Perspectives from the pandemic epicenter: Sexual and reproductive health of immigrant women in New York City.

CONTEXT: The United States' response to COVID-19 created a policy, economic, and healthcare provision environment that had implications for the sexual and reproductive health (SRH) of racialized and minoritized communities. Perspectives from heterogenous immigrant communities in New York City, the pandemic epicenter in the United States (US), provides a glimpse into how restrictive social policy environments shape contraception, abortion, pregnancy preferences, and other aspects of SRH for marginalized immigrant communities. METHODS: We conducted in-depth interviews in 2020 and 2021 with 44 cisgender immigrant women from different national origins and 19 direct service providers for immigrant communities in New York City to explore how immigrants were forced to adapt their SRH preferences and behaviors to the structural barriers of the COVID-19 pandemic. We coded and analyzed the interviews using a constant comparative approach. RESULTS: Pandemic-related fears and structural barriers to healthcare access shaped shifts in contraceptive use and preferences among our participants. Immigrant women weighed their concerns for health and safety and the potential of facing discrimination as part of their contraceptive preferences. Immigrants also described shifts in their pregnancy preferences as rooted in concerns for their health and safety and economic constraints unique to immigrant communities. CONCLUSION: Understanding how immigrant women's SRH shifted in response to the structural and policy constraints of the COVID-19 pandemic can reveal how historically marginalized communities will be impacted by an increasingly restrictive reproductive health and immigration policy landscape.

Comparability of estimates and trends in adolescent sexual and contraceptive behaviors from two national surveys: National Survey of Family Growth and the Youth Risk Behavior Survey.

OBJECTIVE: To compare adolescents' reports of sexual and contraceptive behaviors between the National Survey of Family Growth (NSFG) and the Youth Risk Behavior Survey (YRBS). METHODS: For each survey, we estimated the year- and sex-specific prevalence of sexual and contraceptive behaviors among a comparably defined sample of US respondents ages 15-19 currently attending high school. We used logistic regression to test for changes in prevalence from 2007-2019 and conducted sensitivity analyses to investigate between-survey differences. RESULTS: We found differences in both prevalence and trends between the YRBS and NSFG when limited to a comparably defined sample. Compared to the NSFG, adolescents in the YRBS were more likely to report being sexually experienced, less likely to report use of prescription methods for both sexes, and less likely to report condoms among males. Only the YRBS estimated significant declines in sexual experience for both sexes, and significant increases in prescription methods and declines in condom use among males. Differences between surveys in the prevalence of specific contraceptive methods reflected greater combined use of methods in the NSFG. We identified differences in question-wording and other aspects that may influence these differential patterns. CONCLUSIONS: The NSFG and YRBS produced inconsistent prevalence estimates and trends for sexual and contraceptive behaviors among in-school adolescents. Further efforts to improve these national surveillance systems are critical to inform policy and research efforts that support adolescent sexual and reproductive health and wellbeing.

Differences in Abortion Rates between Asian Populations by Country of Origin and Nativity Status in New York City, 2011-2015.

Despite the size of the Asian population in New York City (NYC) and the city's robust abortion surveillance system, abortion-related estimates for this population have not been calculated previously. This study examined the use of abortion services among specific Asian groups in NYC from 2011-2015. Using NYC surveillance data, we estimated abortion rates for Asians, disaggregated by five country of origin groups and nativity status, and for other major racial/ethnic groups. We compared rates between groups and over time. From 2014-2015, the abortion rate for Asian women in NYC was 12.6 abortions per 1000 women aged 15-44 years, lower than the rates for other major racial/ethnic groups. Among country of origin groups, Indian women had the highest rate (30.5 abortions per 1000 women), followed by Japanese women (17.0), Vietnamese women (13.0), Chinese women (8.8), and Korean women (5.1). Rates were higher for U.S.-born Asian groups compared to foreign-born groups, although the differential varied by country of origin. The abortion rate declined or remained steady for nearly all Asian groups from 2011-2015. These findings reinforce the importance of disaggregating data on this population at multiple levels and begin to provide much-needed evidence on the use of abortion services among Asian groups.

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.

Sexual activity, contraceptive use and sexual violence among Asian high school students in the United States.

OBJECTIVE: To compare the prevalence of sexual behaviors and experiences between Asian high school students in the U.S. and students of other race/ethnicities. STUDY DESIGN: We pooled the 2013, 2015 and 2017 rounds of the Youth Risk Behavior Survey (N = 42,854). Logistic regression was used to identify differences between racial/ethnic groups and by sex. RESULTS: Compared to their peers, a smaller proportion of Asian students reported engaging in sexual behaviors or using contraception, including prescription methods, at last sex. Asian students also reported fewer experiences of forced sexual intercourse compared to their peers. CONCLUSIONS: These findings demonstrate distinct patterns in Asian students' sexual health behaviors compared to their peers. Future research should examine determinants of these differences. IMPLICATIONS: Filling a gap in the literature, these data can inform education and health practices that support the sexual and reproductive health needs of Asian and all adolescents in the country.

Characteristics of Immigrants Obtaining Abortions and Comparison with U.S.-Born Individuals.

Background: Little information exists about individuals born outside of the United States who seek abortion services from U.S.-based providers. Baseline data are necessary to identify future changes in the profile of this population. Materials and Methods: Using the Guttmacher Institute's Abortion Patient Survey, we pooled two national samples of individuals obtaining abortions from 2008-2009 to 2013-2014 to provide data on 17,873 respondents, 16% of whom were immigrants. We estimated the distribution of immigrant and U.S.-born respondents across demographic and circumstantial characteristics such as age, poverty level, and gestational age at abortion. We compared the distribution of characteristics by nativity status using chi-square tests. Results: The majority of immigrants obtaining abortions were in their 20s (51%), had poverty-level (50%) or near poverty-level incomes (23%), and had graduated from high school (78%). Almost half (45%) were uninsured and a similar proportion had been in the United States for less than 10 years (44%); nearly one-quarter completed their survey in Spanish. Compared with U.S.-born respondents, a larger proportion of immigrants were older, uninsured, and had not completed high school. A smaller proportion of immigrants compared with nonimmigrants had their abortions after 12 weeks (8% vs. 11%) or traveled over 50 miles to obtain their abortion (9% vs. 16%). Conclusions: Particularly with the continued rise in both restrictive abortion and immigration policies in the United States, it is critical to monitor how immigrants' use of and access to abortion services are impacted in the changing environment. Ensuring that policies and clinical practices facilitate abortion access for immigrants will serve to better support the reproductive health needs of all women.

Data Opportunities for Studying the Sexual and Reproductive Health of Immigrants in the United States.

This paper aims to identify, review, and evaluate publicly available national- and local-level data sources that collect information on the sexual and reproductive health (SRH) of immigrants in the United States. We review public-use sources from the last 30 years that include information on immigration, SRH, health service utilization, and race/ethnicity. For each source, we evaluated the strengths and challenges of the study design and content as they relate to studying immigrant SRH. We identified and reviewed 22 national and seven local sources. At the national level, the National Longitudinal Study of Adolescent to Adult Health and the National Survey of Family Growth contained the most information; at the local level, the New York City Community Health Survey was the most robust. These sources present opportunities to advance research, improve public health surveillance, and inform policies and programs related to the SRH of this rapidly growing and often underserved population.

Immigrant Women's Access to Sexual and Reproductive Health Coverage and Care in the United States.

Issue: Immigrant women of reproductive age in the U.S. face significant challenges obtaining comprehensive and affordable health insurance coverage and care--including sexual and reproductive health services--compared with U.S.-born women, because of myriad policy and systemic factors. Goals: Synthesize recent evidence on immigrant women's access to sexual and reproductive health coverage and care and provide recommendations for policymaking and research. Methods: A rapid literature review to identify and summarize evidence from peer-reviewed and select grey literature published since 2011 on health insurance coverage and sexual and reproductive health care services use among immigrant women in the U.S. Where available, evidence is compared to U.S.-born women. Findings and Conclusions: Immigrant women are less likely to have coverage and use sexual and reproductive health services than U.S.-born women, which may increase their risk of negative outcomes. Federal and state policymakers could take actions to advance immigrant women's sexual and reproductive health, including expanding eligibility for coverage and shoring up the nation's health care safety net. Further research is needed to understand the needs, use of services, and outcomes of immigrant women, as well as the factors that contribute to differences between immigrant and U.S.-born women, and among groups of immigrant women.

Training in aspiration abortion care: An observational cohort study of achieving procedural competence.

BACKGROUND: Studies in multiple countries have found that the provision of aspiration abortion care by trained nurses, midwives, and other front-line health care workers is safe and acceptable to women. In the United States, most state abortion laws restrict the provision of abortion to physicians; nurse practitioners, nurse-midwives, and physician assistants, can legally perform medication abortion in only twelve states and aspiration abortion in five. Expansion of abortion care by these providers, consistent with their scopes of practice, could help alleviate the increasing difficulty of accessing abortion care in many states. OBJECTIVES: This study used a competency-based training model to teach advanced practice clinicians to perform vacuum aspiration for the abortion care. Previous research reporting on the training of providers other than physicians primarily focused on numbers of procedures performed, without assessment of skill competency or clinician confidence. DESIGN: In this prospective, observational cohort study, advanced practice clinician trainees were recruited from 23 clinical sites across six partner organizations. Trainees participated in a standardized, competency-based didactic and clinical training program in uterine aspiration for first-trimester abortion. SETTINGS: Trainee clinicians needed to be employed by one of the six partner organizations and have an intention to remain in clinical practice following training. PARTICIPANTS: California-licensed advanced practice clinicians were eligible to participate in the training if they had at least 12 months of clinical experience, including at least three months of medication abortion provision, and certification in Basic Life Support. METHODS: A standardized, competency-based training program consisting of both didactic and clinical training in uterine aspiration for first-trimester abortion was completed by 46 advanced practice clinician participants. Outcomes related to procedural safety and to the learning process were measured between August 2007 and December 2013, and compared to those of resident physician trainees. RESULTS: Essentially identical odds of complications occurring from advanced practice clinician-performed procedures were not significantly different than the odds of complications occurring from resident-performed procedures (OR: 0.99; CI: 0.46-2.02; p > 0.05) after controlling for patient sociodemographic and medical history. The number of training days to foundational competence ranged from six to 10, and the number of procedures to competence for those who completed training ranged from 40 to 56 (median = 42.5). CONCLUSIONS: A standardized, competency-based trainingprogram can prepare advanced practice clinicians to safely provide first-trimester aspiration abortions. Access to safe abortion care can be enhanced by increasing the number of providers from cadres of clinicians other than physicians.

Changing Patterns of Contraceptive Use and the Decline in Rates of Pregnancy and Birth Among U.S. Adolescents, 2007-2014.

PURPOSE: To investigate the influence of sexual activity and contraceptive use on the decline in adolescent birth rates and pregnancy rates since 2007. METHODS: We estimated trends in pregnancy risk from 2007 to 2014 using national data on behaviors of women aged 15-19. RESULTS: In 2007-2014, increases occurred in use of one or more contraceptive methods at last sex (78%-88%), dual method use (24%-33%), long-acting reversible contraception including intrauterine device and implant (1%-7%), withdrawal (15%-26%), and withdrawal in combination with other methods (7%-17%). Pill use rose and then fell over time. Level of sexual activity did not change over time. The decline in pregnancy risk among women aged 15-19 was entirely attributable to improvements in contraceptive use. CONCLUSIONS: Improvements in contraceptive use-including increases in use of long-acting reversible contraception and withdrawal in combination with another method-appear to be driving recent declines in adolescent birth and pregnancy rates.

A prospective measure of unintended pregnancy in the United States.

OBJECTIVE: To describe a new measure, the unintended pregnancy risk index (UPRI), which is based primarily on attitudinal and behavioral measures of women's prospective pregnancy desire, and compare it to the unintended pregnancy rate, typically calculated retrospectively. STUDY DESIGN: We used three rounds of the National Survey of Family Growth to calculate trends in the UPRI and compare it to the retrospective rate. The UPRI estimates the annual risk of becoming unintentionally pregnant on a scale from 0 to 100. It is based on women's prospective pregnancy desire as well as fecundity, sexual activity and contraceptive use patterns. RESULTS: Among all women aged 15-34, the UPRI ranged from 7.4 in 2002 to 5.7 in 2013. The retrospective unintended pregnancy rate had similar levels and declines for the same overall period, although the UPRI declined earlier than the retrospective rate. CONCLUSIONS: Changes in the use of any contraceptive method, the methods used and the effectiveness of the methods used all contributed to the decline in the UPRI. IMPLICATIONS: The sufficiency of retrospective measures of pregnancy intention has been challenged, and data availability has constrained needed surveillance of the unintended pregnancy rate. The UPRI offers a new measure that can be calculated with existing national surveillance data or for any population for which data on prospective pregnancy desire, pregnancy risk and contraceptive use are available.

Prevalence of conscientious objection to legal abortion among clinicians in northern Ghana.

OBJECTIVE: To assess the prevalence of conscientious objection (CO), motivations, knowledge of Ghana's abortion law, attitudes, and behaviors toward abortion provision among medical providers in northern Ghana, and measures to regulate CO. METHODS: Between June and November 2015, the present cross-sectional survey-based descriptive study measured prevalence, knowledge, and attitudes about CO among 213 eligible health practitioners who were trained in abortion provision and working in hospital facilities in northern Ghana. Results were stratified by facility ownership and provider type. RESULTS: Approximately half (94/213, 44.1%) of trained providers reported that they were currently providing abortions. The overall prevalence of self-identified and hypothetical objection was 37.9% and 33.8%, respectively. Among 87 physicians, 37 (42.5%) and 39 (44.8%) were categorized as self-identified and hypothetical objectors, respectively. Among 126 midwives, nurses, and physician assistants, 43 (34.7%) and 33 (26.2%) were coded as self-identified and hypothetical objectors, respectively. A high proportion of providers reported familiarity with Ghana's abortion law and supported regulation of CO. CONCLUSION: CO based on moral and religious grounds is prevalent in northern Ghana. Providers indicated an acceptance of policies and guidelines that would regulate its application to reduce the burden that CO poses for women seeking abortion services.

Estimating abortion provision and abortion referrals among United States obstetrician-gynecologists in private practice.

OBJECTIVE: The objective was to examine the provision of abortion by obstetrician-gynecologists in private practice in the United States (U.S.) and their willingness to provide referrals for abortion services. STUDY DESIGN: We conducted a cross-sectional national survey of 1961 U.S. obstetrician-gynecologists to estimate the frequency with which abortions and referrals for abortion care were provided in private practice settings. Key measures included whether respondents had provided any abortions in 2013 or 2014, type of abortions provided and willingness to provide abortion referrals. Facility location by region was the only measured correlate of abortion provision. RESULTS: We received a total of 988 surveys for a response rate of 65%. Sixty-seven (7%) obstetrician-gynecologists reported providing at least one abortion in 2013 or 2014, though this result ranged from 4% (n=23) to 13% (n=44) of obstetrician-gynecologists depending on survey response type. Among physicians practicing in the Northeast and West, 14% and 10%, respectively (n=24 in each region) were abortion providers compared to 4% (n=9) and 3% (n=10) of physicians in the Midwest and South, respectively. Twenty-three (42%) providers indicated only performing surgical abortions, 14 (25%) indicated only medication abortions, and 18 (33%) reported providing both. Among respondents who did not provide abortions, just over half (n=415, 54%) indicated that they referred patients to a facility or practice where they could obtain an abortion, but 271 (35%) said they would not provide a referral. CONCLUSIONS: Only a small proportion of all obstetrician-gynecologists in private practice settings provide abortions. Among nonproviders, a substantial minority do not offer abortion referrals. IMPLICATIONS: Particularly in geographic areas with few abortion providers, continued efforts are needed to equip medical professionals with information and training to make direct referrals.

Reasons why women have induced abortions: a synthesis of findings from 14 countries.

OBJECTIVE: Many reasons inform women's reproductive decision-making. This paper aims to present the reasons women give for obtaining induced abortions in 14 countries. STUDY DESIGN: We examined nationally representative data from 14 countries collected in official statistics, population-based surveys, and facility-based surveys of abortion patients. In each country, we calculated the percentage distribution of women who have abortions by main reason given for the abortion. We examined these reasons across countries and within countries by women's sociodemographic characteristics (age, marital status, educational attainment, and residence). Where data are available, we also studied the multiple reasons women give for having an abortion. RESULTS: In most countries, the most frequently cited reasons for having an abortion were socioeconomic concerns or limiting childbearing. With some exceptions, little variation existed in the reasons given by women's sociodemographic characteristics. Data from three countries where multiple reasons could be reported in the survey showed that women often have more than one reason for having an abortion. CONCLUSION: This study shows that women have abortions for a variety of reasons, and provides a broad picture of the circumstances that inform women's decisions to have abortions. IMPLICATIONS: Future research should examine in greater depth the personal, social, economic, and health factors that inform a woman's decision to have an abortion as these reasons may shed light on the potential consequences that unintended births can have on women's lives.

Correction: Characteristics of women obtaining induced abortions in selected low- and middle-income countries.

[This corrects the article DOI: 10.1371/journal.pone.0172976.].

Characteristics of women obtaining induced abortions in selected low- and middle-income countries.

BACKGROUND: In 2010-2014, approximately 86% of abortions took place in low- and middle-income countries (LMICs). Although abortion incidence varies minimally across geographical regions, it varies widely by subregion and within countries by subgroups of women. Differential abortion levels stem from variation in the level of unintended pregnancies and in the likelihood that women with unintended pregnancies obtain abortions. OBJECTIVES: To examine the characteristics of women obtaining induced abortions in LMICs. METHODS: We use data from official statistics, population-based surveys, and abortion patient surveys to examine variation in the percentage distribution of abortions and abortion rates by age at abortion, marital status, parity, wealth, education, and residence. We analyze data from five countries in Africa, 13 in Asia, eight in Europe, and two in Latin America and the Caribbean (LAC). RESULTS: Women across all sociodemographic subgroups obtain abortions. In most countries, women aged 20-29 obtained the highest proportion of abortions, and while adolescents obtained a substantial fraction of abortions, they do not make up a disproportionate share. Region-specific patterns were observed in the distribution of abortions by parity. In many countries, a higher fraction of abortions occurred among women of high socioeconomic status, as measured by wealth status, educational attainment, and urban residence. Due to limited data on marital status, it is unknown whether married or unmarried women make up a larger share of abortions. CONCLUSIONS: These findings help to identify subgroups of women with disproportionate levels of abortion, and can inform policies and programs to reduce the incidence of unintended pregnancies; and in LMICs that have restrictive abortion laws, these findings can also inform policies to minimize the consequences of unsafe abortion and motivate liberalization of abortion laws. Program planners, policymakers, and advocates can use this information to improve access to safe abortion services, postabortion care, and contraceptive services.

Understanding the Decline in Adolescent Fertility in the United States, 2007-2012.

PURPOSE: The decline in U.S. adolescent fertility has accelerated since 2007. Modeling fertility change using behavioral data can inform adolescent pregnancy prevention efforts. METHODS: We used data on sexual activity and contraceptive use from National Surveys of Family Growth for young women 15-19 years of age, and contraceptive failure rates, to estimate a Pregnancy Risk Index (PRI) for the periods 2007, 2009, and 2012. Logistic regression was used to test for change over time in sexual activity, contraceptive use, and PRI. Statistical decomposition was used to calculate attribution of change in the PRI to changes in sexual activity or contraceptive method use. RESULTS: Sexual activity in the last 3 months did not change significantly from 2007 to 2012. Pregnancy risk declined among sexually active adolescent women (p = .046), with significant increases in the use of any method (78%-86%, p = .046) and multiple methods (26%-37%, p = .046). Use of highly effective methods increased significantly from 2007 to 2009 (38%-51%, p = .010). Overall, the PRI declined at an annual rate of 5.6% (p = .071) from 2007 to 2012 and correlated with birth and pregnancy rate declines. Decomposition estimated that this decline was entirely attributable to improvements in contraceptive use. CONCLUSIONS: Improvements in contraceptive use appear to be the primary proximal determinants of declines in adolescent pregnancy and birth rates in the United States from 2007 to 2012. Efforts to further improve access to and use of contraception among adolescents are necessary to ensure they have the means to prevent pregnancy.