Rachel K. Jones

Contraceptive use among U.S. women having abortions in 2000-2001.

CONTEXT Knowing the extent to which contraceptive nonuse, incorrect or inconsistent use, and method failure account for unintended pregnancies ending in abortion, as well as reasons for nonuse and imperfect use, can help policymakers and family planning providers support effective contraceptive use. METHODS Contraceptive use patterns among a nationally representative sample of 10,683 women receiving abortion services in 2000-2001 were examined, as well as reasons for nonuse, problems with the most frequently used methods and the impact emergency contraceptive pills have had on abortion rates. RESULTS Forty-six percent of women had not used a contraceptive method in the month they conceived, mainly because of perceived low risk of pregnancy and concerns about contraception (cited by 33% and 32% of nonusers respectively). The male condom was the most commonly reported method among all women (28%), followed by the pill (14%). Inconsistent method use was the main cause of pregnancy for 49% of condom users and 76% of pill users; 42% of condom users cited condom breakage or slippage as a reason for pregnancy. Substantial proportions of pill and condom users indicated perfect method use (13-14%). As many as 51,000 abortions were averted by use of emergency contraceptive pills in 2000. CONCLUSIONS Women and men need accurate information about fertility cycles and about the risk of pregnancy when a contraceptive is not used or is used imperfectly. Increased use of emergency contraceptive pills could further reduce levels of unintended pregnancy and abortion.

Abortion Incidence and Service Availability In the United States, 2011

CONTEXT Following a long-term decline, abortion incidence stabilized between 2005 and 2008. Given the proliferation of state-level abortion restrictions, it is critical to assess abortion incidence and access to services since that time. METHODS In 2012-2013, all facilities known or expected to have provided abortion services in 2010 and 2011 were surveyed. Data on the number of abortions were combined with population data to estimate national and state-level abortion rates. Incidence of abortions was assessed by provider type and caseload. Information on state abortion regulations implemented between 2008 and 2011 was collected, and possible relationships with abortion rates and provider numbers were considered. RESULTS In 2011, an estimated 1.1 million abortions were performed in the United States; the abortion rate was 16.9 per 1,000 women aged 15-44, representing a drop of 13% since 2008. The number of abortion providers declined 4%; the number of clinics dropped 1%. In 2011, 89% of counties had no clinics, and 38% of women of reproductive age lived in those counties. Early medication abortions accounted for a greater proportion of nonhospital abortions in 2011 (23%) than in 2008 (17%). Of the 106 new abortion restrictions implemented during the study period, few or none appeared to be related to state-level patterns in abortion rates or number of providers. CONCLUSIONS The national abortion rate has resumed its decline, and no evidence was found that the overall drop in abortion incidence was related to the decrease in providers or to restrictions implemented between 2008 and 2011.

Patterns in the socioeconomic characteristics of women obtaining abortions in 2000-2001.

CONTEXT Information about the socioeconomic characteristics of women obtaining abortions in the United States can help policymakers and family planning providers determine which groups of women need better access to contraceptive services. METHODS A representative sample of more than 10,000 women obtaining abortions from a stratified probability sample of 100 U.S. providers were surveyed in 2000-2001; survey data are used to examine the demographic characteristics of women who terminate pregnancies. This information, along with other national-level data, is used to estimate abortion rates and ratios for subgroups of women and examine recent changes in these measures. RESULTS. In 2000, 21 out of every 1,000 women of reproductive age had an abortion. Women who are aged 18-29, unmarried, black or Hispanic, or economically disadvantaged-including those on Medicaid-have higher abortion rates. The overall abortion rate decreased by 11% between 1994 and 2000. The decline was greatest for 15-17-year-olds, women in the highest income category, those with college degrees and those with no religious affiliation. Abortion rates for women with incomes below 200% of poverty and for women with Medicaid coverage increased between 1994 and 2000. The rate of decline in abortion among black and Hispanic adolescents was lower than that among white adolescents, and the abortion rate among poor teenagers increased substantially. CONCLUSIONS Increased efforts are needed to help both adolescent women and adult women of all economic statuses avoid unintended pregnancies.

Changes in Abortion Rates Between 2000 and 2008 and Lifetime Incidence of Abortion

OBJECTIVE: To estimate abortion rates among subpopulations of women in 2008, assess changes in subpopulation abortion rates since 2000, and estimate the lifetime incidence of abortion. METHODS: We combined secondary data from several sources, including the 2008 Abortion Patient Survey, the Current Population Surveys for 2008 and 2009, and the 2006–2008 National Survey of Family Growth, to estimate abortion rates by subgroup and lifetime incidence of abortion for U.S. women of reproductive age. RESULTS: The abortion rate declined 8.0% between 2000 and 2008, from 21.3 abortions per 1,000 women aged 15–44 to 19.6 per 1,000. Decreases in abortion were experienced by most subgroups of women. One notable exception was poor women; this group accounted for 42.4% of abortions in 2008, and their abortion rate increased 17.5% between 2000 and 2008 from 44.4 to 52.2 abortions per 1,000. In addition to poor women, abortion rates were highest for women who were cohabiting (52.0 per 1,000), aged 20–24 (39.9 per 1,000), or non-Hispanic African American (40.2 per 1,000). If the 2008 abortion rate prevails, 30.0% of women will have an abortion by age 45. CONCLUSION: Abortion is becoming increasingly concentrated among poor women, and restrictions on abortion disproportionately affect this population. LEVEL OF EVIDENCE: III

Discontinuation and resumption of contraceptive use : results from the 2002 National Survey of Family Growth

BACKGROUND Discontinuation of contraceptive use that is not immediately followed by resumption of use of another method while a woman is at risk is a common cause of unintended pregnancy. STUDY DESIGN We provide new estimates of discontinuation for the pill, injectable, male condom, withdrawal and fertility-awareness-based methods, and identify socioeconomic characteristics associated with discontinuation for the pill, male condom and withdrawal. We provide new estimates of resumption of use by prior method used and identify socioeconomic characteristics associated with resumption of use. Estimates are obtained using the 2002 National Survey of Family Growth, supplemented by the 2001 Abortion Patient Survey to correct for underreporting of abortion. RESULTS The fraction of method use segments discontinued for method-related reasons within 1 year was highest for the male condom (57%), withdrawal (54%) and fertility-awareness-based methods (53%), and lowest for the pill (33%), with the injectable in-between (44%). However, contraception was abandoned altogether in only 25% of cases. The probability of resuming use of a contraceptive was 72% in the initial month of exposure to the risk of an unintended pregnancy; this rose to 76% by the third month. CONCLUSION The risk of discontinuation of use of reversible methods of contraception for method-related reasons, including a change of method, is very high, but fortunately the risk of abandoning use of contraception altogether is far lower, and most spells of exposure to risk of an unintended pregnancy following discontinuation are protected from the start by a switch to another method.

Noncoital Sexual Activities Among Adolescents

PURPOSE Although prior research has demonstrated that many adolescents engage in noncoital sexual behavior, extant peer-reviewed studies have not used nationally representative data or multivariate methods to examine these behaviors. We used data from Cycle 6 of National Survey of Family Growth (NSFG) to explore factors related to oral and anal sex among adolescents. METHODS Data come from 2,271 females and males aged 15-19 in 2002. Computer-assisted self-administered interviews were used to collect sensitive information, including whether respondents had ever engaged in vaginal, oral or anal sex. We used t tests and multivariate logistic regression to test for differences and identify independent characteristics associated with experience with oral or anal sex. RESULTS In all, 54% of adolescent females and 55% of adolescent males have ever had oral sex, and one in 10 has ever had anal sex. Both oral sex and anal sex were much more common among adolescents who had initiated vaginal sex as compared with virgins. The initiations of vaginal and oral sex appear to occur closely together; by 6 months after first vaginal intercourse, 82% of adolescents also engaged in oral sex. The strongest predictor of anal sex involvement was time since initiation of vaginal sex and the likelihood of anal sex increased with greater time since first vaginal intercourse. Teens of white ethnicity and higher socioeconomic status were more likely than their peers to have ever had oral or anal sex. CONCLUSIONS Health professionals and sexual health educators should address noncoital sexual behaviors and risk for sexually transmitted infections risk, understanding that noncoital behaviors commonly co-occur with coital behaviors.

Mifepristone for early medical abortion: experiences in France, Great Britain and Sweden.

Rachel K. Jones is senior research associate, and Stanley K. Henshaw is senmorfellow, both at The Alan Guttmacher Institute, New York. In September 2000, the Food and Drug Administration (FDA) approved mifepristone (also known by the trade name Mifeprex or its original French name, RU-486) for use along with a prostaglandin for ending pregnancies up to 49 days from the onset of a womans last menstrual period. The FDA-approved protocol involves the administration of 600 mg of mifepristone followed two days later by 400 mg of oral misoprostol administered at a medical facility. Many abortion providers soon adopted the method, at least on a trial basis, but it is not universally available. As of early 2002, two-thirds of providers belonging to the National Abortion Federation (NAF) were offering the method to eligible patients. 1 NAF members perform about half of all abortions in the United States, they include the majority of Planned Parenthood Federation of America facilities that provide abortions. The brief U.S. experience with mifeprnstone leaves many questions unanswered about its ultimate level of acceptance: How many abortion providers and physicians who have not previously offered abortion services will provide medical abortions using mifepristone? What proportion of abortion patients will choose medical abortion? How will the availability of mifepristone affect the overall abortion rate? Other questions concern the appropriate protocols that most providers in the United States will ultimately use for early medical abortion involving mifepristone. Experience in other countries indicates that protocols can vary in mifepristone dosage, the gestational limits that determine whether women are eligible for the method and whether the prostaglandin used to stimulate uterine contractions is administered at a medical facility or at a womans home. The experience of European countries can shed light on these issues. Mifepristone is approved for use in most of Europe,* and three countries have had a decade or more of experience with its use: France, Great BritainT and Sweden. In this report, we synthesize information from national abortion statistics, professional guidelines and interviews with experts in these three countries to describe levels of

Abortion Incidence and Service Availability In the United States, 2014: Abortion Incidence and Service Availability In the United States, 2014

CONTEXT National and state-level information about abortion incidence can help inform policies and programs intended to reduce levels of unintended pregnancy. METHODS In 2015–2016, all U.S. facilities known or expected to have provided abortion services in 2013 or 2014 were surveyed. Data on the number of abortions were combined with population data to estimate national and state-level abortion rates. The number of abortion-providing facilities and changes since a similar 2011 survey were also assessed. The number and type of new abortion restrictions were examined in the states that had experienced the largest proportionate changes in clinics providing abortion services. RESULTS In 2014, an estimated 926,200 abortions were performed in the United States, 12% fewer than in 2011; the 2014 abortion rate was 14.6 abortions per 1,000 women aged 15–44, representing a 14% decline over this period. The number of clinics providing abortions declined 6% between 2011 and 2014, and declines were steepest in the Midwest (22%) and the South (13%). Early medication abortions accounted for 31% of nonhospital abortions, up from 24% in 2011. Most states that experienced the largest proportionate declines in the number of clinics providing abortions had enacted one or more new restrictions during the study period, but reductions were not always associated with declines in abortion incidence. CONCLUSIONS The relationship between abortion access, as measured by the number of clinics, and abortion rates is not straightforward. Further research is needed to understand the decline in abortion incidence.

Who has second-trimester abortions in the United States?

BACKGROUND Little is known about the characteristics of second-trimester abortion patients. STUDY DESIGN Data come from a national sample of 9493 women obtaining abortions in 2008. Chi-square statistics and logistic regression were used to examine demographic characteristics of women having abortions at 13 or more weeks since last menstrual period (LMP) and women having abortions at 13-15 weeks LMP compared to 16+ weeks LMP. RESULTS In 2008, 10.3% of abortions in the United States were 13 weeks LMP or later, including 4.0% at 16+ weeks. Groups most likely to have abortions at 13 weeks or later included black women, women with less education, those using health insurance to pay for the procedure and those who had experienced three or more disruptive events in the last year. Groups more likely to have an abortion at 16 weeks or later included black women, higher income women and those paying with health insurance. CONCLUSIONS Black women and those with less education would most benefit from increased availability of first-trimester abortion services.

Better than nothing or savvy risk-reduction practice? The importance of withdrawal.

This commentary discusses the causes and consequences of the family planning fields lack of enthusiasm for withdrawal use despite its comparative effectiveness. It also includes possible ways to improve measurement and understanding of withdrawal use and how to discuss it with contraceptive clients after the review of new data on the prevalence and practices of withdrawal.