To examine demand for abortion medications through an online telemedicine service in the United States.
We examined requests from US residents to the online telemedicine abortion service Women on Web ...(WoW) between October 15, 2017, and August 15, 2018. We calculated the population-adjusted rate of requests by state and examined the demographics, clinical characteristics, and motivations of those seeking services, comparing those in states with hostile versus supportive abortion policy climates.
Over 10 months, WoW received 6022 requests from US residents; 76% from hostile states. Mississippi had the highest rate of requests (24.9 per 100 000 women of reproductive age). In both hostile and supportive states, a majority (60%) reported a combination of barriers to clinic access and preferences for self-management. Cost was the most common barrier (71% in hostile states; 63% in supportive states;
< .001). Privacy was the most common preference (49% in both hostile and supportive states;
= .66).
Demand for self-managed medication abortion through online telemedicine is prevalent in the United States. There is a public health justification to make these abortions as safe, effective, and supported as possible.
CONTEXT
Abortion availability and accessibility vary by state. Especially in areas where services are restricted or limited, some women travel to obtain abortion services in other states. Little is ...known about the experience of travel to obtain abortion.
METHODS
In January and February 2015, in‐depth interviews were conducted with 29 patients seeking abortion services at six facilities in Michigan and New Mexico. Eligible women were 18 or older, spoke English, and had traveled either across state lines or more than 100 miles within the state. Respondents were asked to describe their experience from pregnancy discovery to the day of the abortion procedure. Barriers to accessing abortion care and consequences of these barriers were identified through inductive and deductive analysis.
RESULTS
Respondents described 15 barriers to abortion care while traveling to obtain services, and three major consequences of experiencing those barriers. Barriers were grouped into five categories: travel‐related logistical issues, system navigation issues, limited clinic options, financial issues, and state or clinic restrictions. Consequences were delays in care, negative mental health impacts and considering self‐induction. The experience of barriers complicated the process of obtaining an abortion, but the effect of any individual barrier was unclear. Instead, the experience of multiple barriers appeared to have a compounding effect, resulting in negative consequences for women traveling for abortion.
CONCLUSION
The amalgamation of barriers to abortion care experienced simultaneously can have significant consequences for patients.
In the United States, mifepristone is available for medical abortion (for use with misoprostol) only with Risk Evaluation and Mitigation Strategy (REMS) restrictions, despite an absence of evidence ...to support such restrictions. Mifepristone has been available in Canada with a normal prescription since November 2017.
Using population-based administrative data from Ontario, Canada, we examined abortion use, safety, and effectiveness using an interrupted time-series analysis comparing trends in incidence before mifepristone was available (January 2012 through December 2016) with trends after its availability without restrictions (November 7, 2017, through March 15, 2020).
A total of 195,183 abortions were performed before mifepristone was available and 84,032 after its availability without restrictions. After the availability of mifepristone with a normal prescription, the abortion rate continued to decline, although more slowly than was expected on the basis of trends before mifepristone had been available (adjusted risk difference in time-series analysis, 1.2 per 1000 female residents between 15 and 49 years of age; 95% confidence interval CI, 1.1 to 1.4), whereas the percentage of abortions provided as medical procedures increased from 2.2% to 31.4% (adjusted risk difference, 28.8 percentage points; 95% CI, 28.0 to 29.7). There were no material changes between the period before mifepristone was available and the nonrestricted period in the incidence of severe adverse events (0.03% vs. 0.04%; adjusted risk difference, 0.01 percentage points; 95% CI, -0.06 to 0.03), complications (0.74% vs. 0.69%; adjusted risk difference, 0.06 percentage points; 95% CI, -0.07 to 0.18), or ectopic pregnancy detected after abortion (0.15% vs. 0.22%; adjusted risk difference, -0.03 percentage points; 95% CI, -0.19 to 0.09). There was a small increase in ongoing intrauterine pregnancy continuing to delivery (adjusted risk difference, 0.08 percentage points; 95% CI, 0.04 to 0.10).
After mifepristone became available as a normal prescription, the abortion rate remained relatively stable, the proportion of abortions provided by medication increased rapidly, and adverse events and complications remained stable, as compared with the period when mifepristone was unavailable. (Funded by the Canadian Institutes of Health Research and the Women's Health Research Institute.).
CONTEXT
Following a long‐term decline, abortion incidence stabilized between 2005 and 2008. Given the proliferation of state‐level abortion restrictions, it is critical to assess abortion incidence ...and access to services since that time.
METHODS
In 2012–2013, all facilities known or expected to have provided abortion services in 2010 and 2011 were surveyed. Data on the number of abortions were combined with population data to estimate national and state‐level abortion rates. Incidence of abortions was assessed by provider type and caseload. Information on state abortion regulations implemented between 2008 and 2011 was collected, and possible relationships with abortion rates and provider numbers were considered.
RESULTS
In 2011, an estimated 1.1 million abortions were performed in the United States; the abortion rate was 16.9 per 1,000 women aged 15–44, representing a drop of 13% since 2008. The number of abortion providers declined 4%; the number of clinics dropped 1%. In 2011, 89% of counties had no clinics, and 38% of women of reproductive age lived in those counties. Early medication abortions accounted for a greater proportion of nonhospital abortions in 2011 (23%) than in 2008 (17%). Of the 106 new abortion restrictions implemented during the study period, few or none appeared to be related to state‐level patterns in abortion rates or number of providers.
CONCLUSIONS
The national abortion rate has resumed its decline, and no evidence was found that the overall drop in abortion incidence was related to the decrease in providers or to restrictions implemented between 2008 and 2011.
Unintended pregnancy and abortion estimates document trends in sexual and reproductive health and autonomy. These estimates inform and motivate investment in global health programmes and policies. ...Variability in the availability and reliability of data poses challenges for measuring and monitoring trends in unintended pregnancy and abortion. We developed a new statistical model that jointly estimated unintended pregnancy and abortion that aimed to better inform efforts towards global equity in sexual and reproductive health and rights.
We developed a model that simultaneously estimated incidence of unintended pregnancy and abortion within a Bayesian framework. Data on pregnancy intentions and abortion were compiled from country-based surveys, official statistics, and published studies found through a literature search, and we obtained data on livebirths from the World Population Prospects. We analysed results by World Bank income groups, Sustainable Development Goal regional groupings, and the legal status of abortion.
In 2015–19, there were 121·0 million unintended pregnancies annually (80% uncertainty interval UI 112·8–131·5), corresponding to a global rate of 64 unintended pregnancies (UI 60–70) per 1000 women aged 15–49 years. 61% (58–63) of unintended pregnancies ended in abortion (totalling 73·3 million abortions annually 66·7–82·0), corresponding to a global abortion rate of 39 abortions (36–44) per 1000 women aged 15–49 years. Using World Bank income groups, we found an inverse relationship between unintended pregnancy and income, whereas abortion rates varied non-monotonically across groups. In countries where abortion was restricted, the proportion of unintended pregnancies ending in abortion had increased compared with the proportion for 1990–94, and the unintended pregnancy rates were higher than in countries where abortion was broadly legal.
Between 1990–94 and 2015–19, the global unintended pregnancy rate has declined, whereas the proportion of unintended pregnancies ending in abortion has increased. As a result, the global average abortion rate in 2015–19 was roughly equal to the estimates for 1990–94. Our findings suggest that people in high-income countries have better access to sexual and reproductive health care than those in low-income countries. Our findings indicate that individuals seek abortion even in settings where it is restricted. These findings emphasise the importance of ensuring access to the full spectrum of sexual and reproductive health services, including contraception and abortion care, and for additional investment towards equity in health-care services.
UK Aid from the UK Government, Dutch Ministry of Foreign Affairs, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), and The Bill & Melinda Gates Foundation.
In August 2003, North Carolina became the first U.S. state to offer restitution to victims of state-ordered sterilizations carried out by its eugenics program between 1929 and 1975. The decision was ...prompted by newspaper stories based on the research of Johanna Schoen, who was granted unique access to summaries of 7,500 case histories and the papers of the North Carolina Eugenics Board.In this book, Schoen situates the state's reproductive politics in a national and global context. Widening her focus to include birth control, sterilization, and abortion policies across the nation, she demonstrates how each method for limiting unwanted pregnancies had the potential both to expand and to limit women's reproductive choices. Such programs overwhelmingly targeted poor and nonwhite populations, yet they also extended a measure of reproductive control to poor women that was previously out of reach.On an international level, the United States has influenced reproductive health policies by, for example, tying foreign aid to the recipients' compliance with U.S. notions about family planning. The availability of U.S.-funded family planning aid has proved to be a double-edged sword, offering unprecedented opportunities to poor women while subjecting foreign patients to medical experimentation that would be considered unacceptable at home.Drawing on the voices of health and science professionals, civic benefactors, and American women themselves, Schoen's study allows deeper understandings of the modern welfare state and the lives of women.
Summary Background Information about the incidence of induced abortion is needed to motivate and inform efforts to help women avoid unintended pregnancies and to monitor progress toward that end. We ...estimate subregional, regional, and global levels and trends in abortion incidence for 1990 to 2014, and abortion rates in subgroups of women. We use the results to estimate the proportion of pregnancies that end in abortion and examine whether abortion rates vary in countries grouped by the legal status of abortion. Methods We requested abortion data from government agencies and compiled data from international sources and nationally representative studies. With data for 1069 country-years, we estimated incidence using a Bayesian hierarchical time series model whereby the overall abortion rate is a function of the modelled rates in subgroups of women of reproductive age defined by their marital status and contraceptive need and use, and the sizes of these subgroups. Findings We estimated that 35 abortions (90% uncertainty interval UI 33 to 44) occurred annually per 1000 women aged 15–44 years worldwide in 2010–14, which was 5 points less than 40 (39–48) in 1990–94 (90% UI for decline −11 to 0). Because of population growth, the annual number of abortions worldwide increased by 5·9 million (90% UI −1·3 to 15·4), from 50·4 million in 1990–94 (48·6 to 59·9) to 56·3 million (52·4 to 70·0) in 2010–14. In the developed world, the abortion rate declined 19 points (−26 to −14), from 46 (41 to 59) to 27 (24 to 37). In the developing world, we found a non-significant 2 point decline (90% UI −9 to 4) in the rate from 39 (37 to 47) to 37 (34 to 46). Some 25% (90% UI 23 to 29) of pregnancies ended in abortion in 2010–14. Globally, 73% (90% UI 59 to 82) of abortions were obtained by married women in 2010–14 compared with 27% (18 to 41) obtained by unmarried women. We did not observe an association between the abortion rates for 2010–14 and the grounds under which abortion is legally allowed. Interpretation Abortion rates have declined significantly since 1990 in the developed world but not in the developing world. Ensuring access to sexual and reproductive health care could help millions of women avoid unintended pregnancies and ensure access to safe abortion. Funding UK Government, Dutch Ministry of Foreign Affairs, Norwegian Agency for Development Cooperation, The David and Lucile Packard Foundation, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.
Summary Background Data of abortion incidence and trends are needed to monitor progress toward improvement of maternal health and access to family planning. To date, estimates of safe and unsafe ...abortion worldwide have only been made for 1995 and 2003. Methods We used the standard WHO definition of unsafe abortions. Safe abortion estimates were based largely on official statistics and nationally representative surveys. Unsafe abortion estimates were based primarily on information from published studies, hospital records, and surveys of women. We used additional sources and systematic approaches to make corrections and projections as needed where data were misreported, incomplete, or from earlier years. We assessed trends in abortion incidence using rates developed for 1995, 2003, and 2008 with the same methodology. We used linear regression models to explore the association of the legal status of abortion with the abortion rate across subregions of the world in 2008. Findings The global abortion rate was stable between 2003 and 2008, with rates of 29 and 28 abortions per 1000 women aged 15–44 years, respectively, following a period of decline from 35 abortions per 1000 women in 1995. The average annual percent change in the rate was nearly 2·4% between 1995 and 2003 and 0·3% between 2003 and 2008. Worldwide, 49% of abortions were unsafe in 2008, compared to 44% in 1995. About one in five pregnancies ended in abortion in 2008. The abortion rate was lower in subregions where more women live under liberal abortion laws (p<0·05). Interpretation The substantial decline in the abortion rate observed earlier has stalled, and the proportion of all abortions that are unsafe has increased. Restrictive abortion laws are not associated with lower abortion rates. Measures to reduce the incidence of unintended pregnancy and unsafe abortion, including investments in family planning services and safe abortion care, are crucial steps toward achieving the Millennium Development Goals. Funding UK Department for International Development, Dutch Ministry of Foreign Affairs, and John D and Catherine T MacArthur Foundation.
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