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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.

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Introduction/Objective: Medication abortion is a common experience for women in the United States, now totaling over 50% of all abortions. The purpose of this exploratory analysis is to understand women's medication abortion and abortion pill reversal decision-making experiences, with a particular focus on their communication with their medical providers. Methods: We surveyed women who contacted Heartbeat International to inquire about abortion pill reversal. Eligible women had to complete a minimum of the 2-week progesterone protocol in order to answer the questions on the electronic survey about their medication abortion and abortion pill reversal decisions. We assessed decision difficulty using a Likert scale and provider communication using the Questionnaire on the Quality of Physician-Patient (QQPPI) and analyzed women's narratives about their experiences using thematic analysis. Results: Thirty-three respondents met the eligibility criteria and filled out the QQPPI and decision-difficulty scales. Using the QQPPI scale, women scored their communication with their APR providers as significantly better than their communication with their abortion providers (p < 0.0001). Women reported that choosing medication abortion was significantly more difficult than choosing abortion pill reversal (p < 0.0001). White women, women with college degrees, and women who were not in a relationship with the father of the child reported more difficulty in choosing APR. Conclusion: As the number of women who contact the national hotline to inquire about abortion pill reversal increases, the need to understand the experiences of this growing population of women becomes more salient. This need is particularly important for health care providers who prescribe medication abortion and abortion pill reversal. The quality of the physician-patient interaction is essential to providing effective medical care to pregnant women.

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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.

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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.

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Introduction As medication abortion accounts for a growing share of abortions in the United States, an increasing number of women are seeking abortion pill reversal (APR). These decisions are typically not made in isolation. However, little research exists on women's APR decision-making and the role played by people close to them. Methods We surveyed women who contacted a national hotline for information on APR and who completed a two-week treatment protocol with progesterone (n = 67). We analyzed women's open-ended answers using thematic analysis to identify memorable messages about medication abortion and APR. Participants' communication with other people in their lives was assessed using the Isolation subscale of the Individual Level Abortion Stigma (ILAS) scale, and decision-making difficulty was assessed using a Likert scale. Results Thirty-six respondents met the eligibility criteria and filled out the ILAS and decision-difficulty scales. Women tended to talk with family and friends about their medication abortion decisions, while they typically sought information online when deciding about APR. Women reported greater stigma in their disclosures about their abortions than in their disclosures about APR (p = 0.006). Conclusion Memorable messages influence women's decisions to pursue medication abortion and APR.

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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.

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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.

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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.

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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.

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One out of four women in the United States will have an abortion by age 45. While abortion rates are steadily declining in the United States, the rate of medication abortions continues to increase, with 39% of all abortions being medication abortions. Our study is one of the first to analyze women's narratives after having had a medication abortion. Using relational dialectics theory, we conducted a case study of the nonpartisan website, Abortion Changes You. Our contrapuntal analysis rendered four sites of dialectical tension found across women's blog posts: only choice vs. other alternatives, unprepared vs. knowledgeable, relief vs. regret, and silence vs. openness. Each site of struggle characterized a different noteworthy moment within a woman's medication abortion experience: the decision, the medication abortion process, identity after abortion, and managing the stigmatizing silence before and after the abortion. We discuss theoretical and practical implications about how the larger politicized discourses prevalent within the abortion debate impact the liminality of women who are contemplating a medication abortion and affect their own narrative construction about the medication abortion experience.

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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.

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Controversy exists regarding whether doctors who perform abortions should be required to hold hospital admitting privileges, but no research exists as to the extent to which they actually hold and use such privileges. Extensive Internet and government data sources were used to identify and verify abortionists in Florida. All medical and osteopathic abortion doctors who were licensed to practice at any time during the period 2011 to 2016 were included in the study (n = 85). Every abortionist hospital admission of a female patient aged 15 to 44 occurring during the 6-year study period was identified (n = 21 502). Abortionist physicians are 74.1% male, 62% have been in practice for 30 years or longer, 27.1% are graduates of foreign medical schools, and 55.3% are board certified. Nearly half (48.2%) of the abortionists had at least 1 malpractice claim, public complaint, disciplinary action, or criminal charge. Half (50.6%) of the abortionists reported hospital privileges, but only 32 (37.6%) admitted at least 1 patient to a hospital. Seven physicians accounted for 68.2% of all the admissions, and 79.6% of all admissions were related to a live birth. Black was the modal race (47.6%) and Medicaid the most frequent (64.9%) pay source. Nearly one-fifth (19.4%) of admissions came through the emergency department. Physicians who hold hospital privileges are significantly (P < .05) more likely to be board certified and to be approved for Medicaid payment than their colleagues without privileges. Of those doctors who hold and use hospital privileges, the lowest admission volume physicians are significantly less likely to be involved in live births, more likely to admit commercially insured and white inpatients, and much more likely to use the emergency room as the route to hospital admissions for their Medicaid-eligible and black patients. Further study of abortionist physicians is indicated regarding their heterogeneous personal and professional characteristics; their career pathways and practice concentrations; their relative integration with or isolation from peers and the professional network; the importance of black and poor induced abortion patients in their total caseload; and, especially for abortionists without hospital privileges, the means by which their patients requiring emergency care and hospitalization are accommodated.