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BACKGROUND: Despite representing 4% of the global population, the US has the fifth highest number of intentional homicides in the world. Peripartum people represent a unique and vulnerable subset of homicide victims. This study aimed to understand the risk factors for peripartum homicide. STUDY DESIGN: We used data from the 2018 to 2020 National Violent Death Reporting System to compare homicide rates of peripartum and nonperipartum people capable of becoming pregnant (12 to 50 years of age). Peripartum was defined as currently pregnant or within 1-year postpartum. We additionally compared state-level peripartum homicide rates between states categorized as restrictive, neutral, or protective of abortion. Pearson's chi-square and Wilcoxon rank-sum tests were used. RESULTS: There were 496 peripartum compared with 8,644 nonperipartum homicide victims. The peripartum group was younger (27.4 ± 71 vs 33.0 ± 9.6, p < 0.001). Intimate partner violence causing the homicide was more common in the peripartum group (39.9% vs 26.4%, p < 0.001). Firearms were used in 63.4% of homicides among the peripartum group compared with 49.5% in the comparison (p < 0.001). A significant difference was observed in peripartum homicide between states based on policies regarding abortion access (protective 0.37, neutral 0.45, restrictive 0.64; p < 0.01); the same trend was not seen with male homicides. CONCLUSIONS: Compared with nonperipartum peers, peripartum people are at increased risk for homicide due to intimate partner violence, specifically due to firearm violence. Increasing rates of peripartum homicide occur in states with policies that are restrictive to abortion access. There is a dire need for universal screening and interventions for peripartum patients. Research and policies to reduce violence against pregnant people must also consider the important role that abortion access plays in protecting safety. [ABSTRACT FROM AUTHOR]

Young women, low-income women, and women of color make up a disproportionate share of abortion patients and experience higher rates of unintended pregnancy, maternal morbidity and mortality, and infant mortality. Furthermore, these individuals are also less likely to have access to preventive gynecologic care. Whereas lay health worker interventions have been developed to help link individuals to care in other fields, the use of such interventions to link individuals to preventive care after abortion is novel. This article describes a training protocol and curriculum that provided nonmedically trained individuals with knowledge, skills, and competency to conduct a behavioral theory–based counseling intervention to help individuals achieve self-identified goals regarding obtaining postabortion reproductive health care and contraception. When piloted with 60 patients presenting for abortion who lacked a regular health care provider and desired to delay pregnancy for at least 6 months, participants found the lay health worker skills and the counseling session highly acceptable. Specifically, participants reported feeling comfortable speaking to lay health workers about contraception and reproductive health care. These findings indicate that lay health worker interventions may present an important opportunity to help individuals address their postabortion preventive and contraceptive health care needs. [ABSTRACT FROM AUTHOR]

Introduction: Balancing the need to provide individual support for patients and the need for an efficient clinic can be challenging in the abortion setting. This study explores physician, staff, and specially trained abortion doula perspectives on doula support, one approach to patient support. Methods: We conducted separate focus groups with physicians, staff members, and doulas from a high‐volume, first‐trimester aspiration abortion clinic with a newly established volunteer abortion doula program. Focus groups explored 1) abortion doula training, 2) program implementation, 3) program benefits, and 4) opportunities for improvement. Interviews were transcribed and computer‐assisted content analysis was performed; salient findings are presented. Results: Five physicians, 5 staff members, and 4 abortion doulas participated in separate focus group discussions. Doulas drew on both their prior personal skills and experiences in addition to their abortion doula training to provide women with support at the time of abortion. Having doulas in the clinic to assist with women's emotional needs allowed physicians and staff to focus on technical aspects of the procedure. In turn, both physicians and staff believed that introducing doulas resulted in more patient‐centered care. Although staff did not experience challenges to integrating doulas, physicians and doulas experienced initial challenges in incorporating doula support into the clinical flow. Staff and doulas reported exchanging skills and techniques that they subsequently used in their interactions with patients. Discussion: Physicians, clinic staff, and doulas perceive abortion doula support as an approach to provide more patient‐centered care in a high‐volume aspiration abortion clinic. [ABSTRACT FROM AUTHOR]

Objectives To determine the prevalence and correlates of having a regular physician among women presenting for induced abortion. Methods We conducted a retrospective review of women presenting to an urban, university-based family planning clinic for abortion between January 2008 and September 2011. We conducted bivariate analyses, comparing women with and without a regular physician, and multivariable regression modeling, to identify factors associated with not having a regular physician. Results Of 834 women, 521 (62.5%) had a regular physician and 313 (37.5%) did not. Women with a prior pregnancy, live birth, or spontaneous abortion were more likely than women without these experiences to have a regular physician. Women with a prior induced abortion were not more likely than women who had never had a prior induced abortion to have a regular physician. Compared with women younger than 18 years, women aged 18 to 26 years were less likely to have a physician (adjusted odds ratio [aOR], 0.25; 95% confidence interval [CI], 0.10–0.62). Women with a prior live birth had increased odds of having a regular physician compared with women without a prior pregnancy (aOR, 1.89; 95% CI, 1.13–3.16). Women without medical/fetal indications and who had not been victims of sexual assault (self-indicated) were less likely to report having a regular physician compared with women with medical/fetal indications (aOR, 0.55; 95% CI, 0.17–0.82). Conclusions The abortion visit is a point of contact with a large number of women without a regular physician and therefore provides an opportunity to integrate women into health care. [ABSTRACT FROM AUTHOR]

Objective To understand women's experiences communicating with their regular gynecologic care provider about abortion decision making before obtaining an abortion at a dedicated abortion clinic. Study Design Semistructured interviews were conducted with women presenting for first-trimester surgical abortion at a high-volume, hospital-based abortion clinic. Women were asked whether and why they did or did not discuss their abortion decision with their gynecologic care provider. Interviews were transcribed and computer-assisted content analysis was performed; salient themes are presented. Results Thirty women who obtained an abortion were interviewed. A majority of the 24 women who had a regular gynecologic care provider did not discuss their decision with that provider. Themes associated with not discussing their decision included: 1) perceiving that the discussion would not be beneficial, 2) expecting that gynecologic care providers do not perform abortions, 3) anticipating or experiencing logistical barriers, and 4) worrying about disrupting the patient–provider relationship. Women who did discuss their decision primarily did so because the pregnancy was diagnosed at the time of a previously scheduled appointment and generally did not believe that their provider performed abortions. Conclusion For many women, seeking counsel from a regular gynecologic provider before seeking an abortion may not afford a significant benefit. However, some women express concerns with regard to seeking abortion counselling from their regular provider. These concerns underscore the need for gynecologic providers to foster patient–provider relationships that allow women to feel comfortable discussing all aspects of their reproductive health. [ABSTRACT FROM AUTHOR]

Objective: To explore how doula support influences women's experiences with first-trimester surgical abortion.Study Design: We conducted semistructured interviews with women given the option to receive doula support during first-trimester surgical abortion in a clinic that uses local anesthesia and does not routinely allow support people to be present during procedures. Dimensions explored included (a) reasons women did or did not choose doula support; (b) key aspects of the doula interaction; and (c) future directions for doula support in abortion care. Interviews were transcribed, and computer-assisted content analysis was performed; salient themes are presented.Results: Thirty women were interviewed: 19 received and 11 did not receive doula support. Reasons to accept doula support included (a) wanting companionship during the procedure and (b) being concerned about the procedure. Reasons to decline doula support included (a) a sense of stoicism and desiring privacy or (b) not wanting to add emotion to this event. Women who received doula support universally reported positive experiences with the verbal and physical techniques used by doulas during the procedure, and most women who declined doula support subsequently regretted not having a doula. Many women endorsed additional roles for doulas in abortion care, including addressing informational and emotional needs before and after the procedure.Conclusion: Women receiving first-trimester surgical abortion in this setting value doula support at the time of the procedure. This intervention has the potential to be further developed to help women address pre- and postabortion informational and emotional needs.Implications: In a setting that does not allow family or friends to be present during the abortion procedure, women highly valued the presence of trained abortion doulas. This study speaks to the importance of providing support to women during abortion care. Developing a volunteer doula service is one approach to addressing this need, especially in clinics that otherwise do not permit support people in the procedure room or for women who do not have a support person and desire one. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To evaluate the relationship between duration of labor during second-trimester medication abortion and adverse outcomes. METHODS: We conducted a retrospective cohort study including all individuals with a singleton gestation undergoing second-trimester medication abortion without evidence of advanced cervical dilation, rupture of membranes, or preterm labor at four centers. The primary exposure was duration of labor (ie, hours spent from receiving misoprostol to fetal expulsion). The primary outcome was composite morbidity, defined as uterine rupture, need for blood transfusion, clinical chorioamnionitis, intensive care unit admission, or need for readmission. We performed bivariate and multivariate negative binomial analyses. A post hoc subgroup analysis was performed to assess for the risk of the primary outcome by gestational age. We performed tests of homogeneity based on history of uterine scarring and parity. RESULTS: Six hundred eighty-one individuals were included. The median duration of labor was 11 hours (interquartile range 8-17 hours). One hundred thirty-one (19.2%) experienced the primary outcome. When duration of labor was evaluated continuously, a longer duration of labor was associated with an increased frequency of morbidity (adjusted b50.68, 95% CI, 0.32-1.04). When duration of labor was evaluated categorically, those experiencing the highest quartile of duration (ie, 17 hours or more) had a statistically higher risk for experiencing morbidity compared with individuals in all other quartiles (adjusted relative risk 1.99, 95% CI, 1.34-2.96). When we focused on components of the composite outcome, clinical chorioamnionitis was significantly different between those experiencing a longer duration and those experiencing a shorter duration of labor (26.2% vs 10.6%, P,.001). On subgroup analysis, gestational age was not associated with the risk of composite morbidity. Tests of homogeneity demonstrated no significant difference in the risk for morbidity among individuals with a history of uterine scarring or based on parity. CONCLUSION: Duration of labor was independently associated with risks for adverse maternal outcomes during second-trimester medication abortion, specifically clinical chorioamnionitis. [ABSTRACT FROM AUTHOR]

Although obtaining specific consent for examinations under anesthesia with learners is recommended by major professional organizations and mandated by many state laws and institutions, it is not practiced universally. We sought to investigate physicians' experiences using a formalized process to obtain consent from patients presenting for surgical abortions under anesthesia for pelvic examinations with learners. Semistructured qualitative interviews were conducted with residents, fellows, and faculty who work or have rotated in a single family planning clinic after the clinic introduced this consent process. Participants were asked about their experiences obtaining informed consent from patients for examinations under anesthesia with learners. Interviews were audiorecorded, transcribed, and analyzed using modified grounded theory. All study procedures were institutional review board approved. Twenty interviews were performed, achieving thematic saturation, with 14 residents, 4 fellows, and 2 faculty members. Participants described initial discomfort with the consent process and their wording choices, which improved with increased familiarity and almost universal patient acceptance. Some participants felt that an informal training or practice before obtaining informed consent may have been helpful. Participants stressed the importance of this consent process to foster patient autonomy and choice. Participants reported that the fact that patients were presenting for abortion care did not influence their overall process or comfort level obtaining consent for pelvic examinations under anesthesia with learners; however, some noted that they gave patients more time to process the consent or used more intentional language during these encounters. Physicians desire and accept the integration of a formal consent process for examinations under anesthesia with learners at the time of abortion. [ABSTRACT FROM AUTHOR]

Objective The objective of the study was to evaluate the impact of doula support on first-trimester abortion care. Study Design Women were randomized to receive doula support or routine care during first-trimester surgical abortion. We examined the effect of doula support on pain during abortion using a 100 mm visual analog scale. The study had the statistical power to detect a 20% difference in mean pain scores. Secondary measures included satisfaction, procedure duration, and patient recommendations regarding doula support. Results Two hundred fourteen women completed the study: 106 received doula support, and 108 received routine care. The groups did not differ regarding demographics, gestational age, or medical history. Pain scores in the doula and control groups did not differ at speculum insertion (38.6 [±26.3 mm] vs 43.6 mm [±25.9 mm], P = .18) or procedure completion (68.2 [±28.0 mm] vs 70.6 mm [±23.5 mm], P = .52). Procedure duration (3.39 [±2.83 min] vs 3.18 min [±2.36 min], P = .55) and patient satisfaction (75.2 [±28.6 mm] vs 74.6 mm [±27.4 mm], P = .89) did not differ between the doula and control groups. Among women who received doula support, 96.2% recommended routine doula support for abortion and 60.4% indicated interest in training as doulas. Among women who did not receive doula support, 71.6% of women would have wanted it. Additional clinical staff was needed to provide support for 2.9% of women in the doula group and 14.7% of controls ( P < .01). Conclusion Although doula support did not have a measurable effect on pain or satisfaction, women overwhelmingly recommended it for routine care. Women receiving doula support were less likely to require additional clinic support resources. Doula support therefore may address patient psychosocial needs. [ABSTRACT FROM AUTHOR]

Since abortion became legal nationwide, federal and state "conscience clauses" have been established to define the context in which health professionals may decline to participate in contested services. Patients and health care providers may act according to conscience in making health care decisions and in deciding whether to abstain from or to participate in contested services. Historically, however, conscience clauses largely have equated conscience in health care with provider abstinence from such services. We propose a framework to analyze the ethical implications of conscience laws. There is a rich literature on the exercise of conscience in the clinical encounter. This essay addresses the need to ensure that policy, too, is grounded in an ethical framework. We argue that the ideal law meets three standards: it protects patients' exercise of conscience, it safeguards health care providers' rights of conscience, and it does not contradict standards of ethical conduct established by professional societies. We have chosen Illinois as a test of our framework because it has one of the nation's broadest conscience clauses and because an amendment to ensure that women receive consistent access to contested services has just passed in the state legislature. Without such an amendment, Illinois law fails all three standards of our framework. If signed by the governor, the amended law will provide protections for patients' positive claims of conscience. We recommend further protections for providers' positive claims as well. Enacting such changes would offer a model for how ethics-based analysis could be applied to similar policies nationwide. [ABSTRACT FROM AUTHOR]

This study aimed to assess the prevalence of and factors correlated with accepting a pelvic examination under anesthesia (EUA) by learners at the time of surgical abortion. Retrospective chart review assessing the prevalence of and comparing factors associated with accepting EUA by learners at the time of abortion. Most (88%) of the 274 patients accepted EUA by learners. Declining was associated with prior intimate partner violence. Most patients accept EUA by learners at the time of abortion. In adhering to fundamental principles of medical ethics, professional guidelines, and legal mandates, consent prior to pelvic EUA by learners should be obtained universally. [ABSTRACT FROM AUTHOR]

Objectives We sought to compare the effectiveness of at least 1 h of 400 mcg of buccal misoprostol to overnight osmotic dilators for early second-trimester surgical abortion cervical preparation. Design We conducted a retrospective cohort study, reviewing 145 consecutive charts to compare procedure duration for women who received 400 mcg of buccal misoprostol at least 1 h preprocedure vs. overnight osmotic dilators before dilation and evacuation between 14 weeks, 0 days and 15 weeks, 6 days' gestation. Primary outcome was procedure duration and secondary outcomes included maximum mechanical dilator size, estimated blood loss and side effects. Results Sixty-four women (44.1%) received buccal misoprostol (mean 1.6 h), and 81 women (55.9%) received overnight osmotic dilators. Groups did not differ regarding mean gestational age or gynecologic history. All procedures in both groups were completed. Procedure duration was not significantly different between the misoprostol and osmotic dilator groups (median 11.0 min vs. 10.0 min, p=.22), even after multivariable linear regression (p=.17). The mean total cervical preparation duration was 1.6 h for women in the misoprostol group compared to 20.3 h in the osmotic dilator group (p<.001). Secondary outcomes did not differ between groups. Conclusions We found that at least 1 h of preprocedure misoprostol decreased the duration of cervical preparation for early second-trimester procedures performed by an experienced surgeon. Implications In this small, retrospective review, at least 1 h of preprocedure buccal misoprostol decreased the duration from cervical preparation initiation to procedure completion in early second-trimester procedures performed by an experienced surgeon. These results should be considered as a pilot evaluation, and further prospective study is needed to further clarify whether this short interval could be applied in general practice. [ABSTRACT FROM AUTHOR]