An estimate of lifetime incidence of abortion in the United States using the 2021-2022 Abortion Patient Survey.

OBJECTIVES: The Guttmacher Institute estimated that, in 2014, 24% of US women of reproductive age would have an abortion by age 45 if the 2014 abortion rate was maintained. This study updates the estimated lifetime incidence of abortion in the year(s) just prior to the Dobbs decision, which removed federal protections for abortion. STUDY DESIGN: We used data from the Guttmacher Institute's 2021-2022 Abortion Patient Survey and population data for 2020 and 2021 from the Census Bureau, as well as abortion counts from the Guttmacher Institute's 2020 Abortion Provider Census, to estimate abortion rates, first-abortion rates, and cumulative abortion rates, all by age group. We calculated multiple estimates of lifetime incidence under varying hypothetical conditions as tests of sensitivity. RESULTS: We estimate that 24.7% (95% CI: 22.9-26.3) of women aged 15-44 in 2020 would have had an abortion by age 45 if abortion rates in 2020 remain constant. These figures changed slightly when we examined scenarios assuming a 5% increase in abortion between 2020 and 2021 (25.9, 95% CI: 24.0-27.6) and when we adjusted for the potential overrepresentation of adolescent and young adult respondents in the 2021-2022 Abortion Patient Survey (23.9, 95% CI: 22.2-25.6). CONCLUSIONS: In the year(s) prior to the Dobbs decision, one-quarter of US women would have been expected to have at least one abortion in their lifetime if abortion rates for those years stayed the same. IMPLICATIONS: Significant numbers of individuals are being affected by abortion bans, but we are unable to predict how these restrictions will impact abortion incidence or the lifetime incidence in the coming years.

Characteristics and Circumstances of Adolescents Obtaining Abortions in the United States.

The purpose of this study is to describe the sociodemographic and situational circumstances of adolescents obtaining abortion in the United States prior to the Dobbs decision. We use data from the Guttmacher Institute's 2021-2022 Abortion Patient Survey, a cross-sectional survey of 6698 respondents; our analytic sample includes 633 adolescents (<20 years), 2152 young adults (20-24 years), and 3913 adults (25+ years). We conducted bivariate analyses to describe the characteristics and logistical and financial circumstances of adolescents obtaining abortions in comparison to respondents in the other age groups. The majority of adolescents identified as non-white (70%), and 23% identified as something other than heterosexual. We found that 26% of adolescents reported having no health insurance, and two-thirds of adolescent respondents reported that somebody had driven them to the facility. Adolescents differed from adults in their reasons for delays in accessing care; a majority of adolescents (57%) reported not knowing they were pregnant compared to 43% of adults, and nearly one in five adolescents did not know where to obtain the abortion compared to 11% of adults. Adolescents were more likely than adults to obtain a second-trimester abortion, which has increased costs. This study found that this population was more vulnerable than adults on several measures. Findings suggest that adolescents navigate unique barriers with regard to information and logistics to access abortion care.

Medicaid's role in alleviating some of the financial burden of abortion: Findings from the 2021-2022 Abortion Patient Survey.

BACKGROUND: Medicaid is the most common type of health insurance held by abortion patients, but the Hyde amendment prohibits the use of Medicaid to pay for this care. Seventeen states allow state Medicaid funds to cover abortion. METHODS: We used data from a national sample of 6698 people accessing abortions at 56 facilities across the United States between June 2021 and July 2022. We compare patient characteristics and issues related to payment for the abortion across patients residing in states where state Medicaid funds covered abortion (Medicaid states) and those where it did not (Hyde states). We also examine which abortion patient populations were most likely to use Medicaid in states where it covers abortion care. RESULTS: In Medicaid states, 62% of respondents used this method to pay for care while a majority of individuals in Hyde states, 82%, paid out of pocket. Some 71% of respondents in Medicaid states paid USD0 and this was substantially lower, 10%, in Hyde states. In Hyde states, two-thirds of respondents had to raise money for the abortion (e.g., by delaying bills) compared to 28% in Medicaid states. Within Medicaid states, groups most likely to rely on this method of payment included respondents who identified as Black (70%) or Latinx (66%), those in the lowest income group (78%) and those having second-trimester abortions (75%). DISCUSSION: When state Medicaid funds cover abortion, it substantially reduces the financial burden of care. Moreover, it may increase access for groups historically marginalized within the health care system.

Characteristics of U.S. Abortion Patients Who Obtained Care Out of State Prior to the Overturning of Roe v. Wade.

CONTEXT: In light of the Dobbs v. Jackson Women's Health Organization decision overturning Roe v. Wade, the number of people who need to travel out of state for abortion is increasing as several states impose abortion bans. Better understanding the characteristics of patients who obtained out-of-state abortions before the decision can provide a reference point for future research and inform efforts to improve abortion access. METHODS: We used data from the 2014 Abortion Patient Survey, administered by the Guttmacher Institute, to examine the prevalence and characteristics of patients obtaining nonhospital abortions outside of their state of residence. We examined bivariate and multivariable associations between selected characteristics and obtaining an abortion out of state. RESULTS: Six percent of abortion patients traveled out of state for care. Among patients who obtained their abortion out of state, more than half (56.9%) were non-Hispanic (NH) white, 26.6% were non-Hispanic Black, and 10.2% were Hispanic. Two-fifths (43.9%) resided in the South, one-third (34.3%) resided in the Midwest, 15% resided in the Northeast, and 7% resided in the West. More than one-third (38.2%) had family incomes below 100% of the federal poverty level (FPL), and two-thirds (67.7%) paid out of pocket; only 3% used Medicaid. Profiles of out-of-state abortion patients differed from in-state abortion patients by all characteristics except age. In adjusted analyses, NH Black (adjusted odds ratio [AOR]: 0.76; 95% confidence interval [CI]: 0.61-0.96), NH Asian, South Asian, and Asian Pacific Islander (AOR: 0.37; 95% CI: 0.20-0.67), and Hispanic (AOR: 0.46; 95% CI: 0.33-0.64) patients had lower odds of traveling out of state compared with their NH white counterparts. Compared with those paying for their abortion with private insurance, those who paid out of pocket had higher odds of traveling out of state (AOR: 1.75; 95% CI: 1.29-2.37) and those paying with Medicaid had lower odds (AOR: 0.27; 95% CI: 0.15-0.47). CONCLUSION: Given the observed differences by race/ethnicity and method of payment for abortion, people of color and those without resources to pay out of pocket may especially benefit from efforts to support access to abortion care via interstate travel as an increasing number of states ban abortion.

Characteristics of people obtaining medication vs procedural abortions in clinical settings in the United States: Findings from the 2021-2022 Abortion Patient Survey.

OBJECTIVES: This study aimed to compare the characteristics of people obtaining medication and procedural abortions in clinical settings in the United States. STUDY DESIGN: We conducted a cross-sectional survey of people obtaining abortions at a sample of 56 US facilities between June 2021 and July 2022. We restricted analyses to patients with pregnancies less than 11 weeks' gestation presenting at 43 clinics offering both medication and procedural abortion. We conducted bivariate analyses and multivariable logistic regression to identify factors associated with obtaining a medication vs procedural abortion. RESULTS: Our analytic sample includes 4717 respondents, 57% of whom obtained a medication abortion. In bivariate analyses, individuals who identified as Asian or White, had no prior births or abortions, or were paying out of pocket were all more likely to have a medication abortion. Non-Hispanic Black individuals, those with incomes at or below the poverty level, and those paying with insurance were more likely to have a procedural abortion. Some 24% of respondents chose the facility because it offered medication abortion, but even after controlling for this proxy for method preference in a logistic regression model, Black respondents and those with poverty-level incomes were less likely to have a medication abortion. CONCLUSIONS: The findings of the study suggest that Black individuals and those with low incomes-who often face systemic barriers to care-are less likely to have medication abortions. When medication abortion is the only option available, for example, at a medication-only clinic or from an online source, these groups may be most impacted by the lack of options. IMPLICATIONS: To the extent possible, offering both medication and procedural abortion and increasing access to both types are important to meet patients' individual needs and preferences.

Characteristics of abortion patients in protected and restricted states accessing clinic-based care 12 months prior to the elimination of the federal constitutional right to abortion in the United States.

BACKGROUND: As a result of the June 2022 decision of the United States (US) Supreme Court, as many as 24 states have, or are expected to, ban or severely restrict abortion. We provide baseline information about abortion patients living in different state environments prior to this decision. METHODS: We obtained surveys from 6674 women, transgender men, and other pregnancy capable individuals accessing abortion care at 56 facilities across the US between June 2021 and July 2022. The final analytic sample uses information from 5930 abortion patients to compare the demographic and situational profiles of those living in the 24 states likely to ban abortion (restricted) to those living in states where it is likely to remain legal (protected). RESULTS: Compared to respondents who lived in protected states, abortion patients in restricted states were more likely to be Black (39% vs. 30%) or white (35% vs. 28%) and less likely to be Latinx (18% vs. 32%). Respondents in restricted states were more likely to be paying out-of-pocket for care (87% vs. 42%), be relying on financial assistance (22% vs. 11%), and indicate that it was difficult to pay for the abortion (54% vs. 28%). Twelve percent of respondents who lived in a restricted state crossed state lines for care and the majority (59%) was going to another restricted state. DISCUSSION: Prior to June 2022, abortion patients in restricted states encountered more situational and financial barriers compared to those in protected states. These barriers have undoubtedly been exacerbated by abortion bans.

Abortion incidence and service availability in the United States, 2020.

BACKGROUND: This study provides a baseline assessment of abortion incidence and service delivery prior to Roe v. Wade being overturned. METHODS: We collected information from all facilities known to have provided abortion services in the United States in 2019 and 2020. We examined abortion incidence by state, region and nationally and combined data on number of abortions with population data to estimate abortion rates. We also examined the number of abortion clinics, trends in medication abortion and service disruptions and changes in abortion protocols that occurred during the COVID-19 pandemic. We compare these findings to those of our prior Abortion Provider Census, which collected information for 2017. RESULTS: We documented 930,160 abortions in 2020, an 8% increase from 2017. Between 2017 and 2020, abortion incidence increased in all four regions of the country and in a majority of states. The total number of clinics providing abortion care remained stable nationally but increased in the Midwest and the West and declined in the Northeast and South. There were 492,210 medication abortions in 2020, a 45% increase from 2017. A substantial minority of clinics adjusted protocols in response to COVID, most commonly adopting remote pre- and post-abortion counseling. DISCUSSION: This study did not address factors behind the increase in abortion. However, this report demonstrates that the need for abortion care was growing just prior to the overturning Roe v. Wade, and the impact of this decision will be even more far-reaching than previously expected.

Telehealth for Contraceptive Care During the COVID-19 Pandemic: Results of a 2021 National Survey.

Objectives. To investigate trends in the use and quality of telehealth for contraceptive care during the COVID-19 pandemic in the United States. Methods. The 2021 Guttmacher Survey of Reproductive Health Experiences is a national online survey of 6211 people assigned female at birth, aged 18 to 49 years, and that ever had penile‒vaginal sex. We used weighted bivariable and multivariable logistic regressions to analyze the use of telehealth for contraceptive care and the quality of this care. Results. Of the respondents, 34% received a contraceptive service in the 6 months before the survey; of this group, 17% utilized telehealth. Respondents who were uninsured at some point in the 6 months before the survey had greater odds of using telehealth for this care. Respondents had lower odds of rating the person-centeredness of their care as "excellent" if they received services via telehealth compared with in person (25% vs 39%). Conclusions. Telehealth has helped bridge gaps in contraceptive care deepened by COVID-19. More work is needed to improve the quality of care and reduce access barriers to ensure telehealth can meet its full potential as part of a spectrum of care options. (Am J Public Health. 2022;112(S5):S545-S554. https://doi.org/10.2105/AJPH.2022.306886).

Abortion Access for Incarcerated People: Incidence of Abortion and Policies at U.S. Prisons and Jails.

OBJECTIVE: To understand abortion incidence among incarcerated people and the relation to prison and jail pregnancy policies. METHODS: We collected abortion numbers and policy data from convenience sample of 22 state prison systems, all Federal Bureau of Prisons sites, and six county jails that voluntarily reported monthly, aggregate pregnancy outcomes for 12 months in 2016-2017. Sites also completed a baseline survey of institution characteristics and pregnancy policies, including abortion. We reported facility policies and abortion incidence according to state-level abortion characteristics. RESULTS: Only half of state prisons in the study allowed abortion in both the first and second trimesters, and 14% did not allow abortion at all. Of the 19 state prisons permitting abortion, two thirds required the incarcerated woman to pay. Four jails of the six study jails (67%) allowed abortions in the first and second trimesters, and 25% of those required the incarcerated woman to pay for the procedure. The three prisons and two jails that did not allow abortions were in states considered hostile to abortion access. In the state and federal prisons studied, 11 of the 816 pregnancies (1.3%) that ended during the study time period were abortions. Of the 224 pregnancies that ended at study jails, 33 were abortions (15%), with more than half of those (55%) occurring in the first trimester. The abortion ratio (proportion of pregnancies ending in abortion) was 1.4% for prisons and 18% for jails. CONCLUSION: Although some incarcerated individuals have abortions, many prisons and jails have restrictive policies surrounding abortion, either through self-payment requirements or explicit prohibition. Findings from this study should prompt further inquiry into abortion incidence in these settings and address interventions to ensure incarcerated people, in accordance with legal requirements and health equity, have access to abortion.

Fertility intentions and recent births among US abortion patients.

OBJECTIVE: To examine fertility intentions among abortion patients and the potential of abortion for avoiding short birth intervals. STUDY DESIGN: We used national data from a sample of more than 8000 individuals obtaining abortions in the United States in 2014. We created a measure of fertility intentions based on prior births and responses to an item asking about future childbearing expectations. We identify respondents who reported having a birth in the last 12 months as at risk of a short birth interval. We used simple logistic regression to assess for differences in these measures according to key demographic variables. RESULTS: Most commonly, 39% of patients intended to have (more) children, with similar proportions wanting to delay a first birth (20%) or postpone a second or higher order birth (19%). Some 31% of abortion patients had completed childbearing; they had one or more prior births and did not want to have any more children. Similar proportions of respondents were not sure if they wanted to have children (16%) or did not want to have any children (15%). Among abortion patients who had children, 14% had had a birth in the prior year. We estimate that as many as 77,800 short birth intervals were averted in 2014 because individuals had access to abortion. CONCLUSIONS: These findings support the view that abortion allows individuals to plan and space their births according to their reproductive life plans and intentions. IMPLICATIONS: Access to abortion may help thousands of individuals in the United States avoid short birth intervals, potentially leading to improvements in maternal and child health.

Sexual orientation-related differences in contraceptive use: A brief report based on a cohort of adolescent and young women.

OBJECTIVES: To examine contraceptive methods used by adolescent/young adult women of diverse sexual orientations. STUDY DESIGN: We collected data from 12,902 females, born 1982-1995, from the longitudinal Growing Up Today Study. RESULTS: Compared to heterosexuals, lesbians were half as likely to use contraceptives; other sexual minority subgroups (e.g., bisexuals) were more likely to use contraceptives, particularly long-acting reversible contraceptives. CONCLUSIONS: Many sexual minority women use contraception throughout adolescence/young adulthood, though use is low among lesbians. IMPLICATIONS: With limited contraception use, lesbians miss opportunities for care and need to be brought into the healthcare system in other ways.

Trends in medication abortion and the role of low-volume and nonmetropolitan mifepristone purchasers: 2008-2011 and 2014-2017.

OBJECTIVE: The objective was to examine trends in the number of low-volume and nonmetropolitan mifepristone purchasers and their role in the expansion of medication abortion. METHODS: We use deidentified data from Danco Laboratories, the sole distributor of mifepristone during the study period, to examine trends in mifepristone distribution. We focus on customers who purchased < 100 doses a year and a subset of those who purchased < 10 doses for the periods of 2008-2011 and 2014-2017. We use data from the Guttmacher Institute Abortion Provider Census (APC) studies in 2008 and 2017 to examine the extent to which some facilities that purchased mifepristone may be missing from Guttmacher's APC. RESULTS: Between 2008 and 2017, the number of medication abortions increased 73%, though the number of mifepristone purchasers only increased 15%. The number of low-volume mifepristone customers, or those who purchased < 100 tablets of mifepristone per year, decreased 8% over the study period, while the number purchasing < 10 tablets per year decreased 14%. However, in recent years, low-volume customers were more likely to have purchased mifepristone in multiple years. In nonmetropolitan areas, the number of sites purchasing mifepristone increased slightly but the amount of mifepristone that was purchased more than doubled between 2008 and 2017. CONCLUSIONS: While reliance on medication abortion increased substantially between 2008 and 2017, there is no evidence that this was due to an increase in the number of facilities that purchased low volumes of mifepristone. IMPLICATIONS: While their numbers declined, abortion providers purchasing low volumes of mifepristone likely played an important role for the individuals they cared for. Access to abortion could increase if a wider network of health care practitioners, especially those in settings that do not currently provide abortions, was able to offer medication abortion.

Abortion service delivery in clinics by state policy climate in 2017.

OBJECTIVE: The objective was to examine service delivery in clinics that provided abortions in 2017, including differences by abortion policy climate. STUDY DESIGN: Using data from the Guttmacher Institute's 2017 Abortion Provider Census, we examine amount charged for abortion care, pregnancy gestation at which abortions were offered, number of days per week that clinics provided abortions and types of nonabortion services offered. Our analysis focuses on the 808 clinic facilities that provided 95% of abortions that year. Measures were calculated nationally and according to whether the clinic was in a state we categorized as hostile, middle ground or supportive of abortion rights. RESULTS: In 2017, 64% of clinics offered abortion at 11 weeks pregnancy gestation, and 22% did so at 20 weeks gestation. Supportive states had a higher density of clinics that provide abortion for every measured gestation than hostile states. Clinics charged an average of $549 for a surgical abortion at 10 weeks and $551 for medication abortion. Some 46% of clinics in supportive states offered abortion care 5 or more days per week compared to 29% in hostile states. Most clinics offered standalone contraception and family planning (87%) and gynecological care (85%), but the proportion of clinics that provided these services was higher in supportive states (93% and 90%) than in hostile states (75% and 73%). CONCLUSIONS: A substantial proportion of abortion facilities provide a range of other health care services. Aspects of service delivery, such as number of days abortions are provided, may vary according to abortion policy climate. IMPLICATIONS STATEMENT: Onerous policies in states hostile to abortion rights may inhibit some facilities from providing abortion more days per week, and if so, could further burden patients obtaining abortion care in these states.

Change and stability in contraceptive use patterns among US women over a 12-month period: analysis using the 2013-2015 National Survey of Family Growth life history calendar.

OBJECTIVE: To improve understanding of contraceptive use over 1 year among women in the United States. STUDY DESIGN: We used the 2013-2015 National Survey of Family Growth to examine monthly contraceptive use patterns over a 12-month period. We focused on use of contraception during months in which non-sterilized women were sexually active and not pregnant; our outcomes were contraceptive use in every month, some months, and no months. We used simple and multivariate logistic regression to examine socio-demographic and method use characteristics associated with contraceptive use patterns. RESULTS: Some 72% of non-pregnant, non-surgically sterile women used contraception in every sexually active month. After controlling for other demographic and individual characteristics, adolescents had higher odds (aOR = 2.45) of using contraception in each sexually active month compared to women aged 25-29. Other groups more likely to use contraception monthly included those with some college (aOR = 1.58) compared to less than high school and non-cohabiting unmarried women (aOR = 1.49) compared to married women. Those with gaps in insurance coverage during the past year (aOR = 0.70), women who were not sexually active all 12 months (aOR = 0.42), and those with more than two male sexual partners (aOR = 0.49), were less likely to use contraception every sexually active month. Nearly half (46%) of contraceptive users in our sample used more than one type of contraceptive method over the 12-month period. CONCLUSIONS: The majority of women use contraception every month they are sexually active, although there is variation between socio-demographic groups. However, over a one-year period, many women used dynamic contraceptive strategies. IMPLICATIONS: Health care providers should recognize that contraceptive use patterns are dynamic and change over a relatively short time period for many women.

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.

Pregnancy Prevalence and Outcomes in U.S. Jails.

OBJECTIVE: To describe the number of admissions of pregnant people to U.S. jails and the outcomes of pregnancies that end in custody. METHODS: We prospectively collected pregnancy data from six U.S. jails, including the five largest jails, on a monthly basis for 12 months. Jails reported de-identified, aggregate numbers of pregnant people admitted, births, preterm births, cesarean deliveries, miscarriages, induced abortions, ectopic pregnancies, and maternal and newborn deaths. RESULTS: There were 1,622 admissions of pregnant people in 12 months in the selected jails. The highest 1-day count of pregnant people at a single jail was 65. The majority of these admissions involved the release of a pregnant person. Of the 224 pregnancies that ended in jail, 144 (64%) were live births, 41 (18%) were miscarriages, 33 (15%) were induced abortions, and four were ectopic (1.8%). One third of the births were cesarean deliveries and 8% were preterm. There were two stillbirths, one newborn death, and no maternal deaths. CONCLUSION: About 3% of admissions of females to U.S. jails are of pregnant people; extrapolating study results to national female jail admission rates suggests nearly 55,000 pregnancy admissions in 1 year. It is feasible to track pregnancy statistics about this overlooked group.