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BackgroundFive U.S. states where recreational cannabis is legal require Mandatory Warning Signs for cannabis use during pregnancy (MWS-cannabis) to be posted in cannabis dispensaries. Previous research has found adverse health consequences associated with MWS-cannabis and that people lack trust in information on signs. This qualitative study explores people's perspectives and preferences regarding MWS-cannabis.MethodsWe conducted in-depth interviews with 34 pregnant or recently pregnant individuals from multiple states with varying policy climates in the U.S. who used cannabis before and/or during pregnancy. We asked participants about their perspectives on MWS-cannabis and reactions to specific messages. We reviewed transcripts using thematic analysis.ResultsParticipants reported mostly negative views on MWS-cannabis, suggesting they may have stigmatizing and negative impacts on pregnant people who use cannabis, discouraging them from seeking care. Many said that the scientific evidence is not strong enough to justify MWS-cannabis, and that they are unlikely to deter pregnant people from using cannabis. Participants asserted that vague or fear-based messages, distrust of government, and the location and timing of the signs undermine the goals of MWS-cannabis. When reacting to specific messages, participants preferred messages that are evidence-based, clear, specific, and aligned with autonomous decision-making.ConclusionsPregnant and recently pregnant people who use cannabis have mostly negative perceptions of MWS-cannabis and believe they have negative consequences. More work is needed to develop health information resources that meet the needs of people who use cannabis in pregnancy without increasing stigma.

This is a protocol for a systematic review and meta-analysis of research on mental health outcomes of abortion. Does abortion increase the risk of adverse mental health outcomes? That is the central question for this review. Our review aims to inform policy and practice by locating, critically appraising, and synthesizing empirical evidence on associations between abortion and subsequent mental health outcomes. Given the controversies surrounding this topic and the complex social, political, legal, and ideological contexts in which research and reviews on abortion are conducted, it is especially important to conduct this systematic review and meta-analysis with comprehensive, rigorous, unbiased, and transparent methods. We will include a variety of study designs to enhance understanding of studies methodological strengths and weaknesses and to identify potential explanations for conflicting results. We will follow open science principles, providing access to our methods, measures, and results, and making data available for re-analysis.

ImportanceBefore 2021, the US Food and Drug Administration required mifepristone to be dispensed in person, limiting access to medication abortion.ObjectiveTo estimate the effectiveness, acceptability, and feasibility of dispensing mifepristone for medication abortion using a mail-order pharmacy.Design, setting, and participantsThis prospective cohort study was conducted from January 2020 to May 2022 and included 11 clinics in 7 states (5 abortion clinics and 6 primary care sites, 4 of which were new to abortion provision). Eligible participants were seeking medication abortion at 63 or fewer days' gestation, spoke English or Spanish, were age 15 years or older, and were willing to take misoprostol buccally. After assessing eligibility for medication abortion through an in-person screening, mifepristone and misoprostol were prescribed using a mail-order pharmacy. Patients had standard follow-up care with the clinic. Clinical information was collected from medical records. Consenting participants completed online surveys about their experiences 3 and 14 days after enrolling. A total of 540 participants were enrolled; 10 withdrew or did not take medication. Data were analyzed from August 2022 to December 2023.InterventionMifepristone, 200 mg, and misoprostol, 800 µg, prescribed to a mail-order pharmacy and mailed to participants instead of dispensed in person.Main outcomes and measuresProportion of patients with a complete abortion with medications only, reporting satisfaction with the medication abortion, and reporting timely delivery of medications.ResultsClinical outcome information was obtained and analyzed for 510 abortions (96.2%) among 506 participants (median [IQR] age, 27 [23-31] years; 506 [100%] female; 194 [38.3%] Black, 88 [17.4%] Hispanic, 141 [27.9%] White, and 45 [8.9%] multiracial/other individuals). Of these, 436 participants (85.5%; 95% CI, 82.2%-88.4%) received medications within 3 days. Complete abortion occurred after medication use in 499 cases (97.8%; 95% CI, 96.2%-98.9%). There were 24 adverse events (4.7%) for which care was sought for medication abortion symptoms; 3 patients (0.6%; 95% CI, 0.1%-1.7%) experienced serious adverse events requiring hospitalization (1 with blood transfusion); however, no adverse events were associated with mail-order dispensing. Of 477 participants, 431 (90.4%; 95% CI, 87.3%-92.9%) indicated that they would use mail-order dispensing again for abortion care, and 435 participants (91.2%; 95% CI, 88.3%-93.6%) reported satisfaction with the medication abortion. Findings were similar to those of other published studies of medication abortion with in-person dispensing.Conclusions and relevanceThe findings of this cohort study indicate that mail-order pharmacy dispensing of mifepristone for medication abortion was effective, acceptable to patients, and feasible, with a low prevalence of serious adverse events. This care model should be expanded to improve access to medication abortion services.

Interest in ending a pregnancy outside the formal healthcare sector, also known as self-managed abortion (SMA), is expected to increase in the wake of the overturning of Roe v Wade. However, there is little social scientific research on public perceptions of SMA, particularly regarding opinions around legality and criminalization. We seek to fill this gap in this paper by drawing on 54 in-depth interviews with a mixed-gender sample (men, women, nonbinary) recruited from eight U.S. states with the most restrictive abortion laws. Our analysis finds that most participants believed that SMA should not be illegal or criminalized largely due to two overarching justifications: (1) due to a belief that people should have a right to their own bodily autonomy even in the case of potential self-harm and (2) the belief that criminalizing SMA would be against public health goals. Further, many are concerned that making SMA illegal will lead to unfair or even cruel punishment. However, an underlying thread connecting both support and opposition to SMA legality and criminalization is the assumption that SMA is inherently harmful or dangerous, indicating a lack of lay awareness about the safety and efficacy of SMA using medication abortion pills. These findings indicate the power of medicalization and a valuing of medicalization as a social good, as many believe that behaviors occurring within the healthcare system are inherently safer, more justified, and more moral.

BackgroundThis qualitative study aims to assess perspectives of clinicians and clinic staff on mail-order pharmacy dispensing for medication abortion.MethodsParticipants included clinicians and staff involved in implementing a mail-order dispensing model for medication abortion at eleven clinics in seven states as part of a prospective cohort study, which began in January 2020 (before the FDA removed the in-person dispensing requirement for mifepristone). From June 2021 to July 2022, we invited participants at the participating clinics, including six primary care and five abortion clinics, to complete a semi-structured video interview about their experiences. We then conducted qualitative thematic analysis of interview data, summarizing themes related to perceived benefits and concerns about the mail-order model, perceived patient interest, and potential barriers to larger-scale implementation.ResultsWe conducted 24 interviews in total with clinicians (13 physicians and one nurse practitioner) and clinic staff (n = 10). Participants highlighted perceived benefits of the mail-order model, including its potential to expand abortion services into primary care, increase patient autonomy and privacy, and to normalize abortion services. They also highlighted key logistical, clinical, and feasibility concerns about the mail-order model, and specific challenges related to integrating abortion into primary care.ConclusionClinicians and clinic staff working in primary care and abortion clinics were optimistic that mail-order dispensing of medication abortion can improve the ability of some providers to provide abortion and enable more patients to access services. The feasibility of mail-order pharmacy dispensing of medication abortion following the Supreme Court Dobbs decision is to be determined.Trial registrationRegistry: Clinicaltrials.gov.Trial registration numberNCT03913104. Date of registration: first submitted on April 3, 2019 and first posted on April 12, 2019.

INTRODUCTION: In 2017, Chile decriminalized abortion on three grounds: (i) if the pregnant persons life is at risk, (ii) fetal nonviability, and (iii) rape or incest. This multicase study explores the experiences of pregnant people legally entitled to but denied access to legal abortion in Chile. METHODS: Through a snowball sampling approach, we recruited adult Chilean residents who sought, were eligible for, and were denied a legal abortion after September 2017. We conducted semistructured interviews with participants to explore their experiences in seeking and being denied legal abortions. We recorded and transcribed the interviews, then coded and analyzed the transcriptions to identify common themes. RESULTS: We identified four women who met the eligibility criteria. The interviews revealed five common themes in their experiences: (i) disparate levels of social support in accessing abortion, (ii) abundant access barriers, (iii) forced pregnancy, (iv) abortion stigma, and (v) a failure of the law to provide access to abortion. DISCUSSION AND HEALTH EQUITY IMPLICATIONS: Although the 2017 law expanded legal access to abortion in Chile, significant barriers remain. Compounded with social stigma, and the socioeconomic disparities in abortion access, pregnant people continue to face insurmountable obstacles in obtaining legal abortions, even when their lives are at risk and the pregnancy is not viable. The state must prioritize equity of access to legal abortions. Future studies should continue to explore the challenges people face accessing legal abortion care to inform strategies to ensure people are able to obtain the quality care that they are legally entitled to.

BackgroundAbortion stigma likely affects the terminology abortion patients, providers and the public use or avoid using to refer to abortion care. Knowing the terminology people seeking abortion prefer could help inform the language used in clinical interactions and improve patients' experiences with abortion care. However, research in the U.S. has not examined patients' preferences in this area or whether terminology preferences vary by participant characteristics, in the way that experiences of stigma vary across different contexts and communities. This study aims to describe preferred terminology among people presenting for abortion care and to explore the pregnancy-related characteristics associated with these preferences.MethodsWe surveyed abortion patients about their experiences accessing abortion care, including preferred terms for the procedure. Respondents could mark more than one term, suggest their own term, or indicate no preference. We recruited people ages 15-45 seeking abortion from four U.S. abortion facilities located in three states (California, Illinois, and New Mexico) from January to June 2019. We used descriptive statistics and multivariable multinomial logistic regression to explore associations between respondents' pregnancy-related characteristics and their preferred terminology.ResultsAmong the 1092 people approached, 784 (77%) initiated the survey and 697 responded to the terminology preference question. Most participants (57%, n = 400) preferred only one term. Among those participants, "abortion" (43%) was most preferred, followed by "ending a pregnancy" (29%), and "pregnancy termination" (24%). In adjusted multivariable models, participants who worried "very much" that other people might find out about the abortion (29%) were significantly more likely than those who were "not at all" worried (13%) to prefer "ending a pregnancy" over having no preference for a term (adjusted relative risk ratio: 2.68, 95% Confidence Interval: 1.46-4.92).ConclusionsPeople seeking abortion have varied preferences for how they want to refer to their abortions, in particular if they anticipate abortion stigma. Findings can be useful for clinicians and researchers so that they can be responsive to people's preferences during clinical interactions and in the design and conduct of abortion research.

Granular materials in rotating drums are of wide interest not only because of their extensive use in the industrial contexts, but also as model systems in the study of natural disasters, such as avalanches or landslides. Most of available experimental methods are restricted to surface layer flows and dilute systems whilst the remainder can only resolve the granular dynamics to a fine scale with relatively poor temporal resolution or vice versa. In contrast, speckle visibility spectroscopy (SVS) is able to resolve the average of the three components of motion of grains in dense systems in small volume of granular media several layer deep with spatio-temporal resolutions that allow the probing of the granular micro-dynamics. We have used this technique to study granular dynamics of surface avalanche flow in the slumping regime using both spherical glass and irregular sand particles. Although results are very similar, we determined that visually observed compaction at the beginning of avalanche process for irregular sand particles influence time evolution of the particle fluctuation velocity during avalanches.

ObjectivesTo determine the socioeconomic consequences of receipt versus denial of abortion.MethodsWomen who presented for abortion just before or after the gestational age limit of 30 abortion facilities across the United States between 2008 and 2010 were recruited and followed for 5 years via semiannual telephone interviews. Using mixed effects models, we evaluated socioeconomic outcomes for 813 women by receipt or denial of abortion care.ResultsIn analyses that adjusted for the few baseline differences, women denied abortions who gave birth had higher odds of poverty 6 months after denial (adjusted odds ratio [AOR] = 3.77; P

ObjectiveTo develop a drug facts label prototype for a combination mifepristone and misoprostol product and to conduct a label-comprehension study to assess understanding of key label concepts.MethodsWe followed U.S. Food and Drug Administration guidance, engaged a multidisciplinary group of experts, and conducted cognitive interviews to develop a drug facts label prototype for medication abortion. To assess label comprehension, we developed 11 primary and 13 secondary communication objectives related to indications for use, eligibility, dosing regimen, contraindications, warning signs, side effects, and recognizing the risk of treatment failure, with corresponding target performance thresholds (80-90% accuracy). We conducted individual structured video interviews with people with a uterus aged 12-49 years, recruited through social media. Participants reviewed the drug facts label and responded to questions to assess their understanding of each communication objective. After transcribing and coding interviews, we estimated the proportion of correct responses and exact binomial 95% CIs by age and literacy group.ResultsWe interviewed 851 people (of 1,507 people scheduled); responses from 844 were eligible for analysis, and 35.7% (n=301) of participants were aged 12-17 years. The overall sample met performance criteria for 10 of the 11 primary communication objectives (93-99% correct) related to indications for use, eligibility for use, the dosing regimen, and contraindications; young people met nine and people with limited literacy met eight of the 11 performance criteria. Only 79% (95% CI 0.76-0.82) of the overall sample understood to contact a health care professional if little or no bleeding occurred soon after taking misoprostol, not meeting the prespecified threshold of 85.0%.ConclusionOverall, high levels of comprehension suggest that people can understand most key drug facts label concepts for a medication abortion product without clinical supervision and recommend minor modifications.

Objective(s)To estimate the effectiveness, acceptability, and feasibility of medication abortion with mifepristone dispensed by a mail-order pharmacy after in-person clinical assessment.Study designThis is an interim analysis of an ongoing prospective cohort study conducted at five sites. Clinicians assessed patients in clinic and, if they were eligible for medication abortion and ≤ 63 days' gestation, electronically sent prescriptions for mifepristone 200 mg orally and misoprostol 800 mcg buccally to a mail-order pharmacy, which shipped medications for next-day delivery. Participants completed surveys three and 14 days after enrollment, and we abstracted medical chart data.ResultsBetween January 2020 and April 2021 we enrolled 240 participants and obtained clinical outcome information for 227 (94.6%); 3 reported not taking either medication. Of those with abortion outcome information (N = 224), 216 (96.4%) completed day-3 and 212 (94.6%) day-14 surveys. Of the 224 that took medications, none reported taking past 70 days' gestation, and complete medication abortion occurred for 217 participants (96.9%, 95% CI 93.7%-98.7%). Most received medications within three days (82.1%, 95% CI 76.5%-86.9%). In the day-3 survey, 95.4% (95% CI 91.7%-97.8%) reported being very (88.4%) or somewhat (6.9%) satisfied with receiving medications by mail. In the day-14 survey, 89.6% (95% CI 84.7%-93.4%) said they would use the mail-order service again if needed. Eleven (4.9%, 95% CI 2.5%-8.6%) experienced adverse events; two were serious (one blood transfusion, one hospitalization), and none were related to mail-order pharmacy dispensing.ConclusionsMedication abortion with mail-order pharmacy dispensing of mifepristone appears effective, feasible, and acceptable to patients.ImplicationsThe in-person dispensing requirement for mifepristone, codified in the drug's Risk Evaluation and Mitigation Strategy, should be removed.

IntroductionWith increasing restrictions on abortion across the United States, we sought to understand whether people seeking abortion would consider ending their pregnancy on their own if unable to access a facility-based abortion.MethodsFrom January to June 2019, we surveyed patients seeking abortion at 4 facilities in 3 US states. We explored consideration of self-managed abortion (SMA) using responses to the question: "Would you consider ending this pregnancy on your own if you are unable to obtain care at a health care facility?" We used multivariable Poisson regression to assess associations between individual sociodemographic, pregnancy and care-seeking characteristics and prevalence of considering SMA. In bivariate Poisson models, we also explored whether consideration of SMA differed by specific obstacles to abortion care.ResultsOne-third (34%) of 741 participants indicated they would definitely or probably consider ending the pregnancy on their own if unable to obtain care at a facility. Consideration of SMA was higher among those who reported no health insurance (adjusted prevalence ratio [aPR] = 1.66; 95% Confidence Interval [CI] 1.12-2.44), described the pregnancy as unintended (aPR = 1.53; 95% CI 1.08-2.16), were seeking abortion due to concerns about their own physical or mental health (aPR = 1.50, 95% CI 1.02, 2.20), or experienced obstacles that delayed their abortion care seeking (aPR = 2.26, 95% CI 1.49, 3.40). Compared to those who would not consider SMA, participants who would consider SMA expressed higher difficulty finding an abortion facility (35 vs. 27%, p = 0.019), figuring out how to get to the clinic (29 vs 21%, p = 0.021) and needing multiple clinic visits (23 vs 17%, p = 0.044).ConclusionsOne in three people seeking facility-based abortion would consider SMA if unable to obtain abortion care at a facility. As abortion access becomes increasingly restricted in the US, SMA may become more common. Future research should continue to monitor people's consideration and use of SMA and ensure that they have access to safe and effective methods.

BackgroundA growing body of evidence indicates that some people seek options to terminate a pregnancy without medical assistance, but experiences doing so have largely been documented only among people accessing a clinic-based abortion. We aim to describe self-managed abortion (SMA) experiences of people recruited outside of clinics, including their motivations for SMA, pregnancy confirmation and decision-making processes, method choices, and clinical outcomes.MethodsIn 2017, we conducted 14 in-depth interviews with self-identified females of reproductive age who recently reported in an online survey administered to Ipsos' KnowledgePanel that, since 2000, they had attempted SMA while living in the United States. We asked participants about their reproductive histories, experiences seeking reproductive health care, and SMA experiences. We used an iterative process to develop codes and analyzed transcripts using thematic content analysis methods.ResultsMotivations and perceptions of effectiveness varied by whether participants had confirmed the pregnancy prior to SMA. Participants who confirmed their pregnancies chose SMA because it was convenient, accessible, and private. Those who did not test for pregnancy were motivated by a preference for autonomy and felt empowered by the ability to try something on their own before seeking facility-based care. Participants prioritized methods that were safe and available, though not always effective. Most used herbs or over-the-counter medications; none used self-sourced abortion medications, mifepristone and/or misoprostol. Five participants obtained facility-based abortions and one participant decided to continue the pregnancy after attempting SMA. The remaining eight reported being no longer pregnant after SMA. None of the participants sought care for  SMA complications; one participant saw a provider to confirm abortion completion.ConclusionsThere are many types of SMA experiences. In addition to those who pursue SMA as a last resort (after facing barriers to facility-based care) or as a first resort (because they prefer homeopathic remedies), our findings show that some individuals view SMA as a potential interim step worth trying after suspecting pregnancy and before accessing facility-based care. These people in particular would benefit from a medication abortion product available over the counter, online, or in the form of a missed-period pill.

BackgroundThe U.S. Food and Drug Administration (FDA) restricts dispensing of mifepristone for medication abortion to certified health care providers at clinical facilities, thus prohibiting pharmacist dispensing. Allowing mifepristone dispensing by pharmacists could improve access to medication abortion.ObjectiveTo assess the feasibility of pharmacists dispensing mifepristone to patients who have undergone evaluation for eligibility and counseling for medication abortion by a clinician.MethodsBefore providing a study training on medication abortion, we administered baseline surveys to pharmacists who participated in a multisite mifepristone-dispensing intervention. The survey assessed medication abortion knowledge-using a 15-item score-and perceptions about the benefits and challenges of the model. We administered follow-up surveys in the study's final month that also assessed the pharmacists' satisfaction and experiences with mifepristone dispensing. To investigate the association of the study intervention with the pharmacists' knowledge, perceptions, and experiences dispensing mifepristone, we conducted multivariable linear regression analyses using generalized estimating equation models, accounting for clustering by individual.ResultsAmong the 72 pharmacists invited from 6 pharmacies, 47 (65%) completed the baseline surveys, and 56 (78%) received training. At the study's end (mean 18 months later), 43 of the 56 pharmacists who received training (77%) completed the follow-up surveys. At follow-up, 36 (83%) respondents were very or somewhat satisfied with mifepristone dispensing, and 24 (56%) reported experiencing no challenges dispensing mifepristone. Four (6%) of the 72 pharmacists invited objected to participating in mifepristone dispensing. In regression analyses, average knowledge scores, perceived ease of implementation, and level of support for the pharmacist-dispensing model were higher at follow-up (P < 0.001).ConclusionMost pharmacists were willing to be trained, dispensed mifepristone with few challenges when given the opportunity, were satisfied with the model, and had higher knowledge levels at follow-up. Our findings support removal of FDA's restriction on pharmacist dispensing of mifepristone.

Study objectiveTo understand the diverse reasons why some young women choose contraceptive methods that are less effective at preventing pregnancy, including condoms, withdrawal, and emergency contraception pills, even when more effective contraceptive methods are made available to them.DesignIn-depth interviews with young women at family planning clinics in July-November 2016. Interview data were thematically coded and analyzed using an iterative approach.SettingTwo youth-serving family planning clinics serving predominantly Latinx and African American communities in the San Francisco Bay Area, California.ParticipantsTwenty-two young women ages 15-25 years who recently accessed emergency contraception to prevent pregnancy.InterventionsNone.Main outcome measuresYoung women's experiences using different methods of contraception, with specific attention to methods that are less effective at preventing pregnancy.ResultsYoung women reported having previously used a range of higher- and lower-efficacy contraceptive methods. In interviews, they described affirmative values that drive their decision to use lower-efficacy methods, including: a preference for flexibility and spontaneity over continual contraceptive use, an emphasis on protecting one's body, and satisfaction with the method's effectiveness at preventing pregnancy. Some young women described using a combination of lower-efficacy methods to reduce their pregnancy risk.ConclusionYoung women make contraceptive decisions on the basis of preferences and values that include, but are not limited to, effectiveness at preventing pregnancy. These reasons are salient in their lives and need to be recognized as valid by sexual health care providers to ensure that young women receive ongoing high-quality care.

ObjectiveTo estimate effectiveness and acceptability of medication abortion with mifepristone dispensed by pharmacists.MethodsWe conducted a prospective cohort study at eight clinical sites and pharmacies in California and Washington State from July 2018 to March 2020. Pharmacists at participating pharmacies underwent a 1-hour training on medication abortion. We approached patients who had already been evaluated, counseled, and consented for medication abortion per standard of care. Patients interested in study participation gave consent, and the clinician electronically sent a prescription to the pharmacy for mifepristone 200 mg orally, followed 24-48 hours later by misoprostol 800 micrograms buccally. Participants were sent web-based surveys about their experience and outcomes on days 2 and 14 after enrollment and had routine follow-up with study sites. We extracted demographic and clinical data, including abortion outcome and adverse events, from medical records. We performed multivariable logistic regression to assess the association of pharmacy experience and other covariates with satisfaction.ResultsWe enrolled 266 participants and obtained clinical outcome information for 262 (98.5%), of whom two reported not taking either medication. Of the 260 participants with abortion outcome information, 252 (96.9%) and 237 (91.2%) completed day 2 and 14 surveys, respectively. Complete medication abortion (primary outcome) occurred for 243 participants (93.5%, 95% CI 89.7-96.1%). Four participants (1.5%, 95% CI 0.4-3.9%) had an adverse event, none of which was serious or related to pharmacist dispensing. In the day 2 survey, 91.3% (95% CI 87.1-94.4%) of participants reported satisfaction with the pharmacy experience. In the day 14 survey, 84.4% (95% CI 79.1-88.8%) reported satisfaction with the medication abortion experience. Those reporting being very satisfied with the pharmacy experience had higher odds of reporting overall satisfaction with medication abortion (adjusted odds ratio 2.96, 95% CI 1.38-6.32).ConclusionPharmacist dispensing of mifepristone for medication abortion is effective and acceptable to patients, with a low prevalence of adverse events.Clinical trial registrationClinicalTrials.gov, NCT03320057.

BACKGROUND: In August 2017, Chile lifted its complete ban on abortion by permitting abortion in three limited circumstances: 1) to save a womans life, 2) lethal fetal anomaly, and 3) rape. The new law allows regulated use of conscientious objection (CO) in abortion care, including allowing institutions to register as objectors. This study assesses medical and midwifery students support for CO, following legal reform. METHODS: From October 2017 to May 2018, we surveyed medical and midwifery students from seven universities located in Santiago, Chile. Universities included 4 secular (2 public and 2 private) and 3 private religiously-affiliated universities; all offering medical degrees with a specialization in obstetrics and gynecology (ob-gyn) and five offering midwifery degrees. We used generalized estimating equations (GEE) to identify characteristics associated with student support for CO, intentions to use CO to refuse to care for someone seeking abortion, and support for CO at the institutional level. RESULTS: 333 of the 413 eligible students who opened the survey, completed the questions on conscientious objection; 26% were seeking medical degrees with an ob-gyn specialty, 25% were seeking midwifery degrees, and 49% were seeking medical degrees and had not yet decided their specialty. While nearly all endorse requirements for conscientious objecting clinicians to inform (92%) and refer (91%) abortion-seeking patients, a minority (18%) would personally use conscientious objection to avoid caring for a patient seeking abortion (12% secular and 39% religious university students). About half of religious-university students (52%) and one-fifth of secular-university (20%) students support objections at the institutional level. CONCLUSIONS: Most students support the regulated use of CO which preserves patients access to abortion care. Religious-university student views on the use of conscientious objection in abortion care are discordant with those of their institutions which currently support institutional-level objections.

OBJECTIVE:To prospectively assess perceptions of abortion stigma after receiving or being denied an abortion over 5 years, the factors associated with perceived abortion stigma, and the effects of perceived abortion stigma on psychological well-being. METHODS:We recruited people seeking abortion from 30 facilities across the US, and interviewed them by phone one week post-abortion seeking, then semiannually for 5 years. We used adjusted mixed effects regression analyses to examine the abortion stigma trajectories of those who obtained an abortion near a facility's gestational age limit (Near-limits) compared to those denied an abortion because they were just over the limit and carried their pregnancies to term (Turnaway-births). RESULTS:Of the 956 people recruited, we removed 28 due to ineligibility or missing data, leaving a final sample of 928. In unadjusted analyses, at one-week post-abortion seeking, over half of those seeking abortion perceived that if others knew they had sought an abortion, they would be looked down upon at least "a little bit" by people close to them (60%) or by people in their community (56%). In longitudinal adjusted analyses, people denied an abortion and who carried their pregnancies to term (Turnaway-birth group) reported significantly lower baseline perceived abortion stigma from people close to them (-0.38; 95% CI, -0.59, -0.16) and from people in their community (0.30; 95% CI, -0.52, -0.08), than Near-limits, differences that remained statistically significant for 1.5 years. Overall perceived abortion stigma declined significantly (p < .001) for both study groups. High perceived abortion stigma at baseline was associated with higher odds of experiencing psychological distress years later (adjusted Odds Ratio, 3.98; 95% CI, 1.39, 11.37). CONCLUSIONS:Most people considering abortion perceive some abortion stigma, which is associated with psychological distress years later.

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.

BACKGROUND:The recent focus on increasing access to long-acting reversible contraceptive methods has often overlooked the diverse reasons why women may choose less effective methods even when significant access barriers have been removed. While the copper intrauterine device (IUD) is considered an acceptable alternative to emergency contraception pills (ECPs), it is unclear to what extent low rates of provision and use are due to patient preferences versus structural access barriers. This study explores factors that influence patients' choice between ECPs and the copper IUD as EC, including prior experiences with contraception and attitudes toward EC methods, in settings where both options are available at no cost. METHODS:We telephone-interviewed 17 patients seeking EC from three San Francisco Bay Area youth-serving clinics that offered the IUD as EC and ECPs as standard practice, regarding their experiences choosing an EC method. We thematically coded all interview transcripts, then summarized the themes related to reasons for choosing ECPs or the IUD as EC. RESULTS:Ten participants left their EC visit with ECPs and seven with the IUD as EC option. Women chose ECPs because they were familiar and easily accessible. Reasons for not adopting the copper IUD included having had prior negative experiences with the IUD, concerns about its side effects and the placement procedure, and lack of awareness about the copper IUD. Women who chose the IUD as EC did so primarily because of its long-term efficacy, invisibility, lack of hormones, longer window of post-coital utility, and a desire to not rely on ECPs. Women who chose the IUD as EC had not had prior negative experiences with the IUD, had already been interested in the IUD, and were ready and able to have it placed that day. CONCLUSIONS:This study highlights that women have varied and well-considered reasons for choosing each EC method. Both ECPs and the copper IUD are important and acceptable EC options, each with their own features offering benefits to patients. Efforts to destigmatize repeated use of ECPs and validate women's choice of either EC method are needed to support women in their EC method decision-making.

OBJECTIVE:To assess Chilean medical and midwifery students' attitudes and willingness to become trained to provide abortion care, shortly after abortion was decriminalised in 2017. DESIGN:We fielded a cross-sectional, web-based survey of medical and midwifery students. We used generalised estimating equations to assess differences by type of university and degree sought. SETTING:We recruited students from a combination of seven secular, religiously-affiliated, public and private universities that offer midwifery or medical degrees with a specialisation in obstetrics and gynaecology, located in Santiago, Chile. PARTICIPANTS:Students seeking medical or midwifery degrees at one of seven universities were eligible to participate. We distributed the survey link to medical and midwifery students at these seven universities; 459 eligible students opened the survey link and 377 students completed the survey. PRIMARY AND SECONDARY OUTCOMES:Intentions to become trained to provide abortion services was our primary outcome of interest. Secondary outcomes included moral views and concerns about abortion provision. RESULTS:Most students intend to become trained to provide abortion services (69%), 20% reported that they will not provide an abortion under any circumstance, half (50%) had one or more concern about abortion provision and 16% agreed/strongly agreed that providing abortions is morally wrong. Most believed that their university should train medical and midwifery students to provide abortion services (70%-79%). Secular university students reported higher intentions to provide abortion services (beta 0.47, 95% CI: 0.31 to 0.63), more favourable views (beta 0.52, CI: 0.32 to 0.72) and were less likley to report concerns about abortion provision (adjusted OR 0.47, CI: 0.23 to 0.95) than students from religious universities. CONCLUSION:Medical and midwifery students are interested in becoming trained to provide abortion services and believe their university should provide this training. Integrating high-quality training in abortion care into medical and midwifery programmes will be critical to ensuring that women receive timely, non-judgemental and quality abortion care.

U.S. public attitudes toward abortion have been studied extensively, but little is known about these attitudes among women who seek abortion. This mixed-methods study explores women's attitudes about abortion after receiving or being denied an abortion. Data are from the Turnaway Study, a prospective, longitudinal study of women seeking abortions at 30 U.S. facilities. Participants presented just before a facility's gestational limit and received abortions, or just beyond the limit and were denied abortions. Using mixed effects logistic regression, we assessed 812 participants' attitudes about abortion over four years. At five years after abortion-seeking, we conducted in-depth interviews with 31 participants; this analysis includes the comments of 19 participants who discussed their abortion attitudes in those interviews. We find that six months after abortion-seeking, nearly all women supported abortion legality in all (80%) or some (18%) situations, yet 20% also believed abortion is morally wrong. Women denied an abortion were significantly less likely to support the legal right to abortion at six months (62%) and 4.5 years (77%) after abortion-seeking than women who had received a near-limit abortion (78% and 88%, respectively). In open-ended interviews, women expressed nuanced views, including reporting increased empathy for others facing an unwanted pregnancy. Women's own reproductive experiences impact their views on abortion. Distinguishing between morality and legality of abortion is critical in understanding abortion attitudes.

Key Points: Question: Is medication abortion provided using no-test eligibility screening and mailing of medications as effective as in-person care with ultrasonography and safe overall? Findings: This prospective, observational study found that medication abortion obtained following no-test telehealth screening and mailing of medications was associated with similar rates of complete abortion compared with in-person care with ultrasonography (94.4% vs 93.3%, respectively) and met the 5% noninferiority margin, with a low prevalence of adverse events. Meaning: The findings suggest that models of medication abortion care that rely on no-test eligibility assessment and mailing medications to patients are an option for individuals considering medication abortion. Importance: In the US, access to medication abortion using history-based (no-test) eligibility assessment, including through telehealth and mailing of mifepristone, has grown rapidly. Additional evidence on the effectiveness and safety of these models is needed. Objective: To evaluate whether medication abortion with no-test eligibility assessment and mailing of medications is as effective as in-person care with ultrasonography and safe overall. Design, Setting, and Participants: Prospective, observational study with noninferiority analysis. Sites included 4 abortion-providing organizations in Colorado, Illinois, Maryland, Minnesota, Virginia, and Washington from May 2021 to March 2023. Eligible patients were seeking medication abortion up to and including 70 days' gestation, spoke English or Spanish, and were aged 15 years or older. Exposure: Study groups reflected the model of care selected by the patient and clinicians and included: (1) no-test (telehealth) eligibility assessment and mailing of medications (no-test + mail) (n = 228); (2) no-test eligibility assessment and pickup of medications (no-test + pickup) (n = 119); or (3) in-person with ultrasonography (n = 238). Main Outcomes and Measures: Effectiveness, defined as a complete abortion without the need for repeating the mifepristone and misoprostol regimen or a follow-up procedure, and safety, defined as an abortion-related serious adverse event, including overnight hospital admission, surgery, or blood transfusion. Outcomes were derived from patient surveys and medical records. Primary analysis focused on the comparison of the no-test + mail group with the in-person with ultrasonography group. Results: The mean age of the participants (N = 585) was 27.3 years; most identified as non-Hispanic White (48.6%) or non-Hispanic Black (28.1%). Median (IQR) gestational duration was 45 days (39-53) and comparable between study groups (P =.30). Outcome data were available for 91.8% of participants. Overall effectiveness was 94.4% (95% CI, 90.7%-99.2%) in the no-test + mail group and 93.3% (95% CI, 88.3%-98.2%) in the in-person with ultrasonography group in adjusted models (adjusted risk difference, 1.2 [95% CI, −4.1 to 6.4]), meeting the prespecified 5% noninferiority margin. Serious adverse events included overnight hospitalization (n = 4), blood transfusion (n = 2), and emergency surgery (n = 1) and were reported by 1.1% (95% CI, 0.4%-2.4%) of participants, with 3 in the no-test + mail group, 3 in the in-person with ultrasonography group, and none in the no-test + pickup group. Conclusions and Relevance: This prospective, observational study found that medication abortion obtained following no-test telehealth screening and mailing of medications was associated with similar rates of complete abortion compared with in-person care with ultrasonography and met prespecified criteria for noninferiority, with a low prevalence of adverse events. This prospective, observational study investigates the efficacy and safety of medication abortion provided using no-test telehealth eligibility screening and mailing of medications compared with in-person care with ultrasonography in the US. [ABSTRACT FROM AUTHOR]

OBJECTIVE:Earlier pregnancy discovery is important in the context of prenatal and abortion care. We evaluated characteristics associated with later pregnancy discovery among women seeking abortion care. STUDY DESIGN:Data come from a survey of women seeking abortion care at four family planning facilities in Utah. The participants completed a survey during the state-mandated abortion information visit they are required to complete prior to having an abortion. The outcome in this study was pregnancy discovery before versus after 6 weeks since respondents' last menstrual period (LMP). We used logistic regression to estimate the relationship between sociodemographic and health-related independent variables of interest and pregnancy discovery before versus after 6 weeks. RESULTS:Among the 458 women in the sample, 28% discovered their pregnancy later than 6 weeks since LMP. Most (n=366, 80%) knew the exact date of their LMP and a significant minority estimated it (n=92, 20%). Those who estimated the date of their LMP had higher odds of later pregnancy discovery than those who knew the exact date (adjusted odds ratio (aOR)=1.81[1.07-3.07]). Those who used illicit drugs weekly, daily, or almost daily had higher odds of later pregnancy discovery (aOR=6.33[2.44, 16.40]). CONCLUSION:Women who did not track their menstrual periods and those who frequently used drugs had higher odds of discovering their pregnancies later. IMPLICATIONS:Women who estimated the date of their LMP and who frequently used drugs may benefit from strategies to help them recognize their pregnancies earlier and link them to care when they discover their pregnancies later.

ObjectiveResearch on effects of pregnancy termination on women's alcohol, tobacco, and other drug (ATOD) use suffers from methodological and conceptual problems. Improving on prior methodologies, this study examines changes in ATOD use over 5 years among women seeking terminations.MethodData are from the Turnaway Study, a longitudinal study of 956 women seeking terminations at 30 U.S. facilities. Participants presented just below a facility's gestational limit and received terminations (Near-Limits) or just beyond the limit and were denied terminations (Turnaways). Using mixed-effects logistic regression, we assessed differences in ATOD use over 5 years among Near-Limits and Turnaways.ResultsThere were no differences in ATOD use before pregnancy recognition; 1 week after termination seeking, Turnaways had lower odds than Near-Limits of any and heavy episodic alcohol use (p < .001), but not alcohol problem symptoms, tobacco use, or other drug use. Although both groups increased in any alcohol use over time, Turnaways increased more rapidly. Neither group increased any other ATOD measures over time. Turnaways' lower odds of heavy episodic alcohol use at 1 week after termination seeking were maintained throughout the subsequent 5 years. There was no differential change in problem alcohol use or in tobacco or other drug use over time, yet fewer Turnaways than Near-Limits reported problem alcohol symptoms 6 months through 3.5 years.ConclusionsThere is no indication that terminating a pregnancy led women to increase heavy episodic or problem alcohol use or to increase tobacco or other drug use. Women denied terminations had temporary or sustained reductions in all alcohol measures, but not tobacco or other drugs, suggesting that relationships between pregnancy/parenting and ATOD differ across substances.

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

ObjectivesTo determine the socioeconomic consequences of receipt versus denial of abortion.MethodsWomen who presented for abortion just before or after the gestational age limit of 30 abortion facilities across the United States between 2008 and 2010 were recruited and followed for 5 years via semiannual telephone interviews. Using mixed effects models, we evaluated socioeconomic outcomes for 813 women by receipt or denial of abortion care.ResultsIn analyses that adjusted for the few baseline differences, women denied abortions who gave birth had higher odds of poverty 6 months after denial (adjusted odds ratio [AOR] = 3.77; P