U.S. Fertility in Life Course Context: A Research Note on Using Census-Held Linked Administrative Records for Geographic and Sociodemographic Subgroup Estimation.

Fertility is a life course process that is strongly shaped by geographic and sociodemographic subgroup contexts. In the United States, scholars face a choice: they can situate fertility in a life course perspective using panel data, which is typically representative only at the national level; or they can attend to subnational contexts using rate schedules, which do not include information on life course statuses. The method and data source we introduce here, Census-Held Linked Administrative Records for Fertility Estimation (CLAR-FE), permits both. It derives fertility histories and rate schedules from U.S. Census Bureau-held data for the nation and by state, racial and ethnic subgroups, and the important life course status of parity. We generate three types of rates for 2000-2020 at the national and state levels by race and ethnicity: age-specific rates and both unconditional and conditional parity- and age-specific rates. Where possible, we compare these rates with those produced by the National Center for Health Statistics. Our new rate schedules illuminate state and racial and ethnic differences in transitions to parenthood, providing evidence of the important subgroup heterogeneity that characterizes the United States. CLAR-FE covers nearly the entire U.S. population and is available to researchers on approved projects through the Census Bureau's Federal Statistical Research Data Centers.

Changes in contraceptive method mix following the Colorado Family Planning Initiative.

OBJECTIVES: To describe the changes in contraceptive method use and mix among Colorado Title X clients following the 2009 Colorado Family Planning Initiative (CFPI), which allowed Colorado Title X providers to offer all contraceptive methods without medically unnecessary barriers. STUDY DESIGN: Using data on all visits to Colorado Title X clinics between 2007 and 2016 for women aged 10-49 years, we described trends in contraceptive method use by age group and race/ethnicity prior to and following the implementation of CFPI. RESULTS: The implementation of CFPI saw an abrupt increase in Title X visits. Visits subsequently declined steeply for non-Hispanic White clients while visits by Hispanic clients remained at elevated levels. During CFPI, the use of long-acting reversible contraceptives increased while the use of oral contraceptive pills decreased. Nonetheless, oral contraceptive pills remained the most common method used by Title X clients throughout the study period. Changes in the method mix varied by age and race/ethnicity. Method switching was relatively uncommon among established Title X clinic users. CONCLUSIONS: CFPI, which removed financial barriers to the most expensive methods, was associated with increases in the use of long-acting reversible contraceptives and changes in method mix that varied by age group and race/ethnicity. IMPLICATIONS: CFPI removed barriers to previously inaccessible methods that contributed to changes in the method mix at Title X clinics. That these changes were not uniform across ages and race/ethnicities emphasize that subgroup variation in family planning policy impact stems from heterogeneity in barriers to care and method-specific unmet demand.

Use of Judicial Bypass of Mandatory Parental Consent to Access Abortion and Judicial Bypass Denials, Florida and Texas, 2018-2021.

Objectives. To describe minors' use of judicial bypass to access abortion and the percentage of bypass petitions denied in Florida and Texas. Methods. Data were derived from official state statistics on judicial bypasses and abortions by age in Texas and Florida; abortions in Texas among minor nonresidents were estimated. In addition, judicial bypass petitions as a percentage of abortions received by minors and judicial bypass denials as a percentage of petitions were calculated. Results. Between 2018 and 2021, minors received 5527 abortions in Florida and an estimated 5220 abortions in Texas. Use of judicial bypass was stable at 14% to 15% in Florida and declined from 14% to 10% in Texas. Among petitions for judicial bypass, denials increased in Florida from 6% to a maximum of 13% and remained stable in Texas at 5% to 7%. Conclusions. Minors' use of judicial bypass in Texas and Florida is substantial. The percentage of denials is higher and increasing in Florida. Public Health Implications. Minors who need confidential abortion care may now be forced to seek judicial bypass far from home. Parental involvement laws in states that do not ban abortion will compound barriers to abortion care. (Am J Public Health. 2023;113(3):316-319. https://doi.org/10.2105/10.2105/AJPH.2022.307173).

Expanded Contraceptive Access Linked To Increase In College Completion Among Women In Colorado.

Public subsidies for contraception are often justified by assertions regarding their benefits for women's lives, yet there is limited contemporary evidence supporting these assertions. Beginning in 2009 the Colorado Family Planning Initiative abruptly expanded access to the full range of contraceptive methods through Colorado's Title X family planning clinics. Using eleven years of American Community Survey data linked to data from two decennial censuses, we assessed whether exposure to the program led to improvements in college completion among women. Exposure to the Colorado Family Planning Initiative at high school ages was associated with a population-level increase of 1.8-3.5 percentage points in women's on-time bachelor's degree attainment, which represents a 6-12 percent increase in women obtaining their degrees compared with earlier cohorts. Federal and state policies restricting or expanding access to the full range of contraceptive methods can affect women's attainment of higher education in addition to their reproductive health.

Measuring US fertility using administrative data from the Census Bureau.

BACKGROUND: Longitudinal data available for studying fertility in the United States are not representative at the state level, limiting analyses of subnational variation in US fertility. The US Census Bureau makes available restricted data that may be used for measuring fertility, but the data have not previously been described for a scholarly audience or used for fertility research. OBJECTIVE: This paper describes and analyzes restricted-use administrative birth data available through the Census Numident for nearly all US births for more than the last century. Within these data, most births since 1997 are linked to parents through the Census Household Composition Key (CHCK). These analyses are designed to illustrate the scope and limitations of these data for the study of US fertility. METHODS: We describe the creation and content of the Census Numindent and CHCK data sets and compare the data to published US vital statistics. We also analyze the geographic coverage of both data sets and compare the demographic composition of the new data sources to national demographic composition. We further illustrate how these novel data sources may be used by comparing them to survey responses at the individual level. CONTRIBUTION: This paper describes an underutilized source of national US data for studying fertility, shows the quality of these data by performing analyses, and explains how scholars can access these data for research.

The Pregnancy-Related Mortality Impact of a Total Abortion Ban in the United States: A Research Note on Increased Deaths Due to Remaining Pregnant.

In this research note, I estimate one component of the mortality impact of denying all wanted induced abortions in the United States. This estimate quantifies the magnitude of an increase in pregnancy-related deaths that would occur solely because of the greater mortality risk of continuing a pregnancy rather than having a legal induced abortion. Using published statistics on pregnancy-related mortality ratios, births, and abortions, I estimate U.S. pregnancy-related deaths by race and ethnicity before and in the first and subsequent years of a hypothetical total abortion ban. The number of estimated deaths following a total abortion ban is determined by assuming three conditions: that all wanted induced abortions are denied, that each abortion denied leads to 0.8 births, and that there is a corresponding increase in exposure to pregnancy-related mortality. I find that in the first year of such a ban, estimated pregnancy-related deaths would increase from 675 to 724 (49 additional deaths, representing a 7% increase), and in subsequent years to 815 (140 additional deaths, for a 21% increase). Non-Hispanic Black people would experience the greatest increase in deaths (a 33% increase in subsequent years). Estimated pregnancy-related deaths would increase for all races and ethnicities examined. Overall, denying all wanted induced abortions in the United States would increase pregnancy-related mortality substantially, even if the rate of unsafe abortion did not increase.

The impact of contraceptive access on high school graduation.

Does access to the full range of contraceptive methods increase young women's educational attainment? Family planning programs are often justified by claims that it does, but contemporary evidence is unexpectedly weak. We use a natural experiment afforded by a 2009 Colorado policy change to assess the impact of expanded access to contraception on women's high school graduation. Linking survey and Census data, we follow a population-representative U.S. sample, including large subsamples of young women living in Colorado in 2010 and in comparison states. Using a difference-in-differences design, we find expansion of access to contraception was associated with a statistically significant 1.66 percentage-point increase in high school graduation. This increase in graduation represents a 14% decrease in the baseline percentage not graduating high school before the policy change. Results are robust to a variety of sensitivity tests. Our findings indicate that improving access to contraception increases young women's human capital formation.

Psychosocial adjustment to Mild Cognitive Impairment: The role of illness perceptions, cognitive fusion and cognitive impairment.

BACKGROUND AND OBJECTIVE: Receiving a Mild Cognitive Impairment diagnosis and adjusting to this condition is challenging, given the uncertain clinical trajectory surrounding progression to dementia. We aimed to explore the influence of illness perceptions and cognitive fusion on coping and emotional responses in a sample of people diagnosed with Mild Cognitive Impairment.Research design and method: A cross-sectional study of 34 participants with Mild Cognitive Impairment (47% female and 53% male; mean age 76.4 years) evaluated the relationships between cognitive impairment, illness perceptions and cognitive fusion on levels of distress and quality of life. Participants completed standardised measures for cognitive assessment, illness perceptions, cognitive fusion, depression, anxiety and quality of life. Relationships between variables were analysed using correlation, regression and conditional process analyses. RESULTS: At the group level, illness perceptions were found to be a stronger predictor of depression and quality of life in the current sample than objective cognitive impairment. Illness perceptions did not directly predict anxiety, rather cognitive fusion significantly mediated this relationship. Cognitive fusion also significantly mediated the relationship between illness perceptions and depression. Illness perceptions had a significant, direct effect on quality of life; however, there was no significant indirect effect via cognitive fusion. Greater fusion with threatening illness perceptions was significantly related to increased anxiety and depression.Discussion and implications: Data suggest multiple potential treatment targets in helping people diagnosed with Mild Cognitive Impairment to successfully adapt and adjust. Targeting appraisals (illness perceptions) using Cognitive Therapy is one potential treatment target. In addition, psychological treatments such as Acceptance and Commitment Therapy, which target cognitive fusion, could also warrant further investigation in this population, due to the significant indirect paths from illness perceptions to distress and quality of life, via cognitive fusion.

Judicial bypass attorneys' experiences with abortion stigma in Texas courts.

Texas requires pregnant young people under 18 (i.e., minors) seeking abortion without parental consent to go to court with an attorney to petition a judge for permission to obtain abortion. There is a lack of empirical data on the process through which abortion laws stigmatize abortion and on the actors involved. We use data from in-depth qualitative interviews with 19 attorneys who participated in a collective 800 judicial bypass cases to explore what's at stake for multiple actors within a shared social space and how interactions between those actors reproduce stigma. We extend stigma theory to explain how structural abortion restrictions produce stigma at the individual level. We find that to protect their interests in "keeping pregnant minors in," the Texas court system constrains attorneys' ability to represent minors through politicization and stigmatization; attorneys face logistical and emotional challenges, including navigating hostile or ill-informed courts, witnessing court actors humiliate their clients without means of recourse, and experiencing stigma themselves. Although what's most at stake for their clients becomes most at stake for attorneys- helping young people obtain a judicial bypass so they can access abortion and protecting them from humiliation and trauma- they must reconcile their own violation of norms stigmatizing abortion with their consciences' motivation to represent bypass clients and protect their professional identity and career advancement from being "tainted" by taking judicial bypass cases. In order to protect what is at stake for their clients in the context of the highly stigmatized Texas courts, attorneys rationally make trade-offs that protect some stakes while undermining others. Moreover, attorneys' management of experienced stigma and their violation of norms stigmatizing abortion leads some to reproduce abortion stigma in their interactions with minors.

Adolescents Obtaining Abortion Without Parental Consent: Their Reasons and Experiences of Social Support.

CONTEXT: Most states require adolescents younger than 18 to involve a parent prior to obtaining an abortion, yet little is known about adolescents' reasons for choosing abortion or the social support received by those who seek judicial bypass of parental consent for abortion. METHODS: In-depth interviews were conducted with 20 individuals aged 16-19 who sought judicial bypass in Texas between 2015 and 2016 to explore why they chose to get an abortion, who they involved in their decision and what their experiences of social support were. Data were analyzed thematically using stigma and social support theories. RESULTS: Participants researched their pregnancy options and involved others in their decisions. They chose abortion because parenting would limit their futures, and they believed they could not provide a child with all of her or his needs. Anticipated stigma motivated participants to keep their decision private, although they desired emotional and material support. Not all male partners agreed with adolescents' decisions to seek an abortion, and agreement by some males did not guarantee emotional or material support; some young women described their partners' giving them the "freedom" to make the decision as avoiding responsibility. After a disclosure of their abortion decision, some participants experienced enacted stigma, including shame and emotional abuse. CONCLUSIONS: Abortion stigma influences adolescents' disclosure of their abortion decisions and limits their social support. Fears of disclosing their pregnancies and abortion decisions are justified, and policymakers should consider how laws requiring parental notification may harm adolescents. Further research is needed on adolescents' experiences with abortion stigma.

Denials of Judicial Bypass Petitions for Abortion in Texas Before and After the 2016 Bypass Process Change: 2001-2018.

Objectives. To estimate the percentage of Texas judicial bypass petitions for abortion denied annually from 2001 to 2018, and to assess whether that fraction changed after the state's 2016 bypass process change.Methods. Because official statistics on Texas judicial bypass case counts and outcomes are only available for 2016 and later, we systematically reviewed monthly internal reports from Jane's Due Process (JDP), an organization providing legal representation to pregnant minors seeking bypass from 2001 to 2018. We report numbers and percentages of JDP cases denied for 2001 to 2018 and numbers and percentages of all cases denied from official Texas statistics for 2016 to 2018 (all available years).Results. At least 1 denial occurred in 11 out of 15 years observed before the bypass law changed in Texas (percentages = 0%-6.2%). After Texas made its bypass process more restrictive, the percentage denied increased (from 2.8% in 2015 to 10.3% in 2016 among JDP cases).Conclusions. We found the greatest percentages of judicial bypass for abortion petitions denied after the policy was implemented and after the bypass process changed. Judicial bypass for abortion may expose pregnant minors to judicial veto of their abortion decision.

Young Women's Experiences Obtaining Judicial Bypass for Abortion in Texas.

PURPOSE: Like many states, Texas requires parental consent for adolescents under 18 to access abortion care. Adolescents who cannot obtain parental consent can try to obtain a judicial bypass of parental consent through the court system. Little is known about adolescents' experiences with the judicial bypass process. Working with Jane's Due Process, an organization providing legal representation for adolescents, we explored adolescents' experiences with the judicial bypass process. METHODS: We conducted phone interviews with 20 adolescents, 16-19 years old in Texas between September and December 2016 about their experiences trying to obtain a judicial bypass. Data analysis included inductive and deductive coding based on theories about engaging with the court system and stigma regarding abortion and adolescent sexuality. RESULTS: In addition to unpredictability and logistic burdens such as finding time away from school and arranging transportation, participants described the bypass process as "intimidating" and "scary" and described judges and guardians-ad-litem who shamed them, "preached" at them, and discredited evidence of their maturity. Data suggest adolescents internalize stigma and trauma they experienced through rationalizing both the need for the bypass process and disrespectful treatment by authority figures. CONCLUSIONS: We found the bypass process functions as a form of punishment and allows state actors to humiliate adolescents for their personal decisions. The bypass process was implemented to protect adolescents from alleged negative emotional consequences of abortion, yet our results suggest the bypass process itself causes emotional harm through unpredictability and humiliation. Despite participants' resilience, the process may have negative consequences for adolescent health.

Unmet demand for short-acting hormonal and long-acting reversible contraception among community college students in Texas.

OBJECTIVE: To identify preferences for and use of short-acting hormonal (e.g., oral contraceptives, injectable contraception) or long-acting reversible contraception (LARC) among community college students in Texas. PARTICIPANTS: Female community college students, ages 18 to 24, at risk of pregnancy, sampled in Fall 2014 or Spring 2015 (N = 966). METHODS: We assessed characteristics associated with preference for and use of short-acting hormonal or LARC methods (i.e., more-effective contraception). RESULTS: 47% preferred short-acting hormonal methods and 21% preferred LARC, compared to 21% and 9%, respectively, who used these methods. A total of 63% of condom and withdrawal users and 78% of nonusers preferred a more effective method. Many noted cost and insurance barriers as reasons for not using their preferred more-effective method. CONCLUSIONS: Many young women in this sample who relied on less-effective methods preferred to use more-effective contraception. Reducing barriers could lead to higher uptake in this population at high risk of unintended pregnancy.

Does information about abortion safety affect Texas voters' opinions about restrictive laws? A randomized study.

OBJECTIVE: The objective was to assess whether information about abortion safety and awareness of abortion laws affect voters' opinions about medically unnecessary abortion regulations. STUDY DESIGN: Between May and June 2016, we randomized 1200 Texas voters to receive or not receive information describing the safety of office-based abortion care during an online survey about abortion laws using simple random assignment. We compared the association between receiving safety information and awareness of recent restrictions and beliefs that ambulatory surgical center (ASC) requirements for abortion facilities and hospital admitting privileges requirements for physicians would make abortion safer. We used Poisson regression, adjusting for political affiliation and views on abortion. RESULTS: Of 1200 surveyed participants, 1183 had complete data for analysis: 612 in the information group and 571 in the comparison group. Overall, 259 (46%) in the information group and 298 (56%) in the comparison group believed that the ASC requirement would improve abortion safety (p=.008); 230 (41%) in the information group and 285 (54%) in the comparison group believed that admitting privileges would make abortion safer (p<.001). After multivariable adjustment, the information group was less likely to report that the ASC [prevalence ratio (PR): 0.82; 95% confidence interval (CI): 0.72-0.94] and admitting privileges requirements (PR: 0.76; 95% CI: 0.65-0.88) would improve safety. Participants who identified as conservative Republicans were more likely to report that the ASC (82%) and admitting privileges requirements (83%) would make abortion safer if they had heard of the provisions than if they were unaware of them (ASC: 52%; admitting privileges: 47%; all p<.001). CONCLUSIONS: Informational statements reduced perceptions that restrictive laws make abortion safer. Voters' prior awareness of the requirements also was associated with their beliefs. IMPLICATIONS: Informational messages can shift scientifically unfounded views about abortion safety and could reduce support for restrictive laws. Because prior awareness of abortion laws does not ensure accurate knowledge about their effects on safety, it is important to reach a broad audience through early dissemination of information about new regulations.

Contraception After Delivery Among Publicly Insured Women in Texas: Use Compared With Preference.

OBJECTIVE: To assess women's preferences for contraception after delivery and to compare use with preferences. METHODS: In a prospective cohort study of women aged 18-44 years who wanted to delay childbearing for at least 2 years, we interviewed 1,700 participants from eight hospitals in Texas immediately postpartum and at 3 and 6 months after delivery. At 3 months, we assessed contraceptive preferences by asking what method women would like to be using at 6 months. We modeled preference for highly effective contraception and use given preference according to childbearing intentions using mixed-effects logistic regression testing for variability across hospitals and differences between those with and without immediate postpartum long-acting reversible contraception (LARC) provision. RESULTS: Approximately 80% completed both the 3- and 6-month interviews (1,367/1,700). Overall, preferences exceeded use for both-LARC: 40.8% (n=547) compared with 21.9% (n=293) and sterilization: 36.1% (n=484) compared with 17.5% (n=235). In the mixed-effects logistic regression models, several demographic variables were associated with a preference for LARC among women who wanted more children, but there was no significant variability across hospitals. For women who wanted more children and had a LARC preference, use of LARC was higher in the hospital that offered immediate postpartum provision (P<.035) as it was for U.S.-born women (odds ratio [OR] 2.08, 95% CI 1.17-3.69) and women with public prenatal care providers (OR 2.04, 95% CI 1.13-3.69). In the models for those who wanted no more children, there was no significant variability in preferences for long-acting or permanent methods across hospitals. However, use given preference varied across hospitals (P<.001) and was lower for black women (OR 0.26, 95% CI 0.12-0.55) and higher for U.S.-born women (OR 2.32, 95% CI 1.36-3.96), those 30 years of age and older (OR 1.82, 95% CI 1.07-3.09), and those with public prenatal care providers (OR 2.04, 95% CI 1.18-3.51). CONCLUSION: Limited use of long-acting and permanent contraceptive methods after delivery is associated with indicators of health care provider and system-level barriers. Expansion of immediate postpartum LARC provision as well as contraceptive coverage for undocumented women could reduce the gap between preference and use.

Women's Knowledge of and Support for Abortion Restrictions in Texas: Findings from a Statewide Representative Survey.

CONTEXT: States have passed numerous laws restricting abortion, and Texas passed some of the most restrictive legislation between 2011 and 2013. Information about women's awareness of and support for the laws' provisions could inform future debates regarding abortion legislation. METHODS: Between December 2014 and January 2015, some 779 women aged 18-49 participated in an online, statewide representative survey about recent abortion laws in Texas. Poisson regression analysis was used to assess correlates of support for a law that would make obtaining an abortion more difficult. Women's knowledge of specific abortion restrictions in Texas and reasons for supporting these laws were also assessed. RESULTS: Overall, 31% of respondents would support a law making it more difficult to obtain an abortion. Foreign-born Latinas were more likely than whites to support such a law (prevalence ratio, 1.5), and conservative Republicans were more likely than moderates and Independents to do so (2.3). Thirty-six percent of respondents were not very aware of recent Texas laws, and 19% had never heard of them. Among women with any awareness of the laws, 19% supported the requirements; 42% of these individuals said this was because such laws would make abortion safer. CONCLUSIONS: Many Texas women of reproductive age are unaware of statewide abortion restrictions, and some support these requirements because of misperceptions about the safety of abortion. Advocates and policymakers should address these knowledge gaps in efforts to protect access to legal abortion.

Barriers to Postpartum Contraception in Texas and Pregnancy Within 2 Years of Delivery.

OBJECTIVE: To assess pregnancies that could have been averted through improved access to contraceptive methods in the 2 years after delivery. METHODS: In this cohort study, we interviewed 403 postpartum women in a hospital in Austin, Texas, who wanted to delay childbearing for at least 2 years. Follow-up interviews were completed at 3, 6, 9, 12, 18, and 24 months after delivery; retention at 24 months was 83%. At each interview, participants reported their pregnancy status and contraceptive method. At the 3- and 6-month interviews, participants were also asked about their preferred contraceptive method 3 months in the future. We identified types of barriers among women unable to access their preferred method and used Cox models to analyze the risk of pregnancy from 6 to 24 months after delivery. RESULTS: Among women interviewed 6 months postpartum (n=377), two thirds had experienced a barrier to accessing their preferred method of contraception. By 24 months postpartum, 89 women had reported a pregnancy; 71 were unintended. Between 6 and 24 months postpartum, 77 of 377 women became pregnant (20.4%), with 56 (14.9%) lost to follow-up. Women who encountered a barrier to obtaining their preferred method were more likely to become pregnant less than 24 months after delivery. They had a cumulative risk of pregnancy of 34% (95% confidence interval [CI] 0.25-0.43) as compared with 12% (95% CI 0.05-0.18) for women with no barrier. All but three of the women reporting an unintended pregnancy had earlier expressed interest in using long-acting reversible contraception or a permanent method. CONCLUSION: In this study, most unintended pregnancies less than 24 months after delivery could have been prevented or postponed had women been able to access their desired long-acting and permanent methods.

Effect of Removal of Planned Parenthood from the Texas Women's Health Program.

BACKGROUND: Texas is one of several states that have barred Planned Parenthood affiliates from providing health care services with the use of public funds. After the federal government refused to allow (and courts blocked) the exclusion of Planned Parenthood affiliates from the Texas Medicaid fee-for-service family-planning program, Texas excluded them from a state-funded replacement program, effective January 1, 2013. We assessed rates of contraceptive-method provision, method continuation through the program, and childbirth covered by Medicaid before and after the Planned Parenthood exclusion. METHODS: We used all program claims from 2011 through 2014 to examine changes in the number of claims for contraceptives according to method for 2 years before and 2 years after the exclusion. Among women using injectable contraceptives at baseline, we observed rates of contraceptive continuation through the program and of childbirth covered by Medicaid. We used the difference-in-differences method to compare outcomes in counties with Planned Parenthood affiliates with outcomes in those without such affiliates. RESULTS: After the Planned Parenthood exclusion, there were estimated reductions in the number of claims from 1042 to 672 (relative reduction, 35.5%) for long-acting, reversible contraceptives and from 6832 to 4708 (relative reduction, 31.1%) for injectable contraceptives (P<0.001 for both comparisons). There was no significant change in the number of claims for short-acting hormonal contraceptive methods during this period. Among women using injectable contraceptives, the percentage of women who returned for a subsequent on-time contraceptive injection decreased from 56.9% among those whose subsequent injections were due before the exclusion to 37.7% among those whose subsequent injections were due after the exclusion in the counties with Planned Parenthood affiliates but increased from 54.9% to 58.5% in the counties without such affiliates (estimated difference in differences in counties with affiliates as compared with those without affiliates, -22.9 percentage points; P<0.001). During this period in counties with Planned Parenthood affiliates, the rate of childbirth covered by Medicaid increased by 1.9 percentage points (a relative increase of 27.1% from baseline) within 18 months after the claim (P=0.01). CONCLUSIONS: The exclusion of Planned Parenthood affiliates from a state-funded replacement for a Medicaid fee-for-service program in Texas was associated with adverse changes in the provision of contraception. For women using injectable contraceptives, there was a reduction in the rate of contraceptive continuation and an increase in the rate of childbirth covered by Medicaid. (Funded by the Susan T. Buffett Foundation.).

Abortion access and state variation in observed unintended pregnancy.

OBJECTIVE: The state-level proportion of pregnancies that are unintended is an important social and public health indicator, and comparisons between states inform policy discussions. Unintended pregnancy is measured as a composite of abortions and unintended births, each of which is measured with error. We investigate whether between-state differences in abortion access and demand may bias comparisons between states' unintended pregnancy proportions when pregnancy intentions are misreported. STUDY DESIGN: We algebraically specify the model currently used to estimate unintended pregnancy, extend it to include underreporting, and simulate the impact of underreporting on observed unintended pregnancy. Comparing the impact of underreporting across states, we identify levels of underreporting at which between-state comparisons are compromised. RESULTS: We find that underreporting of unintended pregnancies could bias between-state comparisons when reporting of unintended pregnancies is less than 90-95%. CONCLUSION: Current methods for estimating state-level unintended pregnancy proportions may underestimate unintended pregnancy to a greater degree in places with less abortion, and between-state comparisons may be biased. Estimates of state-level unintended pregnancy proportions would be more comparable if adjustment for completeness of retrospective underreporting were included in the estimation process. IMPLICATIONS: Estimates of unintended pregnancy should be adjusted for nonsampling error and include variances based on sampling and nonsampling error in order to permit robust comparisons between states, between populations, and across time. More research on the fidelity of retrospective reporting of pregnancy intention would facilitate this endeavor.