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.

Implementation of a Booster Sexual Health Education Curriculum for Older Adolescents in Rural Communities.

Ongoing education on sexual health and other health promotion topics is critical as young people transition into adulthood. A "booster" round of education may be an effective strategy to reinforce information previously taught and expand to additional topics relevant later in adolescence. In partnership with a Youth Advisory Council, we co-designed READY, Set, Go!, a booster curriculum for older adolescents with modules covering adult preparation skills, sexual identity, relationships, reproductive health, and mental health. From November 2021 to January 2023, we provided the curriculum to 21 cohorts of 12th grade students (N = 433) in rural communities of Fresno County, CA, and conducted an implementation evaluation to assess its feasibility in school settings, acceptability by participants, and changes in short-term outcomes. Health educators completed implementation logs to track program adaptations. Youth completed pretest/posttest surveys to assess changes in outcomes and participant satisfaction. We used descriptive statistics to examine program adaptations and satisfaction. We used multivariable regression models to examine changes in outcomes, adjusted for sociodemographic characteristics. Health educators completed most activities as planned, with adaptations occurring in response to youth needs and scheduling limitations. Sexual health knowledge, confidence in adult preparation skills, awareness of local sexual and mental health services, and willingness to seek health services all increased significantly from pretest to posttest. Youth feedback was strongly positive. We conclude that booster sexual health education is a promising strategy to address critical knowledge gaps and support health promotion, especially in rural and other under-resourced communities.

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.

Out-of-State Travel for Abortion among Texas Residents following an Executive Order Suspending In-State Services during the Coronavirus Pandemic.

During the COVID-19 pandemic, existing and new abortion restrictions constrained people's access to abortion care. We assessed Texas abortion patients' out-of-state travel patterns before and during implementation of a state executive order that prohibited most abortions for 30 days in 2020. We received data on Texans who obtained abortions between February and May 2020 at 25 facilities in six nearby states. We estimated weekly trends in the number of out-of-state abortions related to the order using segmented regression models. We compared the distribution of out-of-state abortions by county-level economic deprivation and distance traveled. The number of Texas out-of-state abortions increased 14% the week after (versus before) the order was implemented (incidence rate ratio [IRR] = 1.14; 95% CI: 0.49, 2.63), and increased weekly while the order remained in effect (IRR = 1.64; 95% CI: 1.23, 2.18). Residents of the most economically disadvantaged counties accounted for 52% and 12% of out-of-state abortions before and during the order, respectively (p < 0.001). Before the order, 38% of Texans traveled ≥250 miles one way, whereas during the order 81% traveled ≥250 miles (p < 0.001). Texans' long-distance travel for out-of-state abortion care and the socioeconomic composition of those less likely to travel reflect potential burdens imposed by future abortion bans.

Reasons for Having Unprotected Sex Among Adolescents and Young Adults Accessing Reproductive Health Services.

INTRODUCTION: Although research suggests that young people are more likely to have unprotected sex than adults, their reasons for doing so are not well-understood. Among a sample of young people accessing no-cost contraceptive services, we explored their reported reasons for having unprotected sex and their willingness to have unprotected sex in the future. METHODS: We recruited sexually active assigned female at birth youth at 10 family planning clinics in the San Francisco Bay Area (n = 212). Participants completed a self-administered survey reporting their reasons for having unprotected sex and willingness to do so in the future. We used bivariate analyses to assess associations between reasons for unprotected sex and age group (adolescents ages 14-19 vs. young adults ages 20-25) and willingness to have unprotected sex in the future. RESULTS: Most young people (69%) had recently engaged in unprotected sex and 41% were willing to in the future. The most common reported reasons for having unprotected sex included not planning to have sex, a preference for unprotected sex, and difficulty using contraception. Worrying about contraceptive side effects and a preference for unprotected sex were significantly associated with a willingness to have unprotected sex in the future (p < .01). Age group was not associated with most reasons for having unprotected sex. CONCLUSIONS: Person-centered care should give attention to the range of reasons that may influence young people's sexual and contraceptive decision-making.

Geographic disparities in disruptions to abortion care in Louisiana at the onset of the COVID-19 pandemic.

OBJECTIVES: Prior research identified a significant decline in the number of abortions in Louisiana at the onset of the COVID-19 pandemic, as well as increases in second-trimester abortions and decreases in medication abortions. This study examines how service disruptions in particular areas of the state disparately affected access to abortion care based on geography. STUDY DESIGN: We collected monthly service data from Louisiana's abortion clinics (January 2018-May 2020) and conducted mystery client calls to determine whether clinics were scheduling appointments at pandemic onset (April-May 2020). We used segmented regression to assess whether service disruptions modified the main pandemic effects on the number, timing, and type of abortions using stratified models and interaction terms. Additionally, we calculated the median distance that Louisiana residents traveled to the clinic where they obtained care. RESULTS: For residents whose closest clinic was consistently scheduling appointments at the onset of the pandemic, the number of monthly abortions did not change (IRR = 1.07, 95% CI: 0.84-1.36). For those whose closest clinic services were disrupted, the number of monthly abortions decreased by 46% (IRR = 0.54, 95% CI: 0.45-0.65). Similarly, increases in second-trimester abortions and decreases in medication abortions were concentrated in areas where residents experienced service disruptions (AOR = 2.25, 95% CI: 1.21-4.56 and AOR = 0.59, 95% CI: 0.29-0.87, respectively) and were not seen elsewhere in the state. CONCLUSION: Changes in the number, timing and type of abortions were concentrated among residents in particular areas of Louisiana. The early stages of the COVID-19 pandemic exacerbated geographic disparities in access to abortion care. IMPLICATIONS: Disruptions in services at the beginning of the COVID-19 pandemic in Louisiana meaningfully affected pregnant people's ability to obtain an abortion at their nearest clinic. These findings reinforce the importance of developing mechanisms to support pregnant people during emergency situations when traveling to a nearby clinic is no longer possible.

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.

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.

The Role of Health Care Providers in Young Women's Attitudes about and Willingness to Use Emergency Contraceptive Pills.

BACKGROUND: Emergency contraceptive pills (ECPs) are an underused resource among adolescent and young adult women who have unprotected sex. This analysis examines young women's attitudes about and willingness to use ECPs, with particular attention to their experiences with health care providers. METHODS: Sexually active young women (ages 15-25, assigned female at birth, N = 212) completed a self-administered survey at 10 family planning clinics in the San Francisco Bay Area. Participants reported attitudes about ECP effectiveness, safety, effect on sex drive, and whether it should not be taken often, and their willingness to use ECPs in the next 3 months. The predictors of interest were past and current contraceptive experiences with health care providers. Data were analyzed through descriptive statistics and multivariable logistic regression analyses controlling for sociodemographic characteristics, prior contraceptive use, pregnancy history, and pregnancy intentions. RESULTS: Most young women agreed that ECPs are effective at preventing pregnancy (75%) and safe to use (71%); few reported that they reduce sex drive (11%). Yet, the majority (62%) believed ECPs should not be taken often and only 35% reported willingness to use ECPs. In multivariable analyses, more positive health care experiences were associated with more positive attitudes about ECP safety, less concern that ECPs should not be taken often, and greater willingness to use ECPs (p < .05). CONCLUSIONS: Health care providers play an important role in the acceptance and provision of ECPs, especially for young women who prefer ECPs over other contraceptive methods. In particular, providers can use the contraceptive visit as an opportunity to destigmatize repeat ECP use.

"It's Worked Well for Me": Young Women's Reasons for Choosing Lower-Efficacy Contraceptive Methods.

STUDY OBJECTIVE: To understand the diverse reasons why some young women choose contraceptive methods that are less effective at preventing pregnancy, including condoms, withdrawal, and emergency contraception pills, even when more effective contraceptive methods are made available to them. DESIGN: In-depth interviews with young women at family planning clinics in July-November 2016. Interview data were thematically coded and analyzed using an iterative approach. SETTING: Two youth-serving family planning clinics serving predominantly Latinx and African American communities in the San Francisco Bay Area, California. PARTICIPANTS: Twenty-two young women ages 15-25 years who recently accessed emergency contraception to prevent pregnancy. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Young women's experiences using different methods of contraception, with specific attention to methods that are less effective at preventing pregnancy. RESULTS: Young women reported having previously used a range of higher- and lower-efficacy contraceptive methods. In interviews, they described affirmative values that drive their decision to use lower-efficacy methods, including: a preference for flexibility and spontaneity over continual contraceptive use, an emphasis on protecting one's body, and satisfaction with the method's effectiveness at preventing pregnancy. Some young women described using a combination of lower-efficacy methods to reduce their pregnancy risk. CONCLUSION: Young women make contraceptive decisions on the basis of preferences and values that include, but are not limited to, effectiveness at preventing pregnancy. These reasons are salient in their lives and need to be recognized as valid by sexual health care providers to ensure that young women receive ongoing high-quality care.

Perspectives on Adolescent Pregnancy Prevention Strategies in the United States: Looking Back, Looking Forward.

Attempts to solve the "problem of adolescent pregnancy" have long been a  focus of national, state, and local efforts in the United States. This review article summarizes trends and strategies around adolescent pregnancy prevention, provides lessons learned and best practices, and presents ideas for future directions. Over the past decades, a wide variety of policy and programmatic interventions have been implemented - including educational efforts, clinical health services, and community-wide coalitions - accompanied by a growing consensus regarding viable solutions. While notable reductions in adolescent pregnancy and childbearing have occurred across all sociodemographic groups, racial/ethnic, geographic, and socioeconomic disparities persist. Many adolescents who most need sexual health information and services are underserved by current programs and policies. A growing understanding of the role of social determinants of health, the impacts of structural racism, and the need for equity and inclusion must inform the next set of interventions and societal commitments to not only ameliorate the occurrence of unintended adolescent pregnancy but also foster healthy adolescent development. Recommendations for future efforts include improving the content, quality, and sustainability of education programs; actively engaging youth in the design of policies, programs, and clinical services; using technology thoughtfully to improve health literacy; expanding access to services through telehealth and other delivery options; and designing programs and policies that recognize and address structural racism, health equity, and inclusion.

Pregnant Women's Acceptability of Alcohol, Tobacco, and Drug Use Screening and Willingness to Disclose Use in Prenatal Care.

PURPOSE: Despite the prevalence of alcohol, tobacco, and other drug (ATOD) use screening as part of prenatal care, pregnant women's perspectives on screening are largely absent from research and clinical practice. This study examines pregnant women's acceptability of ATOD screening and willingness to disclose their ATOD use in prenatal care. METHODS: Pregnant women completed a self-administered survey and structured interview at four prenatal care facilities in Louisiana and Maryland (N = 589). Participants reported the acceptability of screening and their willingness to honestly disclose their ATOD use to their provider. Data were analyzed through descriptive statistics, tests of proportions, simple regression models, and coding of open-ended responses. RESULTS: Nearly all pregnant women found screening acceptable for alcohol (97%), tobacco (98%), and other drug use (97%) during prenatal care. The acceptability of alcohol use screening was higher among those who reported binge drinking (98% vs. 96%; p = .002) and risky alcohol consumption (99% vs. 96%; p = .018). The acceptability of screening for other drugs was higher among women reporting binge drinking (98% vs. 96%; p = .032) and other drug use (98% vs. 96%; p = .058). Almost all pregnant women indicated that they were willing to disclose their alcohol (99%), tobacco (99%), and other drug use (98%) to their provider. CONCLUSIONS: Almost all women considered verbal screening for ATOD use during prenatal care acceptable and indicated that they were willing to honestly disclose their ATOD use. Verbal screening may allow for the opportunity to initiate safe, nonjudgmental conversations about women's substance use, risk, and goals for their ATOD use, pregnancy, and parenting.

Experiences of harassment and empowerment after sharing personal abortion stories publicly.

OBJECTIVE: In recent years, in an attempt to counter stigma and increase empathy, public education campaigns have encouraged people to share their personal abortion stories. This exploratory study sought to document negative and positive experiences of those who have shared their abortion stories publicly. STUDY DESIGN: We conducted an anonymous online survey of people who have shared their abortion story publicly (N = 88), recruited via partners affiliated with two abortion story-sharing campaigns. The survey asked about the context in which respondents shared their abortion story, any negative and positive experiences online and in "real life" as a result of story sharing, and any problems or benefits resulting from these experiences. We analyzed survey data using descriptive statistics, bivariate analyses and categorizing responses to open-ended questions. RESULTS: Sixty percent of respondents reported experiencing harassment and other negative incidents after sharing their story publicly. These experiences contributed to emotional stress, problems with loved ones and difficulties at work and/or school. These harms were reported even by many respondents who used only a first name or alias when sharing their story. Despite this, positive experiences as a result of story sharing were reported by four out of five respondents and motivated many to continue sharing their story. CONCLUSIONS: This exploratory study indicates that many people who share their abortion story publicly find it to be an empowering, rewarding experience. Yet they also experience harassment and threats at high rates. Future research should explore both positive and negative experiences in more depth. IMPLICATIONS: Sharing one's personal abortion story as part of a public education campaign can be a positive, empowering experience. Nevertheless, policymakers, journalists and reproductive health advocates should recognize the potential harms experienced by people who share their abortion story publicly and consider measures to support these individuals.

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.

Complex situations: Economic insecurity, mental health, and substance use among pregnant women who consider - but do not have - abortions.

We examine characteristics and experiences of women who considered, but did not have, an abortion for this pregnancy. Participants were recruited at prenatal care clinics in Louisiana and Maryland for a mixed-methods study (N = 589). On self-administered surveys and structured interviews, participants were asked if they had considered abortion for this pregnancy and, if so, reasons they did not obtain one. A subset (n = 83), including participants who considered abortion for this pregnancy, completed in-depth phone interviews. Multivariable logistic regression analyses examined characteristics associated with having considered abortion and experiencing a policy-related barrier to having an abortion; analyses focused on economic insecurity and of mental health/substance use as main predictors of interest. Louisiana interviews (n = 43) were analyzed using modified grounded theory to understand concrete experiences of policy-related factors. In regression analyses, women who reported greater economic insecurity (aOR 1.21 [95% CI 1.17, 1.26]) and more mental health diagnoses/substance use (aOR 1.29 [1.16, 1.45] had higher odds of having considered abortion. Those who reported greater economic insecurity (aOR 1.50 [1.09, 2.08]) and more mental health diagnoses/substance use (aOR 1.45 [95% CI 1.03, 2.05] had higher odds of reporting policy-related barriers. Interviewees who considered abortion and were subject to multiple restrictions on abortion identified material and instrumental impacts of policies that, collectively, contributed to them not having an abortion. Many described simultaneously navigating economic insecurity, mental health disorders, substance use, and interpersonal opposition to abortion from family and the man involved in the pregnancy. Current restrictive abortion policies appear to have more of an impact on women who report greater economic insecurity and more mental health diagnoses/substance use. These policies work in concert with each other, with people's individual complex situations-including economic insecurity, mental health, and substance use-and with anti-abortion attitudes of other people to make abortion care impossible for some pregnant women to access.

Trends in Adolescent Birth Rates in California: Examining the Influence of Community Characteristics Through Geographic and Temporal Analysis.

PURPOSE: The aim of the article was to understand community-level factors associated with the decline in the adolescent birth rate (ABR) in California from 2000 to 2014. METHODS: We consolidated multiple data sources at the level of the Medical Service Study Area (MSSA), a federally recognized subcounty geographic unit (N = 497). We used ordinary least squares regression to examine predictors of change in the ABR at the MSSA level over three periods of notable change in California's ABR: 2000-2002, 2006-2008, and 2012-2014. Variables assessed include geographic density, change in sociodemographic and economic characteristics, and change in the availability of publicly funded sexual health services. RESULTS: The ABR declined more in urban than rural MSSAs. In the earlier period, growth in the black, Hispanic, and foreign-born populations, unemployment, and receipt of public assistance were associated with smaller declines in the ABR. Growth in the share of married households and high school completion were associated with larger declines in the ABR. In the later period, growth in public assistance receipt was associated with smaller declines in the ABR, whereas growth in high school completion and college attendance were associated with larger declines. Decline in the ABR was steeper in areas that began offering publicly funded long-acting contraception to adolescents. Rural-urban differences were no longer significant after controlling for change in the provision of long-acting contraception. CONCLUSIONS: Identifying the independent contributions of changes in sociodemographic, economic, and service characteristics to changes in the ABR supports the development of programs and policies that are more responsive to the communities they serve.

The Health and Social Service Needs of Pregnant Women Who Consider but Do Not Have Abortions.

PURPOSE: States have enacted an increasing number of policies restricting access to abortion. As a result, some women are unable to obtain an abortion and instead continue their pregnancies. These women may have particular needs that would bring them to the attention of public health programs. METHODS: Pregnant women entering prenatal care completed a self-administered survey and structured interview at four prenatal facilities in Louisiana and Maryland (N = 586). Participants reported their pregnancy intentions, whether they had considered abortion, and their reasons for not having an abortion (e.g., personal reasons, policy barriers to care). Participants completed up to 13 items indicating their service needs; an index was created by summing across nine common items. Data were analyzed through descriptive statistics, bivariate analyses, and multivariable regression models that controlled for sociodemographic characteristics. RESULTS: On average, women reported 2.99 service needs. The most common needs were WIC (93%), food stamps (85%), dental care (59%), and housing assistance (53%). In multivariable analyses, women who considered abortion but did not face a policy barrier reported greater service needs compared to women who did not consider abortion (3.45 vs. 2.82; b = 0.64; 95% confidence interval, 0.25-1.04). Women reporting a policy barrier to abortion reported the highest service needs (3.95) of all groups, although differences were not statistically significant possibly owing to sample size. CONCLUSIONS: Pregnant women who consider abortion before entering prenatal care have considerable health and social service needs. Public health programs that serve women and children should consider the specific needs of women who seek abortions.