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.

Association of Highly Restrictive State Abortion Policies With Abortion Rates, 2000-2014.

Importance: Although abortion is common in the United States, patients face substantial barriers to obtaining an abortion. Recently enacted abortion restrictions pose such barriers. Objectives: To assess the association between a state legislative climate that is highly restrictive toward abortion provision and the abortion rate and to evaluate whether distance to a facility providing abortion care mediates the association between legislative climate and the abortion rate. Design, Setting, and Participants: This cohort study examined county-of-residence abortion rates from all states that publicly provided them and used data on abortion restrictions, facility locations, and county demographic characteristics for the years 2000 to 2014. The association between legislative climate and abortion rates was evaluated using propensity score-weighted, linear regression difference-in-difference analysis. All models included state and year fixed effects and standard errors adjusted for state-level clustering. Exposures: Highly restrictive legislative climate, defined as having at least 3 of 4 types of abortion restrictions; distance to a high-volume facility providing abortion care (ie, performing ≥395 abortions per year) in miles. Main Outcomes and Measures: County-level abortion rate, defined as abortions per 1000 women per year. Results: Abortion rate data were obtained from 1178 counties in 18 states for a median of 12.5 years (range, 5-14). The median abortion rate was 2.89 per 1000 women (interquartile range, 1.71-4.46 per 1000 women). A highly restrictive legislative climate, when compared with a less restrictive one, was associated with 0.48 fewer abortions per 1000 women (95% CI, -0.92 to -0.04 abortions per 1000 women; P = .03). Adjusted for distance to a facility providing abortion care, a highly restrictive legislative climate was associated with 0.44 fewer abortions per 1000 women (95% CI, -0.85 to -0.03; P = .04). Each mile to a facility was associated with 0.02 fewer abortions per 1000 women (95% CI, -0.03 to -0.01 abortions per 1000 women; P = .003). Legislative climate was not significantly associated with distance to a facility providing abortion care (change in distance associated with highly restrictive climate, -2.73 [95% CI, -6.02 to 0.57] miles; P = .10). Conclusions and Relevance: This study provides evidence that a state legislative climate that is highly restrictive toward abortion provision is associated with a lower abortion rate. The cumulative effect of restrictive policies may pose a barrier to abortion access.

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.

Shining the light on abortion: Drivers of online abortion searches across the United States in 2018.

CONTEXT: Legal abortion restrictions, stigma and fear can inhibit people's voices in clinical and social settings posing barriers to decision-making and abortion care. The internet allows individuals to make informed decisions privately. We explored what state-level policy dimensions were associated with volume of Google searches on abortion and on the abortion pill in 2018. METHODS: We used Google Trends to quantify the relative search volume (RSV) for "abortion" and "abortion pill" (or "abortion pills" hereafter referred to as "abortion pill") as a proportion of total search volume for all queries in each US state. We also identified the top search queries most related to "abortion" and "abortion pill" and considered these as indicators of population concern. Key exposures were healthcare cost, access and health outcomes, and number of legal restrictions and protections at the state level. In descriptive analyses, we first grouped the states into tertiles according to their RSV on "abortion" and "abortion pill". To examine the association between each exposure (and other covariates) with the two outcomes, we used unadjusted and adjusted linear regression. RESULTS: The average RSV for "abortion" in the low, moderate and high tertile groups was 48 (SD = 3.25), 55.5 (SD = 2.11) and 64 (SD = 4.72) (p-value <0.01) respectively; for "abortion pill" the average RSVs were 39.6 (SD = 16.68), 61.9 (SD = 5.82) and 81.7 (SD = 6.67) (p-value < 0.01) respectively. Concerns about contraceptive availability and access, and unplanned pregnancies independently predicted the relative search volumes for abortion and abortion pill. According to our baseline models, states with low contraceptive access had far higher abortion searches. Volume of abortion pill searches was additionally positively associated with poor health outcomes, poor access to abortion facilities and non-rurality. CONCLUSION: Search traffic analysis can help discern abortion-policy influences on population concerns and require close monitoring. State-policies can predict search volume for abortion and abortion pill. In 2018, concerns about contraceptives and unplanned pregnancies, predicted abortion searches. Current decreases in public contraceptive funding and the Title X Gag rule designed to block millions of people from getting care at Planned Parenthood, the largest provider of birth control and abortion care, may increase concerns about unintended pregnancies that can lead to increases in online relative volume of abortion searches.

Percepción del alumnado de medicina sobre la objeción de conciencia a la interrupción voluntaria del embarazo en Galicia / Perception of medical students in Galicia (Spain) regarding conscientious objection to the voluntary termination of pregnancy

OBJETIVO: Conocer si los futuros médicos y médicas de Galicia ejercerían la objeción de conciencia en la práctica de la interrupción voluntaria del embarazo (IVE), así como indagar sobre el conocimiento de que dispone actualmente el alumnado de medicina sobre la objeción de conciencia sanitaria y cuáles creen que son los costes que han de soportar las pacientes al no poder ejercer su derecho a la IVE dentro del servicio sanitario público. MÉTODO: Estudio transversal mediante una encuesta a 350 estudiantes de segundo y quinto curso del Grado de Medicina de la Universidad de Santiago de Compostela, en el curso académico 2017-2018. RESULTADOS: El 70,8% de las personas encuestadas no se declararía objetor/a de conciencia a la IVE. Además, el 70% estima que la objeción de conciencia a la IVE puede provocar consecuencias negativas para las gestantes cuando son derivadas desde la sanidad pública a la sanidad privada. No obstante, el 72,9% está a favor de que los médicos y las médicas tengan derecho a declararse objetores/as de conciencia a la práctica sanitaria de la IVE. CONCLUSIONES: La derivación de gestantes como consecuencia de la objeción de conciencia a la IVE es un importante problema en España en general y en Galicia en particular, frente al cual se observa que el futuro personal médico muestra una elevada predisposición a no objetar esta práctica sanitaria, lo que facilitaría su solución en un futuro próximo

OBJECTIVE: To discover whether future doctors in Galicia (Spain) are willing to express conscientious objection to voluntary termination of pregnancy (VTP). The medical students' level of knowledge regarding conscientious objection in health care was also examined, and their knowledge regarding the costs patients would incur if unable to exercise their right to VTP. METHOD: Cross-sectional study by conducting a survey of 350 medical students in the 2nd and the 5th years of the Degree in Medicine at the University of Santiago de Compostela, in the academic year 2017-2018. RESULTS: 70.8% of those surveyed would not declare conscientious objection to VTP. In addition, 70% believe that conscientious objection to VTP can have negative consequences for pregnant women if they are referred from public to private healthcare. However, 72.9% support physicians having the right to declare their conscientious objection to VTP. CONCLUSIONS: The problem of referring pregnant women to private healthcare, as a consequence of conscientious objection to VTP, is presented as critical in Spain, and in Galicia in particular. The future physicians showed that they strongly favoured not objecting to this healthcare practice, which will enable the problem to be resolved in the near future

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.

Impact of legislative change on waiting time for women accessing surgical abortion services in a rural hospital in the Northern Territory.

BACKGROUND: Women face challenges when accessing abortion, including varied legislation and reduced access to services in rural and remote settings. There are limited clinical guidelines in Australia and little information regarding the patient journey, particularly the timeframe between referral to abortion procedure. Legislation reform in the Northern Territory (NT) legalised early medical abortion (EMA) in primary health care, providing an opportunity to review service provision of elective surgical abortion prior to and after these changes. AIMS: To review the waiting time to access abortion, percentage eligible for EMA based on ultrasound gestation alone, percentage of Indigenous women accessing abortion in the NT and the effects of the legislation change. MATERIALS AND METHODS: Retrospective audit-analysed surgical abortion data from 354 patient files who underwent suction curettage of uterus between 2012-2017 in one NT public hospital. RESULTS: Mean wait-time ranged from 20 to 22 days in 2012-2016 and dropped to 15 days in 2017 following the law reform. Sixty-two percent of women waited longer than that in the recommended clinical guidelines. Indigenous women represented approximately 25% of patients accessing surgical abortion services. Average gestation at surgical abortion procedure increased following reform. Prior to reform up to 95% of patients accessing surgical abortion would have been eligible for EMA at time of referral. CONCLUSIONS: Results demonstrate potential for changes in service provision of abortion in the NT with increased choice, patient-centred care and reduced waiting times. This audit demonstrated the possibility to move the majority of abortion services into primary health care leading to cost savings.

Abortion Need among U.S. Servicewomen: Evidence from an Internet Service.

INTRODUCTION: U.S. servicewomen have high rates of unintended pregnancy, but federal policy prohibits abortion provision at military treatment facilities and military insurance coverage of abortion, except in cases of rape, incest, or a life-endangering pregnancy. Such restrictions pose challenges to abortion access for servicemembers, particularly during deployment. We aimed to explore the experiences of U.S. servicewomen when accessing abortion during overseas tours and deployment. METHODS: We reviewed de-identified data from email inquiries and online consultation forms from U.S. servicewomen or military spouses seeking medication abortion from the telemedicine service Women on Web between January 2010 and December 2017. We used descriptive statistics and inductively coded textual responses to describe client characteristics, circumstances of pregnancy, reasons for abortion, and barriers to abortion care. RESULTS: Our sample included data for 323 individuals. Reasons for abortion related to military service included disruption of deployment, fear of military reprimand, and potential career impacts. Additionally, servicemembers faced barriers to abortion access related to overseas military deployment or tour, including a lack of legal abortion in-country, limited financial resources, language barriers, travel restrictions, and a lack of confidentiality. CONCLUSIONS: U.S. military servicewomen stationed in countries where safe, legal abortion is restricted or unavailable face deployment-related barriers to abortion care, which compound those barriers they may face regardless of deployment status. Removal of federal bans on the provision and coverage of abortion care and improved education about existing regulations could improve access to timely abortion care and in some cases allow servicewomen who wish to obtain abortion care to remain deployed.

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.

Distance Traveled to Obtain Clinical Abortion Care in the United States and Reasons for Clinic Choice.

Introduction: Greater distance to abortion facilities is associated with greater out-of-pocket costs, emergency room follow-up care, negative mental health, and delayed care among U.S. abortion patients. However, the distance U.S. abortion patients travel has not been reported since 2008, and no study has examined reasons abortion patients choose the particular facility where they obtain their abortion. Materials and Methods: We analyzed data from the 2014 Abortion Patient Survey and Abortion Provider Census to report abortion patients' one-way travel from their resident zip code to their abortion clinic, whether they went to the closest clinic, and reasons for facility choice. We report unadjusted and adjusted associations of patients' characteristics with travel distance and differences in average travel distance by abortion patients' reported reasons for choosing their facility. Results: In 2014, 65% of abortion patients traveled less than 25 miles one-way, 17% traveled 25-49 miles, and 18% traveled more than 50 miles. Abortion patients who were white, college-educated, U.S.-born, ≥12 weeks pregnant, and lived outside metropolitan areas were more likely to travel farther. Nearly half of abortion patients went to their nearest provider and 32% chose their facility because it was the closest. Conclusion: These results indicate that travel distance is an important determinant of abortion care access in the United States. Nearly, one-fifth of U.S. abortion patients traveled more than 50 miles one-way and the most common reason reported for clinic choice was that it was the closest.

Why do they take the risk? A systematic review of the qualitative literature on informal sector abortions in settings where abortion is legal.

BACKGROUND: Restrictive abortion laws are the single most important determinant of unsafe abortion, a major, yet preventable, global health issue. While reviews have been conducted on the extent of the phenomenon, no study has so far analysed the evidence of why women turn to informal sector providers when legal alternatives are available. This work provides a systematic review of the qualitative literature on informal sector abortion in setting where abortion is legal. METHODS: We used the PRISMA guidelines to search Pubmed, Web of Science, Sciencedirect and Google Scholar databases between January and February 2018. 2794 documents in English and French were screened for eligibility against pre-determined inclusion and exclusion criteria. Articles investigating women's reasons for aborting in the informal sector in settings where abortion is legal were included. In total, sixteen articles were identified as eligible for this review. Findings were reported following the PRISMA guidelines. RESULTS: The review highlights the diverse reasons women turn to the informal sector, as abortions outside of legal health facilities were reported to be a widespread and normalised practice in countries where legal abortion is provided. Women cited a range of reasons for aborting in the informal sector; these included fear of mistreatment by staff, long waiting lists, high costs, inability to fulfil regulations, privacy concerns and lack of awareness about the legality of abortion or where to procure a safe and legal abortion. Not only was unsafe abortion spoken of in terms of medical and physical safety, but also in terms of social and economic security. CONCLUSION: The use of informal sector abortions (ISAs) is a widespread and normalised practice in many countries despite the liberalisation of abortion laws. Although ISAs are not inherently unsafe, the practice in a setting where it is illegal will increase the likelihood that women will not be given the necessary information, or that they will be punished. This study brings to the fore the diverse reasons why women opt to abort outside formal healthcare settings and their issues with provision of abortion services in legal contexts, providing an evidence base for future research and policies.

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.

Effects of Carrying an Unwanted Pregnancy to Term on Women's Existing Children.

OBJECTIVE: To examine how receiving or being denied a wanted abortion affects the subsequent development, health, caregiving, and socioeconomics of women's existing children at time of seeking abortion. STUDY DESIGN: The Turnaway Study is a 5-year longitudinal study with a quasi-experimental design. Women were recruited from January 2008 to December 2010 from 30 abortion facilities throughout the US. We interviewed women regarding the health and development of their living children via telephone 1 week after seeking an abortion and semiannually for 5 years. We compare the youngest existing children younger than the age 5 years of women denied abortion because they presented for care beyond a facility's gestational limit (Turnaway group) with those of women who received the abortion (Abortion group). We used mixed-effects regression models to test for differences in outcomes of existing children of women in the Turnaway group (n = 55 children) compared with existing children of women in the Abortion group (n = 293 children). RESULTS: From 6 months to 4.5 years after their mothers sought abortions, existing children of women denied abortions had lower mean child development scores (adjusted ß -0.04, 95% CI -0.07 to -0.00) and were more likely to live below the Federal Poverty Level (aOR 3.74, 95% CI 1.59-8.79) than the children of women who received a wanted abortion. There were no significant differences in child health or time spent with a caregiver other than the mother. CONCLUSIONS: Denying women a wanted abortion may have negative developmental and socioeconomic consequences for their existing children.

Access to Abortion Services in Tennessee: Does Distance Traveled and Geographic Location Influence Return for a Second Appointment as Required by the Mandatory Waiting Period Policy?

The purpose of this article was to examine the average distance traveled to access an abortion procedure, rates of return for the procedure, and whether or not those living in rural zip codes were less likely to return for the abortion compared with residents in urban zip codes, in the context of a 48-hour in-person mandatory waiting period in Tennessee. Findings indicated that over 12 percent of patients who attended the in-person counseling session did not return for the procedure. Moreover, abortion patients in this study traveled an average of 50.53 miles to access abortion care, which is notably higher than the estimated national average of 11.00 miles. Rural residents were significantly more likely than urban residents to have to travel farther to access abortion services. However, neither geographic location nor distance traveled were predictive of returning to the clinic for the second appointment to obtain the abortion, suggesting that patients who did return were able to overcome any geographic disparities. Given the policy mandate that requires a minimum of two in-person clinic visits to obtain the abortion, patients who are traveling farther must still use more resources for two trips, which is a burden to them that is not experienced by more urban residents who are located in closer proximity to abortion providers. The article concludes with a discussion of the implications of the findings for social work practice and policy.

Socioeconomic Outcomes of Women Who Receive and Women Who Are Denied Wanted Abortions in the United States.

OBJECTIVES: To determine the socioeconomic consequences of receipt versus denial of abortion. METHODS: Women who presented for abortion just before or after the gestational age limit of 30 abortion facilities across the United States between 2008 and 2010 were recruited and followed for 5 years via semiannual telephone interviews. Using mixed effects models, we evaluated socioeconomic outcomes for 813 women by receipt or denial of abortion care. RESULTS: In analyses that adjusted for the few baseline differences, women denied abortions who gave birth had higher odds of poverty 6 months after denial (adjusted odds ratio [AOR] = 3.77; P < .001) than did women who received abortions; women denied abortions were also more likely to be in poverty for 4 years after denial of abortion. Six months after denial of abortion, women were less likely to be employed full time (AOR = 0.37; P = .001) and were more likely to receive public assistance (AOR = 6.26; P < .001) than were women who obtained abortions, differences that remained significant for 4 years. CONCLUSIONS: Women denied an abortion were more likely than were women who received an abortion to experience economic hardship and insecurity lasting years. Laws that restrict access to abortion may result in worsened economic outcomes for women.

Trends in Abortion Incidence and Availability in North Carolina, 1980-2013.

OBJECTIVES: Abortion incidence has declined nationally during the last decade. In recent years, many states, including North Carolina, have passed legislation related to the provision of abortion services. Despite the changing political environment, there is no comprehensive analysis on past and current trends related to unintended pregnancy and abortion in North Carolina. METHODS: This study is a secondary analysis of vital registration data made publicly available by the North Carolina State Center for Health Statistics. Birth and induced abortion records were obtained for the years 1980 to 2013. We describe abortion incidence and demographic characteristics of women obtaining abortions over time. RESULTS: The number of North Carolina abortions declined 36% between 1980 and 2013. The abortion ratio declined from 26/100 pregnancies (live births and abortions) in 1980 to just 14/100 in 2013. These ratios, however, vary across demographic subgroups. In 2013, the abortion ratio was more than 2 times greater for non-Hispanic black women than non-Hispanic white women (22 and 9, respectively). Among non-Hispanic black and Hispanic women, the abortion ratio is greater among women with a previous pregnancy as compared with women in their first pregnancy. For non-Hispanic white women, the abortion ratios are similar for first and higher-order pregnancies. CONCLUSIONS: Trends in North Carolina are similar to national trends; however, detailed analyses by race/ethnicity, age, and parity demonstrate important distinctions among abortion patients over time in the state. We discuss these trends in relation to policy changes and increased access to effective contraceptives.

Women's experiences seeking informal sector abortion services in Cape Town, South Africa: a descriptive study.

BACKGROUND: In settings where abortion is legally restricted, or permitted but not widely accessible, women face significant barriers to abortion access, sometimes leading them to seek services outside legal facilities. The advent of medication abortion has further increased the prevalence of informal sector abortion. This study investigates the reasons for attempting self-induction, methods used, complications, and sources of information about informal sector abortion, and tests a specific recruitment method which could lead to improved estimates of informal sector abortion prevalence among an at-risk population. METHODS: We recruited women who have sought informal sector abortion services in Cape Town, South Africa using respondent driven sampling (RDS). An initial seed recruiter was responsible for initiating recruitment using a structured coupon system. Participants completed face-to-face questionnaires, which included information about demographics, informal sector abortion seeking, and safe abortion access needs. RESULTS: We enrolled 42 women, nearly one-third of whom reported they were sex workers. Thirty-four women (81%) reported having had one informal sector abortion within the past 5 years, 14% reported having had two, and 5% reported having had three. These women consumed home remedies, herbal mixtures from traditional healers, or tablets from an unregistered provider. Twelve sought additional care for potential warning signs of complications. Privacy and fear of mistreatment at public sector facilities were among the main reported reasons for attempting informal sector abortion. Most women (67%) cited other community members as their source of information about informal sector abortion; posted signs and fliers in public spaces also served as an important source of information. CONCLUSIONS: Women are attempting informal sector abortion because they seek privacy and fear mistreatment and stigma in health facilities. Some were unaware how or where to seek formal sector services, or believed the cost was too high. Many informal methods are ineffective and unsafe, leading to potential warning signs of complications and continued pregnancy. Sex workers may be at particular risk of unsafe abortion. Based on these results, it is essential that future studies sample women outside of the formal health sector. The use of innovative sampling methods would greatly improve our knowledge about informal sector abortion in South Africa.

Characteristics and Circumstances of U.S. Women Who Obtain Very Early and Second-Trimester Abortions.

OBJECTIVE: To determine which characteristics and circumstances were associated with very early and second-trimester abortion. METHODS: Paper and pencil surveys were collected from a national sample of 8,380 non-hospital U.S. abortion patients in 2014 and 2015. We used self-reported LMP to calculate weeks gestation; when LMP was not provided we used self-reported weeks pregnant. We constructed two dependent variables: obtaining a very early abortion, defined as six weeks gestation or earlier, and obtaining second-trimester abortion, defined as occurring at 13 weeks gestation or later. We examined associations between the two measures of gestation and a range of characteristics and circumstances, including type of abortion waiting period in the patients' state of residence. RESULTS: Among first-trimester abortion patients, characteristics that decreased the likelihood of obtaining a very early abortion include being under the age of 20, relying on financial assistance to pay for the procedure, recent exposure to two or more disruptive events and living in a state that requires in-person counseling 24-72 hours prior to the procedure. Having a college degree and early recognition of pregnancy increased the likelihood of obtaining a very early abortion. Characteristics that increased the likelihood of obtaining a second-trimester abortion include being Black, having less than a high school degree, relying on financial assistance to pay for the procedure, living 25 or more miles from the facility and late recognition of pregnancy. CONCLUSIONS: While the availability of financial assistance may allow women to obtain abortions they would otherwise be unable to have, it may also result in delays in accessing care. If poor women had health insurance that covered abortion services, these delays could be alleviated. Since the study period, four additional states have started requiring that women obtain in-person counseling prior to obtaining an abortion, and the increase in these laws could slow down the trend in very early abortion.