Welcomed Pregnancies: Characteristics and Patterns of Adjusting to Unwanted, Unplanned, Untimely or Otherwise Difficult Pregnancies.

Background Women facing problematic pregnancies, defined as "unplanned, mistimed, unwanted, or otherwise difficult," either have abortions or make adjustments to welcome these pregnancies. These adjustments are understudied. Pregnancy resource centers that provide counseling and services to assist in the process of welcoming pregnancies have been the focus of controversy due to their refusal to counsel or refer for abortions. This survey of a national population of women seeks to quantify changes in attitudes toward problematic pregnancies that are not aborted and to gauge levels of contact with pregnancy help centers and perceptions of harm or benefits attributed to those contacts. Methodology A national research firm was enlisted to obtain 1,000 surveys completed by female residents of the United States aged 41-45, inclusive. Women reporting a history of abortion were surveyed along one path. For those who did not have abortions but reported a problematic pregnancy, questions were presented to assess changes in attitude toward their pregnancy from the date they first learned they were pregnant to 90 days later, their considerations of abortion, whether they had contact with a pregnancy help center, and their assessment of that contact on either harming or improving their lives. Results Among 275 respondents who had no history of abortion but had ultimately welcomed a problematic pregnancy, 112 (40.7%) had been at higher risk of abortion. Positive attitudes toward their pregnancies increased most rapidly for women who had been at higher risk of abortion but were lower on the day they first learned they were pregnant. Overall, 34 (12.4%) reported they had contacted a pregnancy help center that did not refer for abortions. Another 37 (13.5%) were uncertain if they had contacted an organization fitting that description. Both groups reported the contact improved their lives, on average. Negative assessments were uncommon and all were of a small degree. Conclusions Women facing problematic pregnancies who did not choose abortion experienced rapid improvements in feelings of wantedness, timeliness, acceptance, welcoming, and desirability toward the pregnancy. The rate of improvement was most rapid among those who had investigated and considered abortion. Women reporting contact with pregnancy help centers almost always assess it as having improved their lives.

A Reanalysis of Mental Disorders Risk Following First-Trimester Abortions in Denmark.

Background: A previous Danish study of monthly and tri-monthly rates of first-time psychiatric contact following first induced abortions reported higher rates compared to first live births but similar rates compared to nine months pre-abortion. Therefore, the researchers concluded abortion has no independent effect on mental health; any differences between psychiatric contacts after abortion and delivery are entirely attributable to pre-existing mental health differences. However, these conclusions are inconsistent with similar studies that used longer time frames. Reanalysis of the published Danish data over slightly longer time frames may reconcile this discordance. Method: Monthly and tri-monthly data was extracted for reanalysis of cumulative effects over nine- and twelvemonths post-abortion. Results: Across all psychiatric diagnoses, cumulative average monthly rate of first-time psychiatric contact increased from an odds ratio of 1.12 (95% CI: 1.02 to 1.22) at 9-months to 1.49 (95% CI: 1.37 to 1.63) at 12 months post-abortion as compared to the 9 months pre-abortion rate. At 12 months post-abortion, first-time psychiatric contact was higher across all four diagnostic groupings and highest for personality or behavioral disorders (OR=1.87; 95% CI:1.48 to 2.36) and neurotic, stress related, or somatoform disorders (OR=1.60; 95% CI: 1.41 to 1.81). Conclusions: Our reanalysis revealed that the Danish data is consistent with the larger body of both record-based and survey- based studies when viewed over periods of observation of at least nine months. Longer periods of observation are necessary to capture both anniversary reactions and the exhaustion of coping mechanisms which may delay observation of post-abortion effects.

Effects of prior reproductive losses on risk of cardiovascular diseases within six months of a first live birth.

Objective: There is emerging evidence suggesting that pregnancy loss (induced or natural) is associated with an increased risk of cardiovascular diseases (CVD). This prospective longitudinal study investigates the effect of prior pregnancy losses on CVD risk during the first six months following a first live birth. Methods: Medicaid claims of 1,002,556 low-income women were examined to identify history of pregnancy losses, CVD, diabetes, and hyperlipidemia prior to first live birth. The study population was categorized into five groups: A: women with no pregnancy loss or CVD history prior to first live birth; B: women with pregnancy loss and no CVD prior to first live birth. C: women with a first CVD diagnosis after a first pregnancy ending in a loss and before their first live birth. D: women with CVD prior to first live birth and no history of pregnancy loss. E: women with both CVD and pregnancy loss prior to their first live birth. Results: After controlling for age, race, state of residence, and history of diabetes and hyperlipidemia, the risk of CVD in the six-month period following a first live birth were 15%, 214%, 79% and 129% more common for Groups B, C, D and E, respectively, compared to Group A. Conclusions: Pregnancy loss is an independent risk factor for CVD risk following a first live birth, both for women with and without a prior history of CVD. The risk is highest when CVD is first diagnosed after a pregnancy loss and prior to a first live birth.

The Effects of Abortion Decision Rightness and Decision Type on Women's Satisfaction and Mental Health.

Background A case series report based on the Turnaway Study has previously concluded that 99% of women with a history of abortion will continue to affirm satisfaction with their decisions to abort. Those findings have been called into question due to a low participation rate (31%) and reliance on a single yes/no assessment of decision satisfaction. Aim To utilize more sensitive scales in assessing decision satisfaction and the associated mental health outcomes women attribute to their abortions. Method  A retrospective survey was completed by 1,000 females, aged 41-45, living in the United States. The survey instrument included 11 visual analog scales for respondents to rate their personal preferences and outcomes they attributed to their abortion decisions. A categorical question allowed women to identify if their abortions were wanted and consistent with their own values and preferences, inconsistent with their values and preferences, unwanted, or coerced. Linear regression models were tested to identify which of three decision scales best predicted positive or negative emotions, effects on mental health, emotional attachment, personal preferences, moral conflict, and other factors relevant to an assessment of satisfaction with a decision to abort. Results Of 226 women reporting a history of abortion, 33% identified it as wanted, 43% as accepted but inconsistent with their values and preferences, and 24% as unwanted or coerced. Only wanted abortions were associated with positive emotions or mental health gains. All other groups attributed more negative emotions and mental health outcomes to their abortions. Sixty percent reported they would have preferred to give birth if they had received more support from others or had more financial security. Conclusions Perceived pressure to abort is strongly associated with women attributing more negative mental health outcomes to their abortions. The one-third of women for whom abortion is wanted and consistent with their values and preferences are most likely over-represented in studies initiated at abortion clinics. More research is needed to understand better the experience of the two-thirds of women for whom abortion is unwanted, coerced, or otherwise inconsistent with their own values and preferences.

A Cohort Study of Mental Health Services Utilization Following a First Pregnancy Abortion or Birth.

Objective: To determine whether exposure to a first pregnancy outcome of induced abortion, compared to a live birth, is associated with an increased risk and likelihood of mental health morbidity. Materials and methods: Participants were continuously eligible Medicaid beneficiaries age 16 in 1999, and assigned to either of two cohorts based upon the first pregnancy outcome, abortion (n = 1331) or birth (n = 3517), and followed through to 2015. Outcomes were mental health outpatient visits, inpatient hospital admissions, and hospital days of stay. Exposure periods before and after the first pregnancy outcome, a total of 17 years, were determined for each cohort. Findings: Women with first pregnancy abortions, compared to women with births, had higher risk and likelihood of experiencing all three mental health outcome events in the transition from pre- to post-pregnancy outcome periods: outpatient visits (RR 2.10, CL 2.08-2.12 and OR 3.36, CL 3.29-3.42); hospital inpatient admissions (RR 2.75, CL 2.38-3.18 and OR 5.67, CL 4.39-7.32); hospital inpatient days of stay (RR 7.38, CL 6.83-7.97 and OR 19.64, CL 17.70-21.78). On average, abortion cohort women experienced shorter exposure time before (6.43 versus 7.80 years), and longer exposure time after (10.57 versus 9.20 years) the first pregnancy outcome than birth cohort women. Utilization rates before the first pregnancy outcome, for all three utilization events, were higher for the birth cohort than for the abortion cohort. Conclusion: A first pregnancy abortion, compared to a birth, is associated with significantly higher subsequent mental health services utilization following the first pregnancy outcome. The risk attributable to abortion is notably higher for inpatient than outpatient mental health services. Higher mental health utilization before the first pregnancy outcome for birth cohort women challenges the explanation that pre-existing mental health history explains mental health problems following abortion, rather than the abortion itself.

Effects of Pressure to Abort on Women's Emotional Responses and Mental Health.

Background Women who feel pressured to agree to abortion are more likely to experience negative emotional and mental health reactions. But relatively little research has been conducted to explore the types and degree of pressures women face and their associated effects. Our study aims to investigate five types of pressure women may face and a sample of effects that may be associated with unwanted abortions. Methods A retrospective survey was distributed through a marketing research firm and completed by 1000 females aged 41 to 45, inclusive, living in the United States. The survey instrument included demographic questions and analog scales for respondents to rate the pressure to abort arising from male partners, family members, other persons, financial concerns, and other circumstances and 10 variables related to both positive and negative outcomes. Results Among 226 respondents who reported a history of abortion, perceived pressure to abort was significantly associated with more negative emotions; more disruption of daily life, work, or relationships; more frequent thoughts, dreams, or flashbacks to the abortion; more frequent feelings of loss, grief or sadness about the abortion; more moral and maternal conflict over the abortion decision; a decline in overall mental health that they attribute to their abortions; more desire or need for help to cope with negative feelings about the abortion. Overall, 61% reported high levels of pressure on at least one scale. Women with a history of abortion were four times more likely to quit the survey than women who did not have abortions, and those with a history of feeling pressured to abort also reported higher levels of stress related to completing the survey. Discussion Perceived pressures to choose abortion should be assessed before an abortion to better guide risk assessments, decision-making, and analyses of post-abortion adjustments in light of these risk factors. A history of abortion, especially when there was pressure to abort, is associated with more stress completing questionnaires touching on abortion experiences and with a higher dropout rate, a finding that is consistent with the view that abortion surveys are likely to underrepresent the experiences of the women who experience the most stress and negative reactions to their abortions. Abortion providers should screen for perceived pressures to abort and be prepared to offer counseling and services that will help women to avoid unwanted abortions.

The Enduring Association of a First Pregnancy Abortion with Subsequent Pregnancy Outcomes: A Longitudinal Cohort Study.

Introduction: Multiple abortions are consistently associated with adverse health consequences. Prior abortion is a known risk factor for another abortion. Objective: To determine the persistence of the association of a first-pregnancy abortion with the likelihood of subsequent pregnancy outcomes. Methods: Data was extracted for a study population of 5453 continuously eligible Medicaid beneficiaries in states which funded and reported elective abortions 1999-2015. Women age 16 in 1999 were organized into three cohorts based upon the first pregnancy outcome: abortion, birth, natural loss. Results: Women in the abortion cohort are more likely than those in the birth cohort to experience another abortion rather than a birth or natural loss, and less likely to experience a live birth rather than an abortion or natural loss, for every subsequent pregnancy. The tendency toward abortion (OR 2.99, CL 2.02-4.43) and away from birth (OR 0.49, CL 0.39-0.63) peaks at the sixth pregnancy, but persists throughout the reproductive period ages 16-32. The pattern is reversed, but similarly consistent, for women in the birth cohort. They remain likelier to have another birth rather than an abortion or natural loss in subsequent pregnancies. Compared to the birth cohort, the abortion cohort had 1.35 times as many pregnancies: 4.31 times the abortions, 1.53 times the natural losses, but only 0.52 times the births. They were 4.3 and 5.0 times as likely to have 2-plus and 3-plus abortions, but only 0.47 times and 0.31 times as likely to have 2-plus and 3-plus births. Of the abortion cohort, 37.1% had no births. By contrast, 73.6% of the birth cohort had no abortions. Conclusion: The first-pregnancy abortion maintains a strong and persistent association with the likelihood of another abortion in subsequent pregnancies, enabling a cascade of adverse events associated with multiple abortions.

A Longitudinal Cohort Study of Emergency Room Utilization Following Mifepristone Chemical and Surgical Abortions, 1999-2015.

INTRODUCTION: Existing research on postabortion emergency room visits is sparse and limited by methods which underestimate the incidence of adverse events following abortion. Postabortion emergency room (ER) use since Food and Drug Administration approval of chemical abortion in 2000 can identify trends in the relative morbidity burden of chemical versus surgical procedures. OBJECTIVE: To complete the first longitudinal cohort study of postabortion emergency room use following chemical and surgical abortions. METHODS: A population-based longitudinal cohort study of 423 000 confirmed induced abortions and 121,283 subsequent ER visits occurring within 30 days of the procedure, in the years 1999-2015, to Medicaid-eligible women over 13 years of age with at least one pregnancy outcome, in the 17 states which provided public funding for abortion. RESULTS: ER visits are at greater risk to occur following a chemical rather than a surgical abortion: all ER visits (OR 1.22, CL 1.19-1.24); miscoded spontaneous (OR 1.88, CL 1.81-1.96); and abortion-related (OR 1.53, CL 1.49-1.58). ER visit rates per 1000 abortions grew faster for chemical abortions, and by 2015, chemical versus surgical rates were 354.8 versus 357.9 for all ER visits; 31.5 versus 8.6 for miscoded spontaneous abortion visits; and 51.7 versus 22.0 for abortion-related visits. Abortion-related visits as a percent of total visits are twice as high for chemical abortions, reaching 14.6% by 2015. Miscoded spontaneous abortion visits as a percent of total visits are nearly 4 times as high for chemical abortions, reaching 8.9% of total visits and 60.9% of abortion-related visits by 2015. CONCLUSION: The incidence and per-abortion rate of ER visits following any induced abortion are growing, but chemical abortion is consistently and progressively associated with more postabortion ER visit morbidity than surgical abortion. There is also a distinct trend of a growing number of women miscoded as receiving treatment for spontaneous abortion in the ER following a chemical abortion.

Estimating the Period Prevalence of Mothers Who Have Abortions: A Population Based Study of Inclusive Pregnancy Outcomes.

INTRODUCTION: The prevalence of induced abortion among women with children has been estimated indirectly by projections derived from survey research. However, an empirically derived, population-based conclusion on this question is absent from the published literature. OBJECTIVE: The objective of this study was to describe the period prevalence of abortion among all other possible pregnancy outcomes within the reproductive histories of Medicaid-eligible women in the U.S. METHODS: A retrospective, cross-sectional, longitudinal analysis of the pregnancy outcome sequences of eligible women over age 13 from the 17 states where Medicaid included coverage of most abortions, with at least one identifiable pregnancy between 1999 and 2014. A total of 1360 pregnancy outcome sequences were grouped into 8 categories which characterize various combinations of the 4 possible pregnancy outcomes: birth, abortion, natural loss, and undetermined loss. The reproductive histories of 4,884,101 women representing 7,799,784 pregnancy outcomes were distributed into these categories. RESULTS: Women who had live births but no abortions or undetermined pregnancy losses represented 74.2% of the study population and accounted for 87.6% of total births. Women who have only abortions but no births constitute 6.6% of the study population, but they are 53.5% of women with abortions and have 51.5% of all abortions. Women with both births and abortions represent 5.7% of the study population and have 7.2% of total births. CONCLUSION: Abortion among low-income women with children is exceedingly uncommon, if not rare. The period prevalence of mothers without abortion is 13 times that of mothers with abortion.

Intervals and Outcomes of First and Second Pregnancies in Low-Income Women: A Record-Linkage Longitudinal Prospective Cohort Study.

BACKGROUND The number of pregnancies and interval between pregnancies can have significant impact on a woman's reproductive, psychological, and general health. Exposure to multiple reproductive losses is especially associated with higher rates of negative outcomes. MATERIAL AND METHODS Medical records from 1999-2012 for all Medicaid beneficiaries born after 1982 in the 17 states that provide coverage for all reproductive services (N=2 162 600) were examined to identify the timing of subsequent pregnancies and their outcomes within 3 years of a first known pregnancy. RESULTS One year after their first pregnancy outcomes, 22.6%, 17.8%, and 11.7% of women who had an induced abortion, a natural loss, or a birth, respectively, conceived at least 1 additional pregnancy. By the second year, the percentage of repeat pregnancies rose to 37.5% after an abortion, 25.6% after a natural loss, and 23.1% after a birth. Graphing the weekly conception rates revealed that women who had abortions and natural losses showed similar patterns of rapid repeat pregnancy, with the rate of second conception spiking quickly within 3 to 4 months after the first pregnancy outcome. CONCLUSIONS These findings support the clinical evidence that pregnancy loss may contribute to rapid repeat pregnancies and may better inform interventions to reduce rapid repeat pregnancies.

Estimating the Period Prevalence of Publicly Funded Abortion to Space Live Births, 1999 to 2014.

INTRODUCTION/OBJECTIVES: Although a majority of women who have an abortion report having 1 or more children, there is no published research on the number of abortions which occur between live births, after a first child but before the last. The objectives of this research, therefore, were to estimate the period prevalence of an induced abortion separating live births in a population of Medicaid eligible enrollees and to identify the characteristics of enrollees significantly associated with the use of abortion to enable child spacing. METHODS: A retrospective, cross-sectional, longitudinal analysis of the pregnancy outcome sequences of eligible enrollees over age 13 from the 17 states where Medicaid included coverage of all abortions, with at least one identifiable pregnancy outcome between 1999 and 2014. Eligibles with a defined sequence of birth-abortion-birth within up to 5 consecutive pregnancies were identified to estimate the number of eligibles who could have practiced birth spacing by abortion. Logistic regression was applied to identify the significant predictor variables of the birth-abortion-birth sequence. RESULTS: There were 50 012 (1.02%) of 4 875 511 Medicaid eligible enrollees exhibited a birth-abortion-birth sequence. Eligibles with the birth-abortion-birth sequence are more likely to be Black than White (OR 2.641, CL 2.581-2.702), less likely to be Hispanic than White (OR 0.667, CL 0.648-0.687), and more likely to have received contraceptive counseling (OR 1.14, CL 1.118-1.163). Increases in months of Medicaid eligibility (OR 1.004, CL 1.003-1.004) and months from first pregnancy to second live birth (OR 1.015, CL 1.015-1.016) are associated with the likelihood of undergoing live births separated by one or more induced abortions. Increases in the age at first pregnancy are associated with a decreased likelihood of the birth-abortion-birth sequence (OR 0.962, CL 0.959-0.964). CONCLUSION: Birth spacing via abortion is uncommon among a low-income population for whom the financial barriers to abortion are somewhat alleviated.

Effects of Pregnancy Loss on Subsequent Postpartum Mental Health: A Prospective Longitudinal Cohort Study.

Pregnancy loss, natural or induced, is linked to higher rates of mental health problems, but little is known about its effects during the postpartum period. This study identifies the percentages of women receiving at least one postpartum psychiatric treatment (PPT), defined as any psychiatric treatment (ICD-9 290-316) within six months of their first live birth, relative to their history of pregnancy loss, history of prior mental health treatments, age, and race. The population consists of young women eligible for Medicaid in states that covered all reproductive services between 1999-2012. Of 1,939,078 Medicaid beneficiaries with a first live birth, 207,654 (10.7%) experienced at least one PPT, and 216,828 (11.2%) had at least one prior pregnancy loss. A history of prior mental health treatments (MHTs) was the strongest predictor of PPT, but a history of pregnancy loss is also another important risk factor. Overall, women with a prior pregnancy loss were 35% more likely to require a PPT. When the interactions of prior mental health and prior pregnancy loss are examined in greater detail, important effects of these combinations were revealed. About 58% of those whose first MHT was after a pregnancy loss required PPT. In addition, over 99% of women with a history of MHT one year prior to their first pregnancy loss required PPT after their first live births. These findings reveal that pregnancy loss (natural or induced) is a risk factor for PPT, and that the timing of events and the time span for considering prior mental health in research on pregnancy loss can significantly change observed effects. Clinicians should screen for a convergence of a history of MHT and prior pregnancy loss when evaluating pregnant women, in order to make appropriate referrals for counseling.

Pregnancy Outcome Patterns of Medicaid-Eligible Women, 1999-2014: A National Prospective Longitudinal Study.

INTRODUCTION: The number and outcomes of pregnancies experienced by a woman are consequential determinants of her health status. However, there is no published research comparing the patterns of subsequent pregnancy outcomes following a live birth, natural fetal loss, or induced abortion. OBJECTIVES: The objective of this study was to describe the characteristic patterns of subsequent pregnancy outcomes evolving from each of three initiating outcome events (birth, induced abortion, natural fetal loss) occurring in a Medicaid population fully insured for all reproductive health services. METHODS: We identified 7,388,842 pregnancy outcomes occurring to Medicaid-eligible women in the 17 states which paid for abortion services between 1999-2014. The first known pregnancy outcome for each woman was marked as the index outcome which assigned each woman to one of three cohorts. All subsequent outcomes occurring up to the fifth known pregnancy were identified. Analyses of the three index outcome cohorts were conducted separately for all pregnancy outcomes, three age bands (<17, 17-35, 36+), and three race/ethnicity groups (Hispanic, Black, White). RESULTS: Women with index abortions experienced more lifetime pregnancies than women with index births or natural fetal losses and were increasingly more likely to experience another pregnancy with each subsequent pregnancy. Women whose index pregnancy ended in abortion were also increasingly more likely to experience another abortion at each subsequent pregnancy. Both births and natural fetal losses were likely to result in a subsequent birth, rather than abortion. Women with natural losses were increasingly more likely to have a subsequent birth than women with an index birth. All age and racial/ethnic groups exhibited the characteristic pattern we have described for all pregnancy outcomes: abortion is associated with more subsequent pregnancies and abortions; births and fetal losses are associated with subsequent births. Other differences between groups are, however, apparent. Age is positively associated with the likelihood of a birth following an index birth, but negatively associated with the likelihood of a birth following an index abortion. Hispanic women are always more likely to have a birth and less likely to have an abortion than Black or White women, for all combinations of index outcome and the number of subsequent pregnancies. Similarly, Black women are always more likely to have an abortion and less likely to experience a birth than Hispanic or White women. CONCLUSION: Women experiencing repeated pregnancies and subsequent abortions following an index abortion are subjected to an increased exposure to hemorrhage and infection, the major causes of maternal mortality, and other adverse consequences resulting from multiple separation events.

Improving the Metrics and Data Reporting for Maternal Mortality: A Challenge to Public Health Surveillance and Effective Prevention.

BACKGROUND: The current measuring metric and reporting methods for assessing maternal mortality are seriously flawed. Evidence-based prevention strategies require consistently reported surveillance data and validated measurement metrics. Main Body: The denominator of live births used in the maternal mortality ratio reinforces the mistaken notion that all maternal deaths are consequent to a live birth and, at the same time, inappropriately inflates the value of the ratio for subpopulations of women with the highest percentage of pregnancies ending in outcomes other than a live birth. Inadequate methods for identifying induced or spontaneous abortion complications assure that most maternal deaths associated with those pregnancy outcomes are unlikely to be attributed. Absent the ability to identify all maternal deaths, and without the ability to differentiate those deaths by specific pregnancy outcomes, existing variations in pregnancy outcome-specific maternal deaths are masked by the use of an aggregated (all outcome) numerator. Under these circumstances, clear and accurate data is not available to inform evidence-based preventive strategies. As the result, algorithms applied for analyzing maternal mortality data may return distorted results Conclusion: Improvement in the effectiveness of maternal mortality surveillance will require: mandatory certification of all fetal losses; linkage of death, birth and all fetal loss (induced and natural) certificates; modification of the structure of the overall maternal mortality ratio to enable pregnancy outcome-specific ratio calculations; development of the appropriate ICD codes which are specific to induced and spontaneous abortions; education for providers on identifying and reporting early pregnancy losses; and, flexible information systems and methods which integrate these capabilities and inform users.

The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities.

The abortion and mental health controversy is driven by two different perspectives regarding how best to interpret accepted facts. When interpreting the data, abortion and mental health proponents are inclined to emphasize risks associated with abortion, whereas abortion and mental health minimalists emphasize pre-existing risk factors as the primary explanation for the correlations with more negative outcomes. Still, both sides agree that (a) abortion is consistently associated with elevated rates of mental illness compared to women without a history of abortion; (b) the abortion experience directly contributes to mental health problems for at least some women; (c) there are risk factors, such as pre-existing mental illness, that identify women at greatest risk of mental health problems after an abortion; and (d) it is impossible to conduct research in this field in a manner that can definitively identify the extent to which any mental illnesses following abortion can be reliably attributed to abortion in and of itself. The areas of disagreement, which are more nuanced, are addressed at length. Obstacles in the way of research and further consensus include (a) multiple pathways for abortion and mental health risks, (b) concurrent positive and negative reactions, (c) indeterminate time frames and degrees of reactions, (d) poorly defined terms, (e) multiple factors of causation, and (f) inherent preconceptions based on ideology and disproportionate exposure to different types of women. Recommendations for collaboration include (a) mixed research teams, (b) co-design of national longitudinal prospective studies accessible to any researcher, (c) better adherence to data sharing and re-analysis standards, and (d) attention to a broader list of research questions.

The Embrace of the Proabortion Turnaway Study: Wishful Thinking? or Willful Deceptions?

The abortion advocacy group Advancing New Standards in Reproductive Health (ANSIRH) has published over twenty papers based on a case series of women taking part in their Turnaway Study. Following the lead of ANSIRH news releases, major media outlets have described these results as proof that (a) most women who have abortions are glad they did, (b) there is no evidence of negative mental health effects following abortion, and (c) the only women really suffering are those who are being denied late-term abortions due to legal restrictions based on gestational age. Buried in ANSIRH's papers are the facts that over 68 percent of the women they sought to interview refused, their own evidence confirms that the remnant who did participate were atypical, there are no known benefits from abortion, their methods are misleadingly described, and their results are selectively reported. Summary: Widely publicized claims regarding the benefits of abortion for women have been discredited. The Turnaway Study, conducted by abortion advocates at thirty abortion clinics, reportedly proves that 95 percent of women have no regrets about their abortions and that abortion causes no mental health problems. But a new exposé reveals that the authors have misled the public, using an unrepresentative, highly biased sample and misleading questions. In fact, over two-thirds of the women approached at the abortion clinics refused to be interviewed, and half of those who agreed dropped out. Refusers and dropouts are known to have more postabortion problems.

Pregnancy associated death in record linkage studies relative to delivery, termination of pregnancy, and natural losses: A systematic review with a narrative synthesis and meta-analysis.

OBJECTIVES: Measures of pregnancy associated deaths provide important guidance for public health initiatives. Record linkage studies have significantly improved identification of deaths associated with childbirth but relatively few have also examined deaths associated with pregnancy loss even though higher rates of maternal death have been associated with the latter. Following PRISMA guidelines we undertook a systematic review of record linkage studies examining the relative mortality risks associated with pregnancy loss to develop a narrative synthesis, a meta-analysis, and to identify research opportunities. METHODS: MEDLINE and SCOPUS were searched in July 2015 using combinations of: mortality, maternal death, record linkage, linked records, pregnancy associated mortality, and pregnancy associated death to identify papers using linkage of death certificates to independent records identifying pregnancy outcomes. Additional studies were identified by examining all citations for relevant studies. RESULTS: Of 989 studies, 11 studies from three countries reported mortality rates associated with termination of pregnancy, miscarriage or failed pregnancy. Within a year of their pregnancy outcomes, women experiencing a pregnancy loss are over twice as likely to die compared to women giving birth. The heightened risk is apparent within 180 days and remains elevated for many years. There is a dose effect, with exposure to each pregnancy loss associated with increasing risk of death. Higher rates of death from suicide, accidents, homicide and some natural causes, such as circulatory diseases, may be from elevated stress and risk taking behaviors. CONCLUSIONS: Both miscarriage and termination of pregnancy are markers for reduced life expectancy. This association should inform research and new public health initiatives including screening and interventions for patients exhibiting known risk factors.