Associations between alcohol taxes and varied health outcomes among women of reproductive age and infants.

OBJECTIVE: No studies have examined whether alcohol taxes may be relevant for reducing harms related to pregnant people's drinking. METHOD: We examined how beverage-specific ad valorem, volume-based, and sales taxes are associated with outcomes across three data sets. Drinking outcomes came from women of reproductive age in the 1990-2020 US National Alcohol Surveys (N = 11 659 women $\le$ 44 years); treatment admissions data came from the 1992-2019 Treatment Episode Data Set: Admissions (N = 1331 state-years; 582 436 pregnant women admitted to treatment); and infant and maternal outcomes came from the 2005-19 Merative Marketscan® database (1 432 979 birthing person-infant dyads). Adjusted analyses for all data sets included year fixed effects, state-year unemployment and poverty, and accounted for clustering by state. RESULTS: Models yield no robust significant associations between taxes and drinking. Increased spirits ad valorem taxes were robustly associated with lower rates of treatment admissions [adjusted IRR = 0.95, 95% CI: 0.91, 0.99]. Increased wine and spirits volume-based taxes were both robustly associated with lower odds of infant morbidities [wine aOR = 0.98, 95% CI: 0.96, 0.99; spirits aOR = 0.99, 95% CI: 0.98, 1.00] and lower odds of severe maternal morbidities [wine aOR = 0.91, 95% CI: 0.86, 0.97; spirits aOR = 0.95, 95% CI: 0.92, 0.97]. Having an off-premise spirits sales tax was also robustly related to lower odds of severe maternal morbidities [aOR = 0.78, 95% CI: 0.64, 0.96]. CONCLUSIONS: Results show protective associations between increased wine and spirits volume-based and sales taxes with infant and maternal morbidities. Policies that index tax rates to inflation might yield more public health benefits, including for pregnant people and infants.

Pregnancy-specific alcohol policies and admissions to substance use disorder treatment for pregnant people in the USA.

AIMS: We examined relationships between pregnancy-specific alcohol policies and admissions to substance use disorder treatment for pregnant people in the USA. METHODS: We merged state-level policy and treatment admissions data for 1992-2019. We aggregated data by state-year to examine effects of nine pregnancy-specific alcohol policies on the number of admissions of pregnant women where alcohol was reported as the primary, secondary, or tertiary substance related to the treatment episode (N = 1331). We fit Poisson models that included all policy variables, state-level controls, fixed effects for state and year, state-specific time trends, and an offset variable of the number of pregnancies in the state-year to account for differences in population size and fertility. RESULTS: When alcohol was reported as the primary substance, civil commitment [incidence rate ratio (IRR) 1.45, 95% CI: 1.10-1.89] and reporting requirements for assessment and treatment purposes [IRR 1.36, 95% CI: 1.04-1.77] were associated with greater treatment admissions. Findings for alcohol as primary, secondary, or tertiary substance were similar for civil commitment [IRR 1.31, 95% CI: 1.08-1.59] and reporting requirements for assessment and treatment purposes [IRR 1.21, 95% CI: 1.00-1.47], although mandatory warning signs [IRR 0.84, 95% CI: 0.72-0.98] and priority treatment for pregnant women [IRR 0.88, 95% CI: 0.78-0.99] were associated with fewer treatment admissions. Priority treatment findings were not robust in sensitivity analyses. No other policies were associated with treatment admissions. CONCLUSIONS: Pregnancy-specific alcohol policies related to greater treatment admissions tend to mandate treatment rather than make voluntary treatment more accessible, raising questions of ethics and effectiveness.

Health care provider reporting practices related to self-managed abortion.

BACKGROUND: Health care providers reporting patients to government authorities is a main way people attempting self-managed abortion (SMA) become exposed to legal risks. Little is known about health care provider decision-making regarding SMA reporting. METHODS: We conducted semi-structured interviews with 37 clinicians who provided care in hospital-based obstetrics or emergency departments (13 obstetricians/gynecologists, two advance practice registered nurses providing obstetrics care, 12 emergency medicine physicians, and 10 family medicine physicians) throughout the United States. The interview guide asked participants to describe one or more cases of caring for a patient who may have attempted SMA and about related reporting decisions. We coded responses to answer two questions: What comes to mind for health care providers when asked to think about experiences caring for a patient who may have attempted SMA? Based on health care provider experiences, how might people who providers suspect may have attempted SMA end up reported? RESULTS: About half of participants had cared for someone who may have attempted SMA for that pregnancy. Only two mentioned SMA with misoprostol. Most participants described cases where they were unsure whether the patient had attempted to end their pregnancy on purpose. In most instances, participants mentioned that that the possibility of reporting never occurred to them nor came up. In some cases, participants described a reporting "adjacent" practice - e.g. beginning processes that could lead to substance use, domestic violence, or self-injury/suicide-related reports - or considered reporting related to a perceived need to report abortion complications. In two cases, hospital staff reported to the police and/or Child Protective Services related to the SMA attempt. These involved passing of a fetus after 20 weeks outside the hospital and a domestic violence incident. CONCLUSION: Reporting patients who may have attempted SMA may occur via provider perception of a need to report abortion complications and fetal demises, particularly at later gestations, and other reporting requirements (e.g. substance use, domestic violence, child maltreatment, suicide/self-harm).

Disseminating Evidence on Abortion Facilities to Health Departments: A Randomized Study of E-mail Strategies.

Given the politicization of abortion, professionals working in U.S. health departments (HDs) may not be receptive to communications about abortion, despite often regulating abortion facilities. This paper reports results of a randomized, prospective, observational study to test the effects of e-mail language when disseminating evidence on abortion to HD professionals. Our sample was 302 HD employees who oversee healthcare facilities inspection/regulation in all 50 U.S. state HDs, clustered by HD and randomized into two study groups. In November-December 2019, we sent biweekly e-mails containing links to a website summarizing evidence on abortion facility regulation. E-mails/headers sent to one group emphasized public health values and did not include the word abortion; e-mails/headers to the other group used the word abortion. Primary outcome measures were e-mail open rates and click-through rates. Among 221 participants to whom e-mails were deliverable, the overall open rate was 36%. Open rate was 25% for PH values and 46% for abortion groups (p < .05). Effects were moderated by state abortion policy environment: in both supportive and restrictive environments, participants in the abortion messaging group were statistically more likely to open e-mails than those in the PH values group. There was no difference between groups in states with middle-ground abortion policy environments. Among participants opening at least one e-mail, 19% clicked through to the website, with no significant difference by group. This study demonstrates that repeated targeted e-mail campaigns can reach HD professionals with research summaries. Concerns that communications to HDs should avoid the word abortion are unsupported.

Relationship between mandatory warning signs for cannabis use during pregnancy policies and birth outcomes in the Western United States.

As U.S. states legalize recreational cannabis, some enact policies requiring Mandatory Warning Signs for cannabis during pregnancy (MWS-cannabis). While previous research has found MWS for alcohol during pregnancy (MWS-alcohol) associated with increases in adverse birth outcomes, research has not examined effects of MWS-cannabis. This study uses Vital Statistics birth certificate data from June 2015 - June 2017 in seven western states and policy data from NIAAA's Alcohol Policy Information System and takes advantage of the quasi-experiment created by Washington State's enactment of MWS-cannabis in June 2016, while nearby states did not. Outcomes are birthweight, low birthweight, gestation, and preterm birth. Analyses use a Difference-in-Difference approach and compare changes in outcomes in Washington to nearby states in the process of legalizing recreational cannabis (Alaska, California, Nevada) and, as a secondary analysis, nearby states continuing to criminalize recreational cannabis (Idaho, Montana, Wyoming). Birthweight was -7.03 g lower (95% CI -10.06, -4.00) and low birthweight 0.3% higher (95% CI 0.0, 0.6) when pregnant people were exposed to MWS-cannabis than when pregnant people were not exposed to MWS-cannabis, both statistically significant (p = 0.005 and p = 0.041). Patterns for gestation, -0.014 weeks earlier (95% CI -0.038, 0.010) and preterm birth 0.2% higher (95% CI -0.2, 0.7), were similar, although not statistically significant (p = 0.168 and 0.202). The direction of findings was similar in secondary analyses, although statistical significance varied. Similar to MWS-alcohol, enacting MWS-cannabis is associated with an increase in adverse birth outcomes. The idea that MWS-cannabis provide a public health benefit is not evidence-based.

Abortion and the Mission of MCH: Perspectives of MCH and Family Planning Professionals in Health Departments.

INTRODUCTION: Prior research shows that maternal and child health (MCH) and family planning (FP) divisions in health departments (HDs) engage in some abortion-related activities, largely when legally mandated; some agencies also initiate abortion-related activities. Yet little is known about health department MCH/FP professionals' views on how abortion-related work aligns with their professional mission. METHODS: Between November 2017 and June 2018, we conducted in-depth interviews with 29 MCH/FP professionals working in 22 state and local HDs across the U.S. We conducted inductive thematic analysis to identify themes regarding participants' professional mission and values in relation to abortion-related work. RESULTS: Participants described a strong sense of professional mission. Two contrasting perspectives on abortion and the MCH/FP mission emerged: some participants saw abortion as clearly outside the scope of their mission, even a threat to it, while others saw abortion as solidly within their mission. In states with supportive or restrictive abortion policy environments, professionals' views on abortion and professional mission generally aligned with their overall state policy environment; in states with middle-ground abortion policy environments, a range of perspectives on abortion and professional mission were expressed. Participants who saw abortion as within their mission anchored their work in core public health values such as evidence-based practice, social justice, and ensuring access to health care. DISCUSSION: There appears to be a lack of consensus about whether and how abortion fits into the mission of MCH/FP. More work is needed to articulate whether and how abortion aligns with the MCH/FP mission.

Reaching Consensus on Politicized Topics: A Convening of Public Health Professionals to Discuss Appropriate Abortion Activities for US Health Departments.

CONTEXT: Public health professionals, particularly those in state and local health departments, do not always have clear understandings of their roles related to politically controversial public health topics. A process of consensus development among public health professionals that considers the best available evidence may be able to guide decision making and lay out an appropriate course of action. APPROACH: In May 2020, a group of maternal and child health and family planning professionals working in health departments, representatives of schools of public health, and members of affiliated organizations convened to explore values and principles relevant to health departments' engagement in abortion and delineate activities related to abortion that are appropriate for health departments. The convening followed a structured consensus process that included multiple rounds of input and opportunities for feedback and revisions. OUTCOMES: Convening participants came to consensus on principles to guide engagement in activities related to abortion, a set of activities related to abortion that are appropriate for health departments, and next steps to support implementation of such activities. LESSONS LEARNED: The experience of the convening indicates that consensus processes can be feasible for politically controversial public health topics such as abortion.

A gender-focused multilevel analysis of how country, regional and individual level factors relate to harm from others' drinking.

BACKGROUND: The aim of this study was to examine how gender, age and education, regional prevalence of male and female risky drinking and country-level economic gender equality are associated with harms from other people's drinking. METHODS: 24,823 adults in ten countries were surveyed about harms from drinking by people they know and strangers. Country-level economic gender equality and regional prevalence of risky drinking along with age and gender were entered as independent variables into three-level random intercept models predicting alcohol-related harm. FINDINGS: At the individual level, younger respondents were consistently more likely to report harms from others' drinking, while, for women, higher education was associated with lower risk of harms from known drinkers but higher risk of harms from strangers. Regional rate of men's risky drinking was associated with known and stranger harm, while regional-level women's risky drinking was associated with harm from strangers. Gender equality was only associated with harms in models in models that did not include risky drinking. CONCLUSIONS: Youth and regional levels of men's drinking was consistently associated with harm from others attributable to alcohol. Policies that decrease the risky drinking of men would be likely to reduce harms attributable to the drinking of others.

Disruptions to Abortion Care in Louisiana During Early Months of the COVID-19 Pandemic.

Objectives. To examine changes in abortions in Louisiana before and after the COVID-19 pandemic onset and assess whether variations in abortion service availability during this time might explain observed changes. Methods. We collected monthly service data from abortion clinics in Louisiana and neighboring states among Louisiana residents (January 2018‒May 2020) and assessed changes in abortions following pandemic onset. We conducted mystery client calls to 30 abortion clinics in Louisiana and neighboring states (April‒July 2020) and examined the percentage of open and scheduling clinics and median waits. Results. The number of abortions per month among Louisiana residents in Louisiana clinics decreased 31% (incidence rate ratio = 0.69; 95% confidence interval [CI] = 0.59, 0.79) from before to after pandemic onset, while the odds of having a second-trimester abortion increased (adjusted odds ratio [AOR] = 1.91; 95% CI = 1.10, 3.33). The decrease was not offset by an increase in out-of-state abortions. In Louisiana, only 1 or 2 (of 3) clinics were open (with a median wait > 2 weeks) through early May. Conclusions. The COVID-19 pandemic onset was associated with a significant decrease in the number of abortions and increase in the proportion of abortions provided in the second trimester among Louisiana residents. These changes followed service disruptions.

Dismantling the legacy of failed policy approaches to pregnant people's use of alcohol and drugs.

Most U.S. states have one or more pregnancy-specific alcohol or drug policies. However, research evidence indicates that some of these policies lead to increases in adverse birth outcomes, including low-birthweight and preterm birth. We offer explanations for why these ineffective policies related to pregnant people's use of alcohol and drugs in the U.S. exist, including: abortion politics; racism and the 'War on Drugs'; the design and application of scientific evidence; and lack of a pro-active vision. We propose alternative processes and concepts to guide strategies for developing new policy approaches that will support the health and well-being of pregnant people who use alcohol and drugs and their children. Processes include: involving people most affected by pregnancy-specific alcohol and drug policies in developing alternative policy and practice approaches as well as future research initiatives. Additionally, we propose that research funding support the development of policies and practices that bolster health and well-being rather than primarily documenting the harms of different substances. Concepts include accepting that policies adopted in response to pregnant people's use of alcohol and drugs cause harms and working to do better, as well as connecting to efforts that re-envision the child welfare system in the U.S.

Healthcare costs for abortions performed in ambulatory surgery centers vs office-based settings.

BACKGROUND: Several states require that abortions be provided in ambulatory surgery centers. Supporters of such laws argue that they make abortions safer, yet previous studies have found no differences in abortion-related morbidities or adverse events for abortions performed in ambulatory surgery centers versus office-based settings. However, little is known about how costs of abortions provided in ambulatory surgery centers differ from those provided in office-based settings. OBJECTIVE: To compare healthcare expenditures for abortions performed in ambulatory surgery centers versus office-based settings using a large national private insurance claims database. MATERIALS AND METHODS: A retrospective cohort study compared expenditures for abortions performed in ambulatory surgery centers versus office-based settings. Data on women who had abortions in an ambulatory surgery center or office-based setting between January 1, 2011, and December 31, 2014 were obtained from the MarketScan Commercial Claims and Encounters database. The sample was limited to women who were continuously enrolled in their insurance plans for at least 1 year before and at least 6 weeks after the abortion. Healthcare expenditures were assessed separately for the index abortion and the 6-week period after the abortion. Costs were measured from the perspective of the healthcare system and included all payments to the provider, including insurance company payments and any patient out-of-pocket payments. RESULTS: Overall, 49,287 beneficiaries who had 50,311 abortions met inclusion criteria. Of the included abortions, 47% were first-trimester aspiration, 27% first-trimester medication, and 26% second-trimester or later abortions. Most abortions (89%) were provided in office-based settings, with 11% provided in ambulatory surgery centers. Unadjusted mean index abortion costs were higher in ambulatory surgery centers than in office-based settings ($1704 versus $810; P < .001). After adjusting for patient clinical and demographic characteristics, costs of index abortions were $772 higher (95% confidence interval, $746-$797), total follow-up costs for abortions that had any follow-up care were $1099 higher (95% confidence interval, $1004-$1,195), and total follow-up costs for abortions that had an abortion-related morbidity or adverse event were not significantly different in ambulatory surgery centers compared to office-based settings. There were also no significant differences in the likelihood of having any follow-up care or abortion-related event follow-up care. CONCLUSION: Abortions performed at ambulatory surgery centers are significantly more costly than those performed in office-based settings, with no difference in the likelihood of receiving follow-up care. Laws requiring that abortions be provided in ambulatory surgery centers may only result in increased costs for abortions, with no effect on abortion safety.

Approaches, barriers, and facilitators to abortion-related work in U.S. health departments: perspectives of maternal and child heath and family planning professionals.

BACKGROUND: Public health agencies in the United States have engaged in abortion-related activities for nearly 50 years. Prior research indicates that, while most state health departments engage in some abortion-related work, their efforts reflect what is required by law rather than the breadth of core public health activities. In contrast, local health departments appear to engage in abortion-related activities less often but, when they do, initiate a broader range of activities. METHODS: This study aimed to: 1) describe the abortion-related activities undertaken by maternal and child health (MCH) and family planning professionals in state and local health departments; 2) understand how health departments approach their programmatic work on abortion, and 3) examine the facilitators and barriers to whether and how abortion work is implemented. Between November 2017 and June 2018, we conducted key informant interviews with 29 professionals working in 22 state and local health departments across the U.S. Interview data were thematically coded and analyzed using an iterative approach. RESULTS: MCH and family planning professionals described a range of abortion-related activities undertaken within their health departments. We identified three approaches to this work: those mandated strictly by law or policy; those initiated when mandated by law but informed by public health principles (e.g., scientific accuracy, expert engagement, lack of bias, promoting access to care) in implementation; and those initiated by professionals within the department to meet identified needs. More state health departments engaged in activities when mandated, and more local health departments initiated activities based on identified needs. Key barriers and facilitators included political climate, funding opportunities and restrictions, and departmental leadership. CONCLUSIONS: Although state health departments are tasked with implementing legally-required abortion-related activities, some agencies bring public health principles to their mandated work. Efforts are needed to engage public health professionals in developing and implementing best practices around engaging in abortion-related activities.

Variations by Education Status in Relationships Between Alcohol/Pregnancy Policies and Birth Outcomes and Prenatal Care Utilization: A Legal Epidemiology Study.

CONTEXT: Previous research finds that some state policies regarding alcohol use during pregnancy (alcohol/pregnancy policies) increase low birth weight (LBW) and preterm birth (PTB), decrease prenatal care utilization, and have inconclusive relationships with alcohol use during pregnancy. OBJECTIVE: This research examines whether effects of 8 alcohol/pregnancy policies vary by education status, hypothesizing that health benefits of policies will be concentrated among women with more education and health harms will be concentrated among women with less education. METHODS: This study uses 1972-2015 Vital Statistics data, 1985-2016 Behavioral Risk Factor Surveillance System data, policy data from National Institute on Alcohol Abuse and Alcoholism's Alcohol Policy Information System and original legal research, and state-level control variables. Analyses include multivariable logistic regressions with education-policy interaction terms as main predictors. RESULTS: The impact of alcohol/pregnancy policies varied by education status for PTB and LBW for all policies, for prenatal care use for some policies, and generally did not vary for alcohol use for any policy. Hypotheses were not supported. Five policies had adverse effects on PTB and LBW for high school graduates. Six policies had adverse effects on PTB and LBW for women with more than high school education. In contrast, 2 policies had beneficial effects on PTB and/or LBW for women with less than high school education. For prenatal care, patterns were generally similar, with adverse effects concentrated among women with more education and beneficial effects among women with less education. Although associations between policies and alcohol use during pregnancy varied by education, there was no clear pattern. CONCLUSIONS: Effects of alcohol/pregnancy policies on birth outcomes and prenatal care use vary by education status, with women with more education typically experiencing health harms and women with less education either not experiencing the harms or experiencing health benefits. New policy approaches that reduce harms related to alcohol use during pregnancy are needed. Public health professionals should take the lead on identifying and developing policy approaches that reduce harms related to alcohol use during pregnancy.

New Estimates of the Mean Ethanol Content of Beer, Wine, and Spirits Sold in the United States Show a Greater Increase in Per Capita Alcohol Consumption than Previous Estimates.

BACKGROUND: Recent increases in alcohol-related morbidity and mortality have not occurred alongside notable increases in per capita alcohol consumption (PCC). This discrepancy may be partially due to U.S. PCC estimates not including annual estimates of the percentage of alcohol by volume (%ABV) of beer, wine, and spirits, but rather relying on time-invariant %ABV values. METHODS: Building on a prior study covering 1950 to 2002, estimates of the annual mean %ABV of beer, wine, and spirits sold in the United States were calculated using the %ABV of major brands and sales of each beverage type for each state and nationally for the period 2003 to 2016. We applied these estimates to the calculation of annual beverage-specific and total PCC, and made descriptive comparisons between our PCC estimates and those estimates using invariant %ABV values. RESULTS: For all beverage types, our mean %ABV estimates increased nationally and for all but 5 states. The PCC estimates from wine and spirits utilizing variable %ABV values were lower than estimates using invariant %ABV, and consumption from beer was higher. Our total PCC estimates were also lower than %ABV-invariant estimates; however, the percent change for %ABV-invariant estimates was 5.8% compared to a 7.9% change in our %ABV-variant estimates over the 2003 to 2016 period. CONCLUSIONS: Given the application of PCC estimates to understand changes in alcohol-related morbidity and mortality, the inclusion of annual estimates of the %ABV of alcoholic beverages sold in the United States is necessary to ensure the precision of PCC measures such that the conclusions drawn from these applications are accurate and valid.

Estimating the proportion of Medicaid-eligible pregnant women in Louisiana who do not get abortions when Medicaid does not cover abortion.

BACKGROUND: To estimate the proportion of pregnant women in Louisiana who do not obtain abortions because Medicaid does not cover abortion. METHODS: Two hundred sixty nine women presenting at first prenatal visits in Southern Louisiana, 2015-2017, completed self-administered iPad surveys and structured interviews. Women reporting having considered abortion were asked whether Medicaid not paying for abortion was a reason they had not had an abortion. Using study data and published estimates of births, abortions, and Medicaid-covered births in Louisiana, we projected the proportion of Medicaid births that would instead be abortions if Medicaid covered abortion in Louisiana. RESULTS: 28% considered abortion. Among women with Medicaid, 7.2% [95% CI 4.1-12.3] reported Medicaid not paying as a reason they did not have an abortion. Existing estimates suggest 10% of Louisiana pregnancies end in abortion. If Medicaid covered abortion, this would increase to 14% [95% CI 12, 16]. 29% [95% CI 19, 41] of Medicaid eligible pregnant women who would have an abortion with Medicaid coverage, instead give birth. CONCLUSIONS: For a substantial proportion of pregnant women in Louisiana, the lack of Medicaid funding remains an insurmountable barrier to obtaining an abortion. Forty years after the Hyde Amendment was passed, lack of Medicaid funding for abortion continues to have substantial impacts on women's ability to obtain abortions.

Associations Between State-Level Policies Regarding Alcohol Use Among Pregnant Women, Adverse Birth Outcomes, and Prenatal Care Utilization: Results from 1972 to 2013 Vital Statistics.

BACKGROUND: Policies regarding alcohol use during pregnancy continue to be enacted and debated in the United States. However, no study to date has examined whether these policies are related to birth outcomes-the outcomes they ultimately aim to improve. Here, we assessed whether state-level policies targeting alcohol use during pregnancy are related to birth outcomes, which has not been done comprehensively before. METHODS: The study involved secondary analyses of birth certificate data from 148,048,208 U.S. singleton births between 1972 and 2013. Exposures were indicators of whether the following 8 policies were in effect during gestation: Mandatory Warning Signs (MWS), Priority Treatment for Pregnant Women, Priority Treatment for Pregnant Women/Women with Children, Reporting Requirements for Data and Treatment Purposes, Prohibitions Against Criminal Prosecution, Civil Commitment, Reporting Requirements for Child Protective Services Purposes, and Child Abuse/Child Neglect. Outcomes were low birthweight (<2,500 g), premature birth (<37 weeks), any prenatal care utilization (PCU), late PCU, inadequate PCU, and normal (≥7) APGAR score. Multivariable fixed-effect logistic regressions controlling for both maternal- and state-level covariates were used for statistical analyses. RESULTS: Of the 8 policies, 6 were significantly related to worse outcomes and 2 were not significantly related to any outcomes. The policy requiring MWS was related to the most outcomes: specifically, living in a state with MWS was related to 7% higher odds of low birthweight (p < 0.001); 4% higher odds of premature birth (p < 0.004); 18% lower odds of any PCU (p < 0.001); 12% higher odds of late PCU (p < 0.002); and 10% lower odds of a normal APGAR score (p < 0.001) compared to living in a state without MWS. CONCLUSIONS: Most policies targeting alcohol use during pregnancy do not have their intended effects and are related to worse birth outcomes and less PCU.

Should prenatal care providers offer pregnancy options counseling?

BACKGROUND: Professional guidelines indicate that pregnancy options counseling should be offered to pregnant women, in particular those experiencing an unintended pregnancy. However, research on whether pregnancy options counseling would benefit women as they enter prenatal care is limited. This study examines which women might benefit from options counseling during early prenatal care and whether women are interested in receiving counseling from their prenatal care provider. METHODS: At four prenatal care facilities in Louisiana and Maryland, women entering prenatal care completed a self-administered survey and brief structured interview (N = 586). Data were analyzed through descriptive statistics, bivariate analyses, multivariate multinomial logistic regression, and coding of open-ended responses. RESULTS: At entry into prenatal care, most women reported that they planned to continue their pregnancy and raise the child. A subset (3%) scored as having low certainty about their decision on the validated Decision Conflict Scale, indicating need for counseling. In addition, 9% of women stated that they would be interested in discussing their pregnancy options with their prenatal care provider. Regression analyses indicated some sociodemographic differences among women who are in need of or interested in options counseling. Notably, women who reported food insecurity in the prior year were found to be significantly more likely to be in need of options counseling (RRR = 3.20, p < 0.001) and interested in options counseling (RRR = 5.48, p < 0.001) than those who were food secure. Most women were open to discussing with their provider if their pregnancy was planned (88%) or if they had considered abortion (81%). More than 95% stated they would be honest with their provider if asked about these topics. CONCLUSIONS: Most women are certain of their decision to continue their pregnancy at the initiation of prenatal care. However, there is a subset of women who, despite entering prenatal care, are uncertain of their decision and wish to discuss their options with their health care provider. Screening tools and/or probing questions are needed to support prenatal care providers in identifying these women and ensuring unbiased, non-directive counseling on all pregnancy options.

The development of facility standards for common outpatient procedures and implications for the context of abortion.

BACKGROUND: In recent years, an increasing number of states have enacted laws that impose specific requirements for facilities in which abortions are performed. In this study, we sought to understand the processes used to develop facility standards in the context of other, less politically charged areas of health care and consider implications for the context of abortion. METHODS: We conducted key informant interviews with 20 clinicians and accreditation professionals involved in facility standards development for common outpatient procedures (endoscopy, gynecology, oral surgery, plastic surgery). We examined the motivations for and processes used in facility standards development, use of scientific evidence in standards development, and decision-making in the absence of evidence. Interview data were thematically coded and analyzed using an iterative approach. RESULTS: In contrast to U.S. state laws that target abortion facilities, standards for other outpatient procedures are commonly set by committees of clinicians organized by professional associations or accreditation organizations. These committees seek to establish standards that ensure patient safety without placing unnecessary burden on clinicians in practice. They aim to create evidence-based standards but can be hampered by lack of relevant research. In the absence of research evidence, committees rely on their clinical expertise and sense of best practices in decision-making. According to respondents, considerations of potential harm (e.g., deeper levels of sedation, invasiveness), rather than the specific procedure, should prompt additional requirements. CONCLUSIONS: If facility standards in the context of abortion were developed through processes similar to other outpatient procedures, 1) professionals who perform the procedure would be involved in standards development and 2) in the absence of clear research evidence, the expertise of clinicians, and the guidelines and standards of other organizations, are used to describe a best practice standard of care.

Association of Facility Type With Procedural-Related Morbidities and Adverse Events Among Patients Undergoing Induced Abortions.

Importance: Multiple states have laws requiring abortion facilities to meet ambulatory surgery center (ASC) standards. There is limited evidence regarding abortion-related morbidities and adverse events following abortions performed at ASCs vs office-based settings. Objective: To compare abortion-related morbidities and adverse events at ASCs vs office-based settings. Design, Setting, and Participants: Retrospective cohort study of women with US private health insurance who underwent induced abortions in an ASC or office-based setting (January 1, 2011-December 31, 2014). Outcomes were abstracted from a large national private insurance claims database during the 6 weeks following the abortion (date of final follow-up, February 11, 2015). Exposures: Facility type for abortion (ASCs vs office-based settings, including facilities such as abortion clinics, nonspecialized clinics, and physician offices). Main Outcomes and Measures: The primary outcome was any abortion-related morbidity or adverse event (such as retained products of conception, abortion-related infection, hemorrhage, and uterine perforation) within 6 weeks after an abortion. Two secondary outcomes, both subsets of the primary outcome, were major abortion-related morbidities and adverse events (such as hemorrhages treated with a transfusion, missed ectopic pregnancies treated with surgery, and abortion-related infections that resulted in an overnight hospital admission) and abortion-related infections. Results: Among 49 287 women (mean age, 28 years [SD, 7.3]) who had 50 311 induced abortions, (23 891 [47%] first-trimester aspiration, 13 480 [27%] first-trimester medication, and 12 940 [26%] second trimester or later), 5660 abortions (11%) were performed in ASCs and 44 651 (89%) in office-based settings. Overall, 3.33% had an abortion-related morbidity or adverse event; 0.32% had a major abortion-related morbidity or adverse event; and 0.74% had an abortion-related infection. In adjusted analyses, there was no statistically significant difference between ASCs vs office-based settings, respectively, in the rates of abortion-related morbidities or adverse events (3.25% vs 3.33%, difference, -0.08%; [corrected] 95% CI, -0.58% to 0.43%; adjusted OR, 0.97; 95% CI, 0.81-1.17), major morbidities or adverse events (0.26% vs 0.33%; difference, -0.06%; 95% CI, -0.18% to 0.06%; adjusted OR, 0.78; 95% CI, 0.45-1.37), or infections (0.58% vs 0.77%; difference, -0.16%; 95% CI, -0.35% to 0.03%; adjusted OR, 0.75; 95% CI, 0.52-1.09). Conclusions and Relevance: Among women with private health insurance who had an induced abortion, performance of the abortion in an ambulatory surgical center compared with an office-based setting was not associated with a significant difference in abortion-related morbidities and adverse events. These findings, in addition to individual patient and individual facility factors, may inform decisions about the type of facility in which induced abortions are performed.

State and Local Health Department Activities Related to Abortion: A Web Site Content Analysis.

CONTEXT: Recent legislation in states across the United States has required governmental health agencies to take on new and different roles in relation to abortion. While there has been media attention to health department roles in regulating abortion providers, there has been no systematic investigation of the range of activities in which state and local health departments are engaged. OBJECTIVE: To systematically investigate health department activities related to abortion. METHODS: We searched state health department Web sites of the 50 states and District of Columbia using key words such as "abortion" and "pregnancy termination". Two trained coders categorized 6093 documents using the 10 Essential Public Health Services (EPHS) framework. We then applied these methods to 671 local health department documents. SETTING: State and local health department Web sites. PARTICIPANTS: N/A. RESULTS: On average, states engaged in 5.1 of 10 Essential Services related to abortion. Most (76%-98%) state health departments engaged in activities to Monitor Health Status (EPHS1), Enforce Laws (EPHS6), and Evaluate Effectiveness, Accessibility, and Quality (EPHS9). Many (47%-69%) engaged in activities to Inform and Educate (EPHS3), Develop Policies (EPHS5), and Link to Services (EPHS7). A minority (4%-29%) engaged in activities to Diagnose and Investigate Health Problems (EPHS2), Mobilize Community Partnerships (EPHS4), and Assure Competent Workforce (EPHS8). No state engaged in Innovative Research (EPHS10). Few local health departments engaged in abortion-related activities. CONCLUSIONS: While most state health departments engage in abortion-related activities, they appear to reflect what the law requires rather than the range of core public health activities. Additional research is needed to assess whether these services meet quality standards for public health services and determine how best to support governmental health agencies in their growing tasks. These findings raise important questions about the role of public health agencies and professionals in defining how health departments should be engaging with abortion.