"I wouldn't even know where to start": unwanted pregnancy and abortion decision-making in Central Appalachia.

How rurality relates to women's abortion decision-making in the United States remains largely unexplored in existing literature. The present study relies on qualitative methods to analyze rural women's experiences related to pregnancy decision-making and pathways to abortion services in Central Appalachia. This analysis examines narratives from 31 participants who disclosed experiencing an unwanted pregnancy, including those who continued and terminated a pregnancy. Results suggest that women living in rural communities deal with unwanted pregnancy in three phases: (1) the simultaneous assessment of the acceptability of continuing the pregnancy and the acceptability of terminating the pregnancy, (2) deciding whether to seek services, and (3) navigating a pathway to service. Many participants who experience an unwanted pregnancy ultimately decide not to seek abortion services. When women living in rural communities assess their pregnancy as unacceptable but abortion services do not appear feasible to obtain, they adjust their emotional orientation towards continuing pregnancy, shifting the continuation of pregnancy to be an acceptable outcome. The framework developed via this analysis expands the binary constructs around abortion access - for example, decide to seek an abortion/decide not to seek an abortion, obtain abortion services/do not obtain abortion services - and critically captures the dynamic, often internal, calculations women make around unwanted pregnancy. It captures the experiences of rural women, a gap in the current literature.

Evaluation of a Training for Health and Social Service Providers on Abortion Referral-Making.

Purpose Engaging trusted care providers and empowering them with information and skills about abortion is a critical opportunity to improve coordination of care for women seeking abortion, if and when these services are needed. Description Provide, a nonprofit that works in partnership with health and social service providers to build a health system that is equipped to respond to women's health care needs around abortion, launched a referrals training program in 2013. To assess the effectiveness of this training program, we conducted an evaluation of satisfaction with training and the impact of the intervention on provider knowledge of safety of abortion, self-efficacy to provide abortion referrals, and intention to provide pregnancy options counseling and referrals in the future. Assessment Approximately 90% of participants were "very satisfied" with their training experience. Results show significant increase in intention to provide non-judgmental pregnancy options counseling and referrals for abortion care after participants went through training. Post-training, significantly more reported that they would present all pregnancy options without judgment or bias (94 vs. 82%, p < .0001), provide a referral for abortion care if needed (80 vs. 50%, p < .0001), and follow-up with the client (71 vs. 39%, p < .0001). Further, more also reported they would refer a client for prenatal care if the client requested it (78 vs. 67%, p < .0001). Conclusion Our results suggest that abortion referrals training hold potential to build the capacity of health and social service providers' ability to meet client needs related to pregnancy and could be implemented at a larger scale.

Assessing research impact: A framework and an evaluation of the Society of Family Planning Research Fund's grantmaking (2007-2017).

The Society of Family Planning Research Fund (SFPRF) provides grants for research on abortion and contraception. In 2017, SFPRF conducted a retrospective evaluation of its investment in family planning research. Using a developmental evaluation approach, we created a framework for assessing research impact in family planning and applied it to an analysis of our grantmaking between 2007 and 2017. Our framework consists of 30 indicators of research impact, which span nine impact categories from building researchers' capacity to influencing individuals, communities, and systems. Through application of this framework to our grantmaking, we learned that our grantmaking has helped build the research capacity of emerging and established family planning scholars and advance the field of family planning by supporting the creation of a robust scholarly evidence base. At the same time, we identified less evidence of impact on policy and practice. The results of this analysis directed SFPRF to move towards more focused funding opportunities, including longer-term and larger investments, and to prioritize partnerships between researchers and knowledge brokers.

Abortion referral-making in the United States: findings and recommendations from the abortion referrals learning community.

In recent years, reproductive health researchers and practitioners have increased their focus on abortion referrals as an overlooked component of access. March 2019 proposed changes to the regulation of publicly funded family planning services that severely restrict abortion referrals have heightened public attention. In October 2017, Provide, Inc. convened researchers and practitioners to assess our knowledge of abortion referral and make recommendations for future research. We found that existing literature on abortion referral is limited and may overlook important outcomes as well as variations in patient experiences by age, race, income, and other attributes. Recommendations include more robust attention to patient experiences and research that assesses a broad range of referral-making practices and outcomes, with specific attention to vulnerable populations and to referral quality and the distinction between appropriate and inappropriate referral.

Access to Abortion in Central Appalachian States: Examining County of Residence and County-Level Attributes.

CONTEXT: Studies of how women's individual characteristics and place of residence are related to variability in gestational age at the time of abortion have not examined county of residence and county-level characteristics. The county level is potentially meaningful, given that county is the smallest geographic unit with policy implications. METHODS: Data on 38,611 abortions that took place in North Carolina, Virginia and West Virginia in 2012 were used to study the relationship between gestational age and county-level attributes (e.g., metropolitan status and poverty). Three-level hierarchical linear models captured individuals nested in county of residence, clustered by state of residence, and adjusted for individual characteristics and distance traveled to care. RESULTS: Eight percent of the variation in gestational age at abortion was attributable to county-level characteristics. Residents of counties characterized by persistent poverty obtained abortions 2.3 days later in gestation than those from counties not characterized by that level of economic hardship. Women living in nonmetropolitan counties obtained abortions 1.7 days later than those living in metropolitan counties, even after distance traveled and county-level poverty were controlled for. CONCLUSION: County of residence is relevant to gestational age at the time of abortion for women in these three states. Evidence that county-level attributes are related to access adds insight to the consequences for women when the landscape of abortion service delivery shifts. Integrating county of residence into research on access to abortion services may be critical to capturing disparities in access.

Resistance and vulnerability to stigmatization in abortion work.

The stigma surrounding abortion in the United States commonly permeates the experience of both those seeking this health service as well as those engaged in its provision. Annually there are approximately 1.2 million abortions performed in the United States; despite that existing research shows that abortion services are highly utilized, women rarely disclose their use of these services. In 2005 only 1787 facilities that offer abortion services remained, a drop of almost 40 percent since 1982 (Jones, Zolna, Henshaw, & Finer, 2008). While it has been acknowledged that all professionals working in abortion are labeled to some degree as different, no published research has explored stigmatization as a process experienced by the range of individuals that comprise the abortion-providing workforce in the USA. Using qualitative data from a group of healthcare professionals doing abortion work in a Western state, this study begins to fill that gap, providing evidence of how the experience of stigma can vary and is managed within interactions in the workplace, in professional circles, among family and friends, and among strangers. The analysis shows that the experience of stigma for those providing abortion care is not a static or fixed loss of status. It is a dynamic situation in which those vulnerable to stigmatization can avoid, resist, or transform the stigma that would attach to them by varying degrees within selective contexts.