Abordaje integral de la Interrupción Voluntaria del Embarazo: (segunda entrega) / Comprehensive approach to the voluntary interruption of pregnancy: (second issue)

La legalización de la interrupción voluntaria del embarazo ha transformado la práctica médica con respecto a la atención de las pacientes que desean interrumpir la gestación hasta la semana 14 en Argentina. En la primera entrega, el equipo PROFAM compartió su punto de vista a través de una adaptación de su material educativo destinado, sobre todo, a aclarar los aspectos legales que hacen a la práctica cotidiana. En esta entrega se desarrolla en detalle el procedimiento para realizar un aborto farmacológico con misoprostol y mifepristona, así como las generalidades del aspirado manual endouterino. (AU)

The legalization of voluntary termination of pregnancy has transformed medical practice regarding the care of patients who wish to terminate a pregnancy up to 14 weeks in Argentina. In the first issue, the PROFAM team shared its point of view through an adaptation of its educational material aimed, above all, at clarifying the legal aspects of daily practice. In this issue, the procedure to perform a pharmacological abortion with misoprostol and mifepristone is developed in detail, as well as the generalities of manual uterine aspiration technique. (AU)

Pregnancy outcomes after exposure to crisis pregnancy centers among an abortion-seeking sample recruited online.

INTRODUCTION: More than 2,500 crisis pregnancy centers (CPCs), which seek to convince people considering abortion to continue their pregnancies, exist in the United States. However, the characteristics of people who visit CPCs and their pregnancy outcomes are largely unknown. This study sought to describe the characteristics of people considering abortion who report visiting CPCs, and whether CPC visit is associated with abortion or continuing the pregnancy 4 weeks later. METHODS: Between August 2017 to May 2018, we recruited pregnant people searching for abortion services online, and 857 participants completed baseline and 4-week follow-up surveys. We described characteristics associated with visiting a CPC and compared pregnancy and abortion outcomes for those who reported CPC visit to those who did not using mixed-effects multivariable logistic regression. RESULTS: Overall, 13.1% of respondents visited a confirmed CPC. Living further away from a CPC was associated with lower odds of a CPC visit. At follow-up, respondents who had visited a CPC were significantly less likely to have had an abortion (29.5%) than those who had not visited a CPC (50.5%). In the adjusted models, respondents who had visited a CPC had higher odds of being pregnant and still seeking abortion (aOR: 2.26, 95% CI: 1.37-3.73) or continuing the pregnancy (aOR: 2.35, 95% CI: 1.33-4.15) (versus having had an abortion), than those who had not visited a CPC. CONCLUSIONS: CPCs may be providing resources to people who are considering continuing their pregnancy and/or they may be misleading people about the care and referrals they provide related to abortion. Pregnant people need access to accurate information, decision support, and resources to make the pregnancy or abortion decision that is best for them.

Disclosure to social network members among abortion-seeking women in low- and middle-income countries with restrictive access: a systematic review.

BACKGROUND: Health care for stigmatized reproductive practices in low- and middle-income countries (LMICs) often remains illegal; when legal, it is often inadequate, difficult to find and / or stigmatizing, which results in women deferring care or turning to informal information sources and providers. Women seeking an induced abortion in LMICs often face obstacles of this kind, leading to unsafe abortions. A growing number of studies have shown that abortion seekers confide in social network members when searching for formal or informal care. However, results have been inconsistent; in some LMICs with restricted access to abortion services (restrictive LMICs), disclosure appears to be limited. MAIN BODY: This systematic review aims to identify the degree of disclosure to social networks members in restrictive LMICs, and to explore the differences between women obtaining an informal medical abortion and other abortion seekers. This knowledge is potentially useful for designing interventions to improve information on safe abortion or for developing network-based data collection strategies. We searched Pubmed, POPLINE, AIMS, LILACS, IMSEAR, and WPRIM databases for peer-reviewed articles, published in any language from 2000 to 2018, concerning abortion information seeking, communication, networking and access to services in LMICs with restricted access to abortion services. We categorized settings into four types by possibility of anonymous access to abortion services and local abortion stigma: (1) anonymous access possible, hyper stigma (2) anonymous access possible, high stigma (3) non-anonymous access, high stigma (4) non-anonymous access, hyper stigma. We screened 4101 references, yielding 79 articles with data from 33 countries for data extraction. We found a few countries (or groups within countries) exemplifying the first and second types of setting, while most studies corresponded to the third type. The share of abortion seekers disclosing to network members increased across setting types, with no women disclosing to network members beyond their intimate circle in Type 1 sites, a minority in Type 2 and a majority in Type 3. The informal use of medical abortion did not consistently modify disclosure to others. CONCLUSION: Abortion-seeking women exhibit widely different levels of disclosure to their larger social network members across settings/social groups in restrictive LMICs depending on the availability of anonymous access to abortion information and services, and the level of stigma.

Women seeking an induced abortion in LMICs often face inexistent or inadequate, difficult to find and/ or stigmatizing legal services, leading to the use of informal methods and providers, and unsafe abortions. A growing number of studies have shown that abortion seekers contact social network members beyond their intimate circle when seeking care. However, results have been inconsistent. We searched Pubmed, POPLINE, AIMS, LILACS, IMSEAR, and WPRIM databases for peer-reviewed articles published in any language from 2000 to 2018, concerning abortion information seeking, communication, networking and access to services in restrictive LMICs. We screened 4101 references, yielding 79 articles with data from 33 countries for extraction. We grouped countries (or social groups within countries) into four types of settings: (1) anonymous access possible, hyper stigma; (2) anonymous access possible, high stigma; (3) non-anonymous access, high stigma; (4) non-anonymous access, hyper stigma. Most studies fitted Type 3. Disclosing to network members increased across setting types: no women confided in network members in Type 1 settings, a minority in Type 2 and a majority in Type 3. No setting fitted Type 4. The informal use of medical abortion did not modify disclosure to others. Abortion seekers in restrictive LMICs frequently contact their social network in some settings/groups but less frequently in others, depending on the availability of anonymous access to abortion care and the level of stigma. This knowledge is useful for designing interventions to improve information on safe abortion and for developing network-based data collection strategies.

Obstacles and opportunities: a qualitative study of the experiences of abortion centre staff with abortion care during the first COVID-19 lockdown in Flanders, Belgium.

The COVID-19 pandemic and corresponding measures impacted the organisation of services for abortion on request in Flanders, Belgium. This study describes abortion centre staff's perceptions of the influence of protective measures on abortion consultations and procedures, and aims to identify obstacles and opportunities that arose from this situation. Through the anonymised patient records of one Flemish abortion centre, we compared the number of requests and abortions during the first lockdown (16 March-14 June 2020) with the same period in the five preceding years. Using a phenomenological approach, we documented the procedures and conducted interviews (all inductively coded in Nvivo) with the centre's coordinator, seven psychosocial staff members and three doctors. Though fewer people requested and had an abortion, the pressure on the staff was high due to changed procedures. A substantial change was the substitution of telephone for in-person consultations, which the staff perceived as less suited for discussing worries, contraception counselling, and building trust. The centre remained accessible, but the staff perceived an influence on the emotional reactions of clients. Staff agreed that the lockdown did not negatively influence the abortion procedure itself. However, they felt a negative influence on the level of psychological support they could offer, especially in interactions with clients who were less certain of their choice and clients with whom there was no common language. When the lockdown was relaxed, a triage system was set up to ensure emotionally safe abortion care - as perceived by staff - for all clients.

Developing and validating the Psychosocial Burden among people Seeking Abortion Scale (PB-SAS).

While there is a large body of research demonstrating that having an abortion is not associated with adverse mental health outcomes, less research has examined which factors may contribute to elevated levels of mental health symptoms at the time of abortion seeking. This study aims to develop and validate a new tool to measure dimensions of psychosocial burden experienced by people seeking abortion in the United States. To develop scale items, we reviewed the literature including existing measures of stress and anxiety and conducted interviews with experts in abortion care and with patients seeking abortion. Thirty-five items were administered to 784 people seeking abortion at four facilities located in three U.S. states. We used exploratory factor analysis (EFA) to reduce items and identify key domains of psychosocial burden. We assessed the predictive validity of the overall scale and each sub-scale, by assessing their associations with validated measures of perceived stress, anxiety, and depression using multivariable linear regression models. Factor analyses revealed a 12-item factor solution measuring psychosocial burden seeking abortion, with four subdomains: structural challenges, pregnancy decision-making, lack of autonomy, and others' reactions to the pregnancy. The alpha reliability coefficients were acceptable for the overall scale (α = 0.83) and each subscale (ranging from α = 0.82-0.85). In adjusted analyses, the overall scale was significantly associated with stress, anxiety and depression; each subscale was also significantly associated with each mental health outcome. This new scale offers a practical tool for providers and researchers to empirically document the factors associated with people's psychological well-being at the time of seeking an abortion. Findings suggest that the same restrictions that claim to protect people from mental health harm may be increasing people's psychosocial burden and contributing to adverse psychological outcomes at the time of seeking abortion.

Abortion on American television: An update on recent portrayals, 2015-2019.

OBJECTIVE: To compare differences in televised abortion depictions from two time periods: 2005 to 2014, as examined in previous studies, and more recent depictions from 2015 to 2019. STUDY DESIGN: Using a database of television abortion plotlines, we analyzed recent portrayals for character demographics, barriers, genre, and safety, calculated proportions, and compared to prior findings. RESULTS: While recent portrayals shift towards reflecting some demographics of U.S. abortion patients, people of color, low-income people, and parents remain under-portrayed. Compared to prior depictions, recent plotlines are more likely to inaccurately depict abortion as easier to access than it is for the majority of U.S. abortion patients. However, recent depictions are also less likely to depict exaggerated and inaccurate medical complications of abortion. Abortion plotlines are increasingly appearing on comedies. CONCLUSION: Despite progress, there remain important ways television could improve abortion depictions. IMPLICATIONS: Content creators should continue to consider diversity, nuance, and medical and demographic accuracy in depicting abortion.

Mandatory pre-abortion counseling is a barrier to accessing safe abortion services.

Empirical research showcases that pre-abortion counseling scarcely reverses the woman's decision either to terminate a pregnancy or not. Growing evidence regarding the high levels of decisional certainty among women seeking abortions renders a careful rethink of the place of mandatory pre-abortion counseling packages. Mandatory counseling packages, when inscribed in the laws, at times contain false information that can deter women from going in for safe abortions. Mandatory waiting times indirectly label opting for an abortion as not being the right thing to do. In areas where abortion stigma from health care providers and communities remains highly prevalent, women are forced to incur extra expenses by travelling to other countries. I argue that pre-abortion counseling on opting-in grounds is ethically sound (enhances the woman's reproductive autonomy), since most clients in need of abortions are certain on their decisions before the abortion care provider and do not regret these decisions after the process. Regrets are prone to be more prevalent in areas with high unsafe abortion practices, generally due to complications from excessive bleeding, pain, and post abortion infections. Allowing systematic mandatory pre-abortion counseling practice as the rule in a competent adult is unjustified ethically and empirically, is time consuming and presents the legality of abortions in most settings an oxymoron.

Factors associated with seeking post-abortion care among women in Guangzhou, China.

BACKGROUND: In China, the vast majority of induced abortions are performed in public hospitals. However, post-abortion care (PAC) services are provided through the national network of family planning clinics, which are independent of the health care system. The integration of PAC services into abortion clinics in public hospitals is a new concept. This study aimed to assess PAC utilization among abortion patients, and identify the possible factors associated with PAC uptake in Guangzhou, China. METHODS: A cross-sectional survey was conducted among 431 women aged 15-43 years in Tianhe district of Guangzhou, China from June to September 2018. We estimated multivariate logistic regression model to examine the factors associated with utilization of PAC services. RESULTS: Less than half (42%) of the participants used PAC services. Married women were 2.7 times significantly more likely to use PAC services than their unmarried counterparts. Immigrants were 52% significantly less likely to use PAC services than non-immigrants. Women who perceived that their fertility could return later and those who did not know were 45 and 61% significantly less likely to use PAC services compared to those who knew that their fertility could return soon after an abortion. Women with limited decision-making autonomy regarding contraceptive use were 54% significantly less likely to use PAC services than those who made such decisions themselves. CONCLUSIONS: The findings suggest the need for policies and programs to not only strengthen the provision of PAC services but also promote uptake among disadvantaged sub-groups of women in the study setting.

Profile of abortion seekers and their views on financial cost of induced abortions: implications for preventing unsafe abortions among young people in Accra, Ghana.

OBJECTIVES: Despite liberal abortion laws, unsafe abortions remain a public health challenge in Ghana. This study examines implications of financial cost of abortion in assessing safer services for young people in Ghana. STUDY DESIGN: This is a retrospective cross-sectional mixed-method study. METHODS: Questionnaires (401) and in-depth interviews (21) were used to collect data from women seeking elective abortions (320) and those treated for postabortion complications (81) in 6 health facilities comprising non-governmental organizations (2) and public (2) and private (2) hospitals from January to December 2018 in Accra. RESULTS: Results suggest high hospital abortion charges as major barriers to accessing safe abortion care in Accra as the surgical procedures cost three times more than that of other methods because of cost of anesthetics and antibiotics. CONCLUSIONS: Standardizing costs of abortion services across hospitals and integrating these costs into the National Health Insurance Scheme is highly recommended.

The Health and Socioeconomic Outcomes of Abortion Denial in Rhode Island: A Health Impact Assessment.

OBJECTIVES: To determine the health and socioeconomic consequences of comprehensive abortion denial in Rhode Island. METHODS: Using Turnaway Study findings and RI abortion data from 2013-2016, we project the burden of negative outcomes for women and their families under 100% abortion denial conditions. RESULTS: Findings suggest negative impacts on the health and socioeconomic well-being of RI women and their families. 982 and 910 women, who would have otherwise received an abortion, will report anxiety and depression, respectively, at one-week post abortion denial, and 1,499 will report receiving Temporary Assistance for Needy Families funding at six months post denial. CONCLUSIONS: If women who would seek a safe and legal abortion in RI are denied one, clear and undue burden will exist for those who carry to term and raise the child, as well as affecting existing children.

The effect of receiving versus being denied an abortion on making and achieving aspirational 5-year life plans.

BACKGROUND: Popular support for access to abortion and contraceptive services is often based on the idea that they will help women determine the trajectory of their life course. This study examined whether receiving versus being denied an abortion affects aspirational life goal setting and attainment 5 years later. METHODS: We compared women who sought and were denied an abortion because they were 3 weeks beyond the gestational limit ('Parenting-Turnaways') to those who received an abortion in the first trimester ('First-Trimesters'); received an abortion within 2 weeks of the facility's gestational limit ('Near-Limits'); and sought an abortion, were turned away and received an abortion elsewhere or placed their baby for adoption ('Non-Parenting-Turnaways'). We used mixed effects logistic regression analyses to estimate the odds of setting an aspirational plan and to estimate the odds of both setting and achieving an aspirational 5-year plan. RESULTS: At 1 week post abortion-seeking, 791 women reported 1864 5-year plans, most of which were aspirational (n=1692, 91%). Parenting-Turnaways had lower odds of setting an aspirational 5-year plan than Near-Limits (OR 0.36, 95% CI 0.18 to 0.73). There were no differences by group in achieving aspirational 5-year plans among those who had them. CONCLUSIONS: Soon after abortion-seeking, women denied a wanted abortion were less optimistic about their long-term futures than women who received a wanted abortion. Abortion access can help women set positive long-term goals.

Perceived abortion stigma and psychological well-being over five years after receiving or being denied an abortion.

OBJECTIVE: To prospectively assess perceptions of abortion stigma after receiving or being denied an abortion over 5 years, the factors associated with perceived abortion stigma, and the effects of perceived abortion stigma on psychological well-being. METHODS: We recruited people seeking abortion from 30 facilities across the US, and interviewed them by phone one week post-abortion seeking, then semiannually for 5 years. We used adjusted mixed effects regression analyses to examine the abortion stigma trajectories of those who obtained an abortion near a facility's gestational age limit (Near-limits) compared to those denied an abortion because they were just over the limit and carried their pregnancies to term (Turnaway-births). RESULTS: Of the 956 people recruited, we removed 28 due to ineligibility or missing data, leaving a final sample of 928. In unadjusted analyses, at one-week post-abortion seeking, over half of those seeking abortion perceived that if others knew they had sought an abortion, they would be looked down upon at least "a little bit" by people close to them (60%) or by people in their community (56%). In longitudinal adjusted analyses, people denied an abortion and who carried their pregnancies to term (Turnaway-birth group) reported significantly lower baseline perceived abortion stigma from people close to them (-0.38; 95% CI, -0.59, -0.16) and from people in their community (0.30; 95% CI, -0.52, -0.08), than Near-limits, differences that remained statistically significant for 1.5 years. Overall perceived abortion stigma declined significantly (p < .001) for both study groups. High perceived abortion stigma at baseline was associated with higher odds of experiencing psychological distress years later (adjusted Odds Ratio, 3.98; 95% CI, 1.39, 11.37). CONCLUSIONS: Most people considering abortion perceive some abortion stigma, which is associated with psychological distress years later.

Women's abortion seeking behavior under restrictive abortion laws in Mexico.

Abortion is regulated in Mexico at the state level, and it is permitted under certain criteria in all 32 states, except in Mexico City where first-trimester abortion is decriminalized. Yet, more than a million abortions occur in Mexico each year. But most terminations occurring outside of Mexico City are clandestine and unsafe due to profound stigma against the procedure, lack of trained providers, lack of knowledge of where to find a safe abortion and poor knowledge of the laws. While this situation is moderated by the increasing use of misoprostol, a relatively safe method of abortion, the safety of the procedure cannot be assured in restrictive legal contexts. The purpose of this study is to explore women's experiences with induced abortion in three federal entities with different legal contexts, and whether abortion seeking behavior and experiences differ across these settings. The study was carried out in three states, representing three different degrees of restrictiveness of abortion legislation. Queretaro with the "most restrictive" law, Tabasco with a "moderately restrictive" law, and Mexico state with the "least restrictive" law. We hypothesize that women living in more restrictive states will resort to the use of more unsafe and risky methods and providers for their abortion than their counterparts in less restrictive states. Women who recently obtained abortions were selected through snowball sampling and qualitative data were collected from them using semi-structured indepth interviews. Data collection took place between mid-2014 and mid-2015, with a final sample size N = 60 (20 from each state). Various themes involved in the process of abortion seeking behavior were developed from the IDIs and examined here: women's knowledge of the abortion law in their state, reasons for having an abortion; the methods and providers used and women's positive and negative experiences with abortion methods and providers used. Our results indicate that abortion safety is not associated with the restrictiveness of abortion legislation. Findings show that there is a new pattern of abortion service provision in Mexico, with misoprostol, a relatively safe and easy to use method, playing an important role. Nevertheless, while access to misoprostol tends to increase the safety of abortion, the improvement is moderated by women and their informants (relatives, friends and partners) not having accurate information on how to safely self-induce an abortion with misoprostol. On the other hand, some women manage to have safe abortion in illegal setting by going to Mexico City or with the support of NGOs knowlegeable on abortion. Findings demonstrate the importance of decriminalization of abortion, but meanwhile, harm reduction strategies, including promotion of accurate information about self-use of misoprostol where abortion is legally restricted will result in safe abortion.

A Prospective Cohort Study of the Effect of Receiving versus Being Denied an Abortion on Educational Attainment.

BACKGROUND: Research on the effects of unintended childbearing has been limited in its ability to disentangle the direct effects of childbearing from common selection factors that predispose women to both unintended childbearing and lower educational attainment. METHODS: Using data from a 5-year prospective cohort study of 876 individuals seeking abortion care, some of whom were denied care because they presented beyond a facility's gestational age limit, we used discrete time survival models to estimate the hazard of graduating and dropping out among those enrolled in high school, college, or other type of school (n = 280). We also examined cluster-adjusted bivariable differences in degrees completed by receipt versus denial of a wanted abortion. RESULTS: Participants denied an abortion who parented were equally likely to be in school as compared with women who received a wanted abortion (33 vs. 28%; p = .19); however, they were more likely to be seeking a high school diploma (40 vs. 24%; p = .05) than a higher degree. In adjusted models, there were no differences in the hazard of graduating (adjusted hazard ratio, 0.76; 95% confidence interval, 0.36-1.61) or dropping out (adjusted hazard ratio, 1.12; 95% confidence interval, 0.67-1.88) between those who were denied versus received an abortion. Among graduates, participants denied a wanted abortion less often completed a postsecondary degree (27%) compared with those who received a wanted abortion (71%; p = .002). CONCLUSIONS: Unintended childbirth was not associated with graduating or dropping out in this population, a finding that is at least partially explained by differences in degrees sought at the time of abortion seeking.

Factors associated with unsafe abortion practices in Nepal: Pooled analysis of the 2011 and 2016 Nepal Demographic and Health Surveys.

BACKGROUND: Unsafe abortion contributes to maternal morbidities, mortalities as well as social and financial costs to women, families, and the health system. This study aimed to examine the factors associated with unsafe abortion practices in Nepal. METHODS: Data were derived from the 2011 and 2016 Nepal Demographic and Health Surveys (NDHS). A total of 911 women aged 15-49 years who aborted five years prior to surveys were included in the analysis. The multivariate logistic regression analysis was employed to determine factors associated with unsafe abortion. RESULTS: Unsafe abortion rate was seven per 1000 women aged 15-49 years. This research found that women living in the Mountains (adjusted Odds Ratio (aOR) 2.36; 95% CI 1.21, 4.60), or those who were urban residents (aOR 2.11; 95% CI 1.37, 3.24) were more likely to have unsafe abortion. The odds of unsafe abortion were higher amongst women of poor households (aOR 2.16; 95% CI 1.18, 3.94); Dalit women (aOR 1.89; 95% CI 1.02, 3.52), husband with no education background (aOR 2.12; 95%CI 1.06, 4.22), or women who reported agriculture occupation (aOR 1.82; 95% CI 1.16, 2.86) compared to their reference's group. Regardless of knowledge on legal conditions of abortion, the probability of having unsafe abortion was significantly higher (aOR 5.13; 95% CI 2.64, 9.98) amongst women who did not know the location of safe abortion sites. Finally, women who wanted to delay or space childbirth (aOR 2.71; 95% CI 1.39, 5.28) or those who reported unwanted birth (aOR = 2.33; 95% CI 1.19, 4.56) were at higher risk of unsafe abortion. CONCLUSION: Going forward, increasing the availability of safe abortion facilities and strengthening family planning services can help reduce unsafe abortion in Nepal. These programmatic efforts should be targeted to women of poor households, disadvantaged ethnicities, and those who reside in mountainous region.

Characteristics of Women Who Present for Abortion Beyond the Legal Limit in Flanders, Belgium.

CONTEXT: Women who seek abortion care beyond the first trimester of gestation are often in a vulnerable socioeconomic position with limited social support, and in Belgium, the details of their circumstances are insufficiently understood. A better understanding of this group is essential to a critical evaluation of Belgian abortion policy, which restricts abortions on request after the first trimester. METHODS: Anonymized patient records were collected between 2013 and 2016 from LUNA centers, which are non-hospital-based abortion clinics in Flanders. Logistic regression analyses were used to identify associations between women's characteristics and whether they presented within or beyond the legal limit, which was 13 weeks and 1 day at the time of the study. RESULTS: A total of 28,741 women requested an abortion, and 972 individuals (3.4%) presented beyond the legal limit; 29% of these latter women were unable to receive abortion care as a result of the mandatory six-day waiting period. Characteristics positively associated with presenting beyond the limit, instead of beforehand, were being younger than 20, as opposed to 20-24 (odds ratio, 1.7); receiving a primary, lower secondary, upper secondary or special-needs education, rather than a higher education (1.8-3.1); being unemployed, rather than employed (1.3); and holding Belgian rather than a foreign nationality (0.8). Being accompanied by someone to the LUNA center (0.8), having irregularly (0.6) or regularly used contraceptives (0.7), and having ever had an abortion (0.8) were negatively associated with presenting beyond, rather than before, the limit. CONCLUSIONS: A fuller consideration of patients' characteristics when evaluating Belgian abortion policy is needed to ensure that the needs and rights of socioeconomically vulnerable women are addressed.

Self-reported Physical Health of Women Who Did and Did Not Terminate Pregnancy After Seeking Abortion Services: A Cohort Study.

Background: Research demonstrates worse short-term morbidity and mortality associated with childbirth than with abortion, but little research has examined long-term physical health in women with unwanted pregnancies after abortion versus childbirth. Objective: To examine the physical health of women who seek and receive or are denied abortion. Design: Prospective cohort study. Setting: 30 U.S. abortion facilities from 2008 to 2010. Participants: Of 1132 women seeking abortion who consented to participate, 874 were included in this analysis (328 who had first-trimester abortion, 383 who had second-trimester abortion, and 163 who gave birth). Measurements: Self-reported overall health; chronic abdominal, pelvic, back, and joint pain; chronic headaches or migraines; obesity; asthma; gestational and nongestational hypertension and diabetes; and hyperlipidemia were assessed semiannually for 5 years. Mortality was assessed by using verbal autopsy and public records. Results: No significant differences were observed in self-rated health or chronic pain after first-trimester versus second-trimester abortion. At 5 years, 27% (95% CI, 21% to 34%) of women who gave birth reported fair or poor health compared with 20% (CI, 16% to 24%) of women who had first-trimester abortion and 21% (CI, 18% to 25%) who had second-trimester abortion. Women who gave birth also reported more chronic headaches or migraines and joint pain, but experienced similar levels of other types of chronic pain and obesity. Gestational hypertension was reported by 9.4% of participants who gave birth. Eight of 1132 participants died during follow-up, 2 in the postpartum period. Maternal mortality did not differ statistically by group. Limitation: Self-reported outcome measures, uncertain generalizability, and 41% loss to follow-up at 5 years. Conclusion: Although some argue that abortion is detrimental to women's health, these study data indicate that physical health is no worse in women who sought and underwent abortion than in women who were denied abortion. Indeed, differences emerged suggesting worse health among those who gave birth. Primary Funding Source: An anonymous foundation.

Beyond autonomy and care: Experiences of ambivalent abortion seekers.

BACKGROUND: While being prepared for abortions, some women experience decisional ambivalence during their encounters with health personnel at the hospital. Women's experiences with these encounters have rarely been examined. OBJECTIVE: The objective of this study was to explore ambivalent abortion-seeking women's experiences of their encounters with health personnel. RESEARCH DESIGN: The data were collected in individual interviews and analysed with dialogical narrative analyses. PARTICIPANTS AND RESEARCH CONTEXT: A total of 13 women (aged 18-36 years), who were uncertain of whether to terminate their pregnancies during the first trimester, were interviewed before and after they made their decisions. The participants were recruited at six Norwegian outpatient clinics. ETHICAL CONSIDERATIONS: Approval was granted by the Regional Committee for Medical and Health Research Ethics. FINDINGS: The ambivalent pregnant women sought to make autonomous decisions while simultaneously involving their closest confidants and health personnel in the process. The following three types of narratives of women's experiences with encounters with health personnel were identified: the respected women; the identified women; and the abandoned women. DISCUSSION: The findings are discussed in terms of the ambivalent pregnant woman's autonomous responsibility in considering an abortion and how her autonomy can be enabled or impaired during encounters with health personnel. CONCLUSION AND IMPLICATION: Although the women considered themselves autonomous and responsible for their final decisions, they wished health personnel were involved in their situations. The health personnel contributed by enabling or disabling the possibility of decision-making in accordance with the women's values. The findings indicate that health personnel who care for women considering abortions must be trained in dialogical competence.

Intended pregnancy after receiving vs. being denied a wanted abortion.

OBJECTIVES: To understand how having or being denied an abortion affects the likelihood of trying to become pregnant, overall pregnancy rates, and the rate and timing of an intended pregnancy in the future. STUDY DESIGN: The Turnaway Study is a prospective cohort study of women who received or were denied a wanted abortion. Women were recruited from one of 30 US abortion facilities. We examined subsequent intended pregnancy among those who presented just under the facility's gestational limit and received an abortion (Near-Limit Abortion Group, n=413) and those who presented for abortion just beyond the facility's gestational limit, were denied an abortion and went on to parent the child (Parenting Turnaways, n=146). First, we modeled the probability of trying to become pregnant using multivariable mixed-effects logistic regression. We then used Cox proportional-hazards models to compare overall pregnancy rates and intended pregnancy rates over 5 years. RESULTS: Parenting Turnaways had lower predicted probabilities of reporting trying to become pregnant in the first 1.5 years after birth/abortion than the Near-Limit Abortion Group. They also had lower pregnancy rates overall [40.4 per 100 woman-years vs. 53.5 per 100 woman-years, adjusted hazards ratio (aHR)=0.69, 95% confidence interval (CI): 0.54-0.89]. The 5-year intended pregnancy rate was low among both groups, but compared to the Near-Limit Abortion Group, Parenting Turnaways had a lower intended pregnancy rate (2.2 per 100 woman-years vs. 7.5 per 100 woman-years, aHR=0.29, 95% CI: 0.10-0.85). CONCLUSION: Being able to obtain a wanted abortion may enable women to have an intended pregnancy later. IMPLICATIONS: Ensuring that women can obtain an abortion for an unwanted pregnancy may enable them to have a subsequent pregnancy when they are ready to have a baby.