow for the assessment of whether an independent variable (such as age, attitudes, protective behaviors or services received) is associated with an outcome variable while controlling for (statistically removing) the outcome’s overlapping associations with other variables. These types of analyses are generally applied to correlational data, such as survey, census or administrative data, in so-called observational studies. Of course, regression analysis is not needed in every study employing quantitative data. For example, results of abortion surveillance over time and across locations can be usefully presented employing just percentage or rate distributions. The potential power and added complexity of regression analysis are best reserved for either predicting outcomes or explaining relationships. The prediction of outcomes on the basis of current characteristics is possible without regard to the causal relationships among variables. For instance, regression analyses have shown that Asian and college-educated parents are the least likely among all social and demographic subgroups to support human papillomavirus vaccination for their daughters; these fi ndings can be used to identify the need for educational campaigns for these two subgroups even without understanding why they are the least supportive of vaccination. However, to develop effective educational campaigns, it is also necessary to understand the factors that infl uence parents’ support for having their daughters vaccinated. When the goal is to understand (i.e., explain) the causal infl uences on a population outcome—a prerequisite for the design and development of any sexual health intervention—regression analysis can be a powerful tool, but it has some fundamental limitations. Its appropriate use requires substantial care and skill, as well as suffi cient inferential humility.

Nurses and Care of Women Seeking Abortions, 1971 to 2011

In its first issue in 1972, JOGNN published a review article reporting surveillance data about abortions in the United States (Bourne, Kahn, Conger, & Tyler, 1972). This historical article predated Roe v. Wade, the U.S. Supreme Court decision legalizing abortion. Since this landmark decision, numerous articles have addressed nurses' role in abortion care. We review current literature on nurses and abortion care and use thematic categories to highlight areas of investigation.

Late pregnancy abortions: an analysis of Québec stillbirth data, 1981–2006

We evaluated late pregnancy abortions from 1981 to 2006 in Québec, Canada. We extracted late abortions from the stillbirth mortality file, and calculated yearly rates per 100,000 pregnancies, including mean gestational age, birth weight, maternal age and education. There were 14.4 late abortions per 100,000 overall pregnancies [95% confidence interval 12.9, 16.1], and rates appeared to increase with time. Mean gestational age (24.7 weeks) and birth weight (886 g) suggested that abortions were performed in the late second and third trimesters. Late abortions in Québec are not common but do occur. Research is needed to determine whether the increase in rates over time reflects better reporting or a true increase. Improved surveillance of late abortions may be warranted.

Does income support increase abortions?

Currently, Temporary Assistance for Needy Families (TANF) programs in 32 American states allow low-income childless pregnant single women (CPSW) to receive monthly cash assistance, while 28 states and the District of Columbia use lump-sum payments to divert low-income families from TANF. Past research has not investigated the possible consequences on abortions of these two welfare policies. We construct a theoretical model of low-income CPSW to investigate them. The results of the theory yields the following hypotheses: (1) diversion payments to low-income mothers lower abortion incidence; and (2) diversion payments and CPSW eligibility together raise abortion incidence. We use data from the US Centers for Disease Control and Prevention’s Abortion Surveillance, and a system GMM dynamic panel, two-way fixed-effects empirical model to test our hypotheses. Our empirical results provide statistically significant evidence for the first hypothesis, but not the second.

Evaluation of surveillance strategies for bovine brucellosis in Japan using a simulation model

Bovine brucellosis is caused by Brucella abortus and induces abortions in female cattle, with other cattle at risk of infection from the aborted fetus or contaminated placenta. In Japan, the number of cases has dramatically reduced due to national surveillance and eradication strategies. Bovine brucellosis is now believed to be eradicated in Japan. Here, we examine the surveillance strategies currently in place for early detection of infected cattle in the event of a future reintroduction of the disease. We compared current serological surveillance for the dairy population with bulk-milk surveillance and abortion surveillance, and used time to detection as the main criterion of surveillance efficacy. A stochastic individual-based model (IBM) was developed to simulate disease transmission within and between farms. Using outputs from the transmission model, a comparison of surveillance strategies was simulated. For evaluation of the robustness of the parameter values used in the transmission model, a sensitivity analysis was conducted. For the purpose of evaluating the direct costs of each surveillance strategy, the annual number of samples to be tested and the annual number of farms to be visited were estimated. Our results indicated that current serological surveillance with 60-month test intervals is not effective enough for rapid detection of a brucellosis outbreak. Bulk-milk surveillance appeared the most effective method based on the early detection of infected cows and a reduced number of samples required. The time to detection for abortion surveillance was greater than that of bulk-milk surveillance but varied widely depending on the reported ratio of abortions. Results from the surveillance model were consistent when alternative scenarios were applied to the transmission model. Although our model cannot exactly replicate an actual brucellosis outbreak, or the results of surveillance, our results may help decision-makers to choose the most effective surveillance strategy.

Scaling Up Post-Abortion Care in Guatemala: Initial Successes at National Level

This article describes a programme to scale up post-abortion care services in 22 of the 33 public sector district hospitals in Guatemala from July 2003 to December 2004. The main interventions included strengthening the knowledge and technical capacity of staff, expanding post-abortion care, enhancing related infrastructure, distributing informational materials andinstituting an abortion surveillance system. A facilitator supported the work through week-long, monthly visits at each hospital. Attention was also devoted to building institutional consensus in support of post-abortion care at government, district hospital and hospital staff levels. Duringthis period, 13,928 women with incomplete abortions were admitted to the 22 hospitals. Use of manual vacuum aspiration for treatment of incomplete first trimester abortion increased from 38% to 68% of cases (p<0.0001). Provision of family planning counselling also increased, from 31% to 78% of women (p<0.0001), and the proportion of women selecting a contraceptivemethod before leaving hospital from 20% to 49% (p<0.0001). Infection was associated with 71% of the incomplete abortions, of which 90% were septic. There were nine deaths and 768 women suffered severe complications, the level of which remained unchanged during the study period. Guatemala still has much to do to institutionalise post-abortion care fully and reduce deaths and complications, but our efforts to date will be valuable to others.

Abortion Surveillance: Trends, Characteristics and the Necessity of Data Collection

In 1969 the Centers for Disease Control and Prevention (CDC) began abortion surveillance to document the number and characteristics of women obtaining legal induced abortions. The data have been published every year since 1970 and recently was released in the November 28 issue of the CDC’s “Morbidity and Mortality Weekly Report” (MMWR). The report entitled “Abortion Surveillance— U.S. 2000” reveals that the total number of legal induced abortions performed in the U.S. for 2000 was down from 1999 and has been on the decline for a decade. It’s important for health care professionals to understand the collection of this information and where it can be obtained as well as to monitor these trends so that we can better understand the differing aspects and evolving patterns of this elective pregnancy outcome. It’s equally important to recognize the necessity of having such data resources available for health care professionals and advocates. (excerpt)

Risk factors for legal induced abortion-related mortality in the United States.

To assess risk factors for legal induced abortion-related deaths. This is a descriptive epidemiologic study of women dying of complications of induced abortions. Numerator data are from the Abortion Mortality Surveillance System. Denominator data are from the Abortion Surveillance System, which monitors the number and characteristics of women who have legal induced abortions in the United States. Risk factors examined include age of the woman, gestational length of pregnancy at the time of termination, race, and procedure. Main outcome measures include crude, adjusted, and risk factor-specific mortality rates. During 1988-1997, the overall death rate for women obtaining legally induced abortions was 0.7 per 100000 legal induced abortions. The risk of death increased exponentially by 38% for each additional week of gestation. Compared with women whose abortions were performed at or before 8 weeks of gestation, women whose abortions were performed in the second trimester were significantly more likely to die of abortion-related causes. The relative risk (unadjusted) of abortion-related mortality was 14.7 at 13-15 weeks of gestation (95% confidence interval [CI] 6.2, 34.7), 29.5 at 16-20 weeks (95% CI 12.9, 67.4), and 76.6 at or after 21 weeks (95% CI 32.5, 180.8). Up to 87% of deaths in women who chose to terminate their pregnancies after 8 weeks of gestation may have been avoidable if these women had accessed abortion services before 8 weeks of gestation. Although primary prevention of unintended pregnancy is optimal, among women who choose to terminate their pregnancies, increased access to surgical and nonsurgical abortion services may increase the proportion of abortions performed at lower-risk, early gestational ages and help further decrease deaths. II-2

Pharmacoeconomics of medical abortion: a review of cost in the United States, Europe and Asia

Procedures for the termination of pregnancy have existed for many years. Vacuum aspiration, otherwise referred to as ‘surgical’ abortion, is a very common and safe procedure. Its efficacy and acceptability has been established and its complication rate is low. Medical abortion is a much more recent phenomenon. It is defined as early pregnancy termination with the use of abortion inducing medications, without surgery [1]. In contrast to surgical abortion, medical abortion is not as routinely offered, nor are many providers comfortable with its use. Medical abortion regimens currently available throughout the world include mifepristone (Mifeprex™, Aventis Pharma AG) and a prostaglandin analogue (usually misoprostol), methotrexate and misoprostol and misoprostol (Cytotec™, CD Searle & Co.) alone. In the US, minimal information exists directly comparing medical to surgical abortion. Most abortion surveillance data was collected by the Centers for Disease Control prior to the approval of mifepristone. In contrast, there is over a decade’s worth of experience from Europe with both the use and provision of medical abortion. A complete review of these issues must include background information on the history and incidence of abortion, who chooses to get an abortion, who provides that service and at what cost. The cost issue is discussed using three different viewpoints: cost to the patient, cost to the provider, cost to society – mainly in the form of government expenditure and savings. Following the cost analysis, there is a summary of relevant information from countries in Europe, primarily the UK, France, Sweden and countries in Asia, mainly China and India.

Abortion surveillance at CDC: Creating public health light out of political heat

Abstract: In the late 1960s, states began to liberalize their abortion laws, and a new era in women’s health began. Under the leadership of Jack Smith, the Centers for Disease Control and Prevention (CDC) established a voluntary abortion surveillance system that provided the first nationwide information on the numbers and characteristics of women having abortions. Studies of abortion morbidity done by the CDC revealed that suction curettage was safer than sharp curettage, local anesthesia was safer than general anesthesia, free-standing clinics were safer than hospitals, and dilation and evacuation (D&E) was safer than the alternative of labor induction for early second-trimester abortions. This evidence, which contradicted traditional medical tenets, rapidly changed the practice of abortion in the United States. CDC also established a surveillance system for abortion deaths. This demonstrated a rapid improvement in the safety of abortion in the early 1970s. Lessons learned from mortality investigations helped to change practice as well.Today, more is known about the epidemiology of abortion than any other operation in the history of medicine. In the midst of strident debate over the abortion issue, CDC abortion surveillance data have helped to guide judicial rulings, legislative actions, and Surgeon General’s reports, which have supported safer choices for women of reproductive age. When medical historians of the future look back on this century, the increasing availability of safe, legal abortion will stand out as a public health triumph.

Legal abortion in Asturias (Spain) after the 1985 law: sociodemographic characteristics of women applying for abortion.

To describe the use of induced abortion (IA) in Asturias after its legalisation as well as the socio-demographic characteristics of women applying for abortion. Descriptive study, population-based, using data collected by the regional abortion surveillance system for the period 1988 1994. The number of IA and the abortion rate (AR) (10 per 1000 women aged 15-49) have been stable in Asturias during the study period. The highest ARs were found for women in the age group 20-34, for divorced/separated, for women with a higher educational level and for women with only one child. The proportion of pregnancies which ended in abortion was one in four; for teenagers and women over 34 years it was one in two. This proportion was also higher for women not married, students and women with two or more children. Ninety-eight percent of all abortions took place in private clinics, the woman's physical/mental health being the medical indication for these abortions. Abortion was most often performed within eight weeks of gestation (65%). Late abortion ocurred more frequently among teenagers and women of low educational level. Eighteen percent of women had repeated abortions. A high proportion (61%) of women applying for abortion had not used the Family Planning (FP) services in the previous two years; adolescents and women of low educational level had the lowest frequencies of FP use. Compared with that of other European countries, the AR in Asturias was intermediate. The results regarding adolescents show the need for evaluation and promotion of sex education and contraceptive programmes. The lower and later use of abortion by women of low educational level shows inequalities that call for specific action.

Abortion Surveillance: Preliminary Analysis—United States, 1995

The Division of Reproductive Health Center for Promotion and Education Center for Disease Control (CDC) initiated ongoing epidemic surveillance of abortion in the US in 1969 to document the numbers and characteristics of women obtaining abortion and to assist in efforts to eliminate preventable morbidity and mortality associated with abortion. A preliminary analysis of legal abortions reported to CDC for 1982 and 1983 are reported. In 1983 for the 1st time since 1969 the total number of legal abortions the rate per 1000 females 15-44 years and the ratio/1000 live births all declined in comparison with reported values for the previous year. The number of legal abortions reported to CDC from the 50 states and the District of Columbia increased from 1300760 in 1981 to 1303980 in 1982 and decreased to 1268987 in 1983. The national abortion ratio continued to decrease from 359 legal abortions/1000 live births in 1980 to 358 in 1981 354 in 1982 and 349 in 1983. The national abortion rate of 34 legal abortions/1000 women 15-44 years dropped to 23 in 1983. In both 1982 and 1983 as in previous years women obtaining abortions tended to be young white unmarried and to have had no live births. In 1982 62.2% of women obtaining legal abortions were under age 25 68.5% were white 78.0% were unmarried and 57.8% had had no live births; these figures were 61.8% 67.6% 78.6% and 57.1% respectively in 1983. An examination of the national abortion surveillance system for 1982 and 1983 suggests that the reported lower abortion ratios and rates reflect real phenomena and are not artifacts of changes in the completeness of reporting. Curettage continued to be the primary abortion method accounting for a higher proportion in 1982 and 1983 than in previous years. Lower proportions of abortions were performed by instillation hysterectomy and hysterotomy. In 1982 and 1983 approximately 96% of all legal abortions were performed by curettage; about 2% were performed byinstillation and less than 0.05% were performed by hysterectomy and hysterotomy. About half of the legal abortions were performed in the first 8 weeks of gestation; approximately 90% were performed during the first 12 weeks of gestation. The number of legal abortion-related deaths increased from 7 in 1981 to 11 in 1982. Mortality data for 1983 are not presented as they may be incomplete. The death-to-case rate for legal abortion was 0.8/100000 in 1982 compared with 0.5 in 1981. Generally the death-to-case rate has been decreasing since 1972 but increases in the abortion-related mortality rate occurred in 1977 and 1979.

From the Centers for Disease Control and Prevention. Abortion surveillance: preliminary data--United States, 1994

From the Centers for Disease Control and Prevention. Abortion surveillance: preliminary data--United States, 1994

Abortion Surveillance: Preliminary Data— United States, 1994

For 1994, CDC received data on legal induced abortions from the 50 states, New York City, and the District of Columbia. This report presents preliminary data for 1994. Final abortion data for 1993 and 1994 will be published during spring 1997.

Abortion surveillance: preliminary data--United States, 1993. From the Centers for Disease Control and Prevention

Abortion surveillance: preliminary data--United States, 1993. From the Centers for Disease Control and Prevention

Abortion Surveillance: Preliminary Data— United States, 1993

Abortion Surveillance: Preliminary Data— United States, 1993

From the Centers for Disease Control and Prevention. Abortion surveillance: preliminary data--United States, 1992

From the Centers for Disease Control and Prevention. Abortion surveillance: preliminary data--United States, 1992