Doctors' Voices Generate Support for Abortion Care: Results from a Nationally Representative Survey.

OBJECTIVE: We tested abortion messaging to develop evidence-based communication recommendations for doctors who provide abortion care. STUDY DESIGN: We conducted an on-line survey in a nationally representative sample of 1,215 people, using NORC's Amerispeak® Panel. We surveyed participants before and after viewing two brief videos featuring doctors who provide abortion care speaking about their work. Doctors' comments were grounded in strategic communications and applied psychology research and emphasized caregiving roles, avoided political-sounding punditry, and acknowledged abortion's complexities. We assessed participants' characterizations of doctors who provide abortion care, how these characterizations impact support for abortion restrictions and overall views on abortion legality. We analyzed pre-post data using descriptive statistics, t-tests and multivariable regression. RESULTS: Post-messaging more participants endorsed positive descriptors of doctors who provide abortion care (p<0.001,t=8.99); fewer endorsed negative descriptors (p<0.001,t=10.32). Increased post-messaging endorsement of positive descriptors predicted declines in support for abortion restrictions (AOR = 1.69,p<0.01); decreased endorsement of negative descriptors did not. After messaging, 37% of respondents said their views of doctors who provide abortion care made them less likely to support abortion restrictions, compared to 14% before (p<0.001,t=-6.9). After messaging there was more overall support for legal, accessible abortion and less for abortion being mostly illegal (46%→48% and 24%→22%,p<0.001;t=-4.11). CONCLUSIONS: When doctors who provide abortion care use messaging recommendations that include speaking about abortion's complexities and avoiding political-sounding punditry, they generate more support for legal abortion and less for restrictions. IMPLICATIONS: The voices of doctors who provide abortion care shape abortion public opinion. When doctors speak from caregiving perspectives, avoid punditry, and acknowledge abortion's complexities they generate more support for legal abortion and less for restrictions. However, audiences may not be aware a priori that ideas of doctors shape their views.

Trends in Encounters for Emergency Contraception in US Emergency Departments, 2006-2020.

This cross-sectional study of female emergency contraception users examines emergency contraception­related emergency department use disparities and associations with policy changes.

Experience of stigma and harassment among respondents to the 2019 Canadian abortion provider survey.

OBJECTIVE: We conducted a national survey to assess the experiences of stigma and harassment among physicians and nurse practitioners providing abortions and abortion service administrators in Canada. STUDY DESIGN: We conducted an exploratory, cross-sectional, national, anonymized, online survey between July and December 2020. Subsections of the survey explored stigma and harassment experienced by respondents, including the 35-item Revised Abortion Providers Stigma Scale and open-ended responses. We analyzed the quantitative data to generate descriptive statistics and employed a reflexive thematic analysis to interpret open-ended responses. RESULTS: Three hundred fifty-four participants started the stigma and harassment section of the survey. Among low-volume clinicians (<30 abortions/year, 60%, n = 180) 8% reported harassment; 21% among higher volume clinicians (≥30 abortions/year, 40%, n = 119) and 47% among administrators (n = 39), most commonly picketing. The mean stigma score was 67.8 (standard deviation 17.2; maximum score 175). Our qualitative analysis identified five themes characterizing perceptions of stigma and harassment: concerns related to harassment from picketing, protestors, and the public; wanting protestor "bubble zones"; aiming to be anonymous to avoid being a target; not providing an abortion service; but also witnessing a safe and positive practice environment. CONCLUSIONS: Being a low-volume clinician compared to higher volume clinician and administrator appears to be associated with less harassment. Clinicians providing abortion care in Canada reported mid-range abortion-related stigma scores, and expressed strong concerns that stigma interfered with their abortion provision. Our results indicate that further de-stigmatization and protection of abortion providers in Canada is needed through policy and practice interventions including bubble zones. IMPLICATIONS: While Canadian abortion care clinicians and administrators reported relatively low incidence of harassment, our results indicate that they are concerned about stigma and harassment. However, as this was an exploratory survey, these data may not be representative of all Canadian abortion providers. Our data identify a need to support abortion clinicians and to bolster protections for dedicated abortion services.

The Impact of New and Renewed Restrictive State Abortion Laws on Pregnancy-Capable People with Diabetes.

PURPOSE OF REVIEW: When the Supreme Court handed down its decision in Dobbs v Jackson Women's Health Organization in June 2022, the constitutional right to abortion was no longer protected by Roe v Wade. Fifteen states now have total or near-total bans on abortion care or no clinics providing abortion services. We review how these restrictions affect the medical care of people with pregestational diabetes. RECENT FINDINGS: Of the ten states with the highest percent of adult women living with diabetes, eight currently have complete or 6-week abortion bans. People with diabetes are at high risk of diabetes-related pregnancy complications and pregnancy-related diabetes complications and are disproportionately burdened by abortion bans. Abortion is an essential part of comprehensive, evidence-based diabetes care, yet no medical society has published guidelines on pregestational diabetes that explicitly discuss the importance and role of safe abortion care. Medical societies enacting standards for diabetes care and clinicians providing diabetes care must advocate for access to abortion to reduce pregnancy-related morbidity and mortality for pregnant people with diabetes.

Levonorgestrel 52-mg Intrauterine Device Efficacy and Safety After More Than 8 Years of Use.

FUNDING SOURCE: Medicines360. The Sponsor, Medicines360, designed the study and oversaw its conduct, including funding the trial and providing all study product free of charge to participants. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT00995150.

Beyond Abortion: The Consequences of Overturning Roe.

The upcoming U.S. Supreme Court decision in Dobbs v. Jackson Women's Health Organization has the potential to eliminate or severely restrict access to legal abortion care in the United States. We address the impact that the decision could have on abortion access and its consequences beyond abortion care. We posit that an abortion ban would, in effect, mean that anyone who becomes pregnant, including those who continue a pregnancy and give birth to healthy newborns and those with pregnancy complications or adverse pregnancy outcomes will become newly vulnerable to legal surveillance, civil detentions, forced interventions, and criminal prosecution. The harms imposed by banning or severely restricting abortion access will disproportionately affect persons of color and perpetuate structural racism. We caution that focusing on Roe as a decision that only protects ending a pregnancy ignores the protection that the decision also affords people who want to continue their pregnancies. It overlooks the ways in which overturning Roe will curtail fundamental rights for all those who become pregnant and will undermine their status as full persons meriting Constitutional protections. Such a singular focus inevitably obscures the common ground that people across the ideological spectrum might inhabit to ensure the safety, health, humanity, and rights of all people who experience pregnancy.

Balancing enhanced contraceptive access with risk of reproductive injustice: A United States comparative case study.

OBJECTIVE: We aimed to examine how peripartum contraceptive care quality improvement efforts address or perpetuate reproductive health injustices. STUDY DESIGN: We conducted a comparative case study of inpatient postpartum contraceptive care implementation in 2017 to 2018, using key informant interviews at 11 United States hospitals. After our primary analysis revealed tensions between enhancing access to contraceptive care and patient-centeredness, we conducted the current inductive content analysis guided by 4 questions developed post-hoc: (1) What are healthcare workers' aspirations for contraceptive quality improvement programs? (2) What are healthcare workers' biases regarding peripartum contraceptive care delivery? (3) Do care delivery processes center patients' needs? (4) Do healthcare workers recognize and engage with structural inequities? RESULTS: Seventy-eight key informants (i.e., clinicians, operations staff, administrators) participated. In nine study sites, we observed evidence of interviewees both mitigating and perpetuating reproductive injustice. Many aspired to provide compassionate, patient-centered care, avoid paternalism, and foster patient autonomy. Simultaneously, interviewees demonstrated biases, including implicit subscription to an ideology of stratified reproduction, stereotyping, and "othering." Even when interviewees endorsed goals of patient-centeredness, care delivery processes sometimes prioritized healthcare systems' needs, and patients were not included on quality improvement teams. Many interviewees recognized structural inequities as driving health outcome disparities, yet relied on individual-level solutions like long-acting reversible contraception, and not structural-level interventions, to address them. CONCLUSION: Alongside enthusiasm for delivering compassionate care exist biases, missed opportunities to center patients, and lack of curiosity about the appropriateness of solving structural-level problems with individual-level solutions. IMPLICATIONS: Our findings call for individual and institutional self-reflection, partnership with patients and communities, and other intentional efforts to mitigate potential for harm in initiatives enhancing access to contraceptive care.

Leveraging Administrative Claims to Understand Disparities in Gender Minority Health: Contraceptive Use Patterns Among Transgender and Nonbinary People.

Purpose: Transgender people face disparities in access to reproductive and sexual health services; however, differences in receipt of contraceptive services have not been quantified. We compare contraceptive patterns between cisgender women and trans masculine people in insurance claims databases. Methods: We analyzed 2014-2018 Truven MarketScan data, using diagnostic and procedural codes to identify sex assigned at birth, and existing coding methodology to identify transgender and nonbinary people. We compared contraceptive patterns between cisgender women and trans masculine people aged 15-49 in Medicaid and commercial databases. Results: We identified 4700 people in the commercial and 1628 people in the Medicaid databases as trans masculine. Trans masculine people were prescribed fewer oral contraceptive pills (Medicaid: 17.44%, commercial: 16.62%) compared to cisgender women (Medicaid: 24.96%, commercial: 27.85%), less long-acting reversible contraception (LARC) use (Medicaid: 7.62%, commercial: 7.49% vs. Medicaid: 12.79%, commercial: 8.51%), had more hysterectomies (Medicaid: 5.77%, commercial: 8.45% vs. Medicaid: 2.15%, commercial: 2.48%), and less evidence of any contraception (Medicaid: 34.21%, commercial: 32.28% vs. Medicaid: 46.80%, commercial: 39.81%). Hysterectomies and LARC use varied by insurance type. Conclusion: We found significant differences in contraceptive patterns between trans masculine people and cisgender women. Data suggest potential differences in hysterectomy occurrences by trans masculine people, and long-acting reversible contraceptive use by cisgender women, in Medicaid versus commercial insurance cohorts. Appropriate counseling, insurance coverage, and removal of structural barriers are needed to ensure adequate access to contraception methods for people of all genders-regardless of whether they are being employed for contraception, menstrual management, or gender affirmation.

Addressing Abortion Provider Stigma: A Pilot Implementation of the Providers Share Workshop in Sub-Saharan Africa and Latin America.

CONTEXT: In much of Sub-Saharan Africa and Latin America, abortion is legally restricted, and abortion providers experience stigma and legal jeopardy. The Providers Share Workshop group intervention has been shown to reduce provider stigma in the United States, but has not been evaluated in other settings. METHODS: In 2014-2015, the Providers Share Workshop was adapted and piloted among 59 abortion caregivers from three Sub-Saharan African countries and 93 caregivers from seven Latin American countries. Survey data collected before, directly following and six months after each workshop measured stigma, attitudes, and legal safety and advocacy engagement, using original items and adapted scales. Univariate analyses and baseline pairwise correlations were used to measure changes in outcomes over time, and between demographic characteristics and outcomes. Mixed-effects linear regressions and multivariable models controlling for demographics were used to assess changes in outcomes over time. RESULTS: Six months after workshop participation, total abortion stigma had decreased among caregivers in Sub-Saharan Africa and in Latin America (beta coefficients, -0.2 and -0.4, respectively). Unfavorable attitudes had decreased in Africa (-0.2) but not in Latin America, where attitudes were favorable to start; emotional exhaustion and depersonalization also had decreased in Africa (-2.9 and -1.2), and legal safety had increased (0.8). Increased total abortion stigma was negatively associated with legal safety, in both Africa and Latin America (-1.9 and -0.6), and with legal advocacy in Africa (-1.5). CONCLUSIONS: The Providers Share Workshop is a promising intervention to support the abortion care workforce in Sub-Saharan African and Latin American settings.

RESUMEN Contexto: En gran parte del África subsahariana y América Latina, el aborto está legalmente restringido y los proveedores de servicios de aborto experimentan estigma y riesgo legal. Se ha demostrado que la intervención grupal del Taller de Proveedores para Compartir Experiencias reduce el estigma del proveedor en los Estados Unidos, pero no se ha evaluado en otros entornos. Métodos: Entre 2014 y 2015, el Taller de Proveedores para Compartir Experiencias fue adaptado y puesto a prueba entre 59 proveedores de servicios de aborto de tres países del África subsahariana y 93 proveedores de servicios de siete países latinoamericanos. Los datos de la encuesta recopilados antes, inmediatamente después y seis meses después de cada taller, mediante el uso de elementos originales y escalas adaptadas, midieron el estigma, las actitudes y la seguridad jurídica, así como el compromiso con la defensa y promoción del aborto. Se utilizaron análisis univariados y correlaciones de referencia por pares para medir los cambios en los resultados a través del tiempo y entre la demografía y los resultados. Se utilizaron regresiones lineales de efectos mixtos y modelos multivariables que controlan las variables demográficas para evaluar los cambios en los resultados a través del tiempo. Resultados: Seis meses después de la participación en el taller, el estigma total del aborto había disminuido entre los proveedores en África y América Latina (coeficientes beta, ­0.2 y ­0.4, respectivamente). Las actitudes desfavorables habían disminuido en África (­0.2) pero no en América Latina, donde las actitudes eran favorables para el inicio; el desgste emocional y la despersonalización también habían disminuido en África (­2.9 y ­1.2, respectivamente) y la seguridad legal había aumentado (0.8). El aumento del estigma total del aborto se asoció negativamente con la seguridad jurídica, tanto en África como en América Latina (coeficientes beta, ­1.9 y ­0.6, respectivamente) y con la defensa jurídica en África (­1.5). Conclusiones: El Taller de Proveedores para Compartir Experiencias es una intervención prometedora para apoyar a la fuerza laboral de atención del aborto en entornos de África subsahariana y América Latina.

RÉSUMÉ Contexte: Dans une grande partie de l'Afrique subsaharienne et de l'Amérique latine, l'avortement est limité par la loi et ses prestataires sont en proie à la stigmatisation et au péril judiciaire. Comme l'indiquent les études, l'intervention du groupe Providers Share Workshop réduit cette stigmatisation aux États-Unis; elle n'a cependant pas été évaluée dans d'autres contextes. Méthodes: En 2014­2015, l'atelier Providers Share Workshop a été adapté et piloté auprès de 59 membres du personnel de soins de l'avortement de trois pays d'Afrique subsaharienne et 93 soignants de sept pays d'Amérique latine. Les données d'enquête collectées avant, directement après et six mois après chaque atelier ont mesuré la stigmatisation, les attitudes et l'engagement de sécurité et de défense juridique sur la base des questions originales et d'échelles adaptées. Les changements de résultats au fil du temps, et entre les caractéristiques démographiques et les résultats, ont été mesurés par analyses univariées et par corrélations par paires de référence. Des régressions linéaires à effets mixtes et des modèles multivariés tenant compte des caractéristiques démographiques ont servi à évaluer les changements de résultats au fil du temps. Résultats: Six mois après la participation à l'atelier, la stigmatisation totale de l'avortement s'était réduite parmi le personnel soignant d'Afrique et d'Amérique latine (coefficients bêta de ­0,2 et ­0,4, respectivement). Les attitudes défavorables étaient en baisse en Afrique (­0,2) mais pas en Amérique latine, où les attitudes étaient favorables dès le début; l'épuisement affectif et la dépersonnalisation étaient en baisse aussi en Afrique (­2,9 et ­1,2, respectivement), tandis que la sécurité juridique était en hausse (0,8). Une stigmatisation totale supérieure de l'avortement s'est révélée associée négativement avec la sécurité juridique, en Afrique aussi bien qu'en Amérique latine (coefficients bêta de ­1,9 et ­0,6, respectivement), et avec la défense juridique en Afrique (­1,5). Conclusions: L'atelier Providers Share Workshop est une intervention prometteuse de soutien du personnel de soins de l'avortement en Afrique subsaharienne et en Amérique latine.

South African abortion attitudes from 2007-2016: the roles of religiosity and attitudes toward sexuality and gender equality.

Abortion is legal in South Africa, but negative abortion attitudes remain common and are poorly understood. We used nationally representative South African Social Attitudes Survey data to analyze abortion attitudes in the case of fetal anomaly and in the case of poverty from 2007 to 2016 (n = 20,711; ages = 16+). We measured correlations between abortion attitudes and these important predictors: religiosity, attitudes about premarital sex, attitudes about preferential hiring and promotion of women, and attitudes toward family gender roles. Abortion acceptability for poverty increased over time (b = 0.05, p < .001), but not for fetal anomaly (b = -0.008, p = .284). Highly religious South Africans reported lower abortion acceptability in both cases (Odds Ratio (OR)anomaly = 0.85, p = .015; ORpoverty = 0.84, p = .02). Premarital sex acceptability strongly and positively predicted abortion acceptability (ORanomaly = 2.63, p < .001; ORpoverty = 2.46, p < .001). Attitudes about preferential hiring and promotion of women were not associated with abortion attitudes, but favorable attitudes about working mothers were positively associated with abortion acceptability for fetal anomaly ((ORanomaly = 1.09, p = .01; ORpoverty = 1.02, p = .641)). Results suggest negative abortion attitudes remain common in South Africa and are closely tied to religiosity, traditional ideologies about sexuality, and gender role expectations about motherhood.

Attitudes toward abortion, social welfare programs, and gender roles in the U.S. and South Africa.

Public abortion attitudes are important predictors of abortion stigma and accessibility, even in legal settings like the U.S. and South Africa. With data from the U.S. General Social Survey and South African Social Attitudes Survey, we used ordinal logistic regressions to measure whether abortion acceptability (in cases of poverty and fetal anomaly) is related to attitudes about social welfare programs and gender roles, then assessed differences by race/ethnicity and education. Social welfare program attitudes did not correlate with abortion acceptability in the U.S., but in South Africa, greater support for income equalization (OR: 0.59, 95% CI: 0.41-0.85) and increased government spending on the poor (OR: 0.66, 95% CI: 0.49-0.91) correlated with lower abortion acceptability in circumstances of poverty. This was significant for Black African and higher educated South Africans. In the U.S., egalitarian gender role attitudes correlated with higher acceptability of abortion in circumstances of poverty (OR: 1.18, 95% CI: 1.03-1.36) and fetal anomaly (OR: 1.15, 95% CI: 1.01-1.31). This was significant for White and less educated Americans. In South Africa, egalitarian gender role attitudes correlated with higher abortion acceptability for fetal anomaly (OR: 1.12, 95% CI: 1.01-1.25) overall and among Black and less educated respondents, but among non-Black South Africans they correlated with higher abortion acceptability in circumstances of poverty. These results suggest abortion attitudes are distinctly related to socioeconomic and gender ideology depending one's national context, race/ethnicity, and socioeconomic status. Reducing abortion stigma will require community-based approaches rooted in intersectional reproductive justice frameworks.

Bridging the Expertise of Advocates and Academics to Identify Reproductive Justice Learning Outcomes.

Phenomenon: Reproductive justice (RJ) is defined by women of color advocates as the right to have children, not have children and parent children while maintaining reproductive autonomy. In the United States, physicians have been complicit in multiple historical reproductive injustices, involving coercive sterilization of thousands of people of color, low income, and disabilities. Currently, reproductive injustices continue to occur; however, physicians have no formal RJ medical education to address injustices. The objective of this study was to engage leading advocates within the movement using a Delphi method to identify critical components for such a curriculum. Approach: In 2016, we invited 65 RJ advocates and leaders to participate in an expert panel to design RJ medical education. A 3-round Delphi survey was distributed electronically to identify content for inclusion in an RJ curriculum. In the next 2 survey rounds, experts offered feedback and revisions and rated agreement with including content recommendations in the final curriculum. We calculated descriptive statistics to analyze quantitative data. A team with educational expertise wrote learning outcomes based on expert content recommendations. Findings: Of the 65 RJ advocates and leaders invited, 41 participated on the expert panel of the Delphi survey. In the first survey, the expert panel recommended 58 RJ content areas through open-ended response. Over the next 2 rounds, there was consensus among the panel to include 52 of 58 of these areas in the curriculum. Recommended content fell into 11 broad domains: access, disparities, and structural competency; advocacy; approaches to reproductive healthcare; contemporary law and policy; cultural safety; historical injustices; lesbian, gay, bisexual, transgender, queer/questioning, and intersex health; oppression, power, and bias training; patient care; reproductive health; and RJ definitions. The 97 learning outcomes created from this process represented both unique and existing educational elements. Insights: A collaborative methodology infused with RJ values can bridge experts in advocacy and academics. New learning outcomes identified through this process can enhance medical education; however, it is just as important to consider education in RJ approaches to care as it is knowledge about that care. We must explore the pedagogic process of RJ medical education while considering that expertise in this area may exist outside of the medical community and thus there is a need to partner with RJ advocates. Finally, we expect to use innovative teaching methods to transform medical education and achieve an RJ focus.

Trusted Colleagues or Incompetent Hacks? Development of the Attitudes About Abortion-Providing Physicians Scale.

BACKGROUND: Many physicians who provide abortion care report feeling marginalized within medicine. Because abortion care can require consultation with many types of physicians, physician opinions of providers may have implications for quality of care. However, no measure of physicians' attitudes about abortion-providing colleagues currently exists. METHODS: We developed a 24-item pool to measure perceptions of the motivations, competence, and standing within the medical profession of physicians who provide abortion care. We administered the survey to a sample of 1,640 faculty physicians at a Midwestern teaching hospital. We used Stata SE/14.0 for all analyses. RESULTS: Our response rate was 34% (n = 560), comparable with other studies of physicians. Exploratory factor analysis resulted in a three-factor solution: opinion, motivations, and competence. The scale demonstrated good internal consistency. Attitudes were largely favorable: 84% of participants agreed that abortion providers provide necessary care for women and 81% felt that abortion providers contribute positively to society. Compared with those who felt abortion should be illegal in all circumstances, attitudes were more favorable among those who felt that abortion should be legal. We observed an inverse relationship between religious attendance and attitudes. Participants with children held more favorable attitudes compared with those without children. CONCLUSIONS: The Attitudes About Abortion-Providing Physicians Scale captures physicians' perceptions of their abortion-providing colleagues along three important dimensions: opinion, motivations, and competence. This sample of physicians held generally favorable views of their colleagues who provide abortion care.

Stigma and abortion complications: stories from three continents.

Complications from abortion, while rare, are to be expected, as with any medical procedure. While the vast majority of serious abortion complications occur in parts of the world where abortion is legally restricted, legal access to abortion is not a guarantee of safety, particularly in regions where abortion is highly stigmatised. Women who seek abortion and caregivers who help them are universally negatively "marked" by their association with abortion. While attention to abortion stigma as a sociological phenomenon is growing, the clinical implications of abortion stigma - particularly its impact on abortion complications - have received less consideration. Here, we explore the intersections of abortion stigma and clinical complications, in three regions of the world with different legal climates. Using narratives shared by abortion caregivers, we conducted thematic analysis to explore the ways in which stigma contributes, both directly and indirectly, to abortion complications, makes them more difficult to treat, and impacts the ways in which they are resolved. In each narrative, stigma played a key role in the origin, management and outcome of the complication. We present a conceptual framework for understanding the many ways in which stigma contributes to complications, and the ways in which stigma and complications reinforce one another. We present a range of strategies to manage stigma which may prove effective in reducing abortion complications.

Conscience reconsidered: The moral work of navigating participation in abortion care on labor and delivery.

How do caregivers make decisions about participating in morally contested care, such as abortion? Debates about conscience in the delivery of health care generally assume that participation decisions stem from religious beliefs and moral values. Few studies have examined this question in the context of everyday practice. Drawing on 50 interviews with the staff of a labor and delivery unit offering abortion care-including nurses, maternal-fetal medicine specialists, obstetrics and gynecology residents, and anesthesiologists-we show that respondents have varied definitions of "participation" in abortion care and that participation decisions are driven by an array of factors beyond personal beliefs. We present a conceptual model of "moral work" that shows conscience to be an emerging, iterative process influenced not only by beliefs-religious and non-religious-but also by personal and work experiences and social and institutional contexts. Our study brings new insights into understanding conscience and participation in contested care.