Randomized experimental testing of new survey approaches to improve abortion reporting in the United States.

CONTEXT: Abortions are substantially underreported in surveys due to social stigma, compromising the study of abortion, pregnancy, fertility, and related demographic and health outcomes. METHODS: In this study, we evaluated six methodological approaches identified through formative mixed-methods research to improve the measurement of abortion in surveys. These approaches included altering the placement of abortion items in the survey, the order of pregnancy outcome questions, the level of detail, the introduction to the abortion question, and the context of the abortion question, and using graduated sensitivity. We embedded a preregistered randomized experiment in a newly designed online survey about sexual and reproductive health behaviors (N = 6536). We randomized respondents to experimental arms in a fully crossed factorial design; we estimated an average treatment effect using standardized estimators from logistic regression models, adjusted for demographic covariates associated with reporting. RESULTS: None of the experimental arms significantly improved abortion reporting compared to the control condition. CONCLUSION: More work is needed to improve reporting of abortion in future surveys, particularly as abortion access becomes increasingly restricted in the United States. Despite this study's null results, it provides a promising path for future efforts to improve abortion measurement. It is proof of concept for testing new approaches in a less expensive, faster, and more flexible format than embedding changes in existing national fertility surveys.

State-Level Variation in Abortion Stigma and Women and Men's Abortion Underreporting in the USA.

Abortion is highly stigmatized in most settings and severely underreported in demographic surveys. In the USA, variation in the context of abortion between states may influence respondents' exposure to abortion stigma and create geographic variation in their likelihood of disclosing abortion in surveys. We used restricted geographic data from the 2006-2010 and 2011-2015 National Survey of Family Growth (NSFG) to investigate the association between abortion reporting in the USA and state-level structural factors that may influence respondents' experience of abortion stigma. At the aggregate level, we compared the weighted number of abortions women reported in the NSFG to abortion counts derived from abortion provider censuses and test for variation in underreporting by state-level structural measures. At the individual level, we tested if state-level structural factors were associated with less reporting of abortion in the face-to-face (FTF) survey mode than the more confidential audio computer-assisted self-interviewing mode (ACASI) of the NSFG. We found that at the aggregate level, there were no differences in reporting by the state-level measures. At the individual level, about 40% of women and men who reported an abortion in their ACASI did not fully report in the FTF interview; however, there were few differences by any state-level factors. This study documents that abortion stigma plagues the quality of reporting in the USA for both women and men, regardless of which state they live in. Survey improvements to reduce abortion underreporting are needed.

The Impact of Abortion Underreporting on Pregnancy Data and Related Research.

INTRODUCTION: The impact on research findings that use pregnancy data from surveys with underreported abortions is not well-established. We estimate the percent of all pregnancies missing from women's self-reported pregnancy histories because of abortion underreporting. METHODS: We obtained abortion and fetal loss data from the 2006-2015 National Survey of Family Growth (NSFG), annual counts of births from US vital statistics, and external abortion counts from the Guttmacher Institute. We estimated the completeness of abortion reporting in the NSFG as compared to the external counts, the proportion of pregnancies resolving in abortion, and the proportion of pregnancies missing in the NSFG due to missing abortions. Each measure was examined overall and by age, race/ethnicity, union status, and survey period. RESULTS: Fewer than half of abortions (40%, 95% CI 36-44) that occurred in the five calendar years preceding respondents' interviews were reported in the NSFG. In 2006-2015, 18% of pregnancies resolved in abortion, with significant variation across demographic groups. Nearly 11% of pregnancies (95% CI 10-11) were missing from the 2006-2015 NSFG due to abortion underreporting. The extent of missing pregnancies varied across demographic groups and was highest among Black women and unmarried women (18% each); differences reflect both the patterns of abortion underreporting and the share of pregnancies ending in abortion. DISCUSSION: Incomplete reporting of pregnancy remains a fundamental shortcoming to the study of US fertility-related experiences. Efforts to improve abortion reporting are needed to strengthen the quality of pregnancy data to support maternal, child, and reproductive health research.

Abortion Reporting in the United States: An Assessment of Three National Fertility Surveys.

Despite its frequency, abortion remains a highly sensitive, stigmatized, and difficult-to-measure behavior. We present estimates of abortion underreporting for three of the most commonly used national fertility surveys in the United States: the National Survey of Family Growth, the National Longitudinal Survey of Youth 1997, and the National Longitudinal Study of Adolescent to Adult Health. Numbers of abortions reported in each survey were compared with external abortion counts obtained from a census of all U.S. abortion providers, with adjustments for comparable respondent ages and periods of each data source. We examined the influence of survey design factors, including survey mode, sampling frame, and length of recall, on abortion underreporting. We used Monte Carlo simulations to estimate potential measurement biases in relationships between abortion and other variables. Underreporting of abortion in the United States compromises the ability to study abortion-and, consequently, almost any pregnancy-related experience-using national fertility surveys.

Effect of Changes in Response Options on Reported Pregnancy Intentions: A Natural Experiment in the United States.

OBJECTIVES: The Pregnancy Risk Assessment Monitoring System (PRAMS), conducted by the Centers for Disease Control and Prevention in collaboration with state health departments, is the largest state-level surveillance system that includes a question on the intention status of pregnancies leading to live birth. In 2012, the question was changed to include an additional response option describing uncertainty before the pregnancy about the desire for pregnancy. This analysis investigated how this additional response option affected women's responses. METHODS: We used the change in the pregnancy intention question in 2012 as a natural experiment, taking advantage of relatively stable distributions of pregnancy intentions during short periods of time in states. Using PRAMS data from 2009-2014 (N = 222 781), we used a regression discontinuity-in-time design to test for differences in the proportion of women choosing each response option in the periods before and after the question change. RESULTS: During 2012-2014, 13%-15% of women chose the new response option, "I wasn't sure what I wanted." The addition of the new response option substantially affected distributions of pregnancy intentions, drawing responses away from all answer choices except "I wanted to be pregnant then." Effects were not uniform across age, parity, or race/ethnicity or across states. CONCLUSIONS: These effects could influence estimated levels and trends of the proportion of births that are characterized as intended, mistimed, or unwanted, as well as estimates of differences between demographic groups. These findings will help to inform new strategies for measuring pregnancy and childbearing desires among women.

Prevalence of Sexual Initiation Before Age 13 Years Among Male Adolescents and Young Adults in the United States.

Importance: Despite similar sexual activity rates among male and female adolescents, males are more likely to have their first sexual intercourse before age 13 years. The developmental needs and pathways to healthy trajectories for young males remain unknown. Objective: To examine the prevalence of sexual intercourse before age 13 years among male adolescents; the variation by race/ethnicity, location, and maternal educational level; and the wantedness of this first sexual experience. Design, Setting, and Participants: This cross-sectional analysis was conducted from September 2017 to June 2018, using pooled 2011, 2013, and 2015 data from the school-based Youth Risk Behavior Surveillance System (YRBSS) and the 2006 to 2015 data of males aged 15 to 24 years from the household-based National Survey of Family Growth (NSFG). The percentage of males reporting sexual onset before age 13 years was estimated using survey-weighted logistic regression to test for differences by race/ethnicity within each national survey and within metropolitan areas (for YRBSS, high school and middle school samples). Among NSFG survey respondents, differences in wantedness of first sexual intercourse by age at first sexual intercourse were examined, along with the associations between sexual initiation and socioeconomic covariates. Main Outcomes and Measures: Sexual onset before age 13 years. Results: Data from a total of 19 916 male high school students (from YRBSS) and 7739 males aged 15 to 24 years (from NSFG) were included in the analysis. The sample was largely composed of non-Hispanic white males: 8789 (57.1%) from the YRBSS and 3737 (58.0%) from the NSFG. Sexual onset before age 13 years was reported nationally by 7.6% (95% CI, 6.8%-8.4%) of male high school students and 3.6% (95% CI, 3.0%-4.2%) of males aged 15 to 24 years. The proportion of male students who reported having sexual intercourse before age 13 years varied across metropolitan sites, from 5% (95% CI, 4%-7%) in San Francisco, California, to 25% (95% CI, 23%-28%) in Memphis, Tennessee, with elevated rates among non-Hispanic black and Hispanic males in most metropolitan areas. In the NSFG data set, respondents whose mothers had a college degree or higher educational level were statistically significantly less likely (OR, 0.31; 95% CI, 0.19-0.49) to report having sexual intercourse before age 13 years compared with those whose mothers did not have a college degree. Among males who reported having their first sexual experience before age 13 years, 8.5% (95% CI, 3.8%-17.8%) described their first sexual intercourse as unwanted. Conclusions and Relevance: Rates of sexual onset before age 13 years among young males varied by race/ethnicity, location, and maternal educational level, presenting important implications for the provision of early, inclusive, and comprehensive sex education and sexual and reproductive health care to male children and adolescents.

The Incidence of Menstrual Regulation Procedures and Abortion in Bangladesh, 2014.

CONTEXT: Menstrual regulation (MR) has been part of the Bangladesh family planning program since 1979. However, clandestine abortion remains a serious health problem in Bangladesh, and anecdotal reports indicate that clandestine use of misoprostol has increased since the most recent estimates (for 2010). Because of this, it is important to assess changes in the use of MR services and the incidence of clandestine abortion since 2010. METHODS: A survey of a nationally representative sample of 829 health facilities that provide MR or postabortion care services and a survey of 322 professionals knowledgeable about these services were conducted in 2014. Direct and indirect methods were applied to calculate the incidence of MR and induced abortion. RESULTS: In 2014, an estimated 1,194,000 induced abortions were performed in Bangladesh (29 per 1,000 women aged 15-49), and 257,000 women were treated for complications of such abortions (a rate of 6 per 1,000 women aged 15-49). Among women with complications, the proportion presenting with hemorrhage increased significantly, from 27% to 48%. An estimated 430,000 MR procedures (using MVA or medication) were performed in health facilities nationwide, a decline of about 40% in the MR rate-from 17 to 10 per 1,000 women aged 15-49-from 2010 to 2014. CONCLUSIONS: Given declines in MR provision, more attention needs to be paid to building capacity, including hiring and training more providers of MR. Harm-reduction approaches should be pursued to increase the safety of clandestine use of misoprostol in Bangladesh.

The Role of Men's Childbearing Intentions in Father Involvement.

An expanding body of research has investigated factors that influence fathers' involvement with their children. Generally overlooked has been the role of pregnancy intentions on men's fathering behaviors. In this study, the authors used nationally representative data from men interviewed in the 2002 and 2006-2010 National Survey of Family Growth to examine relationships between fathers' pregnancy intentions and multiple aspects of their parental involvement. Using propensity score methods to control for confounding, they found that men were less likely to live with a young child from a mistimed than intended pregnancy and that among nonresident fathers, mistimed pregnancies were associated with lower levels of visitation and consequently reduced participation in caregiving and play. Among both resident and nonresident fathers, mistimed pregnancies were also associated with lower self-appraisals of fathering quality when compared with intended pregnancies; for nonresident fathers, however, this association was moderated by other involvement.

Parents' experience of unintended childbearing: A qualitative study of factors that mitigate or exacerbate effects.

Births resulting from an unintended pregnancy affect individuals differentially, and some may experience more negative consequences than others. In this study, we sought to describe the mechanisms through which the severity of effects may be mitigated or exacerbated. We conducted in-depth interviews with 35 women and 30 men, all with a youngest child born resulting from an unintended pregnancy, in two urban sites in the United States. Respondents described both negative and positive effects of the child's birth in the areas of school; work and finances; partner relationships; personal health and outlook on life trajectories. Mechanisms through which unintended pregnancies mitigated or exacerbated certain effects fell at the individual (e.g. lifestyle modification), interpersonal (e.g. partner support) and structural (e.g. workplace flexibility) levels. These qualitative findings deepen understanding of the impact of unintended childbearing on the lives of women, men and families.

Changes in Adolescents' Receipt of Sex Education, 2006-2013.

PURPOSE: Updated estimates of adolescents' receipt of sex education are needed to monitor changing access to information. METHODS: Using nationally representative data from the 2006-2010 and 2011-2013 National Survey of Family Growth, we estimated changes over time in adolescents' receipt of sex education from formal sources and from parents and differentials in these trends by adolescents' gender, race/ethnicity, age, and place of residence. RESULTS: Between 2006-2010 and 2011-2013, there were significant declines in adolescent females' receipt of formal instruction about birth control (70% to 60%), saying no to sex (89% to 82%), sexually transmitted disease (94% to 90%), and HIV/AIDS (89% to 86%). There was a significant decline in males' receipt of instruction about birth control (61% to 55%). Declines were concentrated among adolescents living in nonmetropolitan areas. The proportion of adolescents talking with their parents about sex education topics did not change significantly. Twenty-one percent of females and 35% of males did not receive instruction about methods of birth control from either formal sources or a parent. CONCLUSIONS: Declines in receipt of formal sex education and low rates of parental communication may leave adolescents without instruction, particularly in nonmetropolitan areas. More effort is needed to understand this decline and to explore adolescents' potential other sources of reproductive health information.

Are Pregnancy Intentions Associated with Transitions Into and Out of Marriage?

CONTEXT: In addition to having associations with health outcomes, pregnancy intentions may be associated with social outcomes, including marital transitions. METHODS: Linked data from the 2004-2008 Oklahoma Pregnancy Risk Assessment Monitoring System and The Oklahoma Toddler Survey for 2006-2010 on 3,617 women who were married and 2,123 who were unmarried at conception were used to examine the relationship between pregnancy intention status (intended, mistimed by less than two years, mistimed by two or more years, or unwanted) and marital formation or dissolution by the time of the birth and two years later. Logistic regression analyses were conducted, and propensity score methods were used to adjust for confounding characteristics. RESULTS: Intention status was associated with marital transition two years after the birth, but not between conception and birth. In adjusted models, among women married at conception, those with a birth resulting from an unwanted pregnancy were more likely than those with a birth resulting from an intended pregnancy to transition out of marriage by the time their child was two years old (odds ratio, 2.2). Among women unmarried at conception, those with a birth following an unwanted pregnancy were less likely than those with a birth following an intended pregnancy to marry by the time their child was two (0.5). Births following mistimed pregnancies were not associated with marital transition. CONCLUSIONS: The findings should motivate researchers to broaden the scope of research on the consequences of unintended childbearing. Future research should distinguish between mistimed and unwanted births.

Pregnancy intentions and maternal and child health: an analysis of longitudinal data in Oklahoma.

Better understanding of the impact of unintended childbearing on infant and early childhood health is needed for public health practice and policy. Data from the 2004-2008 Oklahoma Pregnancy Risk Assessment Monitoring System survey and The Oklahoma Toddler Survey 2006-2010 were used to examine associations between a four category measure of pregnancy intentions (intended, mistimed <2 years, mistimed ≥2 years, unwanted) and maternal behaviors and child health outcomes up to age two. Propensity score methods were used to control for confounding. Births mistimed by two or more years (OR .58) and unwanted births (OR .33) had significantly lower odds than intended births of having a mother who recognized the pregnancy within the first 8 weeks; they were also about half as likely as intended births to receive early prenatal care, and had significantly higher likelihoods of exposure to cigarette smoke during pregnancy. Breastfeeding was significantly less likely among unwanted births (OR .68); breastfeeding for at least 6 months was significantly less likely among seriously mistimed births (OR .70). We find little association between intention status and early childhood measures. Measured associations of intention status on health behaviors and outcomes were most evident in the prenatal period, limited in the immediate prenatal period, and mostly insignificant by age two. In addition, most of the negative associations between intention status and health outcomes were concentrated among women with births mistimed by two or more years or unwanted births. Surveys should incorporate questions on the extent of mistiming when measuring pregnancy intentions.

The cost of postabortion care and legal abortion in Colombia.

CONTEXT: Although Colombia partially liberalized its abortion law in 2006, many abortions continue to occur outside the law and result in complications. Assessing the costs to the health care system of safe, legal abortions and of treating complications of unsafe, illegal abortions has important policy implications. METHODS: The Post-Abortion Care Costing Methodology was used to produce estimates of direct and indirect costs of postabortion care and direct costs of legal abortions in Colombia. Data on estimated costs were obtained through structured interviews with key informants at a randomly selected sample of facilities that provide abortion-related care, including 25 public and private secondary and tertiary facilities and five primary-level private facilities that provide specialized reproductive health services. RESULTS: The median direct cost of treating a woman with abortion complications ranged from $44 to $141 (in U.S. dollars), representing an annual direct cost to the health system of about $14 million per year. A legal abortion at a secondary or tertiary facility was costly (medians, $213 and $189, respectively), in part because of the use of dilation and curettage, as well as because of administrative barriers. At specialized facilities, where manual vacuum aspiration and medication abortion are used, the median cost of provision was much lower ($45). CONCLUSIONS: Provision of postabortion care and legal abortion services at higher-level facilities results in unnecessarily high health care costs. These costs can be reduced significantly by providing services in a timely fashion at primary-level facilities and by using safe, noninvasive and less costly abortion methods.

Menstrual regulation, unsafe abortion, and maternal health in Bangladesh.

Maternal mortality has declined considerably in Bangladesh over the past few decades. Some of that decline--though precisely how much cannot be quantified--is likely attributable to the country's menstrual regulation program,which allows women to establish nonpregnancy safely after a missed period and thus avoid recourse to unsafe abortion. Key Points. (1) Unsafe clandestine abortion persists in Bangladesh. In 2010, some 231,000 led to complications that were treated at health facilities, but another 341,000 cases were not. In all, 572,000 unsafe procedures led to complications that year. (2) Recourse to unsafe abortion can be avoided by use of the safe, government sanctioned service of menstrual regulation (MR)--establishing nonpregnancy after a missed period, most often using manual vacuum aspiration. In 2010, an estimated 653,000 women obtained MRs, a rate of 18 per 1,000 women of reproductive age. (3) The rate at which MRs result in complications that are treated in facilities is one-third that of the complications of induced abortions--120 per 1,000 MRs vs. 357 per 1,000 induced abortions. (4) There is room for improvement in MR service provision, however. In 2010, 43% of the facilities that could potentially offer it did not. Moreover, one-third of rural primary health care facilities did not provide the service. These are staffed by Family Welfare Visitors, recognized to be the backbone of the MR program. In addition, one-quarter of all MR clients were denied the procedure. (5) To assure that trends toward lower abortion-related morbidity and mortality continue, women need expanded access to the means of averting unsafe abortion. To that end, the government needs to address barriers to widespread, safe MR services, including women's limited knowledge of their availability, the reasons why facilities do not provide MRs or reject women who seek one, and the often poor quality of care.

The incidence of menstrual regulation procedures and abortion in Bangladesh, 2010.

CONTEXT: Bangladesh is unique in including menstrual regulation (MR) services as part of the government family planning program, despite having a highly restrictive abortion law. The only national estimates of MR and abortion incidence are from a 1995 study, and updated information is needed to inform policies and programs regarding the provision of MR and related reproductive health services. METHODS: Surveys of a nationally representative sample of 670 health facilities that provide MR and postabortion care services and of 151 knowledgeable professionals were conducted in 2010, and MR service statistics of nongovernmental organizations were compiled. Indirect estimation techniques were applied to calculate the incidence and rates of MR and induced abortion. RESULTS: In 2010, an estimated 647,000 induced abortions were performed in Bangladesh, and 231,400 women were treated for complications of such abortions. Furthermore, an estimated 653,000 MR procedures were performed at facilities nationwide. However, an estimated 26% of all women seeking an MR at facilities were turned away, and about one in 10 of those who had an MR were treated for complications. Nationally, the annual abortion rate was 18.2 per 1,000 women aged 15-44, and the MR rate was 18.3 per 1,000 women. CONCLUSIONS: The incidence of induced abortion is the same as that of MR, which suggests considerable unsatisfied demand for the latter service. Furthermore, the high rates of complications from MRs highlight the need to improve the quality of clinical services. Increased access to contraceptives and MR services would help reduce rates of unplanned pregnancy and unsafe abortion.

Consequences of sex education on teen and young adult sexual behaviors and outcomes.

PURPOSE: This study examined whether formal sex education is associated with sexual health behaviors and outcomes using recent nationally representative survey data. METHODS: Data used were from 4,691 male and female individuals aged 15-24 years from the 2006-2008 National Survey of Family Growth. Weighted bivariate and multivariate analyses were conducted by gender, estimating the associations of sex education by type (only abstinence, abstinence and birth control, or neither) before first sexual intercourse, and sexual behaviors and outcomes. RESULTS: Receipt of sex education, regardless of type, was associated with delays in first sex for both genders, as compared with receiving no sex education. Respondents receiving instruction about abstinence and birth control were significantly more likely at first sex to use any contraception (odds ratio [OR] = 1.73, females; OR = 1.91, males) or a condom (OR = 1.69, females; OR = 1.90, males), and less likely to have an age-discrepant partner (OR = .67, females; OR = .48, males). Receipt of only abstinence education was not statistically distinguishable in most models from receipt of either both or neither topics. Among female subjects, condom use at first sex was significantly more likely among those receiving instruction in both topics as compared with only abstinence education. The associations between sex education and all longer-term outcomes were mediated by older age at first sex. CONCLUSIONS: Sex education about abstinence and birth control was associated with healthier sexual behaviors and outcomes as compared with no instruction. The protective influence of sex education is not limited to if or when to have sex, but extends to issues of contraception, partner selection, and reproductive health outcomes.