Replication and validation of a statewide linkage method to estimate incidence proportion of child maltreatment.

PURPOSE: To study familial factors associated with child maltreatment in a birth population, Alaska piloted a mixed-design method that linked child welfare data with the Pregnancy Risk Assessment Monitoring System (PRAMS). We replicated this approach in Oregon and validated it in both states. METHODS: We linked vital records, child welfare, and PRAMS data to create two 2009 birth cohorts for each state: one based on vital records (full birth cohort) and one on PRAMS (stratified random sample). For each cohort, we estimated the incidence proportions (IP) of child maltreatment before age 9 years and compared those estimated using PRAMS with those observed using the full birth cohort. RESULTS: The Oregon PRAMS cohort estimated that 28.7% (95% CI: 24.0, 33.4), 20.9% (17.1, 24.7), and 8.3% (6.0, 10.5) of children experienced an alleged, investigated, and substantiated maltreatment, respectively, versus 32.0%, 25.0%, and 9.9% from the birth cohort. The corresponding Alaska estimates were 29.1% (26.1, 32.0), 22.6% (19.9, 25.2), and 8.3% (6.7, 9.9) of children from the PRAMS cohort versus 29.1%, 23.5%, and 9.1% in the birth cohort. CONCLUSIONS: The IP of child maltreatment in two states was accurately estimated with PRAMS cohorts. Researchers can study a comprehensive set of factors that may influence child maltreatment by incorporating PRAMS into birth cohort linkages.

Gynecologic clostridial toxic shock in women of reproductive age.

Clostridial toxic shock, caused by Clostridium sordellii or Clostridium perfringens, is a rare and largely fatal syndrome among reproductive-aged women with genital tract infection, and may occur following various pregnancy outcomes or without pregnancy. Clinicians should be aware of common clinical features of this very rapidly-progressing syndrome including abdominal pain, tachycardia, hypotension, third-space fluid accumulations, hemoconcentration, and marked leukemoid response, often with lack of fever. In this review, we summarize known cases through mid-2011 and information on clinical presentation, diagnosis, treatment, and results of recent investigations regarding pathogenesis, including germination, toxins, and host response that may have important implications for development of preventive or therapeutic interventions.

Undiagnosed cases of fatal Clostridium-associated toxic shock in Californian women of childbearing age.

OBJECTIVE: In 2005, 4 Clostridium sordellii-associated toxic shock fatalities were reported in young Californian women after medical abortions. The true incidence of this rare disease is unknown, and a population-based study has never been performed. Additional clostridia-associated deaths were sought to describe associated clinical characteristics. STUDY DESIGN: Population-based death certificate review and a clinical case definition for clostridial-associated toxic shock identified women with likelihood of dying from a Clostridium infection. Formalin-fixed autopsy tissues underwent immunohistochemical and polymerase chain reaction assays. RESULTS: Thirty-eight women were suspected of having C sordellii-associated death. Five tested positive for Clostridium species: 3 for Clostridium perfringens, 1 for C sordellii, and 1 for both. Deaths occurred after the medical procedures for cervical dysplasia (n = 2), surgical abortion (n = 1), stillborn delivery (n = 1), and term live birth (n = 1). None had a medical abortion. CONCLUSION: C sordellii and C perfringens are associated with undiagnosed catastrophic infectious gynecologic illnesses among women of childbearing age.

Toxic shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneous abortion.

OBJECTIVE: To better understand the risk of fatal toxic shock caused by Clostridium sordellii in women who had a recent medical abortion with mifepristone and misoprostol. METHODS: We performed active and passive surveillance for cases of toxic shock associated with medical or spontaneous abortion. To identify the cause of toxic shock, immunohistochemical assays for multiple bacteria were performed on formalin-fixed surgical and autopsy tissues. We extracted DNA from tissues, performed Clostridium species-specific polymerase chain reaction assays, and sequenced amplified products for confirmation of Clostridium species. RESULTS: We report four patients with toxic shock associated with Clostridium species infection after medical or spontaneous abortion. Two women had fatal Clostridium perfringens infections after medically induced abortions: one with laminaria and misoprostol and one with the regimen of mifepristone and misoprostol. One woman had a nonfatal Clostridium sordellii infection after spontaneous abortion. Another woman had a fatal C sordellii infection after abortion with mifepristone and misoprostol. All four patients had a rapidly progressive illness with necrotizing endomyometritis. CONCLUSION: Toxic shock after abortion can be caused by C perfringens as well as C sordellii, can be nonfatal, and can occur after spontaneous abortion and abortion induced by medical regimens other than mifepristone and misoprostol. LEVEL OF EVIDENCE: III.

Abortion surveillance--United States, 1998.

PROBLEM/CONDITION: In 1969, CDC began abortion surveillance to document the number and characteristics of women obtaining legal induced abortions, to monitor unintended pregnancy, and to assist efforts to identify and reduce preventable causes of morbidity and mortality associated with abortions. REPORTING PERIOD COVERED: This report summarizes and reviews information reported to CDC regarding legal induced abortions obtained in the United States in 1998. DESCRIPTION OF SYSTEM: For each year since 1969, CDC has compiled abortion data by occurrence. From 1973 to 1997, data were received from or estimated for 52 reporting areas in the United States: 50 states, the District of Columbia, and New York City. In 1998, CDC compiled abortion data from only 48 reporting areas; Alaska, California, New Hampshire, and Oklahoma did not report. RESULTS: In 1998, 884,273 legal induced abortions were reported to CDC, representing a 2% decrease from the 900,171 legal induced abortions reported by the same 48 reporting areas for 1997. The abortion ratio, defined as the number of abortions per 1,000 live births, was 264, compared with 274 in 1997 (for the same 48 areas); the abortion rate for these 48 areas was 17 per 1,000 women aged 15-44 years for both 1997 and 1998. The availability of information about characteristics of women who obtained an abortion in 1998 varied by state and by the number of states reporting each characteristic. The total number of legal induced abortions by state is reported by state of residence and state of occurrence; characteristics of women obtaining abortions in 1998 are reported by state of occurrence. Women undergoing an abortion were likely to be young (i.e., age < 25 years), white, and unmarried; slightly more than one half were obtaining an abortion for the first time. Of all abortions for which gestational age was reported, 56% were performed at < or = 8 weeks of gestation, and 88% were performed before 13 weeks. Overall, 19% of abortions were performed at the earliest weeks of gestation (< or = 6 weeks), 18% at 7 weeks, and 19% at 8 weeks. From 1992 (when this information was first collected) through 1998, an increasing percentage of abortions were performed at the very early weeks of gestation. Few abortions were provided after 15 weeks of gestation; 4% were obtained at 16-20 weeks, and 1.4% were obtained at > or = 21 weeks. A total of 24 reporting areas submitted information stating that they performed medical (nonsurgical) procedures (two of these areas categorized medical abortions with "other" procedures), making up < 1% of all procedures reported from all states. From 1993 through 1997 (years for which data have not been published previously and the most recent years for which such data are available), 36 women died as a result of complications from known legal induced abortion, and three deaths were associated with known illegal abortion. The annual case-fatality rate of legal induced abortion ranged from 0.3 to 0.8 abortion-related deaths per 100,000 reported legal induced abortions. INTERPRETATION: From 1990 through 1995, the number of abortions declined each year; in 1996, the number increased slightly, but in 1997, it declined to its lowest level since 1978. In 1998, the number of abortions continued to decrease when comparing the 48 reporting areas. In 1997, as in previous years, deaths related to legal induced abortions occurred rarely. PUBLIC HEALTH ACTIONS TAKEN: The number and characteristics of women who obtain abortions in the United States should continue to be monitored so that trends in induced abortion can be assessed and efforts to prevent unintended pregnancy can be evaluated.

Abortion-Related Mortality in the United States: 1998-2010.

OBJECTIVE: To examine characteristics and causes of legal induced abortion-related deaths in the United States between 1998 and 2010. METHODS: Abortion-related deaths were identified through the national Pregnancy Mortality Surveillance System with enhanced case-finding. We calculated the abortion mortality rate by race, maternal age, and gestational age and the distribution of causes of death by gestational age and procedure. RESULTS: During the period from 1998-2010, of approximately 16.1 million abortion procedures, 108 women died, for a mortality rate of 0.7 deaths per 100,000 procedures overall, 0.4 deaths for non-Hispanic white women, 0.5 deaths for Hispanic women, and 1.1 deaths for black women. The mortality rate increased with gestational age, from 0.3 to 6.7 deaths for procedures performed at 8 weeks or less and at 18 weeks or greater, respectively. A majority of abortion-related deaths at 13 weeks of gestation or less were associated with anesthesia complications and infection, whereas a majority of abortion-related deaths at more than 13 weeks of gestation were associated with infection and hemorrhage. In 20 of the 108 cases, the abortion was performed as a result of a severe medical condition where continuation of the pregnancy threatened the woman's life. CONCLUSION: Deaths associated with legal induced abortion continue to be rare events-less than 1 per 100,000 procedures. Primary prevention of unintended pregnancy, including those in women with serious pre-existing medical conditions, and increased access to abortion services at early gestational ages may help to further decrease abortion-related mortality in the United States. LEVEL OF EVIDENCE: III.

Large summertime influenza A outbreak among tourists in Alaska and the Yukon Territory.

We investigated a large summertime outbreak of acute respiratory illness during May-September 1998 in Alaska and the Yukon Territory, Canada. Surveillance for acute respiratory illness (ARI), influenza-like illness (ILI), and pneumonia conducted at 31 hospital, clinic, and cruise ship infirmary sites identified 5361 cases of ARI (including 2864 cases of ILI [53%] and 171 cases of pneumonia [3.2%]) occurring primarily in tourists and tourism workers (from 18 and 37 countries, respectively). Influenza A viruses were isolated from 41 of 210 patients with ILI at 8 of 14 land sites and 8 of 17 cruise ship infirmaries. Twenty-two influenza isolates were antigenically characterized, and all were influenza A/Sydney/05/97-like (H3N2) viruses. No other predominant pathogens were identified. We estimated that >33,000 cases of ARI might have occurred during this protracted outbreak, which was attributed primarily to influenza A/Sydney/05/97-like (H3N2) viruses. Modern travel patterns may facilitate similar outbreaks, indicating the need for increased awareness about influenza by health care providers and travelers and the desirability of year-round influenza surveillance in some regions.

Risk factors for legal induced abortion-related mortality in the United States.

OBJECTIVE: To assess risk factors for legal induced abortion-related deaths. METHODS: This is a descriptive epidemiologic study of women dying of complications of induced abortions. Numerator data are from the Abortion Mortality Surveillance System. Denominator data are from the Abortion Surveillance System, which monitors the number and characteristics of women who have legal induced abortions in the United States. Risk factors examined include age of the woman, gestational length of pregnancy at the time of termination, race, and procedure. Main outcome measures include crude, adjusted, and risk factor-specific mortality rates. RESULTS: During 1988-1997, the overall death rate for women obtaining legally induced abortions was 0.7 per 100000 legal induced abortions. The risk of death increased exponentially by 38% for each additional week of gestation. Compared with women whose abortions were performed at or before 8 weeks of gestation, women whose abortions were performed in the second trimester were significantly more likely to die of abortion-related causes. The relative risk (unadjusted) of abortion-related mortality was 14.7 at 13-15 weeks of gestation (95% confidence interval [CI] 6.2, 34.7), 29.5 at 16-20 weeks (95% CI 12.9, 67.4), and 76.6 at or after 21 weeks (95% CI 32.5, 180.8). Up to 87% of deaths in women who chose to terminate their pregnancies after 8 weeks of gestation may have been avoidable if these women had accessed abortion services before 8 weeks of gestation. CONCLUSION: Although primary prevention of unintended pregnancy is optimal, among women who choose to terminate their pregnancies, increased access to surgical and nonsurgical abortion services may increase the proportion of abortions performed at lower-risk, early gestational ages and help further decrease deaths. LEVEL OF EVIDENCE: II-2

Trends in use of medical abortion in the United States: reanalysis of surveillance data from the Centers for Disease Control and Prevention, 2001-2008.

BACKGROUND: With changing patterns and increasing use of medical abortion in the United States, it is important to have accurate statistics on the use of this method regularly available. This study assesses the accuracy of medical abortion data reported annually to the Centers for Disease Control and Prevention (CDC) and describes trends over time in the use of medical abortion relative to other methods. STUDY DESIGN: This analysis included data reported to CDC for 2001-2008. Year-specific analyses included all states that monitored medical abortion for a given year, while trend analyses were restricted to states that monitored medical abortion continuously from 2001 to 2008. Data quality and completeness were assessed by (a) examining abortions reported with an unspecified method type within the gestational age limit for medical abortion (med-eligible abortions) and (b) comparing the percentage of all abortions and med-eligible abortions reported to CDC as medical abortions with estimates based on published mifepristone sales data for the United States from 2001 to 2007. RESULTS: During 2001-2008, the percentage of med-eligible abortions reported to CDC with an unspecified method type remained low (1.0%-2.2%); CDC data and mifepristone sales estimates for 2001-2007 demonstrated strong agreement [all abortions: intraclass correlation coefficient (ICC)=0.983; med-eligible abortions: ICC=0.988]. During 2001-2008, the percentage of abortions reported to CDC as medical abortions increased (p<.001 for all abortions and for med-eligible abortions). Among states that reported medical abortions for 2008, 15% of all abortions and 23% of med-eligible abortions were reported as medical abortions. CONCLUSION: CDC's Abortion Surveillance System provides an important annual data source that accurately describes the use of medical abortion relative to other methods in the United States.

Abortion surveillance--United States, 2009.

PROBLEM/CONDITION: Since 1969, CDC has conducted abortion surveillance to document the number and characteristics of women obtaining legal induced abortions in the United States. REPORTING PERIOD COVERED: 2009. DESCRIPTION OF SYSTEM: Each year, CDC requests abortion data from the central health agencies of 52 reporting areas (the 50 states, the District of Columbia, and New York City). The reporting areas provide this information voluntarily. For 2009, data were received from 48 reporting areas. For the purpose of trend analysis, abortion data were evaluated from the 45 areas that reported data every year during 2000-2009. Census and natality data, respectively, were used to calculated abortion rates (number of abortions per 1,000 women) and ratios (number of abortions per 1,000 live births). RESULTS: A total of 784,507 abortions were reported to CDC for 2009. Of these abortions, 772,630 (98.5%) were from the 45 reporting areas that provided data every year during 2000-2009. Among these same 45 reporting areas, the abortion rate for 2009 was 15.1 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 227 abortions per 1,000 live births. Compared with 2008, the total number and rate of reported abortions for 2009 decreased 5%, representing the largest single year decrease for the entire period of analysis. The abortion ratio decreased 2%. From 2000 to 2009, the total number, rate, and ratio of reported abortions decreased 6%, 7%, and 8%, respectively, to the lowest levels for 2000-2009. In 2009 and throughout the period of analysis, women in their 20s accounted for the majority of abortions and had the highest abortion rates, whereas women aged ≥30 years accounted for a much smaller percentage of abortions and had lower abortion rates. In 2009, women aged 20-24 and 25-29 years accounted for 32.7% and 24.4% of all abortions, respectively, and had an abortion rate of 27.4 abortions per 1,000 women aged 20-24 years and 20.4 abortions per 1,000 women aged 25-29 years. In contrast, women aged 30-34, 35-39, and ≥40 years accounted for 14.7%, 8.8%, and 3.3% of all abortions, respectively, and had an abortion rate of 13.3 abortions per 1,000 women aged 30-34 years, 7.6 abortions per 1,000 women aged 35-39 years, and 2.7 abortions per 1,000 women aged ≥40 years. Throughout the period of analysis, abortion rates decreased among women aged 20-24 and 25-29 years, whereas they increased among women aged ≥40 years. In 2009, adolescents aged 15-19 years accounted for 15.5% of all abortions and had an abortion rate of 13.0 abortions per 1,000 adolescents aged 15-19 years. Throughout the period of analysis, the percentage of all abortions accounted for by adolescents and the adolescent abortion rate decreased. In contrast to the percentage distribution of abortions and abortion rates by age, abortion ratios in 2009 and throughout the entire period of analysis were highest among adolescents and lowest among women aged 30-39 years. Abortion ratios decreased from 2000 to 2009 for women in all age groups except for those aged <15 years, for whom they increased. In 2009, most (64.0%) abortions were performed at ≤8 weeks' gestation, and 91.7% were performed at ≤13 weeks' gestation. Few abortions (7.0%) were performed at 14-20 weeks' gestation, and even fewer (1.3%) were performed at ≥21 weeks' gestation. From 2000 to 2009, the percentage of all abortions performed at ≤8 weeks' gestation increased 12%, whereas the percentage performed at >13 weeks' decreased 12%. Moreover, among abortions performed at ≤13 weeks' gestation, the distribution shifted toward earlier gestational ages, with the percentage of these abortions performed at ≤6 weeks' gestation increasing 47%. In 2009, 74.2% of abortions were performed by curettage at ≤13 weeks' gestation, 16.5% were performed by early medical abortion (a nonsurgical abortion at ≤8 weeks' gestation), and 8.1% were performed by curettage at >13 weeks' gestation. Among abortions that were performed at ≤8 weeks' gestation and thus were eligible for early medical abortion, 25.2% were completed by this method. The use of early medical abortion increased 10% from 2008 to 2009. Deaths of women associated with complications from abortions for 2009 are being investigated under CDC's Pregnancy Mortality Surveillance System. In 2008, the most recent year for which data were available, 12 women were reported to have died as a result of complications from known legal induced abortions. No reported deaths were associated with known illegal induced abortions. INTERPRETATION: Among the 45 areas that reported data every year during 2000-2009, the gradual decrease that had occurred during previous decades in the total number and rate of reported abortions continued through 2005, whereas year-to-year variation from 2006 to 2008 resulted in no net change during this later period. However, the change from 2008 to 2009 for both the total number of abortions and the abortion rate was the largest single year decrease during 2000-2009, and all three measures of abortion (total numbers, rates, and ratios) decreased to the lowest level observed during this period. PUBLIC HEALTH ACTIONS: Unintended pregnancy is the major contributor to abortion. Because unintended pregnancies are rare among women who use the most effective methods of reversible contraception, increasing access to and use of these methods can help further reduce the number of abortions performed in the United States. The data in this report can help program planners and policy makers identify groups of women at greatest risk for unintended pregnancy and help guide and evaluate prevention efforts.

Abortion surveillance - United States, 2007.

PROBLEM/CONDITION: Since 1969, CDC has conducted abortion surveillance to document the number and characteristics of women obtaining legal induced abortions in the United States. REPORTING PERIOD COVERED: 2007. DESCRIPTION OF SYSTEM: Each year, CDC requests abortion data from the central health agencies of 52 reporting areas (the 50 states, the District of Columbia, and New York City). This information is provided voluntarily. For 2007, data were received from 49 reporting areas. For the purpose of trend analysis, data were evaluated from the 45 areas that reported data every year during the preceding decade (1998-2007). Abortion rates (number of abortions per 1,000 women) and ratios (number of abortions per 1,000 live births) were calculated using census and natality data, respectively. RESULTS: A total of 827,609 abortions were reported to CDC for 2007. Among the 45 reporting areas that provided data every year during 1998-2007, a total of 810,582 abortions (97.9% of the total) were reported for 2007; the abortion rate was 16.0 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 231 abortions per 1,000 live births. Compared with 2006, the total number and rate of reported abortions decreased 2%, and the abortion ratio decreased 3%. Reported abortion numbers, rates, and ratios were 6%, 7%, and 14% lower, respectively, in 2007 than in 1998. Women aged 20-29 years accounted for 56.9% of all abortions in 2007 and for the majority of abortions during the entire period of analysis (1998-2007). In 2007, women aged 20-29 years also had the highest abortion rates (29.4 abortions per 1,000 women aged 20-24 years and 21.4 abortions per 1,000 women aged 25-29 years). Adolescents aged 15-19 years accounted for 16.5% of all abortions in 2007 and had an abortion rate of 14.5 abortions per 1,000 adolescents aged 15-19 years; women aged ≥35 years accounted for a smaller percentage (12.0%) of abortions and had lower abortion rates (7.7 abortions per 1,000 women aged 35-39 years and 2.6 abortions per 1,000 women aged ≥40 years). During 1998-2007, the abortion rate increased among women aged ≥35 years but decreased among adolescents aged ≤19 years and among women aged 20-29 years. In contrast to the percentage distribution of abortions and abortion rates, abortion ratios were highest at the extremes of reproductive age, both in 2007 and throughout the entire period of analysis. During 1998-2007 abortion ratios decreased among women in all age groups except for those aged <15 years. In 2007, most (62.3%) abortions were performed at ≤8 weeks' gestation, and 91.5% were performed at ≤13 weeks' gestation. Few abortions (7.2%) were performed at 14-20 weeks' gestation, and 1.3% were performed at ≥21 weeks' gestation. During 1998-2007, the percentage of abortions performed at ≤13 weeks' gestation remained stable; however, abortions performed at ≥16 weeks' gestation decreased by 13%-14%, and among the abortions performed at ≤13 weeks' gestation, the percentage performed at ≤6 weeks' gestation increased 65%. In 2007, 78.1% of abortions were performed by curettage at ≤13 weeks' gestation, and 13.1% were performed by early medical abortion (a nonsurgical abortion at ≤8 weeks' gestation); 7.9% of abortions were performed by curettage at >13 weeks' gestation. Among the 62.3% of abortions that were performed at ≤8 weeks' gestation, and thus were eligible for early medical abortion, 20.3% were completed by this method. Deaths of women associated with complications from abortions for 2007 are being investigated under CDC's Pregnancy Mortality Surveillance System. In 2006, the most recent year for which data were available, six women were reported to have died as a result of complications from known legal induced abortions. No reported deaths were associated with known illegal induced abortions. INTERPRETATION: Among the 45 areas that reported data every year during 1998-2007, the total number, rate, and ratio of reported abortions decreased during 2006-2007. This decrease reversed the increase in reported abortion numbers and rates that occurred during 2005-2006; however, reported abortion numbers and rates for 2007 still were higher than they had been previously in 2005. In 2006, as in previous years, reported deaths related to abortion were rare. PUBLIC HEALTH ACTION: Abortion surveillance in the United States continues to provide the data needed to examine trends in the number and characteristics of women obtaining abortions. Policymakers and program planners can use these data to guide and evaluate efforts to prevent unintended pregnancies.

Abortion surveillance--United States, 2008.

PROBLEM/CONDITION: Since 1969, CDC has conducted abortion surveillance to document the number and characteristics of women obtaining legal induced abortions in the United States. REPORTING PERIOD COVERED: 1999-2008. DESCRIPTION OF SYSTEM: Each year, CDC requests abortion data from the central health agencies of 52 reporting areas (the 50 states, the District of Columbia, and New York City). This information is provided voluntarily. For 2008, data were received from 49 reporting areas. For the purpose of trend analysis, data were evaluated from the 45 areas that reported data every year during 1999-2008. Abortion rates (number of abortions per 1,000 women) and ratios (number of abortions per 1,000 live births) were calculated using census and natality data, respectively. RESULTS: A total of 825,564 abortions were reported to CDC for 2008. Of these, 808,528 abortions (97.9% of the total) were from the 45 reporting areas that provided data every year during 1999-2008. Among these same 45 reporting areas, the abortion rate for 2008 was 16.0 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 234 abortions per 1,000 live births. Compared with 2007, the total number and rate of reported abortions for these 45 reporting areas essentially were unchanged, although the abortion ratio was 1% higher. Reported abortion numbers, rates, and ratios remained 3%, 4%, and 10% lower, respectively, in 2008 than they had been in 1999. Women aged 20-29 years accounted for 57.1% of all abortions reported in 2008 and for the majority of abortions during the entire period of analysis (1999-2008). In 2008, women aged 20-29 years also had the highest abortion rates (29.6 abortions per 1,000 women aged 20-24 years and 21.6 abortions per 1,000 women aged 25-29 years). Adolescents aged 15-19 years accounted for 16.2% of all abortions in 2008 and had an abortion rate of 14.3 abortions per 1,000 adolescents aged 15-19 years; women aged ≥35 years accounted for a smaller percentage (11.9%) of abortions and had lower abortion rates (7.8 abortions per 1,000 women aged 35-39 years and 2.7 abortions per 1,000 women aged ≥40 years). Throughout the period of analysis, abortion rates decreased among adolescents aged ≤19 years, whereas they increased among women aged ≥35 years. Among women aged 20-24 years abortion rates decreased during 1999-2003 and then leveled off during 2004-2008. In contrast to the percentage distribution of abortions and abortion rates by age, abortion ratios in 2008 and throughout the entire period of analysis were highest among adolescents aged ≤19 years and lowest among women aged 30-39 years. Abortion ratios decreased during 1999-2008 for women in all age groups except for those aged <15 years; however, the steady decrease was interrupted from 2007 to 2008 when abortion ratios increased among women in all age groups except for those aged ≥40 years. In 2008, most (62.8%) abortions were performed at ≤8 weeks' gestation, and 91.4% were performed at ≤13 weeks' gestation. Few abortions (7.3%) were performed at 14-20 weeks' gestation, and even fewer (1.3%) were performed at ≥21 weeks' gestation. During 1999-2008, the percentage of abortions performed at ≤13 weeks' gestation remained stable, whereas abortions performed at ≥16 weeks' gestation decreased 13%-17%. Moreover, among the abortions performed at ≤13 weeks' gestation, the distribution shifted toward earlier gestational ages, with the percentage of abortions performed at ≤6 weeks' gestation increasing 53%. In 2008, 75.9% of abortions were performed by curettage at ≤13 weeks' gestation, and 14.6% were performed by early medical abortion (a nonsurgical abortion at ≤8 weeks' gestation); 8.5% of abortions were performed by curettage at >13 weeks' gestation. Among the 62.8% of abortions that were performed at ≤8 weeks' gestation and thus were eligible for early medical abortion, 22.5% were completed by this method. The use of medical abortion increased 17% from 2007 to 2008. Deaths of women associated with complications from abortions for 2008 are being investigated under CDC's Pregnancy Mortality Surveillance System. In 2007, the most recent year for which data were available, six women were reported to have died as a result of complications from known legal induced abortions. No reported deaths were associated with known illegal induced abortions. INTERPRETATION: Among the 45 areas that reported data every year during 1999-2008, the total number and rate of reported abortions essentially did not change from 2007 to 2008. This finding is consistent with the recent leveling off from steady decreases that had been observed in the past. In contrast, the abortion ratio increased from 2007 to 2008 after having decreased steadily. In 2007, as in previous years, reported deaths related to abortion were rare. PUBLIC HEALTH ACTION: This report provides the data for examining trends in the number and characteristics of women obtaining abortions. This information is needed to better understand the reasons why efforts to reduced unintended pregnancy have stalled and can be used by policymakers and program planners to guide and evaluate efforts to prevent unintended pregnancy.

Trends in ectopic pregnancy mortality in the United States: 1980-2007.

OBJECTIVE: To estimate trends in ectopic pregnancy mortality and examine characteristics of recently hospitalized women who died as a result of ectopic pregnancy in the United States. METHODS: We used 1980-2007 national birth and death certificate data to calculate ectopic pregnancy mortality ratios (deaths per 100,000 live births) overall and stratified by maternal age and race. We performed nonparametric tests for trend to assess changes in ectopic pregnancy mortality over time and calculated projected mortality ratios for 2013-2017. Ectopic pregnancy deaths among hospitalized women were identified from 1998-2007 Nationwide Inpatient Sample data. RESULTS: Between 1980 and 2007, 876 deaths were attributed to ectopic pregnancy. The ectopic pregnancy mortality ratio declined by 56.6%, from 1.15 to 0.50 deaths per 100,000 live births between 1980-1984 and 2003-2007; at the current average annual rate of decline, this ratio will further decrease by 28.5% to 0.36 ectopic pregnancy deaths per 100,000 live births by 2013-2017. The ectopic pregnancy mortality ratio was 6.8 times higher for African Americans than whites and 3.5 times higher for women older than 35 years than those younger than 25 years during 2003-2007. Of the 76 deaths among women hospitalized between 1998 and 2007, 70.5% were tubal pregnancies; salpingectomy was performed in 80.6% of cases. Excessive hemorrhage, shock, or renal failure accompanied 67.4% of ectopic pregnancy deaths among hospitalized women. CONCLUSION: Despite a significant decline in ectopic pregnancy mortality since the 1980s, age disparities, and especially racial disparities, persist. Strategies to ensure timely diagnosis and management of ectopic pregnancies can further reduce related mortality and age and race mortality gaps.

Abortion surveillance - United States, 2006.

PROBLEM/CONDITION: Since 1969, CDC has conducted abortion surveillance to document the number and characteristics of women obtaining legal induced abortions in the United States. REPORTING PERIOD COVERED: 2006. DESCRIPTION OF SYSTEM: Each year, CDC requests abortion data from the central health agencies of 52 reporting areas (the 50 states, New York City, and the District of Columbia); these data are provided to CDC voluntarily. In 2006, data were received from 49 reporting areas. For the purpose of trend analysis, data were evaluated from the 46 areas that reported data every year during 1996-2006. RESULTS: For 2006, a total of 846,181 abortions were reported to CDC. Among the 46 areas that provided data consistently during 1996-2006, a total of 835,134 abortions (98.7% of the total) were reported; the abortion rate was 16.1 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 236 abortions per 1,000 live births. During the previous decade (1997-2006), reported abortion numbers, rates, and ratios decreased 5.7%, 8.8%, and 14.8%, respectively; most of these declines occurred before 2001. During the previous year (2005-2006), the total number of abortions increased 3.1%, and the abortion rate increased 3.2%; the abortion ratio was stable. In 2006, as during the previous decade (1997-2006), women aged 20-29 years accounted for the majority (56.8%) of abortions and had the highest abortion rates (29.9 abortions per 1,000 women aged 20-24 years and 22.2 abortions per 1,000 women aged 25-29 years); by contrast, abortion ratios were highest at the extremes of reproductive age. Adolescents aged 15-19 years accounted for 16.5% of all abortions in 2006 and had an abortion rate of 14.8 abortions per 1,000 adolescents aged 15-19 years; women aged >or=35 years accounted for a smaller percentage (12.1%) of abortions and had lower abortion rates (7.8 abortions per 1,000 women aged 35-39 years and 2.6 abortions per 1,000 women aged >or=40 years). During 1997-2006, the percentage of abortions and the abortion rate increased among women aged >or=35 years but declined among adolescents aged or=21 weeks' gestation (1.3%). During 1997-2006, the percentage of abortions performed at

Abortion surveillance--United States, 2005.

PROBLEM/CONDITION: CDC began abortion surveillance in 1969 to document the number and characteristics of women obtaining legal induced abortions. REPORTING PERIOD COVERED: This report summarizes and describes data voluntarily reported to CDC regarding legal induced abortions obtained in the United States in 2005. DESCRIPTION OF SYSTEM: For each year since 1969, CDC has compiled abortion data by state or area of occurrence. Information is requested each year from all 50 states, New York City, and the District of Columbia. For 2005, data were received from 49 reporting areas: New York City, District of Columbia, and all states except California, Louisiana, and New Hampshire. For the purpose of trends analysis, data were evaluated from the 46 reporting areas that have been consistently reported since 1995. RESULTS: A total of 820,151 legal induced abortions were reported to CDC for 2005 from 49 reporting areas, the abortion ratio (number of abortions per 1,000 live births) was 233, and the abortion rate was 15 per 1,000 women aged 15--44 years. For the 46 reporting areas that have consistently reported since 1995, the abortion rate declined during 1995--2000 but has remained unchanged since 2000. For 2005, the highest percentages of reported abortions were for women who were known to be unmarried (81%), white (53%), and aged <25 years (50%). Of all abortions for which gestational age was reported, 62% were performed at 15 weeks' gestation (3.7% at 16--20 weeks and 1.3% at >/=21 weeks). A total of 35 reporting areas submitted data stating that they performed and enumerated medical (nonsurgical) procedures, making up 9.9% of all known reported procedures from the 45 areas with adequate reporting on type of procedure. In 2004 (the most recent years for which data are available), seven women died as a result of complications from known legal induced abortion. One death was associated with known illegal abortion. INTERPRETATION: For the 46 reporting areas that have consistently reported since 1995, the number of abortions has steadily declined over the previous 10 years. The abortion rate declined from 1995 to 2000, but remained unchanged since 2000. In 2004, as in the previous years, deaths related to legal induced abortions occurred rarely. PUBLIC HEALTH ACTION: Abortion surveillance in the United States continues to provide the data necessary for examining trends in numbers and characteristics of women who obtain legal induced abortions and to increase understanding of this pregnancy outcome. Policymakers and program planners use these data to improve the health and well-being of women and evaluate efforts to prevent unintended pregnancies.

Abortion surveillance--United States, 2004.

PROBLEM/CONDITION: CDC began abortion surveillance in 1969 to document the number and characteristics of women obtaining legal induced abortions. REPORTING PERIOD COVERED: This report summarizes and describes data voluntarily reported to CDC regarding legal induced abortions obtained in the United States in 2004. DESCRIPTION OF SYSTEM: For each year since 1969, CDC has compiled abortion data by state or area of occurrence. During 1973-1997, data were received from or estimated for 52 reporting areas in the United States: 50 states, the District of Columbia, and New York City. In 1998 and 1999, CDC compiled abortion data from 48 reporting areas. Alaska, California, New Hampshire, and Oklahoma did not report, and data for these states were not estimated. During 2000-2002, Oklahoma again reported these data, increasing the number of reporting areas to 49; for 2003 and 2004, Alaska again reported and West Virginia did not, maintaining the number of reporting areas at 49. RESULTS: A total of 839,226 legal induced abortions were reported to CDC for 2004 from 49 reporting areas, representing a 1.1% decline from the 848,163 legal induced abortions reported by 49 reporting areas for 2003. The abortion ratio, defined as the number of abortions per 1,000 live births, was 238 in 2004, a decrease from the 241 in 2003. The abortion rate was 16 per 1,000 women aged 15-44 years for 2004, the same since 2000. For the same 47 reporting areas, the abortion rate remained relatively constant during 1998-2004. In 2003 (the most recent years for which data are available), 10 women died as a result of complications from known legal induced abortion. No death was associated with known illegal abortion. The highest percentages of reported abortions were for women who were known to be unmarried (80%), white (53%), and aged <25 years (50%). Of all abortions for which gestational age was reported, 61% were performed at < or =8 weeks' gestation and 88% at <13 weeks. From 1992 (when detailed data regarding early abortions were first collected) through 2004, steady increases have occurred in the percentage of abortions performed at < or =6 weeks' gestation, except for a slight decline in 2003. A limited number of abortions were obtained at >15 weeks' gestation, including 4.0% at 16-20 weeks and 1.4% at > or =21 weeks. A total of 35 reporting areas submitted data stating that they performed and enumerated medical (nonsurgical) procedures, making up 9.7% of all known reported procedures from the 45 areas with adequate reporting on type of procedure. INTERPRETATION: During 1990--1997, the number of legal induced abortions gradually declined. When the same 47 reporting areas are compared, the number of abortions decreased during 1996-2001, then slightly increased in 2002 and again decreased in 2003 and 2004. In 2000 and 2001, even with one additional reporting state, the number of abortions declined slightly, with a minimal increase in 2002 and a further decrease in both 2003 and 2004. In 2003, as in the previous years, deaths related to legal induced abortions occurred rarely. PUBLIC HEALTH ACTION: Abortion surveillance in the United States continues to provide the data necessary for examining trends in numbers and characteristics of women who obtain legal induced abortions and to increase understanding of this pregnancy outcome. Policymakers and program planners use these data to improve the health and well-being of women and infants.

Abortion surveillance--United States, 2003.

PROBLEM/CONDITION: CDC began abortion surveillance in 1969 to document the number and characteristics of women obtaining legal induced abortions. REPORTING PERIOD COVERED: This report summarizes and describes data voluntarily reported to CDC regarding legal induced abortions obtained in the United States in 2003. DESCRIPTION OF SYSTEM: For each year since 1969, CDC has compiled abortion data by state or area of occurrence. During 1973-1997, data were received from or estimated for 52 reporting areas in the United States: 50 states, the District of Columbia, and New York City. In 1998 and 1999, CDC compiled abortion data from 48 reporting areas. Alaska, California, New Hampshire, and Oklahoma did not report, and data for these states were not estimated. During 2000-2002, Oklahoma again reported these data, increasing the number of reporting areas to 49, and for 2003, Alaska again reported and West Virginia did not, maintaining the number of reporting areas at 49. RESULTS: A total of 848,163 legal induced abortions were reported to CDC for 2003 from 49 reporting areas, representing a 0.7% decline from the 854,122 legal induced abortions reported by 49 reporting areas for 2002. The abortion ratio, defined as the number of abortions per 1,000 live births, was 241 in 2003, a decrease from the 246 in 2002. The abortion rate was 16 per 1,000 women aged 15-44 years for 2003, the same as for 2002. For the same 47 reporting areas, the abortion rate remained relatively constant during 1998-2003. During 2001-2002 (the most recent years for which data are available), 15 women died as a result of complications from known legal induced abortion. One death was associated with known illegal abortion. The highest percentages of reported abortions were for women who were unmarried (82%), white (55%), and aged <25 years (51%). Of all abortions for which gestational age was reported, 61% were performed at < or =8 weeks' gestation and 88% at <13 weeks. From 1992 (when detailed data regarding early abortions were first collected) through 2002, steady increases have occurred in the percentage of abortions performed at < or =6 weeks' gestation, with a slight decline in 2003. A limited number of abortions were obtained at >15 weeks' gestation, including 4.2% at 16--20 weeks and 1.4% at > or =21 weeks. A total of 36 reporting areas submitted data documenting that they performed and enumerated medical (nonsurgical) procedures, making up 8.0% of all known reported procedures from the 45 areas with adequate reporting on type of procedure. INTERPRETATION: During 1990-1997, the number of legal induced abortions gradually declined. When the same 47 reporting areas are compared, the number of abortions decreased during 1996-2001, then slightly increased in 2002 and again decreased in 2003. In 2000 and 2001, even with one additional reporting state, the number of abortions declined slightly, with a minimal increase in 2002 and a further decrease in 2003. In 2001 and 2002, as in the previous years, deaths related to legal induced abortions occurred rarely. PUBLIC HEALTH ACTION: Abortion surveillance in the United States continues to provide the data necessary for examining trends in numbers and characteristics of women who obtain legal induced abortions and to increase understanding of this pregnancy outcome. Policymakers and program planners use these data to improve the health and well-being of women and infants.

Surveillance in a time of changing health care practices: estimating ectopic pregnancy incidence in the United States.

OBJECTIVES: Ectopic pregnancy is a common condition with significant health consequences; complications are a major cause of maternal mortality in the United States. Accurate ascertainment of the number of ectopic pregnancies occurring in the United States has been dramatically affected by changing medical practices, causing estimates based on hospital data to be falsely low. This study was performed to identify nationally representative data on ectopic pregnancies and determine overlap of these data, to calculate the annual weighted number of ectopic pregnancies and confidence intervals for these estimates, and to determine barriers to estimation of ectopic pregnancy incidence. METHODS: To assess whether a national estimate of the incidence of ectopic pregnancy could be calculated, we analyzed 1992-99 data from the six nationally representative data sets that include information on ectopic pregnancy. We examined relevant data in each data set and assessed whether any combination of data sets could be used to estimate ectopic pregnancy incidence. We calculated weighted estimates and 95% confidence intervals for hospitalizations, outpatient surgeries, outpatient medical procedures, and physician visits for and self-reports of ectopic pregnancy. RESULTS: Small sample sizes severely limited calculation of estimates of ectopic pregnancy. Data needed for assessing multiple counting was not available consistently. The likelihood of multiple counting of cases was substantial when data set counts were combined. CONCLUSIONS: A reliable incidence rate for ectopic pregnancy in the United States could not be estimated from existing nationally representative data sources. Major advances in diagnosis and treatment of ectopic pregnancy have affected surveillance in two ways: inpatient hospital treatment of ectopic pregnancy has decreased, and multiple health care visits for a single ectopic pregnancy have increased. Alternate means of surveillance are needed to improve understanding of risk factors and trends for ectopic pregnancy, and we recommend examination of the databases of public and private insurance systems and managed care systems. Similar alternate means of surveillance may be needed for other health conditions with comparable changes in management of care.