Abortion Stigma as a Barrier to Mifepristone Use among Obstetrician-Gynecologists in Alabama for Early Pregnancy Loss.

OBJECTIVES: The objective of our study was to identify and characterize barriers to mifepristone use among obstetrician-gynecologists (OB-GYNs) for early pregnancy loss in a southern US state. METHODS: In this qualitative study, we conducted semistructured interviews with 19 OB-GYNs in Alabama who manage early pregnancy loss. The interviews explored participants' knowledge of and experience with mifepristone use for miscarriage management and abortion, along with barriers to and facilitators of clinical mifepristone use. The interviews were coded by multiple study staff using inductive and deductive thematic coding. RESULTS: Nearly all of the interviewees identified abortion-related stigma as a barrier to mifepristone use. Interviewees often attributed stigma to a lack of knowledge about the clinical use of mifepristone for early pregnancy loss. The stigmatization of mifepristone due to its association with abortion was related to religious and political objections. Many interviewees also described stigma associated with misoprostol use. Although providers believed that mifepristone use for abortion would not be accepted in their practice, most believed that mifepristone could be used successfully for miscarriage management after practice-wide education on its use. CONCLUSIONS: Mifepristone is strongly associated with abortion stigma among OB-GYNs in Alabama, which is a barrier to its use for miscarriage management. Interventions to decrease abortion stigma and associated stigma surrounding mifepristone are needed to optimize early pregnancy loss care.

State Abortion Policy and Moral Distress Among Clinicians Providing Abortion After the Dobbs Decision.

Importance: Moral distress occurs when individuals feel powerless to do what they think is right, including when clinicians are prevented from providing health care they deem necessary. The loss of federal protections for abortion following the Dobbs v Jackson Women's Health Organization Supreme Court decision may place clinicians providing abortion at risk of experiencing moral distress, as many could face new legal and civil penalties for providing care in line with professional standards and that they perceive as necessary. Objective: To assess self-reported moral distress scores among abortion-providing clinicians following the Dobbs decision overall and by state-level abortion policy. Design, Setting, and Participants: This survey study, conducted from May to December 2023, included US abortion-providing clinicians (physicians, advanced practice clinicians, and nurses). A purposive electronic survey was disseminated nationally through professional listservs and snowball sampling. Exposure: Abortion policy in each respondent's state of practice (restrictive vs protective using classifications from the Guttmacher Institute). Main Outcomes and Measures: Using descriptive statistics and unadjusted and adjusted negative binomial regression models, the association between self-reported moral distress on the Moral Distress Thermometer (MDT), a validated psychometric tool that scores moral distress from 0 (none) to 10 (worst possible), and state abortion policy was examined. Results: Overall, 310 clinicians (271 [87.7%] women; mean [SD] age, 41.4 [9.7] years) completed 352 MDTs, with 206 responses (58.5%) from protective states and 146 (41.5%) from restrictive states. Reported moral distress scores ranged from 0 to 10 (median, 5) and were more than double for clinicians in restrictive compared with protective states (median, 8 [IQR, 6-9] vs 3 [IQR, 1-6]; P < .001). Respondents with higher moral distress scores included physicians compared with advanced practice clinicians (median, 6 [IQR, 3-8] vs 4 [IQR, 2-7]; P = .005), those practicing in free-standing abortion clinics compared with those practicing in hospitals (median, 6 [IQR, 3-8] vs 4 [IQR, 2-7]; P < .001), those no longer providing abortion care compared with those still providing abortion care (median, 8 [IQR, 4-9] vs 5 [IQR, 2-8]; P = .004), those practicing in loss states (states with the greatest decline in abortion volume since the Dobbs decision) compared with those in stable states (unadjusted incidence rate [IRR], 1.72 [95% CI, 1.55-1.92]; P < .001; adjusted IRR, 1.59 [95% CI, 1.40-1.79]; P < .001), and those practicing in surge states (states with the greatest increase in abortion volume since the Dobbs decision) compared with those in stable states (unadjusted IRR, 1.27 [95% CI, 1.11-1.46]; P < .001; adjusted IRR, 1.24 [95% CI, 1.09-1.41]; P = .001). Conclusions and Relevance: In this purposive national survey study of clinicians providing abortion, moral distress was elevated among all clinicians and more than twice as high among those practicing in states that restrict abortion compared with those in states that protect abortion. The findings suggest that structural changes addressing bans on necessary health care, such as federal protections for abortion, are needed at institutional, state, and federal policy levels to combat widespread moral distress.

Sexual and reproductive health outcomes of women who experienced violence in Germany: Analysis of the German health interview and examination survey for adults (DEGS1).

OBJECTIVES: Violence against women is a widespread public health concern with severe effects to women's sexual and reproductive health, including higher risks for miscarriage or stillbirth, unintended pregnancy and induced abortion. This study examined the association between women exposure to physical violence, psychological violence and sexual and reproductive health outcomes (contraceptive use, miscarriage or stillbirth and abortion) in Germany. METHODS: This study used a cross-sectional research design to analyze data on violence against women and sexual and reproductive health (SRH) outcomes collected through the German Health Interview and Examination Survey for Adults, Wave 1, between 2008 and 2011 (n = 3149 women, aged 18-64 years). Multivariable logistic regression models were used to assess the association between experiences of violence among women and the presence of sexual and reproductive health outcomes, considering the influence of socio-demographic and health-related factors (age, marital status, socioeconomic status, social support, number of children, alcohol consumption, health status, chronic conditions). RESULTS: Three associations remained significant (p<0.05) in fully-adjusted models: (i) exposure to physical violence by a parent or caregiver and birth control pill utilization (aOR, adjusted Odds Ratio, 95% CI: 1.36, 1.02-1.81) (ii) exposure to physical violence since the age of 16 and miscarriage or stillbirth (aOR, 95%CI: 1.89, 1.17-3.04); and (iii) exposure to psychological violence by a parent or caregiver and abortion (aOR, 95%CI: 1.87, 1.30-2.70). CONCLUSIONS: The results suggest that adult German women who experienced physical or psychological violence since the age of 16, including violence perpetrated by a parent or caregiver, were more likely to report miscarriage or stillbirth and abortion. Direct assessment of violence experiences against women should be conducted by healthcare professionals in clinical encounters, particularly by obstetrics and gynaecological specialists, for the prevention of women´s adverse sexual and reproductive health outcomes. Furthermore, violence should be treated as a major public health concern and addressed through a multisectoral approach, involving the healthcare and educational sectors, researchers and relevant policymakers.

Socio-ecological influences on access to abortion care in Costa Rica: a qualitative analysis of key perspectives from clinical and policy stakeholders.

Costa Rica prohibits abortion except under narrow circumstances to save the pregnant person's life. The country boasts historically strong support for social policy and human rights, while also presenting a complex and restrictive abortion access landscape. From September 2021 to March 2022, we conducted 23 interviews with obstetrician-gynecologist (OB/GYN) physicians, OB/GYN medical residents, and policy stakeholders to explore the socio-ecological influences on abortion access in Costa Rica. We sampled clinicians and policy stakeholders from the Universidad de Ciencias Médicas listserv through snowball sampling and conducted semi-structured in-depth interviews in Spanish. We identified limited access to comprehensive sexual health education, lack of support from interpersonal networks, inadequate provider knowledge and training, financial and migratory status, and both provider and community stigma as substantial barriers to abortion access. This study addresses a gap in published research around the social determinants of abortion in Costa Rica and sheds light on the attitudes and opinions of the medical and policy stakeholder communities about abortion access. The results highlight the need for expanded access to comprehensive sexual health education, abortion-related training for healthcare providers, and increased programming efforts, such as funding, outreach, and implementation, to ensure comprehensive reproductive health services are available and accessible, especially for vulnerable populations in Costa Rica.

[Association between induced abortion and depression: A systematic review and meta-analysis]. / Asociación entre aborto inducido y depresión: una revisión sistemática y metaanálisis.

This article is a systematic review (SR) and meta-analysis (MA) whose objective was to identify the association between induced abortion and the development of depression, based on the Cochrane guidelines for SRs. A systematic search was carried out in the WoS, PubMed and Scopus databases. Retrospective and prospective cohort studies, carried out until November 2020, that evaluated a population of women in childbearing age (12 to 46 years) with at least 1 induced and/or provoked abortion, including pharma-cological and surgical abortion. Only studies with healthy women at the beginning of the research were included, i.e., with absence of psychiatric pathology prior to induced abor-tion. The quality of the included studies was measured with the Newcastle-Ottawa Scale (NOS), and for the MA random-effects models were specified using the DerSimonian & Laird method, grouping them into follow-up after abortion before and after one year. The results of the SR were measured with relative risk (RR), hazard ratio (HR), odds ratio (OR), and the chi-square test, which assessed the intensity of the statistical relationship between population and exposure. Systematic review demonstrated an OR of 1.38 (95% CI 1.14-1.68) of depression after induced abortion. Meta-analysis demonstrated a statis-tically significant association between depression and induced abortion when the as-sessment after one year was performed OR: 1.37 (95% CI 1.09-1.71). The risks, harms and mental health consequences of induced abortion, such as depression, should be in-vestigated and warned.

El presente artículo es una revisión sistemática (RS) y metaanálisis (MA) cuyo objetivo fue identificar la asociación entre el aborto inducido y el desarrollo de depresión, con base en los lineamientos Cochrane para RS. Se hizo la búsqueda sistemática en las bases de datos WoS, PubMed y Scopus. Se incluyeron estudios de cohorte retrospectivos y prospectivos, hasta noviembre de 2020, que evaluaron una población de mujeres en edad fértil (12 a 46 años) con al menos un aborto inducido o provocado, incluido el aborto farmacológico y el quirúrgico. Solo se incluyeron estudios con mujeres sanas al inicio de la investigación, es decir, con ausencia de patología psiquiátrica previa al aborto inducido. La calidad de los estudios incluidos se midió con la Newcastle-Ottawa Scale (NOS) y para el MA se especificaron modelos de efectos aleatorios con el método de DerSimonian & Laird y se agruparon en seguimiento posterior al aborto antes y después de un año. Los resultados de la RS fueron medidos con riesgo relativo (RR), hazard ratio (HR), odds ratio (OR) y la prueba de chi cuadrado, que valoraron la intensidad de la relación estadística entre la población y la exposición. La RS demostró un OR 1.38 (IC 95% 1.14-1.68) de depresión tras el aborto inducido. El MA demostró una asociación estadísticamente significativa entre la depresión y el aborto inducido cuando se hizo la evaluación posterior a un año OR: 1.37 (IC 95% 1.09-1.71). Se deberían investigar y advertir los riesgos, daños y consecuencias en la salud mental, como la depresión, tras el aborto inducido.

Primary care and abortion provider perspectives on mail-order medication abortion: a qualitative study.

BACKGROUND: This qualitative study aims to assess perspectives of clinicians and clinic staff on mail-order pharmacy dispensing for medication abortion. METHODS: Participants included clinicians and staff involved in implementing a mail-order dispensing model for medication abortion at eleven clinics in seven states as part of a prospective cohort study, which began in January 2020 (before the FDA removed the in-person dispensing requirement for mifepristone). From June 2021 to July 2022, we invited participants at the participating clinics, including six primary care and five abortion clinics, to complete a semi-structured video interview about their experiences. We then conducted qualitative thematic analysis of interview data, summarizing themes related to perceived benefits and concerns about the mail-order model, perceived patient interest, and potential barriers to larger-scale implementation. RESULTS: We conducted 24 interviews in total with clinicians (13 physicians and one nurse practitioner) and clinic staff (n = 10). Participants highlighted perceived benefits of the mail-order model, including its potential to expand abortion services into primary care, increase patient autonomy and privacy, and to normalize abortion services. They also highlighted key logistical, clinical, and feasibility concerns about the mail-order model, and specific challenges related to integrating abortion into primary care. CONCLUSION: Clinicians and clinic staff working in primary care and abortion clinics were optimistic that mail-order dispensing of medication abortion can improve the ability of some providers to provide abortion and enable more patients to access services. The feasibility of mail-order pharmacy dispensing of medication abortion following the Supreme Court Dobbs decision is to be determined. TRIAL REGISTRATION: Registry: Clinicaltrials.gov. TRIAL REGISTRATION NUMBER: NCT03913104. Date of registration: first submitted on April 3, 2019 and first posted on April 12, 2019.

Investigating depression, anxiety, perceived stress and resilience in fathers faced with their spouse's abortion in Iran: a longitudinal study.

BACKGROUND: Abortion is a stressful event that can often affect the mental health of both parents. It seems that resilient people can adapt to stressful situations. The mental health of fathers plays an important role in improving the mental health of the family, but few studies have been conducted in this regard. Therefore, this study aimed to investigate depression, anxiety, perceived stress and resilience of fathers faced with their spouse's abortion. METHODS: This longitudinal study was conducted on 125 spouses of women hospitalized in the post-partum department of Shiraz hospitals in 2023. Data collection tools included questionnaires of demographic and fertility characteristics, hospital depression and anxiety (HADS), Cohen's perceived stress, and Connor's resilience. The data were analyzed through Spss24 software using Friedman's tests and post hoc tests, Adjusted Bonferroni, Kruskal-Wallis and Mann-Whitney tests. RESULTS: The mean age of the fathers was 35.02 ± 6.22. The scores of the father's anxiety, depression, and perceived stress from 24 h to 12 weeks after abortion were decreased significantly. However, their resilience score increased significantly. Also, there was a significant relationship between the fathers' age, education, job, duration of marriage, type of abortion, number and history of abortion, unwanted pregnancy, number of children and economic status with the mean score of anxiety, depression, perceived stress, and resilience in fathers over time. CONCLUSION: This research pointed out the effect of abortion on depression, anxiety, and perceived stress in fathers; also, resilience as a coping factor could affect these disorders and improve the fathers' mental health. Therefore, screening and managing mental disorders in them are important to improve family health.

Barriers to Abortion among Women and Girls in Selected Districts of Nepal.

BACKGROUND: Even after two decades of legalization of abortion in Nepal, most women and girls still do not have knowledge on abortion legality and face abortion barriers. This study will explore perceived barriers to safe abortion and the factors associated with it. METHODS: A Mixed method study design was conducted in 30 wards of 20 Municipals of seven districts of Lumbini and Sudurpaschim provinces. Quantitative data was analyzed for 673 women of reproductive age of 15-49 years. For qualitative data, key informant interviews were conducted. The analysis was done on five different barriers and a composite variable was created from them. RESULTS: Most women and girls perceived social (34.6%), followed by family (30.6%), physical (30.6%), personal (29.5%), and health facility (14.9%) barriers to access safe abortion services. The key finding was that women and girls with knowledge on abortion legality were more likely to perceive barriers to abortion (AOR:2.31, CI:1.574-3.394). Women and girls with higher educational and economic status as well as Dalit women were less likely to perceive barriers to abortion services whereas never married women and girls perceived more barriers in accessing abortion services. CONCLUSIONS: Women and girls perceived several barriers to access safe abortion services. Women who have better knowledge on abortion legality recognize more barriers regarding abortion. This highlights the importance of raising awareness of women and girls on abortion rights to empower them in recognizing and advocating for the removal of the obstacles that stop them from getting abortion services.

First Trimester Abortion and Psychiatric Morbidity.

BACKGROUND: Early pregnancy loss is a traumatic event following which clients may experience psychological morbidities. Mental illness is associated with multiple obstetric and social factors surrounding the period of pregnancy loss. The aim of this study was to find the prevalence of depression and anxiety before and after undergoing spontaneous or induced first trimester abortion and to analyze demographic and obstetric factors associated with it. METHODS: This is an observational study conducted as Kathmandu Medical College (KMC) for a duration of one year from September 2022 to August 2023. All clients with abortion were screened for psychiatric morbidity using the The Hospital Anxiety and Depression Scale (HADS). Each client was assessed at first hospital visit and then at two weeks and two months following abortion. Level of anxiety and depression was analyzed in relation to socio-demographic factors and the type of abortion. RESULTS: 171 clients with pregnancy loss were enrolled. Pre-abortion, severe anxiety was present in 6(13%) clients with spontaneous abortion. Pre-abortion, mild to severe anxiety was present in 31 (67.3%) clients and at two weeks and two months in 11 (23.9%) and 11 (23.9%) clients respectively. In clients undergoing induced abortion, varying levels of anxiety was present in 54(43.2%) pre-abortion, and 48(38.4%) and 54(43.2%) clients at two weeks and two months. Mild to moderate depression was seen in 21 (45.6%) among spontaneous abortion and 51 (40.8%) clients among induced abortion. Mean score on HADS decreased with time. CONCLUSIONS: Anxiety and depression were common following early pregnancy loss. Rate of anxiety seems to decrease with time in spontaneous abortion but in induced abortion it remains persistent. Rate of depression tends to decrease with time for both types of abortion.

Abortion Attitudes and Behavioral Intentions of Obstetrics and Gynecology Residents at Four Midwestern Residency Programs Prior to Dobbs v Jackson Women's Health.

INTRODUCTION: In June 2022, the United States Supreme Court announced its decision in Dobbs v Jackson Women's Health Organization to overturn Roe v Wade. As a result, half of US states now face proposed or in-effect abortion bans, which affect the ability of obstetrics and gynecology (ObGyn) residency programs to provide abortion training. We sought to establish ObGyn residents' pre-Dobbs attitudes toward abortion, desire to learn about abortion, and intentions about providing abortion care in their future practice. METHODS: From January through December 2021, we surveyed 70 ObGyn residents at 4 programs in Wisconsin and Minnesota to assess their attitudes toward abortion, desire to learn about abortion, and intentions about providing abortion care in their future practice. RESULTS: Fifty-five out of 70 (79%) ObGyn residents completed the survey. Most reported highly favorable attitudes toward abortion, nearly all found the issue of abortion important, and the majority planned to incorporate abortion care into their future work. There were no differences in median attitude scores or behavioral intentions among institutions. CONCLUSIONS: Prior to the Dobbs decision, ObGyn residents in Minnesota and Wisconsin viewed abortion as important health care and intended to provide this care after graduation.

Qualitative Pilot Study: Longitudinal Perspectives From People Who Had Second Trimester Abortions for Fetal Anomaly.

BACKGROUND: We investigated patient experience with abortion for fetal anomaly, about which little is known. METHODS: This qualitative, longitudinal pilot study surveyed 7 patients twice after abortion for fetal anomaly, initially 4 to 5 days after the abortion and a follow-up 3 months post-abortion, at a single Wisconsin hospital from July 2012 to February 2014. RESULTS: Patients indicated that having a choice to have an abortion and choose the modality is imperative, and they remained certain in their decision-making over time. They also described initially strong, then lacking, social support; processed grief; and identified resource constraints. DISCUSSION: Patients emphasized the importance of having the choice to choose abortion and the abortion modality, remaining confident in their decision-making over time. This qualitative pilot study provides areas for future intervention to improve care for people undergoing abortion for fetal anomaly.

Post-abortion care services in Zambian health facilities: a qualitative study of users' experiences and perceptions.

BACKGROUND: Despite attempts to increase Universal Health Coverage, availability, accessibility, acceptability, and quality-related challenges remain barriers to receiving essential services by women who need them. We aimed to explore the experiences and perceptions of women receiving post-abortal care services in Zambia, within a human-rights framework. METHODS: A qualitative case study was conducted between August and September 2021 in Lusaka and Copperbelt provinces of Zambia. Fifteen (15) women seeking post-abortion care services were` interviewed using audio recorders; transcribed data was analyzed using thematic analysis. We report women's experiences and perceptions of the healthcare system, their experiences of abortion, and healthcare-seeking behaviour. We used the availability, accessibility, acceptability, and quality (AAAQ) framework to understand how women claimed their right to healthcare as they sought and utilized post-abortion care services. RESULTS: Women who experienced spontaneous abortions delayed seeking health care by viewing symptoms as 'normal pregnancy symptoms' and not dangerous. Women also delayed seeking care because they feared the negative attitudes from their communities and the health care providers towards abortion in general, despite it being legal in Zambia. Some services were considered costly, impeding their right to access quality care. CONCLUSIONS: Women delayed seeking care compounded by fear of negative attitudes from the community and healthcare providers. To ensure the provision and utilization of quality all abortion-related healthcare services, there is a need to increase awareness of the availability and legality of safe abortion services, the importance of seeking healthcare early for any abortion-related discomfort, and the provision and availability of free services at all levels of care should be emphasized.

Unsafe abortions continue to be an avoidable public health concern both globally and locally. In Zambia, a fifth of maternal deaths are related to unsafe abortions. Unsafe abortions have been defined as any induced termination of pregnancy outside the health facility, performed by untrained health personnel. Several strides have been made including the provision of comprehensive abortion care in all facilities, and the training of health personnel to provide these services at different levels of healthcare. Despite the increased availability of comprehensive abortion care through liberalized abortion laws and regulations and the training of health personnel to provide these services at different levels of healthcare, the need for quality post-abortion care specifically persists. As such, we carried out in-depth interviews to explore the experiences of women who present at healthcare facilities in Lusaka and the Copperbelt provinces in Zambia seeking post-abortion services. It was found that delay in seeking care at a health facility was due to fear that the service is illegal; alongside judgment from health care providers and society for seeking such a service that is generally perceived as evil. The assumption that the cost of receiving such services is high and a general lack of awareness about the service being provided free was also expressed. The study highlighted the need for community awareness of the legal framework on abortions to ensure women access services at any time necessary without fear of being judged, which will consequently reduce the number of abortion-related disabilities and deaths.

Providers' experiences with abortion care: A scoping review.

BACKGROUND: Induced abortion is one of the most common gynecological procedures in the world, with as many as three in every ten pregnancies ending in abortion. It, however, remains controversial. The objective of this scoping review was to explore and map existing literature on the experiences of those who provide abortion care. METHODS AND FINDINGS: This exploratory review followed the Levac et al. guidelines and was reported in accordance with the PRISMA-ScR checklist. CINAHL, Cochrane, EMBASE, PsycInfo, PubMed, and Web of Science were used to identify peer-reviewed, original research articles published on providers' experience of abortion. We identified 106 relevant studies, which include a total sample of 4,250 providers from 28 countries and six continents. Most of the studies were qualitative (n = 83), though quantitative (n = 15) and mixed methods (n = 8) studies were also included. We identified two overarching themes: (1) Providers' experiences with abortion stigma and (2) Providers' reflections on their abortion work. Our findings suggest that providers from around the world experience challenges within society and their communities and workplaces which reinforce the stigmatization and marginalization of abortion and pose questions about the morality of this work. Most, however, are proud of their work, believe abortion care to be socially important and necessary, and remain committed to the provision of care. CONCLUSIONS: The findings of this review provide a comprehensive overview on the known experiences of providing abortion care. It is a key point of reference for international providers, researchers, and advocates to further this area of research or discussion in their own territories. The findings of this review will inform future work on how to support providers against stigmatization and will offer providers the chance to reflect on their own experiences.

Association between parental decisions regarding abortion and severity of fetal heart disease.

The prenatal diagnosis of fetal heart disease potentially influences parental decision-making regarding pregnancy termination. Existing literature indicates that the severity, whether in complexity or lethality, significantly influences parental decisions concerning abortion. However, questions remain as to how fetal heart disease severity impacts parental decisions, given recent advancements in postsurgical outcomes. Therefore, we investigated risk factors associated with parents' decision-making regarding abortion following a prenatal diagnosis of fetal heart disease. Our analysis included 73 (terminated: n = 37; continued: n = 36) pregnancies with a fetal heart disease diagnosed before 22 weeks of gestation. Increased gestational age at diagnosis reduced the likelihood of parents' decision on termination (Model 1: adjusted odds ratio, 0.94; 95% confidence interval 0.89-0.99; Model 2: 0.95 0.90-0.997). Critical disease (5.25; 1.09-25.19) and concurrent extracardiac or genetic abnormalities (Model 1: 4.19, 1.21-14.53; Model 2: 5.47, 1.50-19.96) increased the likelihood of choosing abortion. Notably, complex disease did not significantly influence parental decisions (0.56; 0.14-2.20). These results suggest that parental decision-making regarding abortion may be influenced by earlier gestational age at diagnosis, the lethality of heart disease, and extracardiac or genetic abnormalities, but not its complexity if prenatal diagnosis and parental counseling are provided at a cardiovascular-specialized facility.

The impact of abortion restrictions on American mental health.

The overturning of Roe v. Wade has led to numerous states enacting new abortion restrictions. However, limited empirical evidence exists regarding the general mental health impact of these bans. Leveraging the nationwide Household Pulse Survey, we evaluate the impact of emergent gestational limits and outright bans on self-reported mental health status between July 2021 and June 2023 using a difference in difference approach. Responses indicate a significant increase in reports of mental distress after the institution of such restrictions. These effects appear to persist at least 4 months following a ban and are moderated by household income and education but not by sex, race, age, marital status, or sexual orientation. Less educated and less wealthy subjects reported greater mental health distress compared to wealthier, more educated groups. These results suggest that the institution of abortion restrictions has had broad negative implications for the mental health of people living in the US, particularly those of lower education and personal wealth.

Medication and procedural abortion uptake during a period of increasing abortion hostility.

Hundreds of state-level abortion restrictions were implemented in the US between 2010 and 2020. Medication abortion was being widely adopted during this same period. Understanding the impact of health policies and political climate will improve the delivery of and access to reproductive healthcare in a period of rapid change. To measure the association between state abortion hostility and mifepristone and procedural abortion rates, we conducted a state-level repeated cross-sectional study using 2010-2020 employer-sponsored insurance claims data from Merative MarketScan. The exposure of interest was a 13-point state-level abortion hostility score based on the presence of policies which either reduce or protect access to abortion. Outcomes of interest were annual mifepristone and procedural abortion claims per 100,000 enrollees. We used a linear mixed model adjusting for urbanicity, age group, and year. We assessed whether temporal trends in abortion claims were modified by state abortion hostility by interacting year with two measurements of abortion hostility: baseline score in 2010 and change from baseline score. We found that median state-level mifepristone claims increased from 20 to 37 per 100,000 included enrollees; meanwhile, median procedural abortions claims decreased from 69 to 20 per 100. For mifepristone, every unit increase in a state's baseline abortion hostility score was associated with 7.5 (CI, -12 to -3.6) fewer mifepristone claims per 100,000 in 2010. For states with baseline hostility and change scores of zero, we did not observe a significant time trend over the 11 year study period. For every unit increase in baseline hostility, the time trend changed by 0.5 fewer claims (CI, -0.8 to -0.2) per 100,000 per year. States with higher baseline abortion hostility had fewer overall abortions, less uptake of mifepristone abortions, and slower decline in procedural abortions between 2010 and 2020. Changes in hostility from new restrictions during this time period did not significantly impact claims. Advocates for abortion access must simultaneously attend to individual abortion policies and the overall political climate. Updated research on the relationship between political climate and the evolving clinical landscape of abortion care is needed to inform this work.

Psychological sequelae following second-trimester termination of pregnancy: A longitudinal study.

INTRODUCTION: The decision to terminate a pregnancy due to fetal anomalies can have a significant emotional impact, especially in second-trimester terminations. Previous studies on the psychological consequences of pregnancy termination have had limitations, and little is known about the outcomes for partners and the impact of fetal donation. Therefore, we aimed to investigate the psychological effects of second-trimester pregnancy termination and identify factors associated with outcomes in both women and men, including donation of fetal remains to science. MATERIAL AND METHODS: A longitudinal cohort study was conducted at the Amsterdam UMC in the Netherlands, involving women and partners who underwent termination at or before 23 weeks and 6 days of gestation. Questionnaires were administered at termination, 6 weeks, and 4 months after. We utilized validated questionnaires to assess psychological morbidity (grief, post-traumatic stress and postnatal depression and quality of life [QoL]), and factors that could potentially influence outcomes. RESULTS: Of 241 participants, women displayed more pronounced psychological distress than men, though both groups improved over time. Four months after termination, 27.4% of women and 9.1% of men showed signs of pathological grief. Scores indicative for postnatal depression occurred in 19.8% women and 4.1% of men. A prior psychiatric history was a consistent predictor of poorer outcomes. Fetal donation to the Dutch Fetal Biobank was associated with reduced likelihood of symptoms of complicated grief four months after termination. CONCLUSIONS: Second-trimester termination of pregnancy for fetal anomalies can lead to psychological morbidity, particularly in women. However, there is a notable improvement over time for both groups. Individuals with prior psychiatric history appear more vulnerable post-termination. Also, fetal donation to science did not have a negative impact on psychological well-being.

A qualitative exploration of the reasons and influencing factors for pregnancy termination among young women in Soweto, South Africa: a Socio-ecological perspective.

BACKGROUND: Pregnancy termination is an essential component of reproductive healthcare. In Southern Africa, an estimated 23% of all pregnancies end in termination of pregnancy, against a backdrop of high rates of unintended pregnancies and unsafe pregnancy terminations, which contributes to maternal morbidity and mortality. Understanding the reasons for pregnancy termination may remain incomplete if seen in isolation of interpersonal (including family, peer, and partner), community, institutional, and public policy factors. This study therefore aimed to use a socio-ecological framework to qualitatively explore, in Soweto, South Africa, i) reasons for pregnancy termination amongst women aged 18-28 years, and ii) factors characterising the decision to terminate. METHODS: In-depth interviews were conducted between February to March 2022 with ten participants of varying parity, who underwent a termination of pregnancy since being enrolled in the Bukhali trial, set in Soweto, South Africa. A semi-structured, in-depth interview guide, based on the socioecological domains, was used. The data was analysed using reflexive thematic analysis, and a deductive approach. RESULTS: An application of the socio-ecological framework indicated that the direct reasons to terminate a pregnancy fell into the individual and interpersonal domains of the socioecological framework. Key reasons included financial dependence and insecurity, feeling unready to have a child (again), and a lack of support from family and partners for the participant and their pregnancy. In addition to these reasons, Factors that characterised the participants' decision experience were identified across all socio-ecological domains and included the availability of social support and (lack of) accessibility to termination services. The COVID-19 pandemic and resultant lockdown policies also indirectly impacted participants' decisions through detrimental changes in interpersonal support and financial situation. CONCLUSIONS: Amongst the South African women included in this study, the decision to terminate a pregnancy was made within a complex structural and social context. Insight into the reasons why women choose to terminate helps to better align legal termination services with women's needs across multiple sectors, for example by reducing judgement within healthcare settings and improving access to social and mental health support.

In South Africa, where the number of unintended pregnancies is high, we need an improved understanding of the main reasons why women terminate their pregnancies and what factors characterise this decision. Aside from individual factors, this should also be seen within the context of their environment, including relationships, community, and institutions. We therefore aimed to explore women's reasons for choosing to terminate their pregnancy through semi-structured in-depth interviews with participants. We included ten participants from Soweto, South Africa, who had undergone a pregnancy termination. The main reasons for terminating a pregnancy had to do with personal factors and reasons related to their social relationships and support. These included financial insecurity, not feeling ready to have a child (again), and lack of support from family or partners. We also found factors that characterised how the participant experienced the decision, such as barriers to getting a safe (legal) pregnancy termination. We found that amongst South African women, the decision to terminate is made in the context of their complex (social) environment. Insight into the reasons why women choose to terminate helps to better align legal termination services with women's needs, for example by reducing judgement within healthcare settings and improving access to social and mental health support.

Attitudes, concerns, and perceptions of patients undergoing fertility treatments in an abortion restrictive state in the aftermath of the Roe v. Wade reversal.

PURPOSE: To investigate the abortion views and reproductive concerns of current in vitro fertilization patients after the US Supreme Court Dobbs v. Jackson decision, which overturned the Roe v. Wade decision guaranteeing abortion access. METHODS: This is a cross-sectional survey of English-speaking patients undergoing in vitro fertilization from January to November 2022 at a large academic institution in a state with restricted abortion care. Participants completed a 43-question electronic survey which measured feelings about abortion, future fertility treatments, and embryo disposition both quantitatively and qualitatively. RESULTS: Of 543 eligible patients, 267 (49%) consented to participate when called and were sent the survey. Of those, 180 (67%) completed it, resulting in a total completion rate of 33%. The majority believe abortion should be legal in the case of birth defects (90.8%) or rape or incest (90.3%). A significant proportion (91.4%) expressed concerns about abortion being illegal in the state that they receive infertility care. They reported some concern about making embryos (89.6%), controlling what happens to them (95.4%), and discarding them (94.4%). Patients wrote about their concerns with pursuing fertility treatments, fear of not having access to needed medical care, and the desire to remain close to states with less restrictive abortion laws. CONCLUSIONS: The evolving political landscape surrounding access to reproductive care has created significant concerns regarding legal regulation of these treatments and the disposition of embryos. By understanding patients' concerns, health care providers can more effectively advocate for the protection of fertility treatments and patients' autonomy in embryo disposition.