Abortion incidence and service availability in the United States, 2020.

BACKGROUND: This study provides a baseline assessment of abortion incidence and service delivery prior to Roe v. Wade being overturned. METHODS: We collected information from all facilities known to have provided abortion services in the United States in 2019 and 2020. We examined abortion incidence by state, region and nationally and combined data on number of abortions with population data to estimate abortion rates. We also examined the number of abortion clinics, trends in medication abortion and service disruptions and changes in abortion protocols that occurred during the COVID-19 pandemic. We compare these findings to those of our prior Abortion Provider Census, which collected information for 2017. RESULTS: We documented 930,160 abortions in 2020, an 8% increase from 2017. Between 2017 and 2020, abortion incidence increased in all four regions of the country and in a majority of states. The total number of clinics providing abortion care remained stable nationally but increased in the Midwest and the West and declined in the Northeast and South. There were 492,210 medication abortions in 2020, a 45% increase from 2017. A substantial minority of clinics adjusted protocols in response to COVID, most commonly adopting remote pre- and post-abortion counseling. DISCUSSION: This study did not address factors behind the increase in abortion. However, this report demonstrates that the need for abortion care was growing just prior to the overturning Roe v. Wade, and the impact of this decision will be even more far-reaching than previously expected.

Attempts to purchase misoprostol online in Indonesia: a mystery client study design.

BACKGROUND: Abortion is highly restricted in Indonesia; self-administered misoprostol can safely induce an abortion. Brick and mortar pharmacies, a common place to purchase misoprostol off-label in other parts of the world, are monitored closely by the government authority in Indonesia which controls drugs so that they cannot function outside the law without risking arrest and prosecution. An online marketplace has sprung up in response that sells misoprostol through in-country distributors. Such procurement offers a level of safety and anonymity to the buyer and seller. So as to understand online access to misoprostol, we created a protocol to identify the most visible universe of sellers. METHODS: We carried out a mystery client methodology to replicate the experiences of women procuring misoprostol online. Our study consisted of five stages: (1) identify the universe of online sellers using the most common search terms, drawn from multiple platforms to capture diversity in interactions as well as products sold (2) remove duplicates across sites as determined by their telephone numbers (3) draw a roughly probability proportional to size sample (4) contact sellers as mystery clients through text/chat, depending on the platform, and engage with them and (5) attempt to purchase drugs offered by the seller. Descriptive statistics are presented. RESULTS: The listing generated 727 sites: 441 websites, 153 marketplace sellers, and 133 Instagram profiles. After removing duplicate listings, we identified 281 unique sellers. We selected all sellers with greater than 12 listings, 60% of sellers with 4-12 listings, 50% of sellers with 2-3 listings, and 40% of sellers with only one listing. Mystery clients were able to send initial messages to 110 sellers, of which 16 never responded. The interaction progressed to purchasing misoprostol with 76 sellers, 64 of whom sent drugs. CONCLUSIONS: As women seek to terminate unwanted pregnancies in legally restrictive settings, online sales of misoprostol must be considered. With the Covid pandemic constraining movement, the importance of this way of procuring misoprostol will likely become more appealing. Understanding this unregulated landscape is important if we are to try to improve women's ability to safely conduct an abortion in highly restrictive settings.

Health system capacity for post-abortion care in Java, Indonesia: a signal functions analysis.

BACKGROUND: The quality of obstetric care has been identified as a contributing factor in Indonesia's persistently high level of maternal mortality, and the country's restrictive abortion laws merit special attention to the quality of post-abortion care (PAC). Due to unique health policies and guidelines, in Indonesia, uterine evacuation for PAC is typically administered only by Ob/Gyns practicing in hospitals. METHODS: Using data from a survey of 657 hospitals and emergency obstetric-registered public health centers in Java, Indonesia's most populous island, we applied a signal functions analysis to measure the health system's capacity to offer PAC. We then used this framework to simulate the potential impact of the following hypothetical reforms on PAC capacity: allowing first-trimester uterine evacuation for PAC to take place at the primary care level, and allowing provision by clinicians other than Ob/Gyns. Finally, we calculated the proportion of PAC patients treated using four different uterine evacuation procedures. RESULTS: Forty-six percent of hospitals in Java have the full set of services needed to provide PAC, and PAC capacity is concentrated at the highest-level referral hospitals: 86% of referral hospitals have the full set of services, staffing, and equipment compared to 53% of maternity hospitals and 34% of local hospitals. No health centers are adequately staffed or authorized to offer basic PAC services under Indonesia's current guidelines. PAC capacity at all levels of the health system increases substantially in hypothetical scenarios under which authorization to perform first-trimester uterine evacuation for PAC is expanded to midwives and general physicians practicing in health centers. In 2018, 88% percent of PAC patients were treated using dilation and curettage (D&C). CONCLUSIONS: Offering first-trimester uterine evacuation for PAC in PONEDs and allowing clinicians other than Ob/Gyns to perform this procedure would greatly improve the capacity of Java's health system to serve PAC patients. Increasing the use of vacuum aspiration and misoprostol for PAC-related uterine evacuation would lower the burden of treatment for patients and facilitate the task-shifting efforts needed to expand access to this life-saving service.

Online Abortion Drug Sales in Indonesia: A Quality of Care Assessment.

This study sought to understand the experience of buying misoprostol online for pregnancy termination in Indonesia. We conducted a mystery client study August through October, 2019. Interactions were analyzed quantitatively and qualitatively, along with the contents of the packages. One hundred ten sellers were contacted, from whom mystery clients made 76 purchases and received 64 drug packages. Almost all sellers sold "packets" containing multiple drugs; 73 percent of packets contained misoprostol, and 47 percent contained at least 800 mcg of misoprostol. Thirty-four packets contained insufficient drugs to complete an abortion. When compared to WHO standards, 87 percent of sellers imparted incomplete information about potential physical effects; no seller provided information about possible complications. Women buying misoprostol from informal online drugs sellers will be underprepared for understanding potential side effects and complications. Educational activities are needed to increase women's access to information about safe use of misoprostol as a harm reduction strategy.

Estimating the Incidence of Induced Abortion in Java, Indonesia, 2018.

CONTEXT: In Indonesia, maternal mortality is high and abortion is restricted. Reliable information on induced abortion is needed; however, the difficulty of measuring abortion in settings where it is legally restricted and highly stigmatized calls for innovation in approaches to measuring abortion incidence. METHODS: The data were from three original surveys conducted in Java among health facilities, knowledgeable informants and women aged 15-49, fielded in April 2018-January 2019. Two methods were used to estimate the one-year induced abortion incidence rate in Java: the standard Abortion Incidence Complications Method (AICM) and a modified AICM. Each method was evaluated on the basis of data quality, and what is known about sexual and reproductive health indicators related to abortion rates, to determine which performed best in measuring abortion incidence in Java. RESULTS: Estimates of complications resulting from induced abortion from knowledgeable informants and the women differed substantially. The modified AICM produced an estimate of 42.5 abortions per 1,000 women aged 15-49, while the standard AICM estimate was lower (25.8 per 1,000). A comparison of the distribution of abortion methods used revealed that knowledgeable informants believed abortion was less safe than indicated by women's reports of their own experiences. Therefore, the standard AICM likely underestimates abortion. CONCLUSIONS: The modified AICM performed better than the standard AICM and indicates that abortion is common in Java. Increased access to contraceptives and high-quality postabortion care is needed. Future research should investigate the safety of abortion, especially with respect to self-managed abortion.

RESUMEN Contexto: La mortalidad materna en Indonesia es alta y el aborto está restringido. Se necesita información confiable sobre el aborto inducido; sin embargo, la dificultad de medir el aborto en entornos donde está restringido legalmente y es fuertemente estigmatizado, requiere esfuerzos de innovación en los enfoques para medir la incidencia del aborto. Métodos: Los datos se obtuvieron de tres encuestas originales realizadas en Java entre instituciones de salud, informantes conocedores del tema y mujeres en edades de 15 a 49 años y que fueron aplicadas entre abril de 2018 y enero de 2019. Se usaron dos métodos para estimar la tasa de incidencia de aborto inducido en un año en Java: el método estándar de estimación de aborto por complicaciones (AICM, por sus siglas en inglés) y el AICM modificado. Cada método se evaluó con base en la calidad de los datos y en lo que se sabe sobre indicadores de salud sexual y reproductiva relacionados con las tasas de aborto, para determinar cuál método se desempeñó mejor en la medición de la incidencia de aborto en Java. Resultados: Las estimaciones de complicaciones derivadas del aborto inducido según informantes conocedores del tema y según las mujeres, difirieron sustancialmente. El AICM modificado produjo una estimación de 42.5 abortos por 1,000 mujeres en edades de 15 a 49 años, mientras que la estimación del AICM estándar fue más baja (25.8 por 1,000). Una comparación de la distribución de los métodos de aborto usados reveló que los informantes conocedores creían que el aborto era menos seguro que lo indicado en los informes de las mujeres basados en sus propias experiencias. Por lo tanto, es probable que el método AICM estándar subestime la incidencia del aborto. Conclusiones: El método AICM modificado funcionó mejor que el AICM estándar e indica que el aborto es una práctica común en Java. Son necesarios un mayor acceso a los anticonceptivos y a una atención postaborto de alta calidad. Las futuras investigaciones deben investigar la seguridad del aborto, especialmente en relación con el aborto autoadministrado.

RÉSUMÉ Contexte: En Indonésie, la mortalité maternelle est élevée et l'avortement est limité par la loi. Il existe un besoin d'information fiable concernant l'avortement provoqué. La difficulté de mesurer l'avortement dans les contextes où il est strictement limité et fortement stigmatisé demande cependant des approches innovantes. Méthodes: Les données proviennent de trois enquêtes initiales menées à Java auprès de structures de santé, de sources bien informées et de femmes âgées de 15 à 49 ans, entre avril 2018 et janvier 2019. Le taux d'incidence de l'avortement provoqué à l'échelle d'une année à Java a été estimé selon deux méthodes: la méthode AICM standard d'évaluation de l'incidence de l'avortement en fonction des complications traitées et une méthode AICM modifiée. Chaque méthode a été évaluée en fonction de la qualité des données et de l'information connue sur les indicateurs de santé sexuelle et reproductive relatifs aux taux d'avortement, afin de déterminer celle qui avait le mieux mesuré l'incidence de l'avortement à Java. Résultats: Les estimations des complications résultant de l'avortement provoqué obtenues des sources informées et des femmes consultées se sont avérées nettement différentes. La méthode AICM modifiée a produit une estimation de 42,5 avortements pour 1 000 femmes âgées de 15 à 49 ans, tandis que la méthode AICM standard produisait une estimation inférieure (25,8 pour 1 000). En comparant la distribution des méthodes d'avortement pratiquées, on a constaté que les sources informées estimaient l'avortement moins sùr que ne l'indiquaient les déclarations des femmes concernant leur propre expérience. Il est dès lors probable que la méthode AICM standard sous-estime l'avortement. Conclusions: La méthode AICM modifiée, plus efficace que la méthode standard, fait état d'une pratique courante de l'avortement à Java. Un meilleur accès à la contraception et à des soins après avortement de qualité est nécessaire. La recherche future devrait se pencher sur la sécurité de l'avortement, en ce qui concerne en particulier les interventions autogérées.

The Severity and Management of Complications Among Postabortion Patients Treated in Kinshasa Health Facilities.

CONTEXT: Unsafe abortion is common in Kinshasa, which contributes to high rates of maternal morbidity and mortality. Little is known about the complications and treatment experienced by women seeking postabortion care at health facilities in the city. METHODS: Data from 867 women admitted to a sample of health facilities providing postabortion care in Kinshasa in 2016 were drawn from a Prospective Morbidity Survey. A measure of severity of postabortion complications was developed on the basis of information from these women and their primary care provider. Generalized ordered logistic regression analyses were used to examine associations between the characteristics of postabortion care patients and complication severity. RESULTS: Nearly three-fourths (72%) of postabortion care patients were classified as certainly having had an induced abortion, and another 16% as probably having had one. Sixteen percent of postabortion care patients experienced severe complications, 46% moderate complications and 33% mild complications; 5% had no evidence of complications. Severity of complications was associated with certain patient characteristics: For example, poor patients and those who had never been married had elevated odds of having experienced severe or moderate complications rather than mild or no complications (odds ratios, 1.8-1.9). Patients' complications were most commonly treated with such outdated methods as dilation and curettage and digital curettage (49% and 23%, respectively); only 11% of patients received medication for pain. CONCLUSIONS: Policies and programs promoting contraceptive use and safe legal abortion are needed in Kinshasa to reduce women's recourse to unsafe abortion. Improved quality postabortion care provision is also needed, including World Health Organization-recommended methods.

The incidence of induced abortion in Kinshasa, Democratic Republic of Congo, 2016.

BACKGROUND: In the Democratic Republic of Congo, the penal code prohibits the provision of abortion. In practice, however, it is widely accepted that the procedure can be performed to save the life of a pregnant woman. Although abortion is highly restricted, anecdotal evidence indicates that women often resort to clandestine abortions, many of which are unsafe. However, to date, there are no official statistics or reliable data to support this assertion. OBJECTIVES: Our study provides the first estimates of the incidence of abortion and unintended pregnancy in Kinshasa. METHODS: We applied the Abortion Incidence Complications Method (AICM) to estimate the incidence of abortion and unintended pregnancy. We used data from a Health Facilities Survey and a Prospective Morbidity Survey to determine the annual number of women treated for abortion complications at health facilities. We also employed data from a Health Professionals Survey to calculate a multiplier representing the number of abortions for every induced abortion complication treated in a health facility. RESULTS: In 2016, an estimated 37,865 women obtained treatment for induced abortion complications in health facilities in Kinshasa. For every woman treated in a facility, almost four times as many abortions occurred. In total, an estimated 146,713 abortions were performed, yielding an abortion rate of 56 per 1,000 women aged 15-49. Furthermore, more than 343,000 unintended pregnancies occurred, resulting in an unintended pregnancy rate of 147 per 1,000 women aged 15-49. CONCLUSIONS: Increasing contraceptive uptake can reduce the number of women who experience unintended pregnancies, and as a consequence, result in fewer women obtaining unsafe abortions, suffering abortion complications, and dying needlessly from unsafe abortion. Increasing access to safe abortion and improving post-abortion care are other measures that can be implemented to reduce unsafe abortion and/or its negative consequences, including maternal mortality.

Incidence of induced abortion in Malawi, 2015.

BACKGROUND: In Malawi, abortion is legal only if performed to save a woman's life; other attempts to procure an abortion are punishable by 7-14 years imprisonment. Most induced abortions in Malawi are performed under unsafe conditions, contributing to Malawi's high maternal mortality ratio. Malawians are currently debating whether to provide additional exceptions under which an abortion may be legally obtained. An estimated 67,300 induced abortions occurred in Malawi in 2009 (equivalent to 23 abortions per 1,000 women aged 15-44), but changes since 2009, including dramatic increases in contraceptive prevalence, may have impacted abortion rates. METHODS: We conducted a nationally representative survey of health facilities to estimate the number of cases of post-abortion care, as well as a survey of knowledgeable informants to estimate the probability of needing and obtaining post-abortion care following induced abortion. These data were combined with national population and fertility data to determine current estimates of induced abortion and unintended pregnancy in Malawi using the Abortion Incidence Complications Methodology. RESULTS: We estimate that approximately 141,044 (95% CI: 121,161-160,928) induced abortions occurred in Malawi in 2015, translating to a national rate of 38 abortions per 1,000 women aged 15-49 (95% CI: 32 to 43); which varied by geographical zone (range: 28-61). We estimate that 53% of pregnancies in Malawi are unintended, and that 30% of unintended pregnancies end in abortion. Given the challenges of estimating induced abortion, and the assumptions required for calculation, results should be viewed as approximate estimates, rather than exact measures. CONCLUSIONS: The estimated abortion rate in 2015 is higher than in 2009 (potentially due to methodological differences), but similar to recent estimates from nearby countries including Tanzania (36), Uganda (39), and regional estimates in Eastern and Southern Africa (34-35). Over half of pregnancies in Malawi are unintended. Our findings should inform ongoing efforts to reduce maternal morbidity and mortality and to improve public health in Malawi.

Cost-effectiveness of two interventions for the prevention of postpartum hemorrhage in Senegal.

OBJECTIVE: To compare, at the community level, the cost-effectiveness of oxytocin and misoprostol for the prevention of postpartum hemorrhage (PPH). METHODS: The present cost-effectiveness study used data collected during a randomized trial that compared the prophylactic effectiveness of misoprostol and oxytocin for the prevention of PPH in a rural setting in Senegal between June 6 and September 21 2013. The two interventions were compared, with referral to a higher level facility owing to PPH being the outcome measure. The costs and effects were calculated for two hypothetical cohorts of patients delivering during a 1-year period, with each cohort receiving one intervention. A comparison with a third hypothetical cohort receiving the current standard of care was included. A sensitivity analysis was performed to estimate the impact of variations in model assumptions. RESULTS: The cost per PPH referral averted was US$ 38.96 for misoprostol and US$ 119.15 for oxytocin. In all the scenarios modeled the misoprostol intervention dominated, except in the worst-case scenario, where the oxytocin intervention demonstrated slightly better cost-effectiveness. CONCLUSION: The use of misoprostol for PPH prophylaxis could be cost effective and improve maternal outcomes in low-income settings.

Incidence of Induced Abortion and Post-Abortion Care in Tanzania.

BACKGROUND: Tanzania has one of the highest maternal mortality ratios in the world, and unsafe abortion is one of its leading causes. Yet little is known about its incidence. OBJECTIVES: To provide the first ever estimates of the incidence of unsafe abortion in Tanzania, at the national level and for each of the 8 geopolitical zones (7 in Mainland plus Zanzibar). METHODS: A nationally representative survey of health facilities was conducted to determine the number of induced abortion complications treated in facilities. A survey of experts on abortion was conducted to estimate the likelihood of women experiencing complications and obtaining treatment. These surveys were complemented with population and fertility data to obtain abortion numbers, rates and ratios, using the Abortion Incidence Complications Methodology. RESULTS: In Tanzania, women obtained just over 405,000 induced abortions in 2013, for a national rate of 36 abortions per 1,000 women age 15-49 and a ratio of 21 abortions per 100 live births. For each woman treated in a facility for induced abortion complications, 6 times as many women had an abortion but did not receive care. Abortion rates vary widely by zone, from 10.7 in Zanzibar to 50.7 in the Lake zone. CONCLUSIONS: The abortion rate is similar to that of other countries in the region. Variations by zone are explained mainly by differences in fertility and contraceptive prevalence. Measures to reduce the incidence of unsafe abortion and associated maternal mortality include expanding access to post-abortion care and contraceptive services to prevent unintended pregnancies.

Estimates of the incidence of induced abortion and consequences of unsafe abortion in Senegal.

CONTEXT: Abortion is highly restricted by law in Senegal. Although women seek care for abortion complications, no national estimate of abortion incidence exists. METHODS: Data on postabortion care and abortion in Senegal were collected in 2013 using surveys of a nationally representative sample of 168 health facilities that provide postabortion care and of 110 professionals knowledgeable about abortion service provision. Indirect estimation techniques were applied to the data to estimate the incidence of induced abortion in the country. Abortion rates and ratios were calculated for the nation and separately for the Dakar region and the rest of the country. The distribution of pregnancies by planning status and by outcome was estimated. RESULTS: In 2012, an estimated 51,500 induced abortions were performed in Senegal, and 16,700 (32%) resulted in complications that were treated at health facilities. The estimated abortion rate was 17 per 1,000 women aged 15-44 and the abortion ratio was 10 per 100 live births. The rate was higher in Dakar (21 per 1,000) than in the rest of the country (16 per 1,000). Poor women were far more likely to experience abortion complications, and less likely to receive treatment for complications, than nonpoor women. About 31% of pregnancies were unintended, and 24% of unintended pregnancies (8% of all pregnancies) ended in abortion. CONCLUSIONS: Unsafe abortion exacts a heavy toll on women in Senegal. Reducing the barriers to effective contraceptive use and ensuring access to postabortion care without the risk of legal consequences may reduce the incidence of and complications from unsafe abortion.

Trends in ages at key reproductive transitions in the United States, 1951-2010.

BACKGROUND: Key sexual and reproductive health milestones typically mark changing life stages with different fertility intentions and family planning needs. Knowing the typical ages at such events contributes to our understanding of changes in family formation and transition to adulthood and helps inform needs for reproductive health services. METHODS: We used data from the 1982-2010 National Surveys of Family Growth and the 1995 National Survey of Adolescent Males and event history methods to examine trends over time for women and men in the median ages at several reproductive and demographic events. FINDINGS: Women's reports indicate that age at menarche has changed little since 1951. Women's and men's median ages at first sex declined through the 1978 birth cohort, but increased slightly since then, to 17.8 years for women and 18.1 for men. The interval from first sex to first contraceptive use has narrowed, although Hispanic women have a longer interval. Age at first union (defined as the earlier of first marriage or first cohabiting relationship) has remained relatively stable, but the time between median age at first sex and median age at first birth has increased to 9.2 years for women and 11.4 for men. For some women and men born in the late 1970s, median age at first birth was earlier than median age at first marriage for the first time in at least the past several decades. CONCLUSION: The large majority of the reproductive years are spent sexually active. Thus, women have a lengthy period during which they require effective methods. In particular, the period between first sex and first childbearing has lengthened, but long-acting method use, although increasing, has not kept up with this shift. Moving the contraceptive method mix toward underutilized but highly effective contraceptive methods has the potential to reduce the unintended pregnancy rate.

Sexual initiation, contraceptive use, and pregnancy among young adolescents.

OBJECTIVE: To present new data on sexual initiation, contraceptive use, and pregnancy among US adolescents aged 10 to 19, and to compare the youngest adolescents' behaviors with those of older adolescents. METHODS: Using nationally representative data from several rounds of the National Survey of Family Growth, we performed event history (ie, survival) analyses to examine timing of sexual initiation and contraceptive use. We calculated adolescent pregnancy rates by single year of age using data from the National Center for Health Statistics, the Guttmacher Institute, and the US Census Bureau. RESULTS: Sexual activity is and has long been rare among those 12 and younger; most is nonconsensual. By contrast, most older teens (aged 17-19) are sexually active. Approximately 30% of those aged 15 to 16 have had sex. Pregnancy rates among the youngest teens are exceedingly low, for example, ∼1 per 10 000 girls aged 12. Contraceptive uptake among girls as young as 15 is similar to that of their older counterparts, whereas girls who start having sex at 14 or younger are less likely to have used a method at first sex and take longer to begin using contraception. CONCLUSIONS: Sexual activity and pregnancy are rare among the youngest adolescents, whose behavior represents a different public health concern than the broader issue of pregnancies to older teens. Health professionals can improve outcomes for teenagers by recognizing the higher likelihood of nonconsensual sex among younger teens and by teaching and making contraceptive methods available to teen patients before they become sexually active.