Placement of an intrauterine device within 48 hours after second-trimester medical abortion: a randomized controlled trial.

BACKGROUND: International guidelines recommend placement of intrauterine devices immediately after second-trimester medical abortion, but evidence concerning the optimal time for intrauterine device placement is lacking from clinical trials. OBJECTIVE: This study aimed to investigate effectiveness, safety, and acceptability of intrauterine device placement within 48 hours, compared with placement at 2 to 4 weeks after second-trimester medical abortion. We hypothesized that intrauterine device placement within 48 hours would be superior compared with placement at 2 to 4 weeks after the abortion, in terms of the proportion of intrauterine device use after 6 months, with maintained safety and acceptability. STUDY DESIGN: In this open-label, randomized, controlled, superiority trial, we recruited participants at 8 abortion clinics in Sweden. Eligible participants were aged ≥18 years, requesting medical abortion with gestation ≥85 days, and opting for use of a postabortion intrauterine device. Participants were randomized (1:1) to intrauterine device placement either within 48 hours of complete abortion (intervention) or after 2 to 4 weeks (control). Our primary outcome was self-reported use of an intrauterine device after 6 months. Secondary outcomes included expulsion rates, pain at placement, adverse events and complications, acceptability, and subsequent pregnancies and abortions. Differences in nonnormal continuous variables were analyzed with the Mann-Whitney U test, and differences in dichotomous variables with the chi-square or Fisher exact tests. A P value <.05 was considered statistically significant. Group differences are presented by modified intention-to-treat and per-protocol analyses. RESULTS: Between January 2019 and June 2022, we enrolled 179 participants, of whom 90 were assigned to the intervention and 89 to the control arm. Enrollment was prematurely stopped after an interim analysis exceeded a predefined intrauterine device expulsion rate of 20%. According to modified intention-to-treat analysis, use of intrauterine device after 6 months was 50.7% (34/67) in the intervention group vs 71.6% (48/67) in the control group (proportion difference, 20.9%; 95% confidence interval, 4.4%-35.9%; P=.02). The intrauterine device expulsion rate was 30.1% (22/73) in the intervention group vs 2.9% (2/70; P<.001) in the control group. Other adverse events were rare and patient acceptability was high in both groups. CONCLUSION: Intrauterine device placement within 48 hours after second-trimester medical abortion was nonsuperior in terms of the proportion of intrauterine device use after 6 months when compared with placement after 2 to 4 weeks. Placement within 48 hours after second-trimester abortion can be used in selected individuals after counseling on expulsion risk.

Progesterone after mifepristone: A pilot prospective single arm clinical trial for women who have changed their mind after commencing medical abortion.

AIM: This pilot study aimed to assess the utility of an oral progesterone treatment protocol for women who commenced medical abortion and then changed their mind and wished instead to maintain their pregnancy. METHODS: The Progesterone-After-Mifepristone-pilot for efficacy and reproducibility (PAMper) trial was designed as a prospective single-arm pilot clinical trial, conducted via telehealth. Women aged 18 to 45 years in Australia who reported ingesting mifepristone within the last 72 h to initiate medical abortion and had not taken misoprostol were included. Initial contact was by a web-based form. Following informed consent, participants were prescribed oral progesterone to be taken 400 mg twice per day for 3 days then 400 mg at night until completion of a 19 day course. Pregnancy viability was assessed by ultrasound scan after 14 days of progesterone treatment. RESULTS: Between October 2020 and June 2021, nine women contacted the PAMper trial, of whom six enrolled and commenced progesterone treatment. These women reported ingesting mifepristone at 40-70 days of gestation, with progesterone being commenced within 5.7-72 h of mifepristone ingestion. Five participants had ongoing, live pregnancies at the primary endpoint (ultrasound at >2 weeks). One participant had a miscarriage after 9 days of progesterone treatment. There were no clinically significant adverse events. CONCLUSION: This small study demonstrated a clinically sound protocol for researching the use of progesterone-after-mifepristone for women in this circumstance. Results of this pilot study support the need for further larger scale trials in this field.

Identifying National Availability of Abortion Care and Distance From Major US Cities: Systematic Online Search.

BACKGROUND: Abortion is a common medical procedure, yet its availability has become more limited across the United States over the past decade. Women who do not know where to go for abortion care may use the internet to find abortion facility information, and there appears to be more online searches for abortion in states with more restrictive abortion laws. While previous studies have examined the distances women must travel to reach an abortion provider, to our knowledge no studies have used a systematic online search to document the geographic locations and services of abortion facilities. OBJECTIVE: The objective of our study was to describe abortion facilities and services available in the United States from the perspective of a potential patient searching online and to identify US cities where people must travel the farthest to obtain abortion care. METHODS: In early 2017, we conducted a systematic online search for abortion facilities in every state and the largest cities in each state. We recorded facility locations, types of abortion services available, and facility gestational limits. We then summarized the frequencies by region and state. If the online information was incomplete or unclear, we called the facility using a mystery shopper method, which simulates the perspective of patients calling for services. We also calculated distance to the closest abortion facility from all US cities with populations of 50,000 or more. RESULTS: We identified 780 facilities through our online search, with the fewest in the Midwest and South. Over 30% (236/780, 30.3%) of all facilities advertised the provision of medication abortion services only; this proportion was close to 40% in the Northeast (89/233, 38.2%) and West (104/262, 39.7%). The lowest gestational limit at which services were provided was 12 weeks in Wyoming; the highest was 28 weeks in New Mexico. People in 27 US cities must travel over 100 miles (160 km) to reach an abortion facility; the state with the largest number of such cities is Texas (n=10). CONCLUSIONS: Online searches can provide detailed information about the location of abortion facilities and the types of services they provide. However, these facilities are not evenly distributed geographically, and many large US cities do not have an abortion facility. Long distances can push women to seek abortion in later gestations when care is even more limited.

Progesterone for preventing pregnancy termination after initiation of medical abortion with mifepristone.

INTRODUCTION: Abortion is often a difficult and traumatic decision for a woman to make. Perhaps greater distress occurs when a woman commences a medical abortion but then changes her mind and wishes to keep the now-threatened pregnancy. One published case series detailed a potential method to counter/reverse the abortifacient effect of mifepristone by administering parenteral progesterone in such situations. OBJECTIVES: The present report details cases of women in similar circumstances who have been treated with progesterone. The aims were to document occurrences of where women have changed their mind after commencing medical abortion, as well as to explore some of the controversies and clinical issues surrounding their circumstances. METHODS: Women who had commenced medical abortion by ingesting mifepristone but who had not taken misoprostol independently contacted a national pregnancy support service the same day. Those meeting criteria for treatment received progesterone pessaries per vaginum for two weeks. RESULTS: Cases: 28-year-old woman, 6 weeks plus 1 day gestation; 35-year-old woman, 8 weeks plus 5 days gestation; and 27-year-old woman, 7 weeks plus 3 days gestation. Outcomes respectively were: healthy male baby delivered at 39 weeks gestation; healthy male baby delivered at term; and completed medical abortion. CONCLUSIONS: Women have changed their mind after commencing medical abortion. Progesterone use in early pregnancy is low risk and its application to counter the effects of mifepristone in such circumstances may be clinically beneficial in preserving her threatened pregnancy. Further research is required, however, to provide definitive evidence.

Using chat and text technologies to answer sexual and reproductive health questions: Planned Parenthood pilot study.

BACKGROUND: Teens and young adults in the United States are in need of sexual and reproductive health information, as evidenced by elevated rates of sexually transmitted infections (STIs), pregnancy, and births among this population. In-person sexuality education programs are helpful, but they are unlikely to rapidly accommodate teens and young adults in a moment of crisis. Evidence suggests that technologies such as instant messaging (IM) and text messaging may be effective ways to provide teens and young adults with sexual and reproductive health information. In September 2010, Planned Parenthood Federation of America launched a text and IM program designed to provide immediate answers to urgent sexual and reproductive health questions from a reliable and confidential source and to link young people to sexual and reproductive health services if needed. OBJECTIVE: To assess whether this program is successful in reaching the target population, whether user characteristics vary by mode (IM vs text), and whether mode is associated with reaching individuals with high levels of worry or reducing worry postchat. METHODS: Data were collected from prechat and postchat surveys for all IM and text message conversations between September 2010 and August 2011. A bivariate analysis was conducted using chi-square tests for differences in the main covariates by mode of conversation. In the multivariable analysis, logistic regression was used to identify factors that were independently associated with prechat levels of worry and changes in worry postchat. RESULTS: A total of 32,589 conversations occurred during the program's first year. The odds of feeling very worried prechat were highest for IM users (adjusted odds ratio [AOR] 1.43, 95% CI 1.20-1.72), users 17 years and younger (AOR 1.62, 95% CI 1.50-1.74), Latino/Hispanic users (AOR 1.36, 95% CI 1.27-1.46), and black users (AOR 1.40, 95% CI 1.30-1.50). After controlling for the study covariates, there was no significant difference in the odds of feeling better (less worried) postchat between IM and text message users. Feeling better postchat was associated with being younger (≤17 years: AOR 1.42, 95% CI 1.17-1.72; 18-24 years: AOR 1.20, 95% CI 1.02-1.42), being Latino/Hispanic (AOR 1.31, 95% CI 1.10-1.55), reporting that the service was very helpful (AOR 3.47, 95% CI 3.24-4.32), and asking about emergency contraception (AOR 1.35, 95% CI 1.13-1.61). The odds of feeling better were lowest for users with questions about STIs (AOR 0.61, 95% CI 0.47-0.78). CONCLUSIONS: The results from the process evaluation suggest that the program was able to provide informational support to vulnerable groups, such as teens and racial minorities, in moments of particular worry. Differences between the IM and text message users reveal that each mode appeals to a different population and that both are necessary to reach a diverse audience.

Comparison of Facebook, Google Ads, and Reddit for the Recruitment of People Who Considered but Did Not Obtain Abortion Care in the United States: Cross-sectional Survey.

BACKGROUND: In the United States, abortion access is restricted by numerous logistical, financial, social, and policy barriers. Most studies on abortion-seeking experiences in the United States have recruited participants from abortion clinics. However, clinic-based recruitment strategies fail to capture the experiences of people who consider an abortion but do not make it to an abortion clinic. Research indicates that many people search for abortion information on the web; however, web-based recruitment remains underutilized in abortion research. OBJECTIVE: This study aims to establish the feasibility of using Facebook, Google Ads, and Reddit as recruitment platforms for a study on abortion-seeking experiences in the United States. METHODS: From August to September 2018, we posted recruitment advertisements for a survey about abortion-seeking experiences through Facebook, Google Ads, and Reddit. Eligible participants were US residents aged 15-49 years who had been pregnant in the past 5 years and had considered abortion for a pregnancy in this period but did not abort. For each platform, we recorded staff time to develop advertisements and manage recruitment, as well as costs related to advertisement buys and social marketing firm support. We summarized the number of views and clicks for each advertisement where possible, and we calculated metrics related to cost per recruited participant and recruitment rate by week for each platform. We assessed differences across platforms using the chi-square and Kruskal-Wallis tests. RESULTS: Overall, study advertisements received 77,464 views in the 1-month period (from Facebook and Google; information not available for Reddit) and 2808 study page views. After clicking on the advertisements, there were 1254 initiations of the eligibility screening survey, which resulted in 98 eligible survey participants (75 recruited from Facebook, 14 from Google Ads, and 9 from Reddit). The cost for each eligible participant in each platform was US $49.48 for Facebook, US $265.93 for Google Ads, and US $182.78 for Reddit. A total of 84% (66/79) of those who screened eligible from Facebook completed the short survey compared with 73% (8/11) of those who screened eligible from Reddit and 13% (7/53) of those who screened eligible from Google Ads. CONCLUSIONS: These results suggest that Facebook advertisements may be the most time- and cost-effective strategy to recruit people who considered but did not obtain an abortion in the United States. Adapting and implementing Facebook-based recruitment strategies for research on abortion access could facilitate a more complete understanding of the barriers to abortion care in the United States.

Real-Time Effects of Payer Restrictions on Reproductive Healthcare: A Qualitative Analysis of Cost-Related Barriers and Their Consequences among U.S. Abortion Seekers on Reddit.

OBJECTIVE: The Hyde Amendment and related policies limit or prohibit Medicaid coverage of abortion services in the United States. Most research on cost-related abortion barriers relies on clinic-based samples, but people who desire abortions may never make it to a healthcare center. To examine a novel, pre-abortion population, we analyzed a unique qualitative dataset of posts from Reddit, a widely used social media platform increasingly leveraged by researchers, to assess financial obstacles among anonymous posters considering abortion. METHODS: In February 2020, we used Python to web-scrape the 250 most recent posts that mentioned abortion, removing all identifying information and usernames. After transferring all posts into NVivo, a qualitative software package, the team identified all datapoints related to cost. Three qualitatively trained evaluators established and applied codes, reaching saturation after 194 posts. The research team used a descriptive qualitative approach, using both inductive and deductive elements, to identify and analyze themes related to financial barriers. RESULTS: We documented multiple cost-related deterrents, including lack of funds for both the procedure and attendant travel costs, inability to afford desired abortion modality (i.e., medication or surgical), and for some, consideration of self-managed abortion options due to cost barriers. CONCLUSIONS: Findings from this study underscore the centrality of cost barriers and third-party payer restrictions to stymying reproductive health access in the United States. Results may contribute to the growing evidence base and building political momentum focused on repealing the Hyde Amendment.

A formative evaluation of online information to support abortion access in England, Northern Ireland and the Republic of Ireland.

OBJECTIVES: To evaluate web-based information on accessing abortion services retrieved through internet searches in different jurisdictions from the perspective of service users. To provide a formative evaluative mechanism for enabling user-focused design of abortion access information web pages. DESIGN: Web searches were conducted in three countries-England, Northern Ireland, and the Republic of Ireland-using two search engines in the summer of 2016. Four search terms were used and the first two pages of results were analysed. The perspective of someone seeking abortion services was used. Sources were evaluated using a five-item tool combining user-based indicators identified in other instruments and a question on jurisdictional accuracy. RESULTS: A total of 619 web pages were retrieved through initial searches, 83 of which related to accessing services; 22 pages were retrieved from the Republic of Ireland, 31 from Northern Ireland, and 30 from England. Fewer than a third (n=31) were judged as good or excellent by the tool. The jurisdictional relevancy of information retrieved varied; almost half of all results in each country provided information that was either inaccurate within or irrelevant to the jurisdiction where the search took place. CONCLUSIONS: If online information is to support abortion access, the circumstances and perspective of the user requires more attention. Designers of abortion information pages online need to ensure that information about access is relevant to the jurisdiction in which users are based.

Outcome following therapeutic abortion.

Psychological outcome of abortion was studied in 102 patients, measuring multiple variables over four time intervals. Five measured affects--anxiety, depression, anger, guilt, and shame-were significantly lower six months after the preabortion period. The following variables describe subgroups of patients with significant variations in patterns of responses as indicated by changes in affects: marital status, personality diagnosis, character of object relations, past psychopathologic factors, relationship to husband or lover, relationship to mother, ambivalence about abortion, religion, and previous parity. A complex multivariate model, based on conflict and conflict resolution, is appropriate to conceptualize, the unwanted pregnancy and abortion experience. Data suggest that women most vulnerable to conflict are those who are single and nulliparous, those with previous history of serious emotional problems, conflictual relationships to lovers, past negative relationships to mother, strong ambivalence toward abortion, or negative religious or cultural attitudes about abortion.

PIP: Anxiety, depression, anger, quilt, and shame following induced abortion were studied in 102 patients over 4 time intervals. The study was made before the Supreme Court decision liberalizing abortion when the major therapeutic indication was that the pregnancy would be emotionally damaging to the health of the mother. Minnesota Multiphasic Personality Inventory (MMPI), Profile of Mood States (POMS), and Symptom Rating Scale (SRS) tests were given at the preabortion interview, the POMS and SRS were given in the hospital within 24 hours and at 6 weeks, and all 3 tests were given at 6 months. Levels of all 5 variables dropped immediately after abortion, then rose slightly at 6 weeks, remaining constant at 6 months. Anger, depression, and anxiety generally rose to higher levels at 6 weeks than did quilt and shame. At 6 months, levels for all of these feelings are significantly lower than preabortion (p less than .001). Comparable affects measured by the psychological tests showed a sharp decrease postabortion (p less than .001). Further study was done of 24 subgroups of variables characterized by the headings: demographic factors; mental health and diagnosis; personal relationships; and current pregnancy. Anxiety was the only affect that differed with race or previous illegitimate pregnancy. Black women and those who have had previous illegitimate children show less anziety. White women show a higher level of guilt, but this does not reach significance. Women in low-status employment show the highest levels of housewives and high-status working women were in the middle range. Housewives and low-status working women had the highest levels of anger. Students scored lowest on all variables. Previous mental health was directly related to depression, anxiety, and anger but not guilt or shame. Those who had negative relationships with either her mother or the father of the child had the greatest levels of anger and depression. Those with negative or ambivalent relationships with their children experienced significantly greater depression and shame. Those who had the most ambivilent feelings toward abortion also had the greatest number of negative feelings. A religions or cultural background strongly negative toward abortion and sexuality also led to greater conflict. This information can be used to identify those individuals most likely to benefit from additional support and from brief selective psychotherapy modeled on crisis-intervention techniques.

Psychoses following therapeutic abortion.

PIP: The literature concerning therapeutic abortion suggests that there are few significant psychiatric sequelae of the procedure among women with no previous psychiatric history, and when emotional disturbances do result, they are related to the patient's environment rather than the termination itself. However, 2 case reports are presented in which the patients functioned normally before the abortion but subsequently experienced psychoses precipitated by guilt over the procedure. Both women experienced visual hallucinations and the psychotic thought processes around the time they would have delivered, and had to be hospitalized. These cases suggest that the rationalization and intellectualization of the abortion experience may not constitute adequate defenses aginst guilt, and point to the necessity of physician awareness that the abortion procedure may produce morbidity.^ieng

Motivational factors in abortion patients.

PIP: From June 1970 through January 1971, a psychological comparison between 99 single white pregnant women seeking abortion and a control group of 79 single nonpregnant women of similar background showed that, as a group, the women seeking abortion were no more neurotic than nonpregnant women of the same ages. Both groups (comprised mainly of college students) were equally informed about contraceptives. 77% of the abortion group used no contraceptives prior to the pregnancy. 82% of the sexually active members of the control group consistently used contraceptives. Conscious motivational factors, such as guilt over use of contraception, reactions to loss, or severe acting-out character disorders, may have influenced the occurrence of the pregnancy in 40% of the abortion group. Psychological testing showed that the pregnant group stated themselves as more impulsive and as tending to externalize aggression.^ieng

Determinants of abortion among women admitted to hospitals in Fortaleza, North Eastern Brazil.

BACKGROUND: Maternal mortality from complications of unsafe abortion constitutes a serious problem in several developing countries. There is, however, a paucity of well-designed and implemented studies in this area, especially in Latin America. The aim of this paper is to present the findings on the determinants and medical characteristics of abortions among women admitted to hospitals. METHODS: A descriptive cross-sectional hospital-based study was carried out between October 1992 and September 1993 in Fortaleza, Brazil. A Cox's proportional hazard model was used to estimate prevalence rate ratios after adjustment for confounding. RESULTS: Among 2074 (48%) women who admitted to terminating the pregnancy, 66% reported using misoprostol to induce abortion. Women with an induced abortion as compared with those with an unlikely induced abortion are younger, more often not married, have fewer children alive and experienced one or more previous induced abortions. We have not found any important differences with regard to complication or duration of stay in hospital. CONCLUSIONS: This finding, at odds with most previous studies, could reflect the special situation in Brazil where misoprostol is used for illegally-induced abortion. The use of misoprostol by this population may have contributed to the reduction of severe complications related to induced abortion which were most prevalent with more invasive methods. Recommendations are made as to the need for confirmatory studies as well as on information regarding cultural perceptions and concepts of abortion, and reasons why poor women fail to adopt available family planning methods.

PIP: The characteristics of induced abortion were investigated among women admitted to two public maternity hospitals in Fortaleza, Brazil, in 1992-93. A total of 4359 women admitted to the hospitals during the 12-month study period with a diagnosis of pregnancy loss were interviewed. 48% of abortions were classified as certainly induced, 40% as possibly induced, and 12% as spontaneous. 1369 (66%) of the 2074 women with certainly induced abortion reported use of misoprostol (mean dose, 400 mcg; range, 200-2400 mcg). Although sales of this abortifacient were suspended in 1991 due to concerns about congenital malformations in unsuccessful procedures, the drug remains widely available on the black market. Compared with women with an unlikely induced abortion, women with a certainly induced abortion were significantly younger, more often unmarried, had fewer living children, and were more likely to have experienced one or more previous induced abortions. The risk of infection was increased by 40% in women with certain induced abortion above that of women with unlikely induced abortion. There were no significant differences between groups in terms of the complication rate or duration of hospital stay. The use of misoprostol in this series may have contributed to the relatively low rate of severe abortion-related complications. Wider availability of emergency contraception could reduce the need for unsafe abortion in Brazil.

Impact of a permissive abortion statute on community health care.

PIP: 3542 first-trimester and 876 second-trimester abortions were performed at City Hospital Center, Elmhurst, New York, from July 1,1970 to June 30, 1972. The relatively stable, semi-closed population of women involved permitted an analysis of the effect of a permissive abortion law and practice on general health care. Tables of patient characteristics and abortion statistics over the period indicated the following: a present rate of abortion of 1009 per 1000 births; no maternal mortality; a reduction in maternal morbidity as experience with abortion techniques increased; a reduction by 44.4% of the number of deliveries without prenatal care, by 16.5% of premature deliveries, by 23.1% of immature deliveries; and a 29.2% reduction of the perinatal mortality rate. Also shown was a marked change in age distribution from the beginning of the period to the end: the incidence of abortions decreased among patients less than 20 years old by 47.1%, and among those over 35 by 46.7%. Additionally, the number of abortions among "never-married" women was reduced by 59.5%. There was a threefold increase in utilization of the antepartum clinic during the first trimester and an increase in prenatal visits. Incidence of spontaneous early abortion was reduced 52.2% and septic abortions were almost entirely eliminated. Postpartum psychosis decreased by half, the rate of voluntary sterilization doubled, and registration of new patients for family planning increased by 116%. Improvements were also seen in pregnancy testing and counseling, in cancer detection through an increase in the number of papanicolaou smears, screening for venereal disease and sickle cell trait/disease, and in the detection of medical, surgical and psychosocial diseases. Pregnancies were largely eliminated in "high-risk" obstetric patients from the childbearing population such as the very young or old, the unmarried, or the emotionally disturbed. The influence of liberalized abortion statutes was shown to have served the community not only by solving immediate health crises but also by contributing to the development of a total health care program.^ieng

Factors responsible for delay in obtaining interruption of pregnancy.

PIP: A sample of 132 women undergoing early abortion by suction curettage or late abortion (after the twelfth week of gestation) by intrauterine saline instillation at the Hospital of the Albert Einstein College of Medicine between January 1 and March 31, 1971, were interviewed to explore why there are so many late abortions. Women having late abortions tended to be younger (mean age 22.2 compared to mean age 26.6 for women having early abortions) single and nulliparous and were less likely to use contraception than women seeking early abortions (only 26% under age 25 had used contraception compared to 71% of the same age group who had early abortions). The majority (55%) of the patients delayed abortions for personal reasons, but 26% of the abortions were delayed because of reasons related to the medical care system. Women from outside of New York experienced greater difficulty in obtaining abortions than residents as evidenced by the fact that almost 1/2 of the nonresidents had decided on abortion before the twelfth week and still had late abortions. In both the early and late groups nearly 14% had to wait longer than necessary to obtain abortions. The study suggests that both physicians and patients be made aware of the advantages of early abortion. Over 40% of the women in the study had never used contraception, a result which stresses the need for health education and counseling with emphasis on contraception, particularly among the inexperienced and younger women. Until a major shift is seen from late to early abortion however, saline abortions must be provided safely and with consideration for the woman.^ieng

Attributions, expectations, and coping with abortion.

We examined cognitive predictors of coping with a negative life event. Women undergoing first-trimester abortion were, before the procedure, surveyed regarding their attributions for their pregnancy, expectations for coping, the meaningfulness of the pregnancy, and the degree to which the pregnancy was intended. After the abortion and again at a follow-up visit, we assessed affective state, physical complaints, anticipated negative consequences, and depression. As predicted, women who blamed their pregnancy on their character coped less well than low self-character blamers, but contrary to predictions, self-behavior blame was unrelated to coping. Women who had high coping expectations before the abortion coped much better than those with low coping expectations. Women who found their pregnancy highly meaningful, however, coped worse immediately after the abortion than did women who found their pregnancy less meaningful. Intentionality of the pregnancy was related to depression three weeks after the abortion, and women accompanied by their partner to the abortion clinic coped less well immediately after the abortion than women unaccompanied by their partner.

PIP: This paper examines cognitive predictors of coping with a negative life event. Women undergoing 1st-trimester abortion were, before the procedure, surveyed regarding their attributions for their pregnancy, expectations for coping, the meaningfulness of the pregnancy, and the degree to which the pregnancy was intended. After the abortion, and again at a follow-up visit, affective state, physical complaints, anticipated negative consequences, and depression were assessed. As predicted, women who blamed their pregnancy on their character coped less well than low self-character blamers, but contrary to predictions, self-behavior blame was unrelated to coping. Subjects were 247 women who underwent vacuum aspiration at a free-standing, private abortion clinic in a large metropolitan area in New York State. 65% blamed no other person for their pregnancy; 43% blamed no aspect of their character; 34% blamed no aspect of their situation, and 21% blamed no aspect of chance. The items within a given attributional category tended to be blamed in a somewhat mutually exclusive manner. High situation blamers were significantly more depressed than low situation blamers; those who blamed others anticipated more severe negative consequences than did those who did not blame others; and high chance blamers tended to experience a worse affective state than low chance blamers. External blame was generally unrelated to coping in this study. Further research is clearly needed on the consequences of self-blame for coping and depression, with attention to the characteristics of the particular life event being experienced. The beneficial aspects of high coping expectations persisted 3 weeks after the abortion, even when immediate coping espectations were statistically controlled. Self-efficacy expectations are important factors in both the initiation and persistence of coping behaviors. Partner presence or absence at the abortion clinic had a significant impact on immediate coping responses. Surprisinly, women accompanied by their partners were significantly more depressed and reported more physical complaints than did women unaccompained by their partners. Women accompained by their partner were younger and had expected to cope less well with the abortion than those unaccompained by their partners.

Mental models of attachment and coping with abortion.

This study explored the relationships between mental models of attachment and adjustment to abortion in 408 women undergoing a 1st-trimester abortion at a large free-standing abortion clinic. As expected, mental models of attachment were related to postabortion distress and positive well-being. These relationships were mediated by feelings of self-efficacy for coping with abortion, perceived support from a woman's male partner, and perceived conflict from this same source. Model of self and model of others interacted only in predicting perceived conflict and positive well-being. Model of self was more strongly related to the mediator and outcome variables than was model of others. The effects of model of self, however, were largely a reflection of the overlap between model of self and self-esteem.

PIP: The relationship between mental models of attachment and adjustment to induced abortion was explored in 408 women undergoing first-trimester pregnancy termination at an abortion clinic in Buffalo, New York (US), in 1993. It was hypothesized that mental models would affect how supportive or conflictive a woman perceived her male partner to be and her self-efficacy in coping with the stress of abortion. It was further postulated that social support, social conflict, and self-efficacy would function as mediators of the associations among mental models and postabortion adjustment. 40% of respondents characterized their attachment style as secure; another 32% described themselves as fearful, 9% as preoccupied, and 19% as dismissing. As expected, women with secure attachment styles perceived higher levels of social support and lower levels of conflict from their male partners than other women and had higher self-esteem. The more positive a woman's model of self, the less distress she reported in the immediate postabortion period. A positive model of self also had a promotive effect on self-efficacy for coping. The effects of model of self were largely a reflection, however, of the overlap between model of self and self-esteem. The combination of self-esteem, the attachment variables, and the mediator variables accounted for 24% of the variance in postabortion distress and 65% of the variance in postabortion positive well-being. Further research is needed to clarify the differential effects of general versus specific mental models of attachment on a wide variety of processes.

Contraceptive practices of women requesting termination of pregnancy: a study from China.

In order to develop a program for prevention of unwanted pregnancies, we conducted a survey of contraceptive practices and reasons for contraceptive failures of 1520 women seeking abortion at eight large hospitals in Zheng Zhou City, Henan Province, P.R. China, during the period from March 1996 to May 1996. The most frequent cause of the unplanned pregnancy was contraceptive failure (71.9%) 61.7% (938) of these current pregnancies were potentially predictable by virtue of nonuse of contraception (427) or by recognition of contraceptive failures (511). Among the contraceptive failures, the proportion of condom mishaps was the highest (29.7%), next was IUD failures (23.5%), then rhythm miscalculation (15.9%). Most of abortion seekers (77.1%) used some contraceptive methods previously. But only 19.7% of them used a contraceptive method at the first sexual intercourse. Among 1520 abortion seekers. 57.6% had used condoms previously; 50.9% of the condom users had at least one instance of condom mishap. The rhythm method had been used by 31.7% of abortion seekers previously; 59.1% of the rhythm users had at least one instance of rhythm failure. Of the 16.8% of abortion seekers who had used pills, 58.0% of them had pill failures Among condom and pill failures, most of them (46.4% condom users and 56.0%, pill users) belonged to the users failure category (poor compliance). Of those seeking abortion 56.4% had experienced at least one instance of previous abortion; 5.3% had experienced previous abortions at least two times. Emergency contraception had been utilized by only 10 subjects prior to this current pregnancy.

PIP: A survey of 1520 consecutive Chinese women seeking induced abortion at eight hospitals in Zheng Zhou City, Hunan Province, during March-May 1996 revealed the presence of contraceptive failure in 1093 women (71.9%). The mean age of abortion seekers was 26.9 years; 235 women (15.5%) were unmarried and 871 (57.3%) had no children. 938 (61.7%) of these pregnancies were potentially predictable as a result of nonuse of contraception (427 women) or timely recognition of contraceptive failure (511 women). Condoms accounted for the highest proportion (29.7%) of contraceptive failures, followed by IUD (23.5%), and rhythm (15.9%). 77.1% of abortion seekers had previously used at least one contraceptive method, although only 299 (19.7%) used a method at first intercourse. Overall, 57.6% of contraceptive users had experienced contraceptive failure at some point. In most cases, these failures resulted from user noncompliance (e.g., forgetting to use condoms and missed or delayed pill-taking), suggesting a need for more thorough counseling. Only 10 women (1.1%) had used emergency contraception, but without success. If the remaining 928 women who either had unprotected intercourse or recognized contraceptive failure immediately had used the Yuzpe emergency contraception regimen, about 75% would not have become pregnant. These findings suggest that condom and rhythm users should be targeted for the introduction of an emergency contraception program aimed at reducing the high rate of abortion in China.

The incidence of gonorrhea in an abortion population.

The incidence of gonorrhea was investigated in an abortion population. A total of 1021 women participated in this study. Three asymptomatic cases of gonorrhea were detected. None of these women had had gonorrhea before or had a previous abortion. No relation was found between the incidence of gonorrhea and age. The abortion population in our community cannot be considered to be a high-risk group for gonorrhea. In our opinion, this low incidence neither justifies routine gonococcal culture nor the prophylactic use of antibiotics in the abortion population.

PIP: An abortion population of 1021 women at a clinic in the Netherlands was investigated as to the incidence of gonorrhea among them. The sampling of women was believed to be representative in age, nationality, and marital status of the total abortion population at the clinic. There was no significant connection between previous abortion and venereal disease. Gonorrhea was proven in only 3 out of these 1021 women. A positive cervical culture offered the proof; the urethral cultures were negative. All the 3 cases were asymptomatic. None of the 3 women had had gonorrhea previously nor had they had a previous abortion. The incidence of gonorrhea was not associated with age. This low incidence of gonorrhea among the abortion population does not justify routine gonococcal culture or prophylactic use of antibiotics in the abortion procedure.

The use of contraceptive methods among women seeking a legal abortion.

In a simple random sample study of 404 women 20 to 29 years of age, 201 applying for abortion and 203 continuing their pregnancies, all were interviewed personally and requested to complete a questionnaire. The aim of the study was to analyse the use and experience of contraceptives among the abortion applicants in this age group, and to compare their experience with that of women in a matched control group. The most important reasons given for desisting in the use of contraceptives were the experience of side effects, worry about the side effects, and the "human failure" factor involved even with methods of contraception such as pills, which generally are regarded as safe. This study demonstrates that women living alone without any permanent relationship, having a strained economy or having previously had an abortion, need particular and detailed contraceptive advice plus continued close follow-up. To improve the continuation rate, precise contraception counselling focusing on both positive and adverse effects to reduce worry seems essential.

PIP: A 1988 study in Sweden compared the experiences of contraceptives among 201 women, 20-29 years old, electing to undergo legal abortion with those of 203 age- and residence-matched pregnant controls. The researchers also wanted to study the contraceptive experiences of 20-29 year old women choosing abortion. All study subjects attended the family planning clinic of the University Hospital or maternity centers in Goteborg. Cases who had undergone at least 1 other previous legal abortion (A2) were more likely to report side effects from their chosen contraceptive than the controls (51% vs. 29%; p .01). Both these women and those undergoing their first legal abortion (A1) experienced contraceptive side effects more frequently than controls (p = or .01). Women in the abortion groups who had side effects were more likely to discontinue their current contraceptive method than those in the control group who had side effects (90.8% vs. 20.3%). The abortion groups were more likely to have side effects and fear side effects from the use of oral contraceptives (OCs) than the control group (33% for A1 and 45% for A2 vs. 22%; p .01). The most popular contraceptive used by all groups was OCs (79-84%). Among all 404 women, 77 (19%) became pregnant despite contraception use. Women in the abortion groups were more likely to be using a contraceptive when they conceived than controls (33.6% for A1 and 32.8% for A2 vs. 4.9%). Controls were more likely to be married or living together and had longer relationships than the abortion groups (95% vs. 33-44% and 5 vs. 1.5-2.5 years, respectively). Women in the abortion groups tended to have a poor economic situation (39-42% vs. 17% for controls). These findings show that family planning practitioners need to provide individualized and detailed contraceptive counseling, with continued follow-up, to women not in a permanent relationship, in a poor economic situation, or with a history of previous abortion.

Induced abortion among unmarried women in Sichuan province, China.

This report describes the social and demographic characteristics of 457 unmarried women who underwent a first trimester induced abortion at hospitals and family planning clinics in Sichuan province, China. The data show a very low level of medical complications. However, improved access to contraception for unmarried women is needed in order to reduce the incidence of unintended pregnancies and induced abortion.

PIP: A prospective study conducted in China's Sichuan Province in 1990-91 revealed a high incidence of induced abortion among young, unmarried women and a consequent need to improve this group's access to contraceptive services. Included in the survey were the 457 unmarried women undergoing first-trimester abortion during the study period in six Sichuan counties selected for their diversity in terms of demographic factors and abortion facilities. 129 women (28.2%) were under 20 years old; 296 (64.8%) were 20-24 years of age. 89.8% had a primary or middle school education; 83.8% were from rural areas and 76.6% were employed as farmers. 423 women (92.6%) were not using any form of contraception when the pregnancy occurred and 260 (35%) reported at least one previous abortion. Most abortions were performed by specially trained family planning staff with at least three years of experience in abortion provision. There were no cases of cervical or uterine trauma, retained tissue, or uterine perforation and no significant post-abortal complications. These unmarried abortion patients appeared to be relying on abortion as a family planning method rather than as a back-up method in case of contraceptive failure. It is essential that the Chinese Government's campaign to encourage young people to postpone marriage until their early twenties is accompanied by education on contraception and greater access to contraceptive supplies.