Context

Measurement of pregnancy intentions typically relies on retrospective reporting, an approach that may misrepresent the extent of unintended pregnancy. However, the degree of possible misreporting is unclear, as little research has compared prospective and retrospective reports of intention for the same pregnancies.

Methods

Longitudinal data collected between 2010 and 2015 on 174 pregnancies were used to analyze the magnitude and direction of changes in intendedness (intended, ambivalent or unintended) between prospective and retrospective measurements of intendedness using versions of the London Measure of Unplanned Pregnancy (LMUP). Changes were assessed both continuously and categorically. Differences in the degree of change-by pregnancy outcome and participant characteristics-were examined using mixed-effects linear and logistic regression models.

Results

Over two and one-half years of follow-up, 143 participants reported 174 pregnancies. Approximately half showed changes in intention between the prospective and retrospective assessments, with 38% of participants reporting increased intendedness and 10% decreased intendedness. Reported intendedness increased more among those who gave birth (mean change in continuous LMUP score, 2.2) than among those who obtained an abortion (0.7), as well as among individuals with a college degree (4.1) than among those with a high school diploma (1.2). Participants who reported recent depression or anxiety symptoms showed more stable intentions (0.02) than those who did not (2.1).

Conclusions

Retrospective measurement of pregnancy intentions may underestimate the frequency of unintended pregnancy, with such underestimation being greater among certain subgroups. Estimates based on retrospective reports thus may produce inaccurate impressions of intentionality. Further efforts to refine the measurement of pregnancy preferences are needed.

Objective

Abortion is often characterized as an inherently difficult decision, despite research demonstrating high decision certainty among abortion patients. Minimal research has examined decision certainty among people planning to continue a pregnancy. We examined whether women seeking abortion experience lower decision certainty than those planning to continue pregnancies and whether certainty differs by pregnancy intendedness.

Study design

We administered the decisional conflict scale (DCS) to pregnant women (n = 149) at 8 U.S. primary and reproductive health clinics. Using Poisson regression models adjusted for sociodemographic and pregnancy characteristics, we evaluated differences in DCS scores (<25/100 vs ≥25/100) by pregnancy decision and whether pregnancy intention modified the effect of pregnancy decision on certainty.

Results

Over one-half (58%) of respondents planned to have an abortion, 32% to continue the pregnancy, and 10% were unsure. DCS scores were low overall (median 9.4/100; IQR: 1.6, 25.0), indicative of high certainty, and the percentage scoring ≥25/100, reflecting any uncertainty, did not differ by pregnancy decision (23% abortion vs 19% continuing, p = 0.55). In a multivariable model, there was no statistically significant interaction between pregnancy decision (abortion vs continuing pregnancy) and intention. However, the predicted percentage reporting any uncertainty among respondents with intended pregnancies was comparable among those decided on abortion (13%) and continuing the pregnancy (16%). Among those with unintended pregnancies, these figures were 25% among those decided on abortion vs 36% among those continuing.

Conclusion

Levels of certainty about a pregnancy decision were high and appeared to depend more on whether the pregnancy was intended or unintended than on the pregnancy decision itself.

Implications

Similar levels of uncertainty among individuals who decided to have an abortion versus continue a pregnancy challenge the narrative that abortion is a particularly difficult medical and personal decision. The prevalence of some uncertainty among respondents continuing pregnancies suggests voluntary options counseling may be useful for some patients in prenatal care settings.

Objectives

An understanding of the relationship between individuals' pregnancy preferences and contraceptive use is essential for appropriate patient-centered counseling and care. We examined the relationship between women's pregnancy preferences and contraceptive use using a new prospective measure, the Desire to Avoid Pregnancy (DAP) scale.

Study design

As part of a study examining women's suspicion and confirmation of new pregnancies, we recruited patients aged 15 - 45 from seven reproductive health and primary health facilities in Arizona, New Jersey, New Mexico, South Carolina, and Texas in 2016-2017. We used multivariable logistic, multinomial logistic, and linear regression models to examine the associations among DAP scores (range: 0 - 4) and contraceptive use outcomes and identify factors associated with discordance between DAP and use of contraception.

Results

Participants with a greater preference to avoid pregnancy had higher odds of contraceptive use (aOR = 1.63, 95% CI: 1.31, 2.04) and used contraceptives more consistently (aβ = 8.9 percentage points, 95% CI: 5.2, 12.7). Nevertheless, 63% of women with low preference to avoid pregnancy reported using a contraceptive method. Higher preference to avoid pregnancy was not associated with type of contraceptive method used: women with the full range of pregnancy preferences reported using all method types.

Conclusion

When measured using a rigorously developed instrument, pregnancy preferences were associated with contraceptive use and consistency of use. However, our findings challenge assumptions that women with the highest preference against pregnancy use more effective methods and that women who might welcome pregnancy do not use contraception.

Implications

Women's preferences about pregnancy contribute significantly to their use of contraception. However, health care providers and researchers should consider that contraceptive features besides effectiveness in preventing pregnancy shape contraceptive decision-making and use.

Background

The evidence from epidemiological research into whether use of hormonal contraception increases women's risk of HIV acquisition is inconsistent. We did a robust meta-analysis of existing data to provide summary estimates by hormonal contraceptive method which can be used to inform contraceptive guidelines, models, and future studies.

Methods

We updated a recent systematic review to identify and describe studies that met inclusion criteria. To ensure inclusion of more recent research, we searched PubMed for articles published after December, 2011, using the terms "hormonal contraception", "HIV/acquisition", "injectables", "progestin", and "oral contraceptive pills". We assessed statistical heterogeneity for these studies, and, when appropriate, combined point estimates by hormonal contraception formulation using random-effects models. We assessed publication bias and investigated heterogeneity through subgroup and stratified analyses according to study population and design features.

Findings

We identified 26 studies, 12 of which met inclusion criteria. There was evidence of an increase in HIV risk in the ten studies of depot medroxyprogesterone acetate (pooled hazard ratio [HR] 1·40, 95% CI 1·16-1·69). This risk was lower in the eight studies done in women in the general population (pooled HR 1·31, 95% CI 1·10-1·57). There was substantial between-study heterogeneity in secondary analyses of trials (n=7, I(2) 51·1%, 95% CI 0-79·3). Although individual study estimates suggested an increased risk, substantial heterogeneity between two studies done in women at high risk of HIV infection (I(2) 54%, 0-88·7) precluded pooling estimates. There was no evidence of an increased HIV risk in ten studies of oral contraceptive pills (pooled HR 1·00, 0·86-1·16) or five studies of norethisterone enanthate (pooled HR 1·10, 0·88-1·37).

Interpretation

Our findings show a moderate increased risk of HIV acquisition for all women using depot medroxyprogesterone acetate, with a smaller increase in risk for women in the general population. Whether the risks of HIV observed in our study would merit complete withdrawal of depot medroxyprogesterone acetate needs to be balanced against the known benefits of a highly effective contraceptive.

Funding

None.

Food insecurity (FI) is associated with higher-risk sexual behavior in some studies. However, the overlap between FI and socioeconomic status (SES) has been poorly described. The study objectives were to: (1) determine the relationship between household FI and four dimensions of SES among sexually active Tanzanian women in farming households: expenditures, assets, flooring material of the home, and land ownership; and (2) determine whether FI is associated with higher-risk sexual behavior and relationship power. In male-headed households, FI was associated with assets, flooring material, and land ownership but not expenditures. There was no association between FI and the four dimensions of SES in female-headed households. Among women in male-headed households, but not female household heads themselves, severe FI was associated with a non-significant increase in the likelihood of being in a relationship because of material goods [adjusted prevalence ratio (PRa) = 1.76, 95 % confidence interval (CI) 0.81, 3.81] and was inversely associated with being able to ask partners to use condoms (PRa = 0.47, 95 % CI 0.25, 0.88). There was not a strong association between food security and relationship power. Our findings suggest that the association between FI and HIV risk behavior may differ depending on the type of household.

BACKGROUND:Existing approaches to measuring women's pregnancy intentions suffer important limitations, including retrospective assessment, overly simple categories, and a presumption that all women plan pregnancies. No psychometrically valid scales exist to prospectively measure the ranges of women's pregnancy preferences. MATERIALS AND METHODS:Using a rigorous construct modeling approach, we developed a scale to measure desire to avoid pregnancy. We developed 60 draft items from existing research, assessed comprehension through 25 cognitive interviews, and administered items in surveys with 594 nonpregnant women in 7 primary and reproductive health care facilities in Arizona, New Jersey, New Mexico, South Carolina, and Texas in 2016-2017. We used item response theory to reduce the item set and assess the scale's reliability, internal structure validity, and external validity. Items were included based on fit to a random effects multinomial logistic regression model (partial credit item response model), correspondence of item difficulty with participants' pregnancy preference levels, and consistency of each item's response options with overall scale scores. RESULTS:The 14 final items covered 3 conceptual domains: cognitive preferences, affective feelings, and practical consequences. Items fit the unidimensional model, with a separation reliability of 0.90 (Cronbach α: 0.95). The scale met established criteria for internal validity, including correspondence between each item's response categories and overall scale scores. We found no important differential item functioning by participant characteristics. CONCLUSIONS:A robust measure is available to prospectively measure desire to avoid pregnancy. The measure can aid in identifying women who could benefit from contraceptive care and research on less desired pregnancy.

Background

Research demonstrates worse short-term morbidity and mortality associated with childbirth than with abortion, but little research has examined long-term physical health in women with unwanted pregnancies after abortion versus childbirth.

Objective

To examine the physical health of women who seek and receive or are denied abortion.

Design

Prospective cohort study.

Setting

30 U.S. abortion facilities from 2008 to 2010.

Participants

Of 1132 women seeking abortion who consented to participate, 874 were included in this analysis (328 who had first-trimester abortion, 383 who had second-trimester abortion, and 163 who gave birth).

Measurements

Self-reported overall health; chronic abdominal, pelvic, back, and joint pain; chronic headaches or migraines; obesity; asthma; gestational and nongestational hypertension and diabetes; and hyperlipidemia were assessed semiannually for 5 years. Mortality was assessed by using verbal autopsy and public records.

Results

No significant differences were observed in self-rated health or chronic pain after first-trimester versus second-trimester abortion. At 5 years, 27% (95% CI, 21% to 34%) of women who gave birth reported fair or poor health compared with 20% (CI, 16% to 24%) of women who had first-trimester abortion and 21% (CI, 18% to 25%) who had second-trimester abortion. Women who gave birth also reported more chronic headaches or migraines and joint pain, but experienced similar levels of other types of chronic pain and obesity. Gestational hypertension was reported by 9.4% of participants who gave birth. Eight of 1132 participants died during follow-up, 2 in the postpartum period. Maternal mortality did not differ statistically by group.

Limitation

Self-reported outcome measures, uncertain generalizability, and 41% loss to follow-up at 5 years.

Conclusion

Although some argue that abortion is detrimental to women's health, these study data indicate that physical health is no worse in women who sought and underwent abortion than in women who were denied abortion. Indeed, differences emerged suggesting worse health among those who gave birth.

Primary funding source

An anonymous foundation.

While there is a large body of research demonstrating that having an abortion is not associated with adverse mental health outcomes, less research has examined which factors may contribute to elevated levels of mental health symptoms at the time of abortion seeking. This study aims to develop and validate a new tool to measure dimensions of psychosocial burden experienced by people seeking abortion in the United States. To develop scale items, we reviewed the literature including existing measures of stress and anxiety and conducted interviews with experts in abortion care and with patients seeking abortion. Thirty-five items were administered to 784 people seeking abortion at four facilities located in three U.S. states. We used exploratory factor analysis (EFA) to reduce items and identify key domains of psychosocial burden. We assessed the predictive validity of the overall scale and each sub-scale, by assessing their associations with validated measures of perceived stress, anxiety, and depression using multivariable linear regression models. Factor analyses revealed a 12-item factor solution measuring psychosocial burden seeking abortion, with four subdomains: structural challenges, pregnancy decision-making, lack of autonomy, and others' reactions to the pregnancy. The alpha reliability coefficients were acceptable for the overall scale (α = 0.83) and each subscale (ranging from α = 0.82-0.85). In adjusted analyses, the overall scale was significantly associated with stress, anxiety and depression; each subscale was also significantly associated with each mental health outcome. This new scale offers a practical tool for providers and researchers to empirically document the factors associated with people's psychological well-being at the time of seeking an abortion. Findings suggest that the same restrictions that claim to protect people from mental health harm may be increasing people's psychosocial burden and contributing to adverse psychological outcomes at the time of seeking abortion.

PURPOSE:This study aims to examine the impact of a parental notification (PN) requirement on the frequency, timing, and out-of-state travel of minors seeking abortion, as well as changes in who minors involve in their decision, support received, and decision certainty. METHODS:We analyzed administrative and medical records of 1,577 women obtaining an abortion before and after implementation of a PN requirement at one Illinois facility. Using multivariate regression within a difference-in-differences framework, we quantified changes in the number and timing of women seeking care, frequency of parental awareness and support, travel from out-of-state, decision certainty, and anticipated coping among minors 17 years and below compared with young adults (YAs) aged 18-20 years. RESULTS:A smaller proportion of abortions to women ages 20 years and under post-law were among minors (39%-33%, p = .017). Compared with YAs, minors experienced a larger increase in parental awareness (71%-93% [minors] vs. 53%-58% [YAs], p < .000]; however, parents' support for the decision was unchanged. The proportion of minors certain of their decision went from 77% pre-law to 71% post-law (p = .099) compared with 82% pre- and post-law among YAs (p = .798). Compared with YAs, a larger proportion of minors obtained second trimester care post-law if coming from another state (21%-31% [minors] vs. 23%-16% [YAs], p = .022). CONCLUSIONS:Illinois' PN requirement was associated with a decrease in the number of abortions among minors, delayed care for those from out-of-state, increased parental awareness of the pregnancy, and no change in parents' support.