Abortion Visit Research Articles

Gardasil at the time of abortion visit: A quality improvement initiative

Gardasil at the time of abortion visit: A quality improvement initiative

Intimate Partner Violence Detected during Abortion-Related Visits: A Systematic Review of Screenings and Interventions.

To perform a systematic review of screening tools and interventions focused on reducing adverse health outcomes associated with intimate partner violence (IPV) at abortion-related visits. Studies were eligible if they included individuals seeking pregnancy options health care services in the United States, screening for or implementation of an intervention for IPV, and were published in English after the year 2000. The primary outcomes were to summarize screening tools, interventions studied, and if interventions led to individuals being connected to IPV-related resources. Secondary outcomes included patient responses to the IPV-related interventions and any other outcomes reported by the studies (PROSPERO #42021252199). Among 4,205 abstracts identified, nine studies met inclusion criteria. The majority (n = 6) employed the ARCHES (Addressing Reproductive Coercion in Health Settings) tool for identification of IPV. Interventions included provider-facilitated discussions of IPV, a safety card with information about IPV and community-based resources, and referral pathways to directly connect patients with support services. For the primary outcome, IPV-related interventions were shown to better inform patients of available IPV-related resources as compared to no intervention at all. For the secondary outcomes, screening and intervening on IPV were associated with improvements in patient perception of provider empathy (i.e., caring about safety) and safer responses by patients to unhealthy relationships. Screening for and intervening on IPV at abortion-related visits are associated with positive outcomes for patient safety and the patient-provider relationship. However, data on effective tools for identifying and supporting these patients are extremely limited. This review emphasizes the unmet need for implementation and evaluation of IPV-specific interventions during abortion-related clinical encounters. · The abortion visit offers a crucial setting to address IPV among a highly affected population.. · This study reviews others that analyzed interventions and associated outcomes for IPV at abortion-related visits.. · Appropriate interventions for IPV can improve patient-provider relationships and connect patients to essential resources..

Pharmacist provision of medication abortion: A pilot study

ObjectivesThis study aimed to perform a “proof of concept” pilot and assess patient satisfaction of pharmacist provision of medication abortion utilizing an implementation toolkit. Study designPharmacists completed an online and in-person training followed by an online assessment prior to participating in the pilot. Pharmacists provided medication abortion care using a “no-test” protocol and an implementation toolkit. Participants were administered 200 mg of mifepristone orally on the day of their abortion visit and instructed to take 800 mcg of misoprostol buccally 24 to 48 hours later (with an additional 800 mcg buccally 4 hours after the first dose for patients 63–70 days' gestation). Visits were completed in person in a private room adjacent to the pharmacy. We assessed the rate of completed abortions and any complications. Following their abortion, patients completed a brief interviewer-administered survey and semistructured qualitative interview. ResultsTen patients completed medication abortion visits. Nine of 10 participants had complete abortions. One participant identified that she did not pass her pregnancy and underwent an in-office aspiration. One participant visited an emergency department for pain and received pain medication. No serious adverse events occurred. All patients completed the postabortion survey, and all were “very satisfied” with their abortion experience. Nine patients completed postabortion interviews. ConclusionsIn this pilot study, pharmacists were successful at providing medication abortion to patients. Satisfaction was high, and complications were uncommon. ImplicationsPatients were highly satisfied with pharmacist provision of medication abortion and are likely to utilize this service if available.

The HPV at the Abortion Visit: The Utility of Video Education [ID: 1377357

INTRODUCTION: The human papillomavirus (HPV) vaccine is an important component of comprehensive sexual and reproductive health care and has the potential to completely eradicate cervical cancer. However, many women make it to adulthood without receiving a single vaccine. The abortion visit is an important health care access point for high-risk, unvaccinated individuals. METHODS: Patients (N=20) were recruited from the waiting room at a Chicago Planned Parenthood. Phase 1 included participants completing a 29-question assessment on HPV knowledge, HPV testing, and HPV vaccination. Phase 2 consisted of a randomized control trial of English-speaking patients, aged 18–26, presenting for a medication abortion (N=50). Primary outcome was uptake of vaccine; secondary was HPV knowledge via the same knowledge assessment tool used in phase 1. Patients were randomized to the interventional video or “usual care.” All patients were offered an HPV vaccine during medication abortion counseling. RESULTS: Knowledge scores significantly improved from preintervention (0.68 [±0.06]) to postintervention (0.77±0.05) (P=.03). Patients from the video intervention group demonstrated higher vaccine uptake (16%) compared to the “usual-care” group (0%) (P=.04). HPV knowledge assessment was significantly different between arms, with usual-care patients scoring 60% versus video intervention patients at 72%. CONCLUSION: There was significant improvement in knowledge assessment scores and vaccine uptake among the video intervention group. Video education is an effective tool in increasing HPV knowledge and uptake.

P082Rural-urban differences in post-abortion contraception use and past contraceptive access: A cohort study of abortion patients in utah

<h3>Objectives</h3> To evaluate the role of geography in post-abortion contraception choice and prior contraceptive barriers. <h3>Methods</h3> We recruited English- and Spanish-speaking abortion clients, aged 18–45, at a single facility in Salt Lake City, Utah. Participants enrolled between June 2021 and January 2022, and completed a baseline survey on the day of the abortion and a follow-up survey at three months. Rural-urban residence was determined using the Rural Urban Community Area (RUCA) classification system. We assessed demographic variables, method choice, and prior access barriers relative to geographic status. No-cost contraception was available for uninsured clients. <h3>Results</h3> We approached 779 clients and 527 (68%) completed the baseline survey (9.3% were rural). Rural clients were more likely to be multiparous and not in a committed relationship. Most participants (86.9%) planned to start a method after the abortion. Method choice was similar between groups, and long-acting reversible contraceptive (LARC) methods were most frequently selected (45.2% vs. 44.2%; p=0.62). Rural and urban clients reported similar rates of contraceptive access barriers in the past year (10.2% vs. 14.2%; p=0.52). Rural clients were more likely to report a >30-minute drive for contraception (15.4% vs. 9.2%; p=0.04), and higher rates of discomfort discussing contraception with local providers (30.4% vs. 10.9%; p=0.001). Regardless of residence, clients reporting prior difficulty accessing contraception (n=69) were more likely to select a LARC method (68.1% vs. 41.1%; p<0.01). <h3>Conclusions</h3> The contraceptive needs of rural and urban clients are similar; however, rural clients face unique barriers. The abortion visit is an important opportunity for care provision for clients with limited local access.

Immediate versus delayed postabortal insertion of contraceptive implant.

Contraceptive implants are one of the most effective contraceptive methods, providing a long duration of pregnancy protection and a high safety profile. Hence this method is suitable for optimizing the interpregnancy interval, especially for women undergoing abortion. Women who have had abortions are at high risk of rapid repeat pregnancies. Provision of effective contraception at the time of an abortion visit can be a key strategy to increase access and uptake of contraception. A review of the evidence was needed to evaluate progestin-releasing implants for immediate use at the time of abortion, including whether immediate placement impacts the effectiveness of medical abortion, which relies on antiprogestogens. To compare contraceptive implant initiation rates, contraceptive effectiveness, and adverse outcomes associated with immediate versus delayed insertion of contraceptive implants following abortion. We searched for all relevant studies regardless of language or publication status up to September 2019, with an update search in March 2021. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Ovid EBM Reviews), MEDLINE ALL (Ovid), Embase.com, CINAHL (EBSCOhost) (Cumulative Index to Nursing and Allied Health Literature), Global Health (Ovid), LILACS (Latin American and Caribbean Health Science Information database), Scopus, ClinicalTrials.gov, and the WHO ICTRP. We examined the reference lists of pertinent articles to identify other studies. We sought randomized controlled trials (RCTs) comparing immediate versus delayed insertion of contraceptive implant for contraception following abortion. We followed the standard procedures recommended by Cochrane. To identify potentially relevant studies, two review authors (JS, LS) independently screened the titles, abstracts, and full texts of the search results, assessed trials for risk of bias, and extracted data. We computed the risk ratio (RR) with 95% confidence intervals (CIs) for binary outcomes, and the mean difference (MD) with 95% CIs for continuous variables. We found three RCTs including a total of 1162 women. Our GRADE assessment of the overall certainty of the evidence ranged from moderate to very low, downgraded for risk of bias, inconsistency, and imprecision. Utilization rate at six months may be slightly higher for immediate compared with delayed insertion (RR 1.10, 95% CI 1.05 to 1.15; 3 RCTs; 1103 women; I2 = 62%; low certainty evidence). Unintended pregnancy within six months after abortion was probably lower with immediate insertion compared with delayed insertion (RR 0.25, 95% CI 0.08 to 0.77; 3 RCTs; 1029 women; I2 = 0%; moderate certainty evidence). Immediate insertion of contraceptive implants probably improves the initiation rate compared to delayed insertion following medical abortion (RR 1.26 for medical abortion, 95% CI 1.21 to 1.32; 2 RCTs; 1014 women; I2 = 89%; moderate certainty evidence) and may also improve initiation following surgical abortion (RR 2.32 for surgical abortion, 95% CI 1.79 to 3.01; 1 RCT; 148 women; I2 = not applicable; low certainty evidence). We did not pool results for the implant initiation outcome over both abortion types because of very high statistical heterogeneity. For medical termination of pregnancy, we found there is probably little or no difference between immediate and delayed insertion in overall failure of medical abortion (RR 1.18, 95% CI 0.58 to 2.40; 2 RCTs; 1001 women; I2 = 68%;moderate certainty evidence). There may be no difference between immediate and delayed insertion on rates of abnormal bleeding at one month after abortion (RR 1.00, 95% CI 0.88 to 1.14; 1 RCT; 462 women; I2 = not applicable; low certainty evidence). Provision of progestin-releasing implants concurrently with abortifacient agents likely has little or no negative impact on overall failure rate of medical abortion. Immediate insertion probably improves the initiation rate of contraceptive implant, as well as unintended pregnancy rate within six months after abortion, compared to delayed insertion. There may be no difference between immediate and delayed insertion approaches in bleeding adverse effects at one month after abortion.

A Post Hoc Exploratory Analysis: Induced Abortion Complications Mistaken for Miscarriage in the Emergency Room are a Risk Factor for Hospitalization.

IntroductionPrevious research indicates that an increasing number of women who go to an emergency room for complications following an induced abortion are treated for a miscarriage, meaning their abortion is miscoded or concealed.ObjectiveTo determine if the failure to identify a prior induced abortion during an ER visit is a risk factor for higher rates of subsequent hospitalization.MethodsPost hoc analysis of hospital admissions following an induced abortion and ER visit within 30 days: 4273 following surgical abortion and 408 following chemical abortion; abortion not miscoded versus miscoded or concealed at prior ER visit.ResultsChemical abortion patients whose abortions are misclassified as miscarriages during an ER visit subsequently experience on average 3.2 hospital admissions within 30 days. 86% of the patients ultimately have surgical removal of retained products of conception (RPOC). Chemical abortions are more likely than surgical abortions (OR 1.80, CL 1.38-2.35) to result in an RPOC admission, and chemical abortions concealed are more likely to result (OR 2.18, CL 1.65-2.88) in a subsequent RPOC admission than abortions without miscoding. Surgical abortions miscoded/concealed are similarly twice as likely to result in hospital admission than those without miscoding.ConclusionPatient concealment and/or physician failure to identify a prior abortion during an ER visit is a significant risk factor for a subsequent hospital admission. Patients and ER personnel should be made aware of this risk.

Preferences for contraceptive counseling and access among abortion patients at an independent clinic in Texas

ObjectiveAbortion clinics frequently offer contraceptive counseling, but it is unclear if this is in line with patient preferences or satisfies an unmet need. Our objective was to examine preferences for contraceptive counseling and access among abortion patients in a legally restrictive setting. MethodsIn this cross-sectional study, 181 patients at an abortion clinic in Dallas, Texas completed anonymous, self-administered surveys from June-July 2018. We analyzed data descriptively. Results46.5% of patients offered the survey agreed to participate. 33.1% of respondents preferred to obtain birth control from somewhere near their home. 29.3% preferred to obtain birth control from the same physician they visit for other health care needs. 81.8% were uninterested in contraceptive counseling at their abortion visit. Of these, 52.0% did not want to follow up for contraceptive counseling or services. ConclusionAmong study participants, most lacked interest in contraceptive counseling at the time of their abortion visit. Those interested in follow up preferred a resource handout over other options, such as a follow-up visit or phone call. Practice implicationsA patient-centered approach elicits patient preferences for contraceptive care and honors them by facilitating access when requested, such as through comprehensive resources and referrals.

Acceptance of HPV vaccination at the abortion visit at a clinic in New York City in 2017 to 2018

ObjectivesHuman Papillomavirus vaccination remains a public health concern. Our primary objective was to examine whether eligible people, in an underimmunized population, seeking abortion find the abortion visit an acceptable opportunity to receive the Human Papillomavirus (HPV) vaccine. Our secondary objectives include comparing vaccine acceptors to vaccine decliners on knowledge and attitudinal factors related to the HPV vaccine. Study DesignWe conducted a cross sectional study in which we offered free HPV vaccine series initiation and completion to eligible patients presenting for abortion services at an outpatient health center. We administered surveys to both vaccine acceptors and decliners, to assess utilization of health services, knowledge of the HPV vaccine, and reasons for not having initiated or completed the vaccine series previously. Results101 study participants were offered HPV vaccination; 50 participants accepted and 51 participants declined. All participants completed the survey. Seven of fifty vaccine acceptors completed the vaccine series. Vaccine acceptance was associated with new knowledge that HPV causes cervical cancer. (acceptors = 72.0%, decliners = 52.9%, p = 0.05) The most common reason among both groups for not previously initiating the vaccine was “No one offered it to me” (acceptors = 58.0%, decliners = 53.5%, p = 0.46). A considerable number of participants had not previously heard of the HPV vaccine, 44% of those who accepted, and 35.3% of those who declined (p = 0.64) vaccination at the time of their abortion. ConclusionThe abortion visit offers an important opportunity to start or to finish the HPV vaccine series. Most patients are receptive to receiving additional services and were never previously offered the HPV vaccine. Practices and policies aimed at utilizing missed opportunities for HPV vaccine catch up can increase HPV vaccine prevalence among young adult women to reduce lifetime risk for cervical cancer. ImplicationsThe abortion visit may be an opportunity for HPV vaccination catch up in an underimmunized population. Abortion providers may consider offering patients other preventive health care services.

Impact of contraceptive counseling on Texans who can and cannot receive no-cost post-abortion contraception

ObjectiveTo assess optimal timing, patient satisfaction, and 1-year contraceptive continuation associated with contraceptive counseling among Texans who could and could not receive no-cost long-acting reversible contraception (LARC) via a specialized funding program. Study DesignIn this prospective study conducted between October 2014 and March 2016, we evaluated participants’ desire for contraceptive counseling during abortion visits, impact of counseling on change in contraceptive preference, satisfaction with counseling, and 1-year postabortion contraceptive continuation. We stratified participants into 3 groups by income, insurance status, and eligibility for no-cost LARC: (1) low-income eligible, (2) low-income ineligible, and (3) higher-income and/or insured ineligible. We examined the association between contraceptive counseling rating and 1-year method continuation by program eligibility and post-abortion contraceptive type. ResultsAmong 428 abortion patients, 68% wanted to receive contraceptive counseling at their first abortion visit. Counseling led to a contraceptive preference change for 34%. Of these, 21% low-income eligible participants received a more effective method than initially desired, 10% received a less effective method, and 69% received the method they initially desired. No low-income ineligible participants received a more effective method than they initially desired, 55% received a less effective method, and 45% received the method they initially desired. Five percent of higher-income eligible participants received a more effective method than they initially desired, 48% received a less effective method, and 47% received the method they initially desired. Highest counseling rating was reported by 51%. Compared to those providing a lower rating in each group, highest counseling rating was significantly associated with lower 1-year contraceptive discontinuation for low-income eligible participants (aHR 0.34, 95% CI 0.14, 0.81), but not for low-income ineligible (aHR 1.56, 95% CI 0.83, 2.91) and higher-income (aHR 0.73, 95% CI 0.47,1.13) participants. Additionally, 1-year contraceptive continuation was associated with highest counseling rating (OR 1.72, 95% CI 1.09, 2.72) and post-abortion LARC use (OR 11.70, 95% CI 6.37, 21.48) in unadjusted models, but only postabortion LARC in adjusted models (aOR 1.55, 95% CI 0.90, 2.66 for highest counseling rating vs. aOR 11.83, 95% CI 6.29, 22.25 for postabortion LARC use). ConclusionsIn Texas, where access to affordable postabortion contraception is limited, high quality contraceptive counseling is associated with 1-year contraceptive continuation only among those eligible for no-cost methods. ImplicationsState policies which restrict access to affordable post-abortion contraception limit the beneficial impact of patient-centered counseling and impede patients’ ability to obtain their preferred method.

At-home telemedicine for medical abortion in Australia: a qualitative study of patient experiences and recommendations

IntroductionThis study aimed to explore patient experiences obtaining a medical abortion using an at-home telemedicine service operated by Marie Stopes Australia.MethodsFrom July to October 2017, we conducted semistructured in-depth telephone...

Women's Postabortion Contraceptive Preferences and Access to Family Planning Services in Mississippi.

Women's preferences for postabortion contraceptive care vary, and some may experience difficulties realizing their preferences owing to health systems-level barriers. We assessed Mississippi women's interest in postabortion contraceptive counseling and method use and the extent to which their method preferences were met. In 2016, women ages 18 to 45 completed a self-administered survey at their abortion consultation visit in Mississippi and a follow-up phone survey 4-8weeks later. Thirty-eight participants were selected for in-depth interviews. We computed the percentage of women who were interested in contraceptive counseling, initiating a method, and who obtained a method at the clinic. We also calculated the percentage who were using their preferred method after abortion and the main reasons they were not using this method. We analyzed transcripts using a theme-based approach. Of 323 women enrolled, 222 (69%) completed the follow-up survey. Of those completing follow-up, more than one-half (58%) reported that their consultation or abortion visit was the best time for contraceptive counseling, and 69% wanted to initiate contraception at the clinic. Only 10% obtained a method on site, and in-depth interview respondents reported they could not afford or did not like the options available. At the follow-up survey, 23% of respondents were using their preferred method. Women cited cost or lack of insurance coverage and difficulties scheduling appointments with community clinicians as reasons for not using their preferred method. Mississippi women have a large unmet demand for postabortion contraception. Policies that support on-site provision of contraception at abortion facilities would help women to realize their contraceptive preferences.

Challenges and strategies for contraceptive care in independent abortion clinics in the United States, 2017

ObjectiveMany patients may wish to receive contraceptive counseling and services during an abortion visit, but a 2009 study documented challenges faced by abortion clinics, especially independent ones, in providing contraceptive care. Since then, the Affordable Care Act (ACA) has made contraception more accessible by expanding coverage to millions of individuals and by eliminating out of pocket costs. This paper aims to update this previous work and describe recent challenges in providing contraceptive care in independent abortion settings following the ACA, as well as the strategies used to address these challenges. MethodsWe conducted two focus groups and 19 semi-structured interviews with clinic administrators and directors at independent abortion clinics. ResultsChallenges to providing contraceptive care in independent abortion clinics included navigating new guidelines under the Affordable Care Act for establishing coverage agreements with health insurance plans and receiving timely and sufficient reimbursement for services provided. Study respondents described strategies related to adjusting clinic flow and protocols to address patient needs regarding receiving contraception during abortion care. ConclusionStaff working in independent abortion clinics in the United States experience a tension between trying to provide holistic, patient-centered care – including contraceptive care – and navigating restrictive political and healthcare contexts for the delivery of abortion care.

Five-Year Study Finds No Link Between Abortion, Suicide

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessFive-Year Study Finds No Link Between Abortion, SuicideLinda M. RichmondLinda M. RichmondSearch for more papers by this authorPublished Online:5 Jul 2018https://doi.org/10.1176/appi.pn.2018.7a10AbstractThe latest study on the effect of abortion on women’s mental health suggests that policies requiring that women be warned of increased suicide risk are not evidence based.Women who have abortions are not at increased risk of suicidal ideation or suicide, according to a study published May 24 in AJP in Advance.The results echo previous literature reviews on the psychological effects of abortion and studies on the effects of abortion on suicidal ideation, wrote M. Antonia Biggs, Ph.D., and colleagues at the University of California, San Francisco. “Policies requiring that women be warned that they are at increased risk of becoming suicidal if they choose abortion are not evidence based,” they concluded.“We apparently have to keep proving the same thing that’s been clear for a long time: that terminating a pregnancy doesn’t increase your risk of suicide, substance abuse, or other adverse mental health outcomes,” said Nada Stotland, M.D., M.P.H., a former APA president and a specialist in reproductive psychiatry in Chicago, who reviewed the study at the request of Psychiatric News.Twenty states require women to receive pre-abortion counseling about the psychological consequences of abortion, and eight of those states detail only negative psychological effects (Kansas, Louisiana, Michigan, Nebraska, North Carolina, South Dakota, Texas, and West Virginia), according to the Guttmacher Institute. These states detail serious short- and long-term consequences of abortion including sexual dysfunction, depression, flashbacks, sleep disturbances, grief, anxiety, and nightmares. In two of these states, Texas and West Virginia, women are specifically warned that having an abortion increases their risk of suicidal thoughts or actions.Stotland said such laws “require doctors to violate their Hippocratic Oath by putting them in the impossible position of misinforming their patients. This is contradictory to everything medicine is about and doesn’t occur in any other area of medicine.” APA strongly opposes legislation that intrudes into the privacy of physician-patient communications and that is aimed at discouraging pregnant women from exercising their constitutional right to make their own reproductive choices, according to a position statement approved by the Board of Trustees in December 2013.For the study, Biggs and colleagues re-examined the data from their previous Turnaway study, for which nearly 1,000 women were recruited from 30 U.S. abortion facilities from 2008 through 2010. Women who received late-term abortions (within two weeks of a facility’s gestational age limit) were compared with women who were denied an abortion because they were over the facility’s gestational age limit. For comparison, the study also included a group who obtained a first-trimester abortion.Women were interviewed by telephone one week after their abortion visit, then every six months for five years. During each interview, women completed various assessments, including two suicidal ideation scales.Researchers found rates of suicidal ideation were low among all the groups studied, when compared with women in other studies of pregnant and postpartum women. “For women having an abortion, we found that the proportion with any [suicidal ideation] symptoms did not increase, but rather decreased over the five-year time period,” Biggs and colleagues wrote. “We also found no effect of receiving compared with being denied an abortion on either of our two suicidal ideation measures at any time point, dispelling the notion that abortion increases women’s risk for suicidal ideation over time.”While having an abortion was not associated with suicidal ideation, the researchers did find other factors that raised women’s risk of suicidality: being Hispanic or Latina, being subject to intimate partner violence or sexual assault, problem alcohol use, and a history of anxiety or depression.Ultimately, Biggs said, the study is a testament to the resiliency of the women studied. “At least with regard to their mental health, the women were doing quite well.”The study was funded in part by grants from the Wallace Alexander Gerbode Foundation, the David and Lucile Packard Foundation, and the William and Flora Hewlett Foundation. ■“Five-Year Suicidal Ideation Trajectories Among Women Receiving or Being Denied an Abortion” can be accessed here. APA’s position statements are available here. ISSUES NewArchived

Advance notice of contraceptive availability at surgical abortion: a pilot randomised controlled trial

BackgroundWith advance notice about the availability and effectiveness of contraceptive methods, abortion patients have more time and information for decision-making. We assessed the impact of an informational telephone call prior...

Well-woman Care Barriers and Facilitators of Low-income Women Obtaining Induced Abortion after the Affordable Care Act.

This study uses the abortion visit as an opportunity to identify women lacking well-woman care (WWC) and explores factors influencing their ability to obtain WWC after implementation of the Affordable Care Act. We conducted semistructured interviews with low-income women presenting for induced abortion who lacked a well-woman visit in more than 12months or a regular health care provider. Dimensions explored included 1) pre-abortion experiences seeking WWC, 2) postabortion plans for obtaining WWC, and 3) perceived barriers and facilitators to obtaining WWC. Interviews were transcribed and analyzed using ATLAS.ti. Thirty-four women completed interviews; three-quarters were insured. Women described interacting psychosocial, interpersonal, and structural barriers hindering WWC use. Psychosocial barriers included negative health care experiences, low self-efficacy, and not prioritizing personal health. Women's caregiver roles were the primary interpersonal barrier. Most prominently, structural challenges, including insurance insecurity, disruptions in patient-provider relationships, and logistical issues, were significant barriers. Perceived facilitators included online insurance procurement, care integration, and social support. Despite most being insured, participants encountered WWC barriers after implementation of the Affordable Care Act. Further work is needed to identify and engage women lacking preventive reproductive health care.

Role of Insurance Coverage in Contraceptive Use After Abortion.

To assess postaspiration abortion contraceptive use and the role of insurance coverage for abortion in a state that covers abortion and contraception for low-income women. This is a secondary analysis of a previously published prospective study to assess the safety of abortion provision. From 2007 through 2013, women seeking first-trimester aspiration abortion were recruited at 25 clinical facilities within four Planned Parenthood affiliates and Kaiser Permanente of Northern California. Patients' medical charts were reviewed to assess the contraceptive methods received on the day of the abortion. A 4-week follow-up survey assessed contraceptive use and contraceptive-related incidents. Primary outcomes included leaving with any method on the day of the abortion and use of any method at the 4-week assessment. Secondary outcomes included intrauterine device or implant use on the day of the procedure and at 4 weeks and switching to a less effective method at 4 weeks. A total of 19,673 women agreed to participate, and 13,904 (71%) completed the 4-week follow-up survey. Ninety-four percent (18,486/19,673) left their abortion visit with a contraceptive method: 21% (4,111/19,673) with an intrauterine device, implant, or permanent method. By the 4-week survey, 8% (1,135/13,904) switched from a high- or medium-efficacy method to a low-efficacy or no method; 0.4% (60/13,904) experienced a contraceptive incident. In adjusted regression analyses, women who paid for the abortion with Medicaid were significantly more likely to use any method (adjusted odds ratio [OR] 3.70, 95% CI 3.09-4.42) or an intrauterine device or implant (adjusted OR 2.14, 95% CI 1.92-2.38) on the day of the abortion than those who did not pay with insurance. Experiencing a contraceptive-related incident was associated with switching to a low-efficacy or no method by the 4-week survey (adjusted OR 3.98, 95% CI 2.20-7.22). Insurance coverage for abortion is associated with postabortion contraceptive provision and use, even in settings that cover abortions and contraception for low-income women.

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.

Prevalence and Correlates of Having a Regular Physician among Women Presenting for Induced Abortion

ObjectivesTo determine the prevalence and correlates of having a regular physician among women presenting for induced abortion. MethodsWe conducted a retrospective review of women presenting to an urban, university-based family planning clinic for abortion between January 2008 and September 2011. We conducted bivariate analyses, comparing women with and without a regular physician, and multivariable regression modeling, to identify factors associated with not having a regular physician. ResultsOf 834 women, 521 (62.5%) had a regular physician and 313 (37.5%) did not. Women with a prior pregnancy, live birth, or spontaneous abortion were more likely than women without these experiences to have a regular physician. Women with a prior induced abortion were not more likely than women who had never had a prior induced abortion to have a regular physician. Compared with women younger than 18 years, women aged 18 to 26 years were less likely to have a physician (adjusted odds ratio [aOR], 0.25; 95% confidence interval [CI], 0.10–0.62). Women with a prior live birth had increased odds of having a regular physician compared with women without a prior pregnancy (aOR, 1.89; 95% CI, 1.13–3.16). Women without medical/fetal indications and who had not been victims of sexual assault (self-indicated) were less likely to report having a regular physician compared with women with medical/fetal indications (aOR, 0.55; 95% CI, 0.17–0.82). ConclusionsThe abortion visit is a point of contact with a large number of women without a regular physician and therefore provides an opportunity to integrate women into health care.

Funding policies and postabortion long-acting reversible contraception: results from a cluster randomized trial

Almost one-half of women having an abortion in the United States have had a previous procedure, which highlights a failure to provide adequate preventive care. Provision of intrauterine devices and implants, which have high upfront costs, can be uniquely challenging in the abortion care setting. We conducted a study of a clinic-wide training intervention on long-acting reversible contraception and examined the effect of the intervention, insurance coverage, and funding policies on the use of long-acting contraceptives after an abortion. This subanalysis of a cluster, randomized trial examines data from the 648 patients who had undergone an abortion who were recruited from 17 reproductive health centers across the United States. The trial followed participants 18-25 years old who did not desire pregnancy for a year. We measured the effect of the intervention, health insurance, and funding policies on contraceptive outcomes, which included intrauterine device and implant counseling and selection at the abortion visit, with the use of logistic regression with generalized estimating equations for clustering. We used survival analysis to model the actual initiation of these methods over 1 year. Women who obtained abortion care at intervention sites were more likely to report intrauterine device and implant counseling (70% vs 41%; adjusted odds ratio, 3.83; 95% confidence interval, 2.37-6.19) and the selection of these methods (36% vs 21%; adjusted odds ratio, 2.11; 95% confidence interval, 1.39-3.21). However, the actual initiation of methods was similar between study arms (22/100 woman-years each; adjusted hazard ratio, 0.88; 95% confidence interval, 0.51-1.51). Health insurance and funding policies were important for the initiation of intrauterine devices and implants. Compared with uninsured women, those women with public health insurance had a far higher initiation rate (adjusted hazard ratio, 2.18; 95% confidence interval, 1.31-3.62). Women at sites that provide state Medicaid enrollees abortion coverage also had a higher initiation rate (adjusted hazard ratio, 1.73; 95% confidence interval, 1.04-2.88), as did those at sites with state mandates for private health insurance to cover contraception (adjusted hazard ratio, 1.80; 95% confidence interval, 1.06-3.07). Few of the women with private insurance used it to pay for the abortion (28%), but those who did initiated long-acting contraceptive methods at almost twice the rate as women who paid for it themselves or with donated funds (adjusted hazard ratio, 1.94; 95% confidence interval, 1.10-3.43). The clinic-wide training increased long-acting reversible contraceptive counseling and selection but did not change initiation for abortion patients. Long-acting method use after abortion was associated strongly with funding. Restrictions on the coverage of abortion and contraceptives in abortion settings prevent the initiation of desired long-acting methods.