Is it an abortion: Classification of pregnancy-ending interventions after 24 weeks in the presence of lethal fetal anomalies.

OBJECTIVES: To determine how obstetrician-gynecologists categorize pregnancy-ending interventions in the setting of lethal fetal anomalies. STUDY DESIGN: We conducted a sequential explanatory mixed-methods study of U.S. obstetrician-gynecologists from May to July 2021. We distributed a cross-sectional online survey via email and social media and completed qualitative telephone interviews with a nested group of participants. We assessed institutional classification as induced abortion versus indicated delivery for six scenarios of ending a pregnancy with lethal anomalies after 24 weeks, comparing classification using McNemar chi-square tests with Benjamini-Hochberg correction for multiple comparisons with a false discovery rate of 0.05. We performed the thematic analysis of qualitative data and then performed a mixed-methods analysis. RESULTS: We included 205 respondents; most were female (84.4%), had provided abortion care (80.2%), and were general OB/GYNs (59.3%), with broad representation across pre-Dobbs state and institutional abortion policies. Twenty-one qualitative participants had similar characteristics to the whole sample. All scenarios were classified as induced abortion by the majority of respondents, ranging from 53.2% for 32-week induction for anencephaly, to 82.9% for feticidal injection with 24-week induction for anencephaly. Mixed-methods analysis revealed the relevance of gestational age (later interventions less likely to be considered induced abortion) and procedure method and setting (dilation and evacuation, feticidal injection, and freestanding facility all increasing classification as induced abortion). CONCLUSIONS: There is wide variation in the classification of pregnancy-ending interventions for lethal fetal anomalies, even among trained obstetrician-gynecologists. Method, timing, and location of ending a nonviable pregnancy influence classification, though the perinatal outcome is unchanged. IMPLICATIONS: The classification of pregnancy-ending interventions for lethal fetal anomalies after 24 weeks as indicated delivery versus induced abortion is reflective of sociopolitical regulatory factors as opposed to medical science. The regulatory requirement for classification negatively impacts access to care, especially in environments where induced abortion is legally restricted.

Classification of periviable pregnancy-ending interventions for maternal life endangerment as induced abortion.

OBJECTIVES: To explore how US obstetrician-gynecologists (OB/GYNs) classify periviable pregnancy-ending interventions for maternal life endangerment. STUDY DESIGN: From May to July 2021, we performed an explanatory sequential mixed methods study of US OB/GYNs, recruited through social media and professional listservs. We administered a cross-sectional survey requesting institutional classification of labor induction or surgical evacuation of a 22-week pregnancy affected by intrauterine infection, using chi-square tests and logistic regression to compare determinations by physician and institutional factors. We then conducted semistructured interviews in a diverse nested sample to explore decision-making, merging quantitative and qualitative data in a mixed methods analysis. RESULTS: We received 209 completed survey responses, with 101 (48.3%) current abortion providers and 48 (20.1%) never-providers, and completed 21 qualitative interviews. Fewer than half of respondents reported that pregnancy-ending intervention for 22-week intrauterine infection would be classified as induced abortion at their institution (induction: 21.1%, dilation & evacuation: 42.6%, p < 0.001). In addition to procedure method, decision-making factors for classification as abortion included personal experience with abortion (with more experienced participants more likely to identify care as abortion) and state and institutional abortion regulations ("I have to call it a medical [induction]… I'm not allowed to use the word abortion"). CONCLUSIONS: Most OB/GYNs do not classify periviable pregnancy-ending interventions for life-threatening maternal complications as induced abortion, especially when physicians and institutions have less abortion expertise. Differential classification of pregnancy-ending care may lead to undercounting of later abortion procedures, masking the impact of abortion restrictions. IMPLICATIONS: Under unclear legal definitions, legislative interference, and administrative overreach, subjectivity in classification creates inconsistency in care for pregnancy complications. Failure to classify life-saving care as abortion contributes to stigma and facilitates restrictions, with increased danger and less autonomy for pregnant people.

A mystery client study of crisis pregnancy center practices in New York State.

OBJECTIVES: To evaluate practices of crisis pregnancy centers (CPCs) in a state with supportive abortion policies. STUDY DESIGN: We called all New York State CPCs regarding their services using a "mystery client" protocol, utilizing checklists and thematic analysis. RESULTS: Of 86 CPCs, 67 (78%) encouraged in-person appointments, offering free medical services and support. Twelve centers (14%) spontaneously disclosed their non-medical status, and 36 (42%) disclosed after direct questioning. Sixty-five (76%) made inaccurate or inflammatory statements about pregnancy or abortion. CONCLUSIONS: In a state without specific barriers to abortion and pregnancy care, CPCs claim to provide support while using inflammatory rhetoric and concealing their organizational status.

Individual abortion providers' experiences with targeted harassment in the United States.

OBJECTIVE: To understand individual abortion providers' experiences with targeted harassment. STUDY DESIGN: We conducted a cross-sectional survey of a convenience sample of US physicians with history of abortion provision, recruited through online groups, and listservs. Respondents completed a Qualtrics survey reporting personal and practice characteristics and experiences with harassment. We calculated descriptive statistics, comparing those who had and hadn't experienced targeted harassment using χ2 tests, and we qualitatively analyzed free-text descriptions of harassment experiences to identify themes. RESULTS: Of 321 respondents, 112 (35%) reported harassment. Targeted harassment was more likely with each decade of increasing age, and was greater for respondents providing outpatient versus only inpatient surgical abortion care (40% vs. 7%, p < 0.001) and care beyond the first trimester compared to only in the first trimester (39% vs. 16%, p = 0.001). Sixty-two respondents (19%) were not currently providing abortions, with 33 (52%) explicitly forbidden from doing so by their employers. Qualitative analysis revealed that most harassment is invasive and intimidating rather than overtly violent, with many providers experiencing intentional public exposure of their abortion work and having their professionalism discredited. Ensuing isolation of providers from their communities both perpetuates and facilitates further abortion provider stigma and harassment. CONCLUSIONS: Targeted harassment toward abortion providers is widespread and attempts to intimidate providers and isolate them from their communities. More research is needed to explore ways to mitigate isolation of providers, which could improve safety, and have positive effects on the abortion workforce.

Exploring the Relationship between Abortion Provision and Providers' Personal Pregnancy and Parenting Experiences.

OBJECTIVE: Support for abortion rights is often portrayed as antithetical to valuing family. With abortion provider demographics trending toward younger and female physicians, we sought to understand the influence of personal experiences with parenthood and pregnancy on abortion provision. STUDY DESIGN: We surveyed U.S. physicians who have provided abortions, recruited from listservs and online groups. We calculated descriptive statistics using Stata SE. We used an inductive editing approach in coding free-text responses to questions about the emotional and experiential interplay between pregnancy, parenthood, and abortion provision, iteratively developing and refining a codebook, and ultimately identifying common themes. RESULTS: We collected qualitative data from 227 participants, the majority of whom were under age 40 (51.1%), female (93.0%), and OB/GYN physicians (75.8%). Qualitative analysis yielded four main themes. 1) Providers feel dissonance between the societal expectation of conflict between abortion provision and parenthood and their lived experiences. 2) Abortion providers' personal experiences with pregnancy and parenthood increase compassion and stimulate a stronger therapeutic bond. 3) Pregnant abortion providers are sometimes affected by the contrast between ending one pregnancy while advancing another; however, most providers are able to contextualize their patients' need for abortion separately from their feelings about their own pregnancies and children. 4) Providers feel their abortion work positively impacts their parenting. CONCLUSIONS: Our research demonstrates multiple effects of the interplay between abortion providers' personal reproductive experiences and their abortion provision, with a mutually positive overall relationship between parenting and abortion provision. Exploring this interaction could help to decrease stigma toward both abortion and abortion providers.