"The right thing to do would be to provide care and we can't": Provider experiences with Georgia's 22-week abortion ban.

OBJECTIVES: In 2015, the Georgia (US) legislature implemented a gestational limit, or "ban" on abortion at or beyond 22 weeks from the last menstrual period. In this study, we qualitatively examined abortion provider perspectives on the ban's impact on abortion care access and provision. STUDY DESIGN: Between May 2018 and September 2019, we conducted in-depth individual interviews with 20 abortion providers (clinicians, staff, and administrators) from four clinics in Georgia. Interviews explored perceptions of and experiences with the ban and its effects on abortion care. Team members coded transcripts to 100% agreement using an iterative, group consensus process, and conducted a thematic analysis. RESULTS: Participants reported strict adherence to the ban and also its negative consequences: additional labor plus service-delivery restrictions, legally constructed risks for providers, intrusion into the provider-patient relationship, and impact of limited services felt by patients and, thus, providers. Participants commonly mentioned disparities in the ban's impact and viewed the ban as disproportionately affecting people of color, those experiencing financial insecurity, and those with underlying medical conditions. Nonetheless, participants described a clear, unrelenting commitment to providing quality patient-centered care and dedication to and satisfaction in their work. CONCLUSIONS: Georgia's ban operates as legislative interference, adversely affecting the provision of quality, patient-centered abortion care, despite providers' resilience and commitment. These experiences in Georgia have timely and clear implications for the entire country following the Supreme Court's decision to overturn Roe v Wade, thus reducing care access and increasing negative health and social consequences and inequities for patients and communities on a national scale. IMPLICATIONS: Our findings from Georgia (US) indicate an urgent need for coordinated efforts to challenge the Dobbs v Jackson Women's Health Organization decision and for proactive policies that protect access to later abortion care. Research that identifies strategies for supporting providers and patients faced with continuing restrictive legal environments is warranted.

Estimation of Multiyear Consequences for Abortion Access in Georgia Under a Law Limiting Abortion to Early Pregnancy.

Importance: Following the US Supreme Court ruling in Dobbs v Jackson Women's Health Organization, Georgia's law limiting abortion to early pregnancy, House Bill 481 (HB481), was allowed to go into effect in July 2022. Objectives: To estimate anticipated multiyear effects of HB481, which prohibits abortions after detection of embryonic cardiac activity, on abortion incidence in Georgia, and to examine inequities by race, age, and socioeconomic status. Design, Setting, and Participants: This repeated cross-sectional analysis used abortion surveillance data from January 1, 2007, to December 31, 2017, to estimate future effects of HB481 on abortion care in Georgia, with a focus on the 2 most recent years of data (2016 and 2017). Abortion surveillance data were obtained from the 2007-2017 Georgia Department of Public Health's Induced Termination of Pregnancy files. Linear regression was used to estimate trends in abortions provided at less than 6 weeks' gestation and at 6 weeks' gestation or later in Georgia, and χ2 analyses were used to compare group differences by race, age, and educational attainment. Data were analyzed from July 26 to September 22, 2022. Exposures: HB481, Georgia's law limiting abortion to early pregnancy. Main Outcome and Measures: Weeks' gestation at abortion (<6 vs ≥6 weeks). Results: From January 1, 2007, to December 31, 2017, there were 360 972 reported abortions in Georgia, with an annual mean (SD) of 32 816 (1812) abortions. Estimates from 2016 to 2017 suggest that 3854 abortions in Georgia (11.6%) would likely meet eligibility requirements for abortion care under HB481. Fewer abortions obtained by Black patients (1943 [9.6%] vs 1280 [16.2%] for White patients), patients younger than 20 years (261 [9.1%] vs 168 [15.0%] for those 40 years and older), and patients with fewer years of education (392 [9.2%] with less than a high school diploma and 1065 [9.6%] with a high school diploma vs 2395 [13.5%] for those with some college) would likely meet eligibility requirements under HB481. Conclusions and Relevance: These findings suggest that Georgia's law limiting abortion to early pregnancy (HB481) would eliminate access to abortion for nearly 90% of patients in Georgia, and disproportionately harm patients who are Black, younger, and in lower socioeconomic status groups.

Dispersion of contraceptive access policies across the United States from 2006 to 2021.

Person-centered contraceptive access benefits reproductive autonomy, sexual wellbeing, menstrual regulation, and other preventive health. However, contraceptive access varies by social and geographic position, with policies either perpetuating or alleviating health inequities. We describe geographic and time-trend variation in an index from fewer (less expansive) to greater (more expansive) aggregation of U.S. state-level contraceptive access policies across 50 states and Washington, D.C. (collectively, states) from 2006 to 2021. We collected data from primary and secondary sources on 23 policies regulating contraceptive education, insurance coverage, minor's rights, provider authority, and more. As of 2021, the most enacted policies expanded contraceptive access through: 1) prescribing authority for nurse practitioners, certified nurse-midwives (n = 50, 98 % of states), and clinical nurse specialists (n = 38, 75 %); 2) Medicaid expansion (n = 38, 75 %); 3) prescription method insurance coverage (n = 30, 59 %); and 4) dispensing authority for nurse practitioners and certified nurse-midwives (n = 29, 57 %). The average overall U.S. policy index value increased in expansiveness from 6.9 in 2006 to 8.6 in 2021. States in the West and Northeast regions had the most expansive contraceptive access landscapes (average index values of 9.0 and 8.2, respectively) and grew more expansive over time (increased by 4-5 policies). The Midwest and South had least expansive landscapes (average index values of 5.0 and 6.1, respectively). Regions with more expansive sexual and reproductive health policy environments further expanded access, whereas least expansive environments were maintained. More nuanced understanding of how contraceptive policy diffusion affects health outcomes and equity is needed to inform public health advocacy and law making.

Depressive Symptoms in Relation to Adverse Childhood Experiences, Discrimination, Hope, and Social Support in a Diverse Sample of College Students.

BACKGROUND: Young adulthood is a critical transitory period, with various factors impacting mental health and longer-term health outcomes, particularly among racial/ethnic minorities. Drawing from minority stress theory, this study examined correlates of depressive symptoms, specifically adverse childhood experiences (ACEs), racial/ethnic discrimination, hope, social support, and their interactive effects, among a diverse sample of college students. METHODS: We analyzed data from 666 racial/ethnic minority college students (57% Black, 22% Latinx, 21% Asian) attending seven colleges and universities in the state of Georgia. Depressive symptoms were assessed using the Patient Health Questionnaire-9 Item (PHQ-9). Multivariable linear regressions included ACEs, racial/ethnic discrimination, hope, and social support, adjusting for sex, race/ethnicity, parent education, nativity, and age. We tested two-way interaction terms in four separate models to examine the potential buffering effect of social support and hope on the association between ACEs and discrimination. RESULTS: Participants were on average 20.56 years old (SD = 1.93) and 30% were male. The mean PHQ-9 score was 3.89 (SD = 4.91); 56% reported at least one ACE; 70% experienced racial/ethnic discrimination. ACEs and racial/ethnic discrimination correlated with higher levels of depressive symptoms; higher social support and hope correlated with decreased depressive symptoms. While hope and social support did not moderate the relationships between ACEs or discrimination and depressive symptoms among the full sample, racial/ethnic subgroup analyses indicated that, among Asian students, the positive association between discrimination and depressive symptoms was significantly weaker for those perceiving greater hope. CONCLUSIONS: Eliminating racial/ethnic disparities in mental health requires concerted efforts to prevent and/or reduce ACEs and discrimination and identifying protective factors that can mitigate their relationship to depressive symptoms.

Racial and Ethnic Abortion Disparities Following Georgia's 22-Week Gestational Age Limit.

INTRODUCTION: Georgia's 2012 House Bill 954 (HB954) prohibiting abortions after 22 weeks from last menstrual period (LMP) has been associated with a significant decrease in abortions after 22 weeks. However, the policy's effects by race or ethnicity remain unexplored. We investigated whether changes in abortion numbers and ratios (per 1,000 live births) in Georgia after HB954 varied by race or ethnicity. METHODS: Using Georgia Department of Public Health induced terminations of pregnancy data from 2007 to 2017, we examined changes in number of abortions and abortion ratios (per 1,000 live births) by race and ethnicity following HB954 implementation. RESULTS: After full implementation of HB954 in 2015, the number of abortions and abortion ratios at or after 22 weeks (from last menstrual period) decreased among White (bNumber = -261.83, p < .001; bRatio = -3.31, p < .001), Black (bNumber = -416.17, p < .001; bRatio = -8.84, p < .001), non-Hispanic (bNumber = -667.00, p = .001; bRatio = -5.82, p < .001), and Hispanic (bNumber = -56.25, p = .002; bRatio = -2.44, p = .002) people. However, the ratio of abortions before 22 weeks increased for Black people (bLessThan22Weeks = 44.06, p = .028) and remained stable for White (bLessThan22Weeks = -6.78, p = .433), Hispanic (bLessThan22Weeks = 21.27, p = .212), and non-Hispanic people (bLessThan22Weeks = 26.93, p = .172). CONCLUSION: The full implementation of HB954 had differential effects by race/ethnicity and gestational age. Although abortion at 22 weeks or more decreased for all groups, abortion at less than 22 weeks increased among Black people. Additional research should elucidate the possible causes, consequences, and reactions to differential effects of abortion restrictions by race and ethnicity.

Variation in Restrictive Abortion Policies and Adverse Birth Outcomes in the United States from 2005 to 2015.

BACKGROUND: Since 2011, U.S. states have enacted more than 400 policies restricting abortion access. As structural determinants, abortion policies have the potential to influence maternal and child health access, outcomes, and equity through multiple mechanisms. Limited research has examined their implications for birth outcomes. METHODS: We created a state-level abortion restrictiveness index composed of 18 restrictive abortion policies and evaluated the association between this index and individual-level probabilities of preterm birth (PTB) and low birthweight (LBW) within the United States and by Census Region, using data from the 2005-2015 National Center for Health Statistics Period Linked Live Birth-Infant Death Files. We used logistic multivariable regression modeling, adjusting for individual- and state-level factors and state and year fixed effects. RESULTS: Among 2,500,000 live births, 269,253 (12.0%) were PTBs and 182,960 (8.1%) were LBW. On average from 2005 to 2015, states had approximately seven restrictive abortion policies enacted, with more policies enacted in the Midwest and South. Nationally, relationships between state restrictiveness indices and adverse birth outcomes were insignificant. Regional analyses revealed that a 1 standard deviation increase in a state's restrictiveness index was associated with a 2% increase in PTB in the Midwest (marginal effect [ME], 0.25; 95% confidence interval [CI], 0.04-0.45; p < .01), a 15% increase in LBW in the Northeast (ME, 1.24; 95% CI, 0.12-2.35; p < .05), and a 2% increase in LBW in the West (ME, 0.12; 95% CI, 0.01-0.25; p < .05). CONCLUSION: Variation in restrictive abortion policy environments may have downstream implications for birth outcomes, and increases in abortion restrictions were associated with adverse birth outcomes in three out of four Census Regions.

Parental Involvement Policies for Minors Seeking Abortion in the Southeast and Quality of Care.

Introduction: Thirty-seven states require minors seeking abortion to involve a parent, either through notification or consent. Little research has examined how implementation of these laws affect service delivery and quality of care for those who involve a parent. Methods: Between May 2018 and September 2019, in-depth interviews were conducted with 34 staff members involved in scheduling, counseling, and administration at abortion facilities in three Southeastern states. Interviews explored procedures for documenting parental involvement, minors' and parents' reactions to requirements, and challenges with implementation and compliance. Both inductive and deductive codes, informed by the Institute of Medicine's healthcare quality framework, were used in the thematic analysis. Results: Parental involvement laws adversely affected four quality care domains: efficiency, patient-centeredness, timeliness, and equity. Administrative inefficiencies stemmed from the extensive documentation needed to prove an adult's relationship to a minor, increasing the time and effort needed to comply with state reporting requirements. If parents were not supportive of their minor's decision, participants felt they had a duty to intervene to ensure the minor's decision and needs remained centered. Staff further noted that delays to timely care accumulated as minors navigated parental involvement and other state mandates, pushing some beyond gestational age limits. Lower income families and those with complex familial arrangements had greater difficulty meeting state requirements. Conclusions: Parental involvement mandates undermine health service delivery and quality for minors seeking abortion services in the Southeast. Policy Implications: Removing parental involvement requirements would protect minors' reproductive autonomy and support the provision of equitable, patient-centered healthcare.

Racial/ethnic and educational inequities in restrictive abortion policy variation and adverse birth outcomes in the United States.

BACKGROUND: To examine racial/ethnic and educational inequities in the relationship between state-level restrictive abortion policies and adverse birth outcomes from 2005 to 2015 in the United States. METHODS: Using a state-level abortion restrictiveness index comprised of 18 restrictive abortion policies, we conducted a retrospective longitudinal analysis examining whether race/ethnicity and education level moderated the relationship between the restrictiveness index and individual-level probabilities of preterm birth (PTB) and low birthweight (LBW). Data were obtained from the 2005-2015 National Center for Health Statistics Period Linked Live Birth-Infant Death Files and analyzed with linear probability models adjusted for individual- and state-level characteristics and state and year fixed-effects. RESULTS: Among 2,250,000 live births, 269,253 (12.0%) were PTBs and 182,960 (8.1%) were LBW. On average, states had approximately seven restrictive abortion policies enacted from 2005 to 2015. Black individuals experienced increased probability of PTB with additional exposure to restrictive abortion policies compared to non-Black individuals. Similarly, those with less than a college degree experienced increased probability of LBW with additional exposure to restrictive abortion policies compared to college graduates. For all analyses, inequities worsened as state environments grew increasingly restrictive. CONCLUSION: Findings demonstrate that Black individuals at all educational levels and those with fewer years of education disproportionately experienced adverse birth outcomes associated with restrictive abortion policies. Restrictive abortion policies may compound existing racial/ethnic, socioeconomic, and intersecting racial/ethnic and socioeconomic perinatal and infant health inequities.

Factors associated with reproductive autonomy in Ghana.

Reproductive autonomy is essential for women to achieve reproductive rights and freedom. However, the factors associated with reproductive autonomy in various contexts have not been explored. The aim of this analysis was to understand the socio-demographic, reproductive history and social context variables associated with two validated reproductive autonomy sub-scales among 516 young Ghanaian women age 15 to 24. We used multiple linear regression modelling to test associations between covariates of interest and the communication sub-scale and decision-making sub-scale. Covariates included age, educational attainment, ethnic group, employment, religion, religious attendance, relationship type, previous pregnancy, previous abortion, social support for adolescent sexual and reproductive health, and social stigma towards adolescent sexual and reproductive health. Results from final models demonstrated that factors associated with the communication scale included education (p = 0.008), ethnic group (p = 0.039), and social support for adolescent sexual and reproductive health (B = 0.12, p = 0.003). Factors associated with the decision-making scale included ethnic group (p = 0.002), religion (p = 0.003), religious attendance (p = 0.043), and previous pregnancy (p = 0.008). Communication reproductive autonomy and decision-making reproductive autonomy were associated with different factors, providing insight into potential intervention approaches and points. Social support for adolescent sexual and reproductive health was associated with increases in young women's abilities to communicate with their partners about sexual and reproductive health issues including sex, contraceptive use and fertility.

Abortion attitudes, religious and moral beliefs, and pastoral care among Protestant religious leaders in Georgia.

OBJECTIVE: The purpose of this study is to explore Protestant religious leaders' attitudes towards abortion and their strategies for pastoral care in Georgia, USA. Religious leaders may play an important role in providing sexual and reproductive health pastoral care given a long history of supporting healing and health promotion. METHODS: We conducted 20 in-depth interviews with Mainline and Black Protestant religious leaders on their attitudes toward abortion and how they provide pastoral care for abortion. The study was conducted in a county with relatively higher rates of abortion, lower access to sexual and reproductive health services, higher religiosity, and greater denominational diversity compared to other counties in the state. Interviews were audio-recorded, transcribed verbatim, and analyzed by thematic analysis. RESULTS: Religious leaders' attitudes towards abortion fell on a spectrum from "pro-life" to "pro-choice". However, most participants expressed attitudes in the middle of this spectrum and described more nuanced, complex, and sometimes contradictory views. Differences in abortion attitudes stemmed from varying beliefs on when life begins and circumstances in which abortion may be morally acceptable. Religious leaders described their pastoral care on abortion as "journeying with" congregants by advising them to make well-informed decisions irrespective of the religious leader's own attitudes. However, many religious leaders described a lack of preparation and training to have these conversations. Leaders emphasized not condoning abortion, yet being willing to emotionally support women because spiritual leaders are compelled to love and provide pastoral care. Paradoxically, all leaders emphasized the importance of empathy and compassion for people who have unplanned pregnancies, yet only leaders whose attitudes were "pro-choice" or in the middle of the spectrum expressed an obligation to confront stigmatizing attitudes and behaviors towards people who experience abortion. Additionally, many leaders offer misinformation about abortion when offering pastoral care. CONCLUSION: These findings contribute to limited empirical evidence on pastoral care for abortion. We found religious leaders hold diverse attitudes and beliefs about abortion, rooted in Christian scripture and doctrine that inform advice and recommendations to congregants. While religious leaders may have formal training on pastoral care in general or theological education on the ethical issues related to abortion, they struggle to integrate their knowledge and training across these two areas. Still, leaders could be potentially important resources for empathy, compassion, and affirmation of agency in abortion decision-making, particularly in the Southern United States.

Abortion Trends in Georgia Following Enactment of the 22-Week Gestational Age Limit, 2007-2017.

Objectives. To measure trends before, during, and after implementation of Georgia House Bill 954, a limit on abortion at 22 or more weeks of gestation passed in 2012, in total abortions and abortions by gestational age and state residence.Methods. We analyzed aggregate year-level induced termination of pregnancy data from the Georgia Department of Public Health from 2007 to 2017. We used linear regression to describe annual trends in the number of abortions and χ2 analyses to describe changes in proportions of abortions by gestational age (< 20 weeks, 20-21 weeks, and > 21 weeks) across policy implementation periods (before, partial, and full implementation) for Georgia residents and nonresidents.Results. Although the total number of abortions and abortions at 21 weeks or less remained stable from 2007 to 2017, the number of abortions at more than 21 weeks declined (P = .02). The decline in number of abortions at more than 21 weeks was steeper for nonresidents (31/year; Β = -31.3; P = .02) compared with Georgia residents (14/year; Β = -13.9; P = .06).Conclusions. Findings suggest that implementation of Georgia's 22-week gestational age limit has effectively limited access to needed abortion services in Georgia and beyond. (Am J Public Health. Published online ahead of print May 21, 2020: e1-e5. doi:10.2105/AJPH.2020.305653).

Reproductive autonomy and pregnancy decision-making among young Ghanaian women.

Decision-making regarding the outcome of a pregnancy may include participation of the woman herself, her sexual partner, parents, family, and/or community. This paper examines who had the most say in the outcome of young Ghanaian women's last pregnancy and whether this correlated with her level of reproductive autonomy (RA). We analysed cross-sectional data from 380 previously pregnant young women in urban Ghana. We measured communication and decision-making RA using modified scales ranging from 3 (low RA) to 12 (high RA). We tested unadjusted associations between the RA sub-scales and who made the pregnancy decision (self, partner, both together, or someone else) and used multinomial regression models to understand these associations when controlling for sociodemographic, reproductive history, and social context variables. In final models, a one-point increase in decision-making RA was associated with an adjusted relative risk ratio of 0.79 (95% CI: 0.66-0.93; p = 0.006) of partner having the most say as compared to the woman having the most say. The communication RA scale was not associated. Programmes that increase RA may be effective in increasing women's rights to execute decisions about reproductive health and outcomes. Future research should explore this notion and the role of pregnancy disclosure in this relationship.

Reproductive Autonomy and Modern Contraceptive Use at Last Sex Among Young Women in Ghana.

CONTEXT: Variability in the conceptualization and measurement of women's empowerment has resulted in inconsistent findings regarding the relationships between empowerment and sexual and reproductive health outcomes. Reproductive autonomy-a specific measure of empowerment-and its role in modern contraceptive use have rarely been assessed in Sub-Saharan contexts. METHODS: Survey data were collected from a sample of 325 urban Ghanaian women aged 15-24 recruited from health facilities and schools in Kumasi and Accra in March 2015. Bivariate and multivariable logistic regression analyses were used to examine associations between two adapted reproductive autonomy subscales-decision making and communication-and women's use of modern contraceptives at last sex, controlling for demographic, reproductive and social context (i.e., approval of and stigma toward adolescent sexual and reproductive health) covariates. RESULTS: In multivariable analyses, reproductive autonomy decision making-but not reproductive autonomy communication-was positively associated with women's modern contraceptive use at last sex (odds ratio, 1.1); age, having been employed in the last seven days and living in Kumasi were also positively associated with modern contraceptive use (1.1-9.8), whereas ever having had a previous pregnancy was negatively associated with the outcome (0.3). Reproductive autonomy decision making remained positively associated with contraceptive use in a subsequent model that included social approval of adolescent sexual and reproductive health (1.1), but not in models that included stigma toward adolescent sexual and reproductive health. CONCLUSIONS: The reproductive autonomy construct, and the decision-making subscale in particular, demonstrated relevance for family planning outcomes among young women in Ghana and may have utility in global settings. Future research should explore reproductive autonomy communication and the potential confounding effects of social context.

RESUMEN Contexto: La variabilidad en la conceptualización y medición del empoderamiento de las mujeres ha resultado en hallazgos inconsistentes con respecto a las relaciones entre el empoderamiento y los resultados de salud sexual y reproductiva. La autonomía reproductiva­una medida específica del empoderamiento­y su papel en el uso de anticonceptivos modernos, rara vez han sido evaluados en contextos subsaharianos. Métodos: Los datos de la encuesta se obtuvieron a partir de una muestra de 325 mujeres urbanas ghanesas de 15 a 24 años de edad, reclutadas en centros de salud y escuelas en Kumasi y Accra en marzo de 2015. Se utilizaron análisis de regresión logística bivariada y multivariada para examinar las asociaciones entre dos subescalas adaptadas de autonomía reproductiva: toma de decisiones y comunicación, así como el uso de anticonceptivos modernos en la última relación sexual por parte de las mujeres, después de controlar covariables demográficas, reproductivas y el contexto social (i.e. aprobación y el estigma relacionado con la salud sexual y reproductiva de las adolescentes). Resultados: En los análisis multivariados, la toma de decisiones sobre la autonomía reproductiva­pero no la comunicación sobre la autonomía reproductiva­se asoció positivamente con el uso de anticonceptivos modernos por parte de las mujeres en la última relación sexual (razón de probabilidades, 1.1); La edad, haber estado empleada en los últimos siete días y vivir en Kumasi también se asoció positivamente con el uso de anticonceptivos modernos (1.1-9.8), mientras que el hecho de haber tenido un embarazo previo se asoció negativamente con el resultado (0.3). La toma de decisiones sobre autonomía reproductiva se asoció positivamente con el uso de anticonceptivos en un modelo posterior que incluyó la aprobación social de la salud sexual y reproductiva de las adolescentes (1.1), pero no en los modelos que incluyeron el estigma hacia la salud sexual y reproductiva de las adolescentes. Conclusiones: La construcción teórica de la autonomía reproductiva y la subescala de toma de decisiones en particular, demostraron tener relevancia para los resultados de planificación familiar entre las mujeres jóvenes en Ghana y pueden tener utilidad en entornos globales. Las investigaciones futuras deben explorar la comunicación sobre autonomía reproductiva y los posibles efectos de confusión del contexto social.

RÉSUMÉ Contexte: La variabilité de la conceptualisation et de la mesure de l'autonomisation des femmes a produit des conclusions divergentes sur les relations entre l'autonomisation et les résultats de santé sexuelle et reproductive. L'autonomie reproductive­une mesure spécifique de l'autonomisation­et son rôle dans la pratique contraceptive moderne n'ont guère été évalués dans les contextes subsahariens. Méthodes: Les données de l'étude proviennent d'un échantillon de 325 Ghanéennes urbaines âgées de 15 à 24 ans, recrutées dans des structures sanitaires et écoles de Kumasi et d'Accra en mars 2015. Des analyses de régression logistique bi- et multivariées ont servi à l'examen des associations entre deux sous-échelles adaptées d'autonomie reproductive­ la prise de décision et la communication­et la pratique de la contraception moderne des femmes au dernier rapport sexuel, sous contrôle des covariables de contexte démographique, reproductif et social (approbation et stigmatisation à l'égard de la santé sexuelle et reproductive des adolescentes). Résultats: Dans les analyses multivariées, la prise de décision liée à l'autonomie reproductive­mais pas la communication­ s'est révélée associée positivement à la pratique contraceptive moderne des femmes au dernier rapport sexuel (RC, 1,1). L'âge, l'emploi durant les sept jours précédents et la résidence à Kumasi présentent aussi une association positive avec la pratique contraceptive moderne (1,1-9,8), tandis que l'existence d'une grossesse antérieure est en association négative avec ce résultat (0,3). L'association positive de la prise de décision en matière d'autonomie reproductive avec la pratique contraceptive se maintient dans un modèle ultérieur tenant compte de l'approbation sociale de la santé sexuelle et reproductive des adolescentes (1,1), mais pas dans ceux tenant compte de la stigmatisation à son égard. Conclusions: Le concept d'autonomie reproductive, et la sous-échelle de prise de décision en particulier, se sont avérés pertinents en termes de résultats de la planification familiale parmi les jeunes femmes du Ghana et pourraient se révéler utiles dans les contextes mondiaux. La recherche future devra étudier plus avant la communication, eu égard à l'autonomie reproductive, et les effets de confusion potentiels du contexte social.

A Descriptive Analysis of School and School Shooter Characteristics and the Severity of School Shootings in the United States, 1999-2018.

PURPOSE: The aim of the study was to determine whether characteristics related to the school, shooter, and guns used are associated with school shooting severity (casualty rates, fatality rates, and likelihood of fatality). METHODS: We analyzed associations between individual-, school-, gun-level factors and school shooting severity in the United States from April 1999 through May 2018. RESULTS: Handguns were used in most school shootings (81%); however, substantially, more fatalities occurred when rifles (relative risk [RR] =14.74, 95% confidence interval [CI] [5.00, 43.41]) or shotguns (RR = 8.84, 95% CI [2.20, 35.54]) were used. Fatal shootings were more likely to happen in schools that were majority white, taught younger students, and were rural or suburban. When shooters were aged ≥20 years, shootings were more likely to be fatal (RR = 2.44, 95% CI [1.18, 5.07]), have more casualties (RR = 5.15, 95% CI [2.06, 12.90]), and more deaths (RR = 20.13, 95% CI [4.86, 83.28]). No significant differences were observed based on the presence of resource officers. CONCLUSIONS: More severe shootings were associated with shooters who were older and therefore unlikely to be students, whereas the presence of a school resource officer was unassociated with any reduction in school shooting severity. Importantly, the type of gun used was strongly associated with casualties and fatalities. Study findings suggest a need for prevention efforts beyond those commonly used in schools, as well as the need for improved laws.

Adverse life experiences and risk of unintended pregnancy in adolescence and early adulthood: Implications for toxic stress and reproductive health.

OBJECTIVE: We examined the effects of adverse life experiences (ALEs) on rates of unintended first pregnancy, including differential effects by race/ethnicity and socioeconomic status, among women in a national longitudinal cohort study. METHODS: We drew upon 15-years of data from 8810 adolescent and young adult females in the National Longitudinal Study of Adolescent to Adult Health. Using 40 different ALEs reported across childhood and adolescence, we created an additive ALE index, whereby higher scores indicated greater ALE exposure. We employed Cox proportional hazard models, including models stratified by racial/ethnic and socioeconomic groups, to estimate the effects of ALEs on time to first unintended pregnancy, controlling for time-varying sociodemographic, health and reproductive covariates. RESULTS: Among all women, a 1-standard deviation increase in ALE scores was associated with an increased rate of unintended first pregnancy (adjusted Hazard Ratio 1.11, 95% Confidence Interval=1.04-1.17). In stratified models, associations between ALE scores and risk of unintended pregnancy varied across racial/ethnic, socioeconomic, and age groups and according to various elevated ALE thresholds. For example, the 1-standard deviation increase in ALE score indicator increased the unintended pregnancy risk for African-American (aHR=1.12, CI=1.01-1.25), Asian (aHR 1.69, CI=1.26-2.26), and White women (aHR=1.12, CI=1.03-1.22), women in the lowest ($0-$19,999; aHR=1.21, CI = 1.03-1.23) and highest (>$75,000; aHR=1.36, CI=1.12-1.66) income categories, and women aged 20-24 (aHR=1.13, CI=1.04-1.24) and >24 years (aHR 1.25, CI=1.06-1.47), but not among the other sociodemographic groups. CONCLUSION: ALEs increased the risk of unintended first pregnancy overall, and different levels of exposure impacting the risk of pregnancy differently for different sub-groups of women. Our ongoing research is further investigating the role of stress-associated adversity in shaping reproductive health outcomes and disparities in the United States.

Differences in abortion attitudes by policy context and between men and women in the World Values Survey.

We explored whether abortion attitudes differed by respondents' sex and country-level abortion policy context. Data were collected between 2010 and 2014 from 69,901 respondents from 51 countries. Abortion attitudes were scored on a ten-point Likert scale (1 = "never justifiable"; 10 = "always justifiable"). Country-level abortion policy context was dichotomized as "less restrictive" or "more restrictive." We conducted linear regression modeling with cluster effects by country to assess whether respondents' sex and abortion policy context were associated with abortion attitudes, controlling for sociodemographic characteristics. On average, women had more supportive abortion attitude scores than men (Mean = 3.38 SD = 2.76 vs. Mean = 3.24 SD = 2.82, p < .001). Respondents in countries with more restrictive policy contexts had less supportive attitudes than those in less restrictive contexts (Mean = 2.55 SD = 2.39 vs. Mean = 4.09 SD = 2.96, p < .001). In regression models, abortion attitudes were more supportive among women than men (b = 0.276, p < .001) and in less restrictive versus more restrictive countries (b = 0.611, p < .001). Younger, educated, divorced, non-religious, and employed respondents had more supportive scores (all p < .05). Systematic differences were observed in abortion attitudes by respondents' sex and policy context, which have potential implications for women's autonomy and abortion access, which should be explored in future research.

Medicaid Family Planning Expansions: The Effect of State Plan Amendments on Postpartum Contraceptive Use.

OBJECTIVE: To determine the effect of state Medicaid family planning (FP) programs transitioning from a Section 1115 waiver to a State Plan Amendment (SPA) on reproductive health outcomes. MATERIALS AND METHODS: Data were from the Pregnancy Risk Assessment Monitoring System on 75,082 women who had a live birth between 2007 and 2013 and were living in one of nine states. We performed a difference-in-differences analysis to quantify the effect of the transition on postpartum contraceptive (PPC) use and unintended births (UBs). RESULTS: Over 80% of the sample reported using PPC; half reported an UB. The odds of PPC use among women who were living in a study state and gave birth after the transition were 1.14 times that of women who were living in a comparison state and/or gave birth before the transition (95% confidence interval: 1.04-1.24). CONCLUSIONS: Findings suggest that women living in states that transitioned from a waiver to SPA experienced an increased likelihood of PPC compared with those living in comparison states.

Bad girl and unmet family planning need among Sub-Saharan African adolescents: the role of sexual and reproductive health stigma.

Adolescent pregnancy contributes to high maternal mortality rates in Sub-Saharan Africa. We explored stigma surrounding adolescent sexual and reproductive health (SRH) and its impact on young Ghanaian women's family planning (FP) outcomes. We conducted in-depth, semi-structured interviews with 63 women ages 15-24 recruited from health facilities and schools in Accra and Kumasi, Ghana. Purposive sampling provided diversity in reproductive/relationship/socioeconomic/religious characteristics. Using both deductive and inductive approaches, our thematic analysis applied principles of grounded theory. Participants described adolescent SRH experiences as cutting across five stigma domains. First, community norms identified non-marital sex and its consequences (pregnancy, childbearing, abortion, sexually transmitted infections) as immoral, disrespectful, and disobedient, resulting in bad girl labeling. Second, enacted stigma entailed gossip, marginalization, and mistreatment from all community members, especially healthcare workers. Third, young sexually active, pregnant, and childbearing women experienced internalized stigma as disgrace, shame and shyness. Fourth, non-disclosure and secret-keeping were used to avoid/reduce stigma. Fifth, stigma resilience was achieved through social support. Collectively, SRH stigma precluded adolescents' use of FP methods and services. Our resulting conceptual model of adolescent SRH stigma can guide health service, public health, and policy efforts to address unmet FP need and de-stigmatize SRH for young women worldwide.