Denial of abortion because of provider gestational age limits in the United States.

OBJECTIVES: We examined the factors influencing delay in seeking abortion and the outcomes for women denied abortion care because of gestational age limits at abortion facilities. METHODS: We compared women who presented for abortion care who were under the facilities' gestational age limits and received an abortion (n = 452) with those who were just over the gestational age limits and were denied an abortion (n = 231) at 30 US facilities. We described reasons for delay in seeking services. We examined the determinants of obtaining an abortion elsewhere after being denied one because of facility gestational age limits. We then estimated the national incidence of being denied an abortion because of facility gestational age limits. RESULTS: Adolescents and women who did not recognize their pregnancies early were most likely to delay seeking care. The most common reason for delay was having to raise money for travel and procedure costs. We estimated that each year more than 4000 US women are denied an abortion because of facility gestational limits and must carry unwanted pregnancies to term. CONCLUSIONS: Many state laws restrict abortions based on gestational age, and new laws are lowering limits further. The incidence of being denied abortion will likely increase, disproportionately affecting young and poor women.

Formative research on MySpace: online methods to engage hard-to-reach populations.

The Internet, particularly online social networks, can be an effective and culturally relevant communications channel to engage hard-to-reach populations with HIV prevention interventions. This article describes the process of conducting formative research on a popular social networking site, MySpace, in an effort to involve youth of color in design of programmatic content and formats for an Internet intervention. We discovered that asynchronous focus groups worked well to engage hard-to-reach populations. The synchronous groups allowed maximum participation and easy transcription for analysis. The authors found that using a social networking site to conduct formative research was useful to guide the development of a social networking intervention for youth of color. Researchers need to be flexible in adapting their research methods and interventions to the context of online social networking sites to most effectively engage hard-to-reach populations.

Five-Year Suicidal Ideation Trajectories Among Women Receiving or Being Denied an Abortion.

OBJECTIVE: The aim of this study was to assess the effects of receiving compared with being denied an abortion on women's experiences of suicidal ideation over 5 years. METHOD: The authors recruited 956 women from 30 U.S. abortion facilities. Women were interviewed by telephone 1 week after their abortion visit, then every 6 months for 5 years. Women who received near-limit abortions were compared with women who were denied an abortion and carried their pregnancies to term (turnaway-birth group). Women completed the suicidal ideation items on the Brief Symptom Interview (BSI) and the Patient Health Questionnaire (PHQ-9). The Sheehan Suicidality Tracking Scale was used to assess imminent suicidality. Adjusted mixed-effects regression analyses accounting for clustering by site and individual were used to assess whether levels and trajectories of suicidality differed by group. RESULTS: One week after abortion seeking, 1.9% of the near-limit group and 1.3% of the turnaway-birth group reported any suicidal ideation symptoms on the BSI. Over the 5-year study period, the proportion of women with any suicidal ideation symptoms on the BSI declined significantly to 0.25% for women in the near-limit group and nonsignificantly to 0.21% for those in the turnaway-birth group. In four out of 7,247 observations (0.06%), women reported being imminently suicidal. There was no statistically significant differential loss to follow-up by baseline report of suicidal ideation or history of depression or anxiety. There were no statistically significant group differences on any suicidal ideation outcome over the 5-year study period. CONCLUSIONS: Levels of suicidal ideation were similarly low between women who had abortions and women who were denied abortions. Policies requiring that women be warned that they are at increased risk of becoming suicidal if they choose abortion are not evidence based.

Implementing a prospective study of women seeking abortion in the United States: understanding and overcoming barriers to recruitment.

BACKGROUND: The Turnaway Study is designed to prospectively study the outcomes of women who sought-but did not all obtain-abortions. This design permits more accurate inferences about the health consequences of abortion for women, but requires the recruitment of a large number of women from remote health care facilities to a study a sensitive topic. This paper explores the Turnaway Study's recruitment process. METHODS: From 2008 to 2010, the staff at 30 abortion-providing facilities recruited eligible female patients. Eight interventions were evaluated using multilevel logistic regression for their impact on eligible patients being approached, approached patients agreeing to go through informed consent by phone, and enrolled patients completing the baseline interview. FINDINGS: After site visits, patients had roughly twice the odds of being approached by facility staff and twice the odds of then agreeing to go through informed consent. When all recruitment steps were considered together, the net effect of site visits was to increase the odds that eligible patients participated by nearly a factor of six. After the introduction of a patient gift card incentive, patients had over three times the odds of agreeing to go through informed consent. With each passing month, however, staff demonstrated a 9% reduced odds of approaching eligible patients about the study. CONCLUSION: Prioritizing scientific rigor over the convenience of using existing datasets, the Turnaway Study confronted recruitment challenges common to medical practice-based studies and unique to sensitive services. Visiting sites and communicating frequently with facility staff, as well as offering incentives to patients to hear more about the study before informed consent, may help to increase participation in prospective health studies and facilitate evaluation of sensitive women's health services.

Interest in and experience with IUD self-removal.

OBJECTIVES: In the United States, the popularity of intrauterine devices (IUDs) is low despite many positive attributes such as high effectiveness and ease of use. The requirement that a clinician remove the IUD may limit US women's interest in the method. Our objective was to describe women's experience with self-removal and its effect on attitudes toward the method. STUDY DESIGN: We assessed interest in attempting and success in IUD self-removal among women seeking IUD discontinuation from five US health centers. Women were given the option of attempting self-removal of the IUD. Participants were asked to complete two surveys about their reasons for desiring IUD removal, attitudes toward IUD use and experience with self-removal and/or clinician removal. RESULTS: Three hundred twenty-six racially diverse women participated (mean age, 28 years; body mass index, 27; duration of IUD use, 3 years); more than half were willing to try self-removal [95% confidence interval (CI): 45-65%], and among those who tried, one in five was successful (95% CI: 14-25%). More than half of participants (54%) reported they were more likely to recommend IUD use to a friend now that they know that it might be possible to remove one's own IUD; 6% reported they were less likely to recommend the IUD to a friend. African American women were particularly interested in the option of IUD self-removal. CONCLUSIONS: Many women are interested in the concept of IUD self-removal, although relatively few women currently succeed in removing their own IUD. IMPLICATIONS: Health educators, providers and advocates who inform women of this option potentially increase IUD use, reducing rates of undesired pregnancy.

Predictors of abortion counseling receipt and helpfulness in the United States.

BACKGROUND: Little is known about women's expectations, needs, and experiences with abortion counseling and the factors that influence their experiences. METHODS: This study sought to investigate individual- and facility-level factors that influenced women's reports of receiving abortion counseling and the helpfulness of counseling. Data were drawn from quantitative interviews with 718 patients recruited from 30 abortion facilities, and 27 interviews with facility informants in the United States. FINDINGS: Sixty-eight percent of participants reported receiving counseling; reports varied by facility. Almost all participants who reported receiving counseling described counseling as helpful: 40% extremely, 28% quite, 17% moderately, 10% a little, and 4% not at all. Nearly all (99%) reported that their counselor communicated support for whatever decision they made. No individual-level factors predicted counseling receipt or helpfulness. Facility informant reports that it is their role to counsel patients about emotional issues was positively associated with women's reports of counseling receipt (p < .001). Women at facilities subject to laws requiring provision of specific information and/or state-approved, written materials had lesser odds of finding counseling helpful, compared with women at facilities not subject to such laws (p < .01). CONCLUSIONS: Legal mandates that regulate abortion counseling do not seem to be helpful to women. More research is needed to understand the effects of abortion counseling and whether policies regulating counseling have a deleterious effect on women.