Comparison of No-Test Telehealth and In-Person Medication Abortion.

Importance: In the US, access to medication abortion using history-based (no-test) eligibility assessment, including through telehealth and mailing of mifepristone, has grown rapidly. Additional evidence on the effectiveness and safety of these models is needed. Objective: To evaluate whether medication abortion with no-test eligibility assessment and mailing of medications is as effective as in-person care with ultrasonography and safe overall. Design, Setting, and Participants: Prospective, observational study with noninferiority analysis. Sites included 4 abortion-providing organizations in Colorado, Illinois, Maryland, Minnesota, Virginia, and Washington from May 2021 to March 2023. Eligible patients were seeking medication abortion up to and including 70 days' gestation, spoke English or Spanish, and were aged 15 years or older. Exposure: Study groups reflected the model of care selected by the patient and clinicians and included: (1) no-test (telehealth) eligibility assessment and mailing of medications (no-test + mail) (n = 228); (2) no-test eligibility assessment and pickup of medications (no-test + pickup) (n = 119); or (3) in-person with ultrasonography (n = 238). Main Outcomes and Measures: Effectiveness, defined as a complete abortion without the need for repeating the mifepristone and misoprostol regimen or a follow-up procedure, and safety, defined as an abortion-related serious adverse event, including overnight hospital admission, surgery, or blood transfusion. Outcomes were derived from patient surveys and medical records. Primary analysis focused on the comparison of the no-test + mail group with the in-person with ultrasonography group. Results: The mean age of the participants (N = 585) was 27.3 years; most identified as non-Hispanic White (48.6%) or non-Hispanic Black (28.1%). Median (IQR) gestational duration was 45 days (39-53) and comparable between study groups (P = .30). Outcome data were available for 91.8% of participants. Overall effectiveness was 94.4% (95% CI, 90.7%-99.2%) in the no-test + mail group and 93.3% (95% CI, 88.3%-98.2%) in the in-person with ultrasonography group in adjusted models (adjusted risk difference, 1.2 [95% CI, -4.1 to 6.4]), meeting the prespecified 5% noninferiority margin. Serious adverse events included overnight hospitalization (n = 4), blood transfusion (n = 2), and emergency surgery (n = 1) and were reported by 1.1% (95% CI, 0.4%-2.4%) of participants, with 3 in the no-test + mail group, 3 in the in-person with ultrasonography group, and none in the no-test + pickup group. Conclusions and Relevance: This prospective, observational study found that medication abortion obtained following no-test telehealth screening and mailing of medications was associated with similar rates of complete abortion compared with in-person care with ultrasonography and met prespecified criteria for noninferiority, with a low prevalence of adverse events.

Experiences of delay-causing obstacles and mental health at the time of abortion seeking.

Objectives: The delays and challenges people encounter when seeking abortion are well-documented, but their psychological implications are understudied. Aiming to fill this gap, we explored the associations between experiences of delay-causing obstacles to abortion care and adverse mental health symptoms among individuals seeking abortion care. Study design: In 2019, we surveyed 784 people (of 1092 approached) ages 15-45 accessing abortion care in four clinics in abortion-supportive states: California, Illinois, and New Mexico. We conducted multivariable Poisson regressions to examine associations between experiencing delay-causing obstacles to abortion care and stress, anxiety, and depression at the abortion appointment. We also used Poisson regression to examine whether some individuals are more likely to experience delay-causing obstacles than others. Results: Three in five participants (58%) experienced delay-causing obstacles when accessing abortion care. The most prevalent obstacles were cost-related (45%), followed by access-related (43%), and travel time-related (35%) delays. In adjusted analyses, experiencing any type of delay-causing obstacle to abortion care was significantly associated with more symptoms of stress, anxiety, and depression and higher risk of anxiety and depressive disorders. Participants were more likely to experience delay-causing obstacles if they traveled from another state or over 100 miles to reach the clinic, sought abortion beyond 13 weeks gestation, lacked money for unexpected expenses, and found it difficult to pay for the abortion. Conclusion: Abortion is a time-sensitive healthcare, but most individuals are forced to delay care due to various obstacles that may have a negative impact on their psychological well-being. Implications: Obstacles causing delays in accessing abortion care may contribute to elevated symptoms of stress, anxiety, and depression and higher risk of anxiety and depressive disorders for abortion patients. As restrictive policies increase, delays are likely to worsen, potentially leading to psychological harm for people seeking abortion.

Access to Reproductive Health Services Among People With Disabilities.

Importance: People with disabilities face inequitable access to reproductive health (RH) services, yet the national prevalence of barriers to access experienced across disability types and statuses is unknown. Objective: To assess the national prevalence of barriers to RH access experienced by people with disabilities. Design, Setting, and Participants: This cross-sectional study analyzed results of an online probability-based national survey of RH experiences that was conducted from December 2021 to January 2022. The national sample consisted of English- and Spanish-speaking panel members of a market research firm. Panelists were invited to participate in a survey on their RH experiences and opinions. These participants were aged 15 to 49 years and assigned female at birth (AFAB). Weighted proportions were estimated, and bivariable and multivariable regression analyses were performed to assess associations between disability status and barriers to accessing RH services. Exposure: Using 5 of the 6 Washington Group Short Set on Functioning items, 8 dichotomous disability indicators were created: (1) vision, (2) hearing, (3) mobility, (4) activities of daily living, (5) communication, (6) overall disability status (a lot or more difficulty functioning in ≥1 domain), (7) some difficulty functioning (below the disability threshold; some or more difficulty functioning in ≥1 domain), and (8) multiple disabilities (a lot or more difficulty functioning in ≥2 domains). Main Outcomes and Measures: Number and types of barriers (logistical, access, cost, privacy, and interpersonal relationship) to accessing RH services in the past 3 years. Results: After exclusion, the final sample included 6956 people AFAB, with a mean (SD) age of 36.0 (8.3) years. Of these participants, 8.5% (95% CI, 7.6%-9.5%) met the disability threshold. Participants with disabilities compared with those without disabilities were disproportionately more likely to be non-Hispanic Black (18.8% [95% CI, 14.4%-24.1%] vs 13.2% [95% CI, 11.9%-14.5%]) or Hispanic or Latinx (completed survey in English: 18.1% [95% CI, 14.0%-23.0%] vs 14.6% [95% CI, 13.3%-16.0%]; completed survey in Spanish: 8.9% [95% CI, 6.2%-12.8%] vs 6.2% [95% CI, 5.4%-7.1%]) individuals, to identify as LGBTQAI (lesbian, gay, bisexual, transgender, queer [or questioning], asexual [or allied], intersex; 16.4% [95% CI, 12.3%-21.6%] vs 11.8% [95% CI, 10.6%-13.1%]), to live below the federal poverty level (27.3% [95% CI, 22.3%-32.8%] vs 10.7% [95% CI, 9.7%-11.9%]), and to ever experienced medical mistreatment (49.6% [95% CI, 43.7%-55.5%] vs 36.5% [95% CI, 34.8%-38.2%]). Among those who had ever tried to access RH services (n = 6027), people with disabilities vs without disabilities were more likely to experience barriers (69.0% [95% CI, 62.9%-74.5%] vs 43.0% [95% CI, 41.2%-44.9%]), which were most often logistical (50.7%; 95% CI, 44.2%-57.2%) and access (49.9%; 95% CI, 43.4%-56.4%) barriers. The disability domains with the highest proportion of people who experienced 3 or more barriers in the past 3 years included activities of daily living (75.3%; 95% CI, 61.1%-85.6%), communication (65.1%; 95% CI, 49.5%-78.1%), and multiple (59.9%; 95% CI, 45.6%-72.7%) disabilities. Conclusions and Relevance: This cross-sectional study found large disparities in access to RH services among people AFAB with disabilities. Findings indicated a need to alleviate barriers to RH care, including improving the transportation infrastructure and reinforcing patient-centered approaches that engender inclusivity in health care settings.

Awareness of medication abortion among a nationally representative U.S. sample, 2021-2022.

OBJECTIVES: Assess public awareness of medication abortion in the U.S. STUDY DESIGN: We conducted a cross-sectional survey in 2021-2022 with a probability-based sample, calculating the prevalence of medication abortion awareness and assessing its associations with participant characteristics using multivariable logistic regression. RESULTS: A total of 45% of adults (7201/16,113) and 49% of eligible 15-17-year-old females (175/358) invited completed the survey. In all, 64% of 6992 participants assigned female at birth, and 57% of 360 participants assigned male reported awareness of medication abortion. Race, age, education, poverty level, religion, sexual identity, abortion history, and attitudes toward abortion legality were associated with differences in awareness. CONCLUSIONS: Medication abortion awareness differs by participant groups and is critical for expanding abortion access. IMPLICATIONS: Tailored health information for groups with less awareness of medication abortion may help spread knowledge of the method and how to access it.

Unwanted abortion disclosure and social support in the abortion decision and mental health symptoms: A cross-sectional survey.

OBJECTIVES: To assess the extent of unwanted abortion disclosure and levels of social support in the abortion decision and their association with depression, anxiety, and stress. STUDY DESIGN: From January to June 2019, we surveyed people presenting for abortion at four clinics in California, New Mexico, and Illinois regarding their experiences accessing abortion. We used multivariable regression to examine associations between unwanted abortion disclosure and social support in the abortion decision, and symptoms of depression, anxiety and stress. RESULTS: Among 1092 people approached, 784 (72% response rate) eligible individuals initiated the survey, and 746 responded to the unwanted abortion disclosure item and were included in analyses. Over one-quarter (27%) told someone they would have preferred not to tell about their decision, mostly due to obstacles getting to the appointment-time to appointment (46%), travel distance (33%), and costs (32%). Three-quarters (74%, n=546) had at least one person in their life who supported the abortion decision "very much"; 20% had someone who supported the decision "not at all." In adjusted analyses, unwanted abortion disclosure was associated with more symptoms of depression (B = 0.62, 95% confidence interval: 0.28, 0.95), anxiety (B = 1.79; 95% CI: 0.76, 2.82) and stress (B = 1.80, 95% CI: 0.64, 1.72). People also had more symptoms of depression and stress when one or more person (B = 0.64; 95% CI: 0.27, 1.02 and B = 0.75, 95% CI: 0.15, 1.35, respectively) or the man involved in the pregnancy (B = 0.67, 95% CI: 0.16, 1.18 and B = 0.96, 95% CI: 0.13, 1.78, respectively) supported their decision "not at all" (vs "very much" support). CONCLUSION: Being forced to disclose the abortion decision due to logistical and cost constraints may be harmful to people's mental health. IMPLICATIONS: Logistical burdens such as travel, time to access care, and costs needed to access abortion may force people seeking abortion to involve others who are unsupportive in the abortion decision having negative implications for their mental health.

Comparison of Pregnancy Preferences Preceding vs Year 1 of the COVID-19 Pandemic.

Importance: Understanding how the COVID-19 pandemic affected people's desire to avoid pregnancy is essential for interpreting the pandemic's associations with access to reproductive health care and reproductive autonomy. Early research is largely cross-sectional and relies on people's own evaluations of how their desires changed. Objective: To investigate longitudinal changes in pregnancy desires during the year before and the first year of the COVID-19 pandemic. Design, Setting, and Participants: In this cohort study, participants reported their pregnancy preferences at baseline and quarterly for up to 18 months between March 2019 and March 2021. An interrupted time series analysis with mixed-effects segmented linear regression was used to examine population-averaged time trends. People were recruited from 7 primary and reproductive health care facilities in Arizona, New Mexico, and Texas. Participants were sexually active, pregnancy-capable people aged 15 to 34 years who were not pregnant or sterilized. Data analysis was performed from September 2021 to January 2022. Exposures: Continuous time, with knots at the onset of the first (July 1, 2020, summer surge) and second (November 1, 2020, fall surge) COVID-19 cases surges in the Southwest. Main Outcomes and Measures: Preferences around potential pregnancy in the next 3 months, measured using the validated Desire to Avoid Pregnancy (DAP) scale (range, 0-4, with 4 indicating a higher desire to avoid pregnancy). Results: The 627 participants in the analytical sample had a mean (SD) age of 24.9 (4.9) years; 320 (51.0%) identified as Latinx and 180 (28.7%) as White. Over the year before the first case surge in the US Southwest in summer 2020, population-averaged DAP scores decreased steadily over time (-0.06 point per quarter; 95% CI, -0.07 to -0.04 point per quarter; P < .001). During the summer 2020 surge, DAP scores stopped declining (0.05 point per quarter; 95% CI, -0.03 to 0.13 point per quarter; change in slope, P < .001). During the fall 2020 surge, however, DAP scores declined again at -0.11 point per quarter (95% CI, -0.26 to 0.04 point per quarter; change in slope, P = .10). Participants aged 15 to 24 years and those who were nulliparous and primiparous experienced greater declines in DAP score before the summer surge, and greater reversals of decline between summer and fall 2020, than did those who were aged 25 to 34 years and multiparous. Conclusions and Relevance: These findings suggest that the COVID-19 pandemic onset was associated with the stalling of a prior trend toward greater desire for pregnancy over time, particularly for people earlier in their reproductive lives.

Home pregnancy test use and timing of pregnancy confirmation among people seeking health care.

OBJECTIVES: Understanding the timing of pregnancy suspicion and confirmation, including the role of home pregnancy tests, can facilitate earlier entry into pregnancy-related care and identify individuals likely to be impacted by gestation-based abortion restrictions. STUDY DESIGN: We use data from 259 pregnant individuals participating in a cross-sectional survey at 8 primary and reproductive health care clinics in 6 U.S. states (2016-2017). We use regression models to identify differences in utilization of HPTs, barriers to use, and to compare gestational duration at pregnancy confirmation. RESULTS: Three-quarters (74%) of respondents took a home pregnancy test as the first step in confirming pregnancy; this figure was lower among adolescents versus young adults (65 vs 81%, p = 0.01). Two-thirds (64%) reported delays in home testing, higher among adolescents (85%). People taking a test at home confirmed pregnancy 10 days earlier than those first testing at a clinic (41.3 vs 51.8 days gestation, p = 0.02). Those that did not test at home cited concerns about test accuracy (42%) and difficulties accessing one (26%). While overall 21% confirmed pregnancy at ≥7 weeks gestation, and 35% at ≥6 weeks, confirmation at ≥7 weeks was higher among adolescents versus young adults (47 vs 13%, p = 0.001), Latina versus white women (28 vs 11%, p = 0.02), food insecure versus secure women (28 vs 17%, p = 0.06), and people with unplanned versus planned/mistimed pregnancies (25 vs 13%, p = 0.07). CONCLUSIONS: Home pregnancy testing is common and associated with earlier pregnancy confirmation. Still, barriers to at-home testing are evident, particularly among adolescents. Efforts to expand access to home pregnancy tests and increase knowledge about their accuracy may be impactful in increasing utilization. IMPLICATIONS: While at home pregnancy testing is common and facilitates earlier confirmation of pregnancy, one in 5 confirm pregnancy at 7 weeks gestation or later (and one in 3 do so at 6 weeks or later). Gestational bans in the first trimester will disproportionately prevent young people, people of color, and those living with food insecurity from being able to access abortion.

Accuracy of self-assessment of gestational duration among people seeking abortion.

BACKGROUND: Mifepristone, used together with misoprostol, is approved by the United States Food and Drug Administration for medication abortion through 10 weeks' gestation. Although in-person ultrasound is frequently used to establish medication abortion eligibility, previous research demonstrates that people seeking abortion early in pregnancy can accurately self-assess gestational duration using the date of their last menstrual period. OBJECTIVE: In this study, we establish the screening performance of a broader set of questions for self-assessment of gestational duration among a sample of people seeking abortion at a wide range of gestations. STUDY DESIGN: We surveyed patients seeking abortion at 7 facilities before ultrasound and compared self-assessments of gestational duration using 11 pregnancy dating questions with measurements on ultrasound. For individual pregnancy dating questions and combined questions, we established screening performance focusing on metrics of diagnostic accuracy, defined as the area under the receiver operating characteristic curve, sensitivity (or the proportion of ineligible participants who correctly screened as ineligible for medication abortion), and proportion of false negatives (ie, the proportion of all participants who erroneously screened as eligible for medication abortion). We tested for differences in sensitivity across individual and combined questions using McNemar's test, and for differences in accuracy using the area under the receiver operating curve and Sidak adjusted P values. RESULTS: One-quarter (25%) of 1089 participants had a gestational duration of >70 days on ultrasound. Using the date of last menstrual period alone demonstrated 83.5% sensitivity (95% confidence interval, 78.4-87.9) in identifying participants with gestational durations of >70 days on ultrasound, with an area under the receiver operating characteristic curve of 0.82 (95% confidence interval, 0.79-0.85) and a proportion of false negatives of 4.0%. A composite measure of responses to questions on number of weeks pregnant, date of last menstrual period, and date they got pregnant demonstrated 89.1% sensitivity (95% confidence interval, 84.7-92.6) and an area under the receiver operating curve of 0.86 (95% confidence interval, 0.83-0.88), with 2.7% of false negatives. A simpler question set focused on being >10 weeks or >2 months pregnant or having missed 2 or more periods had comparable sensitivity (90.7%; 95% confidence interval, 86.6-93.9) and proportion of false negatives (2.3%), but with a slightly lower area under the receiver operating curve (0.82; 95% confidence interval, 0.79-0.84). CONCLUSION: In a sample representative of people seeking abortion nationally, broadening the screening questions for assessing gestational duration beyond the date of the last menstrual period resulted in improved accuracy and sensitivity of self-assessment at the 70-day threshold for medication abortion. Ultrasound assessment for medication abortion may not be necessary, especially when requiring ultrasound could increase COVID-19 risk or healthcare costs, restrict access, or limit patient choice.

Abortion method preference among people presenting for abortion care.

OBJECTIVE: To explore abortion method preference, interpersonal and cultural factors associated with preference, and whether, among people with a preference for medication abortion, those presenting past 10 weeks gestation had experienced more obstacles to care. METHODS: In 2019, we invited people aged 15 to 45 years presenting to 4 U.S. abortion clinics to complete a self-administered, anonymous iPad survey prior to seeing the health care provider. Questions focused on their pregnancy, including self-reported gestational age and experiences accessing abortion care, including abortion method preference. We used multivariate logistic regression to assess associations between worry about perceived pregnancy-related stigma or abortion-related health myths and abortion method preference. RESULTS: The majority (784 [77%]) of those approached (1092) initiated the survey and 712 responded to the preference question. Most (597 [84%]) preferred a method: 246 (41%) preferred medication abortion and 351 (59%) an in-clinic procedure. About one-third (110 [32%]) of those preferring medication abortions exceeded 10 weeks gestation and 83% (n = 91) had experienced delay-causing obstacles to care. In multivariate analyses, we found a greater odd of preference for medication abortion over in-clinic procedure among those very worried about people's reaction to the pregnancy (adjusted OR [aOR] 1.95, 95% CI 1.16-3.28), judgment from God or religion (aOR 1.93, 95% CI 1.17-3.19) and abortion affecting mental health (aOR 2.51, 95% CI 1.45-4.34) or ability to get pregnant later (aOR 1.80, 95% CI: 1.09-2.97). CONCLUSIONS: Many people seeking abortion have a method preference; delayed presentation to care may impede ability to obtain desired method. Pregnancy-related stigma and misinformation are associated with preference for medication abortion. IMPLICATIONS STATEMENT: Pregnancy-related stigma and misinformation, such as health and safety myths promulgated by state-mandated abortion counseling, may motivate preference for medication abortion. Abortion access obstacles may impede individuals' ability to obtain their preferred method. Removing barriers to clinic access may enhance people's ability to obtain their preferred abortion method.

Reasons for and Logistical Burdens of Judicial Bypass for Abortion in Illinois.

PURPOSE: Minors seeking abortion in states with parental involvement requirements can obtain judicial bypass (JB) as an alternative. Research on minors' reasons for choosing bypass and the logistical obstacles associated with bypass is limited, yet needed to assess potential burdens introduced by mandated parental involvement. METHODS: Using data from all minors represented in JB proceedings by the Illinois Judicial Bypass Coordination Project in 2017 and 2018, we present descriptive statistics summarizing minors' demographic characteristics, reasons for seeking bypass, individuals involved in decision-making, and distances traveled and time elapsed to attend the court hearing. RESULTS: Most minors obtaining bypass (n = 150) agreed to participate (n = 128). Just more than half (55%) were aged 17 years and lived with one parent (54%). A minority were already parenting (5%) and/or lived with someone besides a parent or on their own (16%). The reasons for bypass included concern about being forced to continue the pregnancy (50%), fear of being kicked out of their home and/or cut off financially (41%), having no/minimal relationship with parents (15%), and fear of physical/emotional abuse (13%). Minors traveled an average of 24 miles one-way (range 1-270 miles) to a courthouse for their hearing. On average, 6.4 days elapsed between contacting the Judicial Bypass Coordination Project and the hearing. CONCLUSIONS: Judicial bypass can offer young people an opportunity to retain autonomy in decision-making, potentially avoiding abuse and other negative outcomes. However, even in a state with a well-organized network of attorneys, JB contributes 1 week to minors' abortion-seeking timeline and necessitates traveling long distances.

Certainty and intention in pregnancy decision-making: An exploratory study.

OBJECTIVE: Abortion is often characterized as an inherently difficult decision, despite research demonstrating high decision certainty among abortion patients. Minimal research has examined decision certainty among people planning to continue a pregnancy. We examined whether women seeking abortion experience lower decision certainty than those planning to continue pregnancies and whether certainty differs by pregnancy intendedness. STUDY DESIGN: We administered the decisional conflict scale (DCS) to pregnant women (n = 149) at 8 U.S. primary and reproductive health clinics. Using Poisson regression models adjusted for sociodemographic and pregnancy characteristics, we evaluated differences in DCS scores (<25/100 vs ≥25/100) by pregnancy decision and whether pregnancy intention modified the effect of pregnancy decision on certainty. RESULTS: Over one-half (58%) of respondents planned to have an abortion, 32% to continue the pregnancy, and 10% were unsure. DCS scores were low overall (median 9.4/100; IQR: 1.6, 25.0), indicative of high certainty, and the percentage scoring ≥25/100, reflecting any uncertainty, did not differ by pregnancy decision (23% abortion vs 19% continuing, p = 0.55). In a multivariable model, there was no statistically significant interaction between pregnancy decision (abortion vs continuing pregnancy) and intention. However, the predicted percentage reporting any uncertainty among respondents with intended pregnancies was comparable among those decided on abortion (13%) and continuing the pregnancy (16%). Among those with unintended pregnancies, these figures were 25% among those decided on abortion vs 36% among those continuing. CONCLUSION: Levels of certainty about a pregnancy decision were high and appeared to depend more on whether the pregnancy was intended or unintended than on the pregnancy decision itself. IMPLICATIONS: Similar levels of uncertainty among individuals who decided to have an abortion versus continue a pregnancy challenge the narrative that abortion is a particularly difficult medical and personal decision. The prevalence of some uncertainty among respondents continuing pregnancies suggests voluntary options counseling may be useful for some patients in prenatal care settings.

Developing and validating the Psychosocial Burden among people Seeking Abortion Scale (PB-SAS).

While there is a large body of research demonstrating that having an abortion is not associated with adverse mental health outcomes, less research has examined which factors may contribute to elevated levels of mental health symptoms at the time of abortion seeking. This study aims to develop and validate a new tool to measure dimensions of psychosocial burden experienced by people seeking abortion in the United States. To develop scale items, we reviewed the literature including existing measures of stress and anxiety and conducted interviews with experts in abortion care and with patients seeking abortion. Thirty-five items were administered to 784 people seeking abortion at four facilities located in three U.S. states. We used exploratory factor analysis (EFA) to reduce items and identify key domains of psychosocial burden. We assessed the predictive validity of the overall scale and each sub-scale, by assessing their associations with validated measures of perceived stress, anxiety, and depression using multivariable linear regression models. Factor analyses revealed a 12-item factor solution measuring psychosocial burden seeking abortion, with four subdomains: structural challenges, pregnancy decision-making, lack of autonomy, and others' reactions to the pregnancy. The alpha reliability coefficients were acceptable for the overall scale (α = 0.83) and each subscale (ranging from α = 0.82-0.85). In adjusted analyses, the overall scale was significantly associated with stress, anxiety and depression; each subscale was also significantly associated with each mental health outcome. This new scale offers a practical tool for providers and researchers to empirically document the factors associated with people's psychological well-being at the time of seeking an abortion. Findings suggest that the same restrictions that claim to protect people from mental health harm may be increasing people's psychosocial burden and contributing to adverse psychological outcomes at the time of seeking abortion.

Comparing Prospective and Retrospective Reports of Pregnancy Intention in a Longitudinal Cohort of U.S. Women.

CONTEXT: Measurement of pregnancy intentions typically relies on retrospective reporting, an approach that may misrepresent the extent of unintended pregnancy. However, the degree of possible misreporting is unclear, as little research has compared prospective and retrospective reports of intention for the same pregnancies. METHODS: Longitudinal data collected between 2010 and 2015 on 174 pregnancies were used to analyze the magnitude and direction of changes in intendedness (intended, ambivalent or unintended) between prospective and retrospective measurements of intendedness using versions of the London Measure of Unplanned Pregnancy (LMUP). Changes were assessed both continuously and categorically. Differences in the degree of change-by pregnancy outcome and participant characteristics-were examined using mixed-effects linear and logistic regression models. RESULTS: Over two and one-half years of follow-up, 143 participants reported 174 pregnancies. Approximately half showed changes in intention between the prospective and retrospective assessments, with 38% of participants reporting increased intendedness and 10% decreased intendedness. Reported intendedness increased more among those who gave birth (mean change in continuous LMUP score, 2.2) than among those who obtained an abortion (0.7), as well as among individuals with a college degree (4.1) than among those with a high school diploma (1.2). Participants who reported recent depression or anxiety symptoms showed more stable intentions (0.02) than those who did not (2.1). CONCLUSIONS: Retrospective measurement of pregnancy intentions may underestimate the frequency of unintended pregnancy, with such underestimation being greater among certain subgroups. Estimates based on retrospective reports thus may produce inaccurate impressions of intentionality. Further efforts to refine the measurement of pregnancy preferences are needed.

Pregnancy preferences and contraceptive use among US women.

OBJECTIVES: An understanding of the relationship between individuals' pregnancy preferences and contraceptive use is essential for appropriate patient-centered counseling and care. We examined the relationship between women's pregnancy preferences and contraceptive use using a new prospective measure, the Desire to Avoid Pregnancy (DAP) scale. STUDY DESIGN: As part of a study examining women's suspicion and confirmation of new pregnancies, we recruited patients aged 15 - 45 from seven reproductive health and primary health facilities in Arizona, New Jersey, New Mexico, South Carolina, and Texas in 2016-2017. We used multivariable logistic, multinomial logistic, and linear regression models to examine the associations among DAP scores (range: 0 - 4) and contraceptive use outcomes and identify factors associated with discordance between DAP and use of contraception. RESULTS: Participants with a greater preference to avoid pregnancy had higher odds of contraceptive use (aOR = 1.63, 95% CI: 1.31, 2.04) and used contraceptives more consistently (aß = 8.9 percentage points, 95% CI: 5.2, 12.7). Nevertheless, 63% of women with low preference to avoid pregnancy reported using a contraceptive method. Higher preference to avoid pregnancy was not associated with type of contraceptive method used: women with the full range of pregnancy preferences reported using all method types. CONCLUSION: When measured using a rigorously developed instrument, pregnancy preferences were associated with contraceptive use and consistency of use. However, our findings challenge assumptions that women with the highest preference against pregnancy use more effective methods and that women who might welcome pregnancy do not use contraception. IMPLICATIONS: Women's preferences about pregnancy contribute significantly to their use of contraception. However, health care providers and researchers should consider that contraceptive features besides effectiveness in preventing pregnancy shape contraceptive decision-making and use.

A Prospective Cohort Study of the Effect of Receiving versus Being Denied an Abortion on Educational Attainment.

BACKGROUND: Research on the effects of unintended childbearing has been limited in its ability to disentangle the direct effects of childbearing from common selection factors that predispose women to both unintended childbearing and lower educational attainment. METHODS: Using data from a 5-year prospective cohort study of 876 individuals seeking abortion care, some of whom were denied care because they presented beyond a facility's gestational age limit, we used discrete time survival models to estimate the hazard of graduating and dropping out among those enrolled in high school, college, or other type of school (n = 280). We also examined cluster-adjusted bivariable differences in degrees completed by receipt versus denial of a wanted abortion. RESULTS: Participants denied an abortion who parented were equally likely to be in school as compared with women who received a wanted abortion (33 vs. 28%; p = .19); however, they were more likely to be seeking a high school diploma (40 vs. 24%; p = .05) than a higher degree. In adjusted models, there were no differences in the hazard of graduating (adjusted hazard ratio, 0.76; 95% confidence interval, 0.36-1.61) or dropping out (adjusted hazard ratio, 1.12; 95% confidence interval, 0.67-1.88) between those who were denied versus received an abortion. Among graduates, participants denied a wanted abortion less often completed a postsecondary degree (27%) compared with those who received a wanted abortion (71%; p = .002). CONCLUSIONS: Unintended childbirth was not associated with graduating or dropping out in this population, a finding that is at least partially explained by differences in degrees sought at the time of abortion seeking.

Self-reported Physical Health of Women Who Did and Did Not Terminate Pregnancy After Seeking Abortion Services: A Cohort Study.

Background: Research demonstrates worse short-term morbidity and mortality associated with childbirth than with abortion, but little research has examined long-term physical health in women with unwanted pregnancies after abortion versus childbirth. Objective: To examine the physical health of women who seek and receive or are denied abortion. Design: Prospective cohort study. Setting: 30 U.S. abortion facilities from 2008 to 2010. Participants: Of 1132 women seeking abortion who consented to participate, 874 were included in this analysis (328 who had first-trimester abortion, 383 who had second-trimester abortion, and 163 who gave birth). Measurements: Self-reported overall health; chronic abdominal, pelvic, back, and joint pain; chronic headaches or migraines; obesity; asthma; gestational and nongestational hypertension and diabetes; and hyperlipidemia were assessed semiannually for 5 years. Mortality was assessed by using verbal autopsy and public records. Results: No significant differences were observed in self-rated health or chronic pain after first-trimester versus second-trimester abortion. At 5 years, 27% (95% CI, 21% to 34%) of women who gave birth reported fair or poor health compared with 20% (CI, 16% to 24%) of women who had first-trimester abortion and 21% (CI, 18% to 25%) who had second-trimester abortion. Women who gave birth also reported more chronic headaches or migraines and joint pain, but experienced similar levels of other types of chronic pain and obesity. Gestational hypertension was reported by 9.4% of participants who gave birth. Eight of 1132 participants died during follow-up, 2 in the postpartum period. Maternal mortality did not differ statistically by group. Limitation: Self-reported outcome measures, uncertain generalizability, and 41% loss to follow-up at 5 years. Conclusion: Although some argue that abortion is detrimental to women's health, these study data indicate that physical health is no worse in women who sought and underwent abortion than in women who were denied abortion. Indeed, differences emerged suggesting worse health among those who gave birth. Primary Funding Source: An anonymous foundation.

Psychometric Evaluation of an Instrument to Measure Prospective Pregnancy Preferences: The Desire to Avoid Pregnancy Scale.

BACKGROUND: Existing approaches to measuring women's pregnancy intentions suffer important limitations, including retrospective assessment, overly simple categories, and a presumption that all women plan pregnancies. No psychometrically valid scales exist to prospectively measure the ranges of women's pregnancy preferences. MATERIALS AND METHODS: Using a rigorous construct modeling approach, we developed a scale to measure desire to avoid pregnancy. We developed 60 draft items from existing research, assessed comprehension through 25 cognitive interviews, and administered items in surveys with 594 nonpregnant women in 7 primary and reproductive health care facilities in Arizona, New Jersey, New Mexico, South Carolina, and Texas in 2016-2017. We used item response theory to reduce the item set and assess the scale's reliability, internal structure validity, and external validity. Items were included based on fit to a random effects multinomial logistic regression model (partial credit item response model), correspondence of item difficulty with participants' pregnancy preference levels, and consistency of each item's response options with overall scale scores. RESULTS: The 14 final items covered 3 conceptual domains: cognitive preferences, affective feelings, and practical consequences. Items fit the unidimensional model, with a separation reliability of 0.90 (Cronbach α: 0.95). The scale met established criteria for internal validity, including correspondence between each item's response categories and overall scale scores. We found no important differential item functioning by participant characteristics. CONCLUSIONS: A robust measure is available to prospectively measure desire to avoid pregnancy. The measure can aid in identifying women who could benefit from contraceptive care and research on less desired pregnancy.