"Adoption is just not for me": How abortion patients in Michigan and New Mexico factor adoption into their pregnancy outcome decisions.

Objectives: In public discourses in the United States, adoption is often suggested as a less objectionable, equal substitute for abortion, despite this pregnancy outcome occurring much less frequently than the outcomes of abortion and parenting. This qualitative study explores whether and how abortion patients weighed adoption as part of their pregnancy decisions and, for those who did, identifies factors that contributed to their ultimate decision against adoption. Study design: We interviewed 29 abortion patients from 6 facilities in Michigan and New Mexico in 2015. We conducted a thematic analysis using both deductive and inductive approaches to describe participants' perspectives, preferences, and experiences regarding the consideration of adoption for their pregnancy. Results: Participants' reasons why adoption was not an appropriate option for their pregnancy were grounded in their ideas of the roles and responsibilities of parenting and fell into three themes. First, participants described continuing the pregnancy and giving birth as inseparable from the decision to parent. Second, choosing adoption would represent an irresponsible abnegation of parental duty. Third, adoption could put their child's safety and well-being at risk. Conclusions: Adoption was not an equally acceptable substitute for abortion among abortion patients. For them, adoption was a decision that represented taking on, and then abdicating, the role of parent. This made adoption a particularly unsuitable choice for their pregnancy. Implications: Rhetoric suggesting that adoption is an equal alternative to abortion does not reflect the experiences, preferences, or values of how abortion patients assess what options are appropriate for their pregnancy.

Use of concurrent multiple methods of contraception in the United States, 2008 to 2015.

OBJECTIVE: To identify prevalence of, characteristics associated with, and combinations of, use of more than one method of contraception at last intercourse among US women between 2008 and 2015. METHODS: We conducted bivariate and multivariable logistic regression analyses using data on concurrent contraceptive use from 2 nationally representative samples of women ages 15 to 44 who had used some form of contraception at last intercourse in the past 3 months in the 2006-2010 (n = 6601) and 2013-2017 (n = 5562) cycles of the National Survey of Family Growth. RESULTS: Use of more than one method of contraception at last sex increased from 14% in 2008 to 18% in 2015 (p<0.001), with increases in use documented across many population groups. Among multiple method users, the majority combined condoms with other methods (58%), while the rest combined other methods (42%). When compared to single method users, dual method users employing condoms are a more homogeneous group of individuals than are dual method users not employing condoms. As age increases, dual use with condoms decreases, but there is no similar linear relationship between age and dual method use without condoms. CONCLUSIONS: A sizable proportion of US women use more than one contraceptive method during sex; current estimates of contraceptive use focused exclusively on single method use may underestimate the extent to which women are protected from unintended pregnancy. The needs and goals of individuals combining contraceptive methods in different ways may change over the life course as pregnancy desires and life circumstances change. IMPLICATIONS: A sizable proportion of US women use more than one contraceptive method during sex; clinicians and health educators in nonclinical settings should assess and acknowledge these more complicated contraceptive strategies in order to help individuals achieve autonomy in method choice and meet their goals around pregnancy and sexually transmitted infection prevention.

Transgender abortion patients and the provision of transgender-specific care at non-hospital facilities that provide abortions.

OBJECTIVE: To estimate the number of transgender and gender non-binary (TGNB) individuals who obtained abortions in the United States and the extent to which abortion facilities offer transgender-specific health services. STUDY DESIGN: We collected survey data from all known health care facilities that provided abortions in 2017. For the first time, the questionnaire included items about TGNB abortion patients and services. RESULTS: We estimate that 462 to 530 TGNB individuals obtained abortions in 2017 and that 23% of clinics provide transgender-specific care. CONCLUSION: Several hundred abortions were provided to TGNB individuals in 2017, primarily at facilities that did not provide transgender-specific health services. IMPLICATIONS: Findings from this study support efforts to implement and expand gender-inclusive and affirming care at health care facilities that provide abortion.

Challenges and strategies for contraceptive care in independent abortion clinics in the United States, 2017.

OBJECTIVE: Many patients may wish to receive contraceptive counseling and services during an abortion visit, but a 2009 study documented challenges faced by abortion clinics, especially independent ones, in providing contraceptive care. Since then, the Affordable Care Act (ACA) has made contraception more accessible by expanding coverage to millions of individuals and by eliminating out of pocket costs. This paper aims to update this previous work and describe recent challenges in providing contraceptive care in independent abortion settings following the ACA, as well as the strategies used to address these challenges. METHODS: We conducted two focus groups and 19 semi-structured interviews with clinic administrators and directors at independent abortion clinics. RESULTS: Challenges to providing contraceptive care in independent abortion clinics included navigating new guidelines under the Affordable Care Act for establishing coverage agreements with health insurance plans and receiving timely and sufficient reimbursement for services provided. Study respondents described strategies related to adjusting clinic flow and protocols to address patient needs regarding receiving contraception during abortion care. CONCLUSION: Staff working in independent abortion clinics in the United States experience a tension between trying to provide holistic, patient-centered care - including contraceptive care - and navigating restrictive political and healthcare contexts for the delivery of abortion care.

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

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

"It's not something you talk about really": information barriers encountered by women who travel long distances for abortion care.

OBJECTIVE: For individuals traveling significant distances for time-sensitive abortion care, accurate information about service options and locations is critical, but little is known regarding information barriers that individuals may encounter and strategies for circumventing these barriers. STUDY DESIGN: In early 2015, we conducted in-depth interviews with 29 patients who had traveled for abortion care at six facilities in Michigan and New Mexico. We identified information-related barriers that respondents encountered in understanding their pregnancy options and/or where to obtain an abortion between the time of pregnancy discovery, including any contact with a crisis pregnancy center, to the day of the abortion procedure through inductive and deductive analysis. RESULTS: We identified two logistical information-related barriers - a general lack of reproductive-related knowledge and unhelpfulness on the part of perceived members of the healthcare community - and one broader barrier of perceived stigma within respondents' narratives. Of the seven respondents who did not encounter a logistical information-related barrier, having previous personal or close experience with abortion and internet savviness were both identified as strategies enabling them to circumvent the barriers. CONCLUSION: Lack of clear, easy-to-find and accurate information about abortion services and availability represents a key barrier to obtaining an abortion; health care providers play a crucial role in ensuring pregnant patients' right to informed consent within reproductive health care delivery. IMPLICATIONS: Women's health care providers should provide their patients with the full spectrum of resources and referrals for pregnancy and abortion care; recent federal guidelines proposing to restrict abortion counseling and referral at Title X-funded facilities would only exacerbate the current challenges that pregnant patients encounter when seeking abortion-related information and further decrease linkages to timely, desired abortion care.

Sexual Orientation and Exposure to Violence Among U.S. Patients Undergoing Abortion.

OBJECTIVE: To assess the characteristics of patients undergoing abortion in the United States according to sexual orientation and exposure to sexual and physical violence. METHODS: Data for this observational study come from the Guttmacher Institute's 2014 Abortion Patient Survey, which obtained information from 8,380 individuals obtaining abortions at nonhospital facilities in the United States; 7,656 of those (91%) provided information on sexual orientation identity. We used simple logistic regression to assess differences between heterosexuals and three sexual minority groups-bisexual, lesbian, and something else-according to demographic characteristics and exposure to sexual and physical violence. Multivariate logistic regression was used to assess associations between sexual orientation and exposure to violence. RESULTS: Among patients undergoing abortion in 2014, 4.1% identified as bisexual (n=316), 1.1% as something else (n=81), and 0.4% as lesbian (n=28); 94.4% identified as heterosexual (n=7,231). Similar proportions of lesbian and heterosexual respondents reported a prior birth (53.6% and 58.2%, P=.62), whereas respondents who identified as something else were more likely to report having had a prior abortion (58.0% vs 43.9%, P=.01). Exposure to sexual violence was substantially and significantly higher among all three sexual minority groups compared with heterosexuals, and lesbian and bisexual respondents were also more likely than their heterosexual peers to report exposure to physical violence by the man involved in the pregnancy (33.3% and 8.7% vs 3.6%, P<.001). CONCLUSION: No patient should be presumed to be heterosexual. Understanding the disproportionate role of sexual violence in unintended pregnancies among sexual minorities may aid in the design of interventions and clinical guidelines that address the needs of sexual minority patients.

What are people looking for when they Google "self-abortion"?

OBJECTIVE: To examine the motivations and circumstances of individuals seeking information about self-abortion on the Internet. STUDY DESIGN: We identified 26 terms that we anticipated someone might use to find information about self-abortion on the internet. Users who entered these terms into the Google search engine were provided with a link to our survey via Google AdWords. We fielded the survey over a 32-day period; users were eligible if accessing the survey from a US-based device. We examined demographic characteristics of the sample, reasons for searching for information on self-abortion, knowledge of the legality of abortion and of nearby providers, and top performing keywords. RESULTS: Our Google AdWords campaign containing the survey link was shown approximately 210,000 times, and clicked 9,800 times; 1,235 respondents completed the survey. The vast majority of the sample was female (96%), and 41% were minors. Almost three-quarters (73%) indicated that they were searching for information because they were pregnant and did not or may not want to be. Eleven percent had ever attempted to self-abort. One-third of respondents did not know if abortion was legal in their state of residence, and knowledge of legality did not differ by age. CONCLUSIONS: There is interest in learning more about self-abortion on the Internet. Our findings suggest that, among those who participated in our survey, online searches for information on self-abortion may be driven by adolescents and young adults facing an unintended pregnancy. IMPLICATIONS: Young women, in particular, may have an unmet need for information about safe and accessible abortion options.

Differences in Abortion Service Delivery in Hostile, Middle-ground, and Supportive States in 2014.

OBJECTIVES: In 2013, the majority of women lived in states considered hostile to abortion rights, or states with numerous abortion restrictions. By comparison, 31% lived in supportive states. This study examined differences in abortion service delivery according to the policy climate in which clinics must operate. METHODS: Data come from the 2014 Abortion Provider Census, which contains information about all known abortion-providing facilities in the United States. In addition to number and type of facility, we examine several aspects of abortion care: provision of only early medication abortion (EMA-only), whether an advanced practice clinician provided abortions, gestational parameters, and average charge for procedure. All indicators were examined nationally and according to whether the clinic was in a state that was hostile, middle ground, or supportive of abortion rights. RESULTS: In 2014, hostile and supportive states accounted for the same proportion of all U.S. abortions-44% (each)-although 57% of women age 15 to 44 lived in hostile states. Hostile states had one-half as many abortion-providing facilities as supportive ones. EMA-only facilities accounted for 37% of clinics in supportive states compared with 8% in hostile states. Sixty-five percent of clinics in supportive states reported that advanced practice clinicians provided abortion care, compared with 3% in hostile states. After cost of living adjustments, a first-trimester surgical abortion was most expensive in middle-ground states ($470) and least expensive in supportive states ($402). CONCLUSIONS: The distribution of abortion services, the type of facility in which they are provided, and the amount a facility charges all vary according to the abortion policy climate.

Which Abortion Patients Have Had a Prior Abortion? Findings from the 2014 U.S. Abortion Patient Survey.

BACKGROUND: Updated information about abortion patients who have had a prior abortion could inform patient-centered practices that help women avoid unintended pregnancies in the future. MATERIALS AND METHODS: Data come from a national sample of 8,380 nonhospital U.S. abortion patients accessing services at 87 facilities. The dependent variable was a self-reported measure of prior abortion. Bivariate and multivariable analyses were used to assess associations between a range of demographic and circumstantial characteristics and reports of obtaining a prior abortion. RESULTS: We found that 45% of patients reported having one or more prior abortions. Age was most strongly associated with this outcome, and patients aged 30 and older had more than two times the odds of having had a prior abortion compared with those aged 20-24. Other characteristics associated with an increased likelihood of prior abortion included having one or more children, being black, relying on insurance or financial assistance to pay for the procedure, and exposure to disruptive events in the last 12 months. Characteristics associated with a decreased likelihood of having a prior abortion included having a college degree and living 25 or more miles from the facility where the current abortion was obtained. CONCLUSIONS: Age is the biggest risk factor for having had a prior abortion; the longer a woman has been alive, the longer she is at risk of unintended pregnancy. Some characteristics associated with prior abortion were beyond the control of the individuals experiencing them.

Contraceptive method use in the United States: trends and characteristics between 2008, 2012 and 2014.

OBJECTIVE: The objective was to examine levels of, correlates of and changes in the use of individual and grouped methods of contraception among US females aged 15-44 from 2008 to 2014. STUDY DESIGN: Using three rounds of the National Survey of Family Growth, we analyzed samples of 12,279 (2008), 5601 (2012) and 5699 (2014) females. We conducted simple and multivariable logistic regression analyses to identify associations between demographic characteristics and contraceptive use, as well as between characteristics and changes in use patterns. RESULTS: In terms of overall trends in contraceptive use between 2008 and 2014, there was no significant change in the proportion of women who used a method among either all women (60%) or those at risk of unintended pregnancy (90%). Significant changes in use occurred among six methods. The largest increase in use was among users of long-acting reversible contraceptive (LARC) methods, including the intrauterine device and implant - from 6% to 14% - across almost all population groups of female contraceptive users, while the largest decrease occurred among users of sterilization - from 37% to 28% - with lower-income women driving the decline in female sterilization and higher-income women driving the decline in a partner's sterilization as a primary method. Moderate increases were seen in the use of withdrawal and natural family planning. CONCLUSION: Most shifts in recent contraceptive use have occurred among the most effective methods - sterilization and LARCs. Differences in method-specific user characteristics underscore the importance of ensuring full access to the broad range of methods available. IMPLICATIONS: The lack of change in the overall use of contraceptives among women at risk for unintended pregnancy may have implications for the extent to which further declines in national rates of unintended pregnancy can be expected.

Population Group Abortion Rates and Lifetime Incidence of Abortion: United States, 2008-2014.

OBJECTIVES: To assess the prevalence of abortion among population groups and changes in rates between 2008 and 2014. METHODS: We used secondary data from the Abortion Patient Survey, the American Community Survey, and the National Survey of Family Growth to estimate abortion rates. We used information from the Abortion Patient Survey to estimate the lifetime incidence of abortion. RESULTS: Between 2008 and 2014, the abortion rate declined 25%, from 19.4 to 14.6 per 1000 women aged 15 to 44 years. The abortion rate for adolescents aged 15 to 19 years declined 46%, the largest of any group. Abortion rates declined for all racial and ethnic groups but were larger for non-White women than for non-Hispanic White women. Although the abortion rate decreased 26% for women with incomes less than 100% of the federal poverty level, this population had the highest abortion rate of all the groups examined: 36.6. If the 2014 age-specific abortion rates prevail, 24% of women aged 15 to 44 years in that year will have an abortion by age 45 years. CONCLUSIONS: The decline in abortion was not uniform across all population groups.

Barriers to Abortion Care and Their Consequences For Patients Traveling for Services: Qualitative Findings from Two States.

CONTEXT: Abortion availability and accessibility vary by state. Especially in areas where services are restricted or limited, some women travel to obtain abortion services in other states. Little is known about the experience of travel to obtain abortion. METHODS: In January and February 2015, in-depth interviews were conducted with 29 patients seeking abortion services at six facilities in Michigan and New Mexico. Eligible women were 18 or older, spoke English, and had traveled either across state lines or more than 100 miles within the state. Respondents were asked to describe their experience from pregnancy discovery to the day of the abortion procedure. Barriers to accessing abortion care and consequences of these barriers were identified through inductive and deductive analysis. RESULTS: Respondents described 15 barriers to abortion care while traveling to obtain services, and three major consequences of experiencing those barriers. Barriers were grouped into five categories: travel-related logistical issues, system navigation issues, limited clinic options, financial issues, and state or clinic restrictions. Consequences were delays in care, negative mental health impacts and considering self-induction. The experience of barriers complicated the process of obtaining an abortion, but the effect of any individual barrier was unclear. Instead, the experience of multiple barriers appeared to have a compounding effect, resulting in negative consequences for women traveling for abortion. CONCLUSION: The amalgamation of barriers to abortion care experienced simultaneously can have significant consequences for patients.

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

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

Abortion Incidence and Service Availability In the United States, 2014.

CONTEXT: National and state-level information about abortion incidence can help inform policies and programs intended to reduce levels of unintended pregnancy. METHODS: In 2015-2016, all U.S. facilities known or expected to have provided abortion services in 2013 or 2014 were surveyed. Data on the number of abortions were combined with population data to estimate national and state-level abortion rates. The number of abortion-providing facilities and changes since a similar 2011 survey were also assessed. The number and type of new abortion restrictions were examined in the states that had experienced the largest proportionate changes in clinics providing abortion services. RESULTS: In 2014, an estimated 926,200 abortions were performed in the United States, 12% fewer than in 2011; the 2014 abortion rate was 14.6 abortions per 1,000 women aged 15-44, representing a 14% decline over this period. The number of clinics providing abortions declined 6% between 2011 and 2014, and declines were steepest in the Midwest (22%) and the South (13%). Early medication abortions accounted for 31% of nonhospital abortions, up from 24% in 2011. Most states that experienced the largest proportionate declines in the number of clinics providing abortions had enacted one or more new restrictions during the study period, but reductions were not always associated with declines in abortion incidence. CONCLUSIONS: The relationship between abortion access, as measured by the number of clinics, and abortion rates is not straightforward. Further research is needed to understand the decline in abortion incidence.

Changes in out-of-pocket costs for hormonal IUDs after implementation of the Affordable Care Act: an analysis of insurance benefit inquiries.

BACKGROUND: The Affordable Care Act (ACA) requires that privately insured women can obtain contraceptive services and supplies without cost sharing. This may substantially affect women who prefer an intrauterine device (IUD), a long-acting reversible contraceptive, because of high upfront costs that they would otherwise face. However, imperfect enforcement of and exceptions to this provision could limit its effect. STUDY DESIGN: We analyzed administrative data for 417,221 women whose physicians queried their insurance plans from January 2012 to March 2014 to determine whether each woman had insurance coverage for a hormonal IUD and the extent of that coverage. RESULTS: In January 2012, 58% of women would have incurred out-of-pocket costs for an IUD, compared to only 13% of women in March 2014. Differentials by age and region virtually dissolved over the period studied, which suggests that the ACA reduced inequality among insured women. CONCLUSIONS: Our findings suggest that the cost of hormonal IUDs fell to US$0 for most insured women following the implementation of the ACA. IMPLICATIONS: Financial barriers to one of the most effective methods of contraception fell substantially following the ACA. If more women interested in this method can access it, this may contribute to a decline in unintended pregnancies in the United States.

Changes in Use of Long-Acting Reversible Contraceptive Methods Among U.S. Women, 2009-2012.

OBJECTIVE: To examine current levels, current correlates of, and changes in long-acting reversible contraceptive (LARC) use, including intrauterine devices and implants, among females aged 15-44 years using contraception between 2008-2010 and 2011-2013 with specific attention to associations between race, income, and age and their LARC use. METHODS: We analyzed data from two rounds of the National Survey of Family Growth, nationally representative samples of females aged 15-44 years, consisting of 6,428 females in 2008-2010 and 5,601 females in 2011-2013. We conducted simple and multivariable logistic regression analyses with adjustments for the sampling design to identify demographic characteristics predictive of LARC use and changes in these patterns between the two time periods. In this cross-sectional, descriptive study, our primary outcome of interest was current prevalence of LARC use among all contraceptive users at the time of the interview. RESULTS: The prevalence of LARC use among contracepting U.S. females increased from 8.5% in 2009 to 11.6% in 2012 (P<.01). The most significant increases occurred among Hispanic females (from 8.5% to 15.1%), those with private insurance (7.1-11.1%), those with fewer than two sexual partners in the previous year (9.2-12.4%), and those who were nulliparous (2.1-5.9%) (all P<.01). In multivariable analyses adjusting for key demographic characteristics, the strongest associations with LARC use in 2012 were parity (adjusted odds ratios [ORs] 4.3-5.5) and having a history of stopping non-LARC hormonal use (adjusted OR 1.9). Women aged 35-44 years (adjusted OR 0.3) were less likely to be LARC users than their counterparts (all P<.001). Poverty status was not associated with LARC use. There were no differences in discontinuation of LARC methods resulting from dissatisfaction between minority women and non-Hispanic white women. CONCLUSION: During the most recent time period surveyed, use of LARC methods, particularly intrauterine devices, increased almost uniformly across the population of users. LEVEL OF EVIDENCE: III.

Benefits of meeting the contraceptive needs of Cameroonian women.

(1) In 2013, an estimated 40% of pregnancies in Cameroon were unintended. (2) More than six in 10 women who want to avoid pregnancy either do not practice contraception or use a relatively ineffective traditional method. These women can be said to have an unmet need for modern contraception. (3) Meeting just half of this unmet need would prevent 187,000 unplanned pregnancies each year, resulting in 65,000 fewer unsafe abortions and 600 fewer maternal deaths annually. (4) If all unmet need for modern methods were satisfied, maternal mortality would drop by more than one-fifth, and unintended births and unsafe abortions would decline by 75%. (5) Investing in contraceptive commodities and services to fulfill all unmet need among women who want to avoid pregnancy would result in a net annual savings of US$5.4 million (2.7 billion CFA francs) over what would otherwise be spent on medical costs associated with unintended pregnancies and their consequences. (6) Expanding contraceptive services confers substantial benefits to women, their families and society. All stakeholders, including the Cameroon government and the private sector, should increase their investment in modern contraceptive services.

Secondary measures of access to abortion services in the United States, 2011 and 2012: gestational age limits, cost, and harassment.

BACKGROUND: Aspects of U.S. clinical abortion service provision such as gestational age limits, charges for abortion services, and anti-abortion harassment can impact the accessibility of abortion; this study documents changes in these measures between 2008 and 2012. METHODS: In 2012 and 2013, we surveyed all known abortion-providing facilities in the United States (n = 1,720). This study summarizes information obtained about gestational age limits, charges, and exposure to anti-abortion harassment among clinics; response rates for relevant items ranged from 54% (gestational limits) to 80% (exposure to harassment). Weights were constructed to compensate for nonresponding facilities. We also examine the distribution of abortions and abortion facilities by region. FINDINGS: Almost all abortion facilities (95%) offered abortions at 8 weeks' gestation; 72% did so at 12 weeks, 34% at 20 weeks, and 16% at 24 weeks in 2012. In 2011 and 2012, the median charge for a surgical abortion at 10 weeks gestation was $495, and $500 for an early medication abortion, compared with $503 and $524 (adjusted for inflation) in 2009. In 2011, 84% of clinics experienced at least one form of harassment, only slightly higher than found in 2009. Hospitals and physicians' offices accounted for a substantially smaller proportion of facilities in the Midwest and South. Clinics in the Midwest and South were exposed to more harassment than their counterparts in the Northeast and West. CONCLUSIONS: Although there was a substantial decline in abortion incidence between 2008 and 2011, the secondary measures of abortion access examined in this study changed little during this time period.

Abortion incidence and service availability in the United States, 2011.

CONTEXT: Following a long-term decline, abortion incidence stabilized between 2005 and 2008. Given the proliferation of state-level abortion restrictions, it is critical to assess abortion incidence and access to services since that time. METHODS: In 2012-2013, all facilities known or expected to have provided abortion services in 2010 and 2011 were surveyed. Data on the number of abortions were combined with population data to estimate national and state-level abortion rates. Incidence of abortions was assessed by provider type and caseload. Information on state abortion regulations implemented between 2008 and 2011 was collected, and possible relationships with abortion rates and provider numbers were considered. RESULTS: In 2011, an estimated 1.1 million abortions were performed in the United States; the abortion rate was 16.9 per 1,000 women aged 15-44, representing a drop of 13% since 2008. The number of abortion providers declined 4%; the number of clinics dropped 1%. In 2011, 89% of counties had no clinics, and 38% of women of reproductive age lived in those counties. Early medication abortions accounted for a greater proportion of nonhospital abortions in 2011 (23%) than in 2008 (17%). Of the 106 new abortion restrictions implemented during the study period, few or none appeared to be related to state-level patterns in abortion rates or number of providers. CONCLUSIONS: The national abortion rate has resumed its decline, and no evidence was found that the overall drop in abortion incidence was related to the decrease in providers or to restrictions implemented between 2008 and 2011.