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People's ability to use their desired contraception is necessary for reproductive autonomy. We conducted longitudinal in-depth interviews over two years with 34 women in Iowa who sought contraceptive and related care at publicly supported sites in 2018/2019 to understand how state-level shifts in funding for these services affected their access to contraception. Twenty-seven of 34 respondents faced cost, access, and quality barriers relevant to policy and health care contexts, and we assessed the overall level of impact of these on access to preferred contraception over the study period. Cost barriers such as high fees for visits and methods as well as restrictive or inadequate insurance coverage, and access barriers such as long appointment wait times were most common; barriers compounded one another. Policies that support funding for contraceptive care, and that limit the need to interact with health systems for routine care, can decrease vulnerability to barriers and increase reproductive autonomy.

Public funding plays a key role in reducing cost barriers to sexual and reproductive health (SRH) care in the United States. In this analysis, we examine sociodemographic and healthcare seeking profiles of individuals in three states where public funding for health services has recently changed: Arizona, Iowa, and Wisconsin. In addition, we examine associations between individuals’ health insurance status and whether they experienced delays or had trouble in obtaining their preferred contraception. This descriptive study draws on data collected between 2018 to 2021 in two distinct cross-sectional surveys in each state, one among a representative sample of female residents aged 18–44 and the other among a representative sample of female patients ages eighteen and older seeking family planning services at healthcare sites that receive public funding to deliver this care. The majority of reproductive-aged women and female family planning patients across states reported having a personal healthcare provider, had received at least one SRH service in the preceding 12 months, and were using a method of birth control. Between 49–81% across groups reported receiving recent person-centered contraceptive care. At least one-fifth of each group reported wanting healthcare in the past year but not getting it, and between 10–19% reported a delay or trouble getting birth control in the past 12 months. Common reasons for these outcomes involved cost and insurance-related issues, as well as logistical ones. Among all populations except Wisconsin family planning clinic patients, those with no health insurance had greater odds of being delayed or having trouble getting desired birth control in the past 12 months than those with health insurance. These data serve as a baseline to monitor access and use of SRH services in Arizona, Wisconsin, Iowa in the wake of drastic family planning funding shifts that changed the availability and capacity of the family planning service infrastructure across the country. Continuing to monitor these SRH metrics is critical to understand the potential effect of current political shifts.

Objective: To identify prevalence of, characteristics associated with, and combinations of, use of more than one method of contraception at last intercourse among US women between 2008 and 2015. Methods: We conducted bivariate and multivariable logistic regression analyses using data on concurrent contraceptive use from 2 nationally representative samples of women ages 15 to 44 who had used some form of contraception at last intercourse in the past 3 months in the 2006–2010 (n = 6601) and 2013–2017 (n = 5562) cycles of the National Survey of Family Growth. Results: Use of more than one method of contraception at last sex increased from 14% in 2008 to 18% in 2015 (p

Objective To examine current levels, correlates of, and changes in contraceptive use among reproductive-age women in the United States between 2014 and 2016. Design We conducted simple and multivariable logistic regression analyses to identify associations between user characteristics and contraceptive use, with specific attention to methods requiring a visit to a health care provider. Setting Not applicable. Patient(s) All self-identified female respondents to the surveys. Secondary analysis of two rounds of the National Survey of Family Growth, an in-home, nationally representative survey of people ages 15–44 years (2013–2015) and 15–49 years (2015–2017). Intervention(s) None. Main Outcome Measure(s) Current use of a contraceptive method, including use of individual methods and grouped method use in 2016, and change in use from 2014. Result(s) Contraceptive use remained steady between 2014 and 2016 among sexually active females not seeking pregnancy (88%). Among users, use of long-acting reversible contraceptive (LARC) methods increased from 14% to 18%, as use of short-acting reversible contraceptive (SARC) methods fell from 32% to 28%. Implant use among 15- to 19-year-olds rose from 6% to 16% and represents one of the largest increases observed. Access to sexual and reproductive health care was strongly associated with use of all LARC and SARC methods except for the implant (adjusted odds ratios ranged from 3.21 to 13.53). Conclusion(s) Contraceptive users are shifting primarily among the most and moderately effective method groups, and not from contraceptive nonuse to use. Reductions in access to sexual and reproductive health care could have implications for individuals’ ability to use their preferred contraceptive methods., Highlights • Contraceptive use in the United States remained steady between 2014 and 2016. • Increases in use of long-acting reversible contraceptive methods paralleled a decrease in use of short-acting reversible contraceptive methods. • Contraceptive users are shifting primarily among the most and moderately effective method groups and not from contraceptive nonuse to use. • Access to sexual and reproductive health care is strongly associated with use of most long- and short-acting reversible contraception.

Context As federal initiatives aim to fundamentally alter or dismantle the Affordable Care Act (ACA), evidence regarding the use of insurance among clients obtaining contraceptive care at Title X-funded facilities under ACA guidelines is essential to understanding what is at stake. Methods A nationally representative sample of 2,911 clients seeking contraceptive care at 43 Title X-funded sites in 2016 completed a survey assessing their characteristics and insurance coverage and use. Chi-square tests for independence with adjustments for the sampling design were conducted to determine differences in insurance coverage and use across demographic characteristics and facility types. Results Most clients (71%) had some form of public or private health insurance, and most of these (83%) planned to use it to pay for their services. Foreign-born clients were less likely than U.S.-born clients to have coverage (46% vs. 75%) and to use it (78% vs. 85%). Clients with private insurance were less likely than those with public insurance to plan to use their insurance (75% vs. 91%). More than one-quarter of clients not planning to use existing insurance for services indicated that the reason was that someone might find out. Conclusion Coverage gaps persist among individuals seeking contraceptive care within the Title X network, despite evidence indicating increases in health insurance coverage among this population since implementation of the ACA. Future research should explore the impact of altering or eliminating the ACA both on the Title X provider network and on the individuals who rely on it.

Scientific Abstracts These scientific abstracts are scheduled for presentation at the 2021 Society of Family Planning Annual Meeting. This year, 225 abstracts were submitted for consideration, of which 12 were selected for oral presentation and 84 were selected for poster presentation. The scientific abstract review was completed by the scientific reviewers and selectors

Objective The objective was to examine levels of, correlates of and changes in the use of individual and grouped methods of contraception among US females aged 15–44 from 2008 to 2014. Study design Using three rounds of the National Survey of Family Growth, we analyzed samples of 12,279 (2008), 5601 (2012) and 5699 (2014) females. We conducted simple and multivariable logistic regression analyses to identify associations between demographic characteristics and contraceptive use, as well as between characteristics and changes in use patterns. Results In terms of overall trends in contraceptive use between 2008 and 2014, there was no significant change in the proportion of women who used a method among either all women (60%) or those at risk of unintended pregnancy (90%). Significant changes in use occurred among six methods. The largest increase in use was among users of long-acting reversible contraceptive (LARC) methods, including the intrauterine device and implant — from 6% to 14% — across almost all population groups of female contraceptive users, while the largest decrease occurred among users of sterilization — from 37% to 28% — with lower-income women driving the decline in female sterilization and higher-income women driving the decline in a partner's sterilization as a primary method. Moderate increases were seen in the use of withdrawal and natural family planning. Conclusion Most shifts in recent contraceptive use have occurred among the most effective methods — sterilization and LARCs. Differences in method-specific user characteristics underscore the importance of ensuring full access to the broad range of methods available. Implications The lack of change in the overall use of contraceptives among women at risk for unintended pregnancy may have implications for the extent to which further declines in national rates of unintended pregnancy can be expected.

CONTEXT Abortion availability and accessibility vary by state. Especially in areas where services are restricted or limited, some women travel to obtain abortion services in other states. Little is known about the experience of travel to obtain abortion. METHODS In January and February 2015, in-depth interviews were conducted with 29 patients seeking abortion services at six facilities in Michigan and New Mexico. Eligible women were 18 or older, spoke English, and had traveled either across state lines or more than 100 miles within the state. Respondents were asked to describe their experience from pregnancy discovery to the day of the abortion procedure. Barriers to accessing abortion care and consequences of these barriers were identified through inductive and deductive analysis. RESULTS Respondents described 15 barriers to abortion care while traveling to obtain services, and three major consequences of experiencing those barriers. Barriers were grouped into five categories: travel-related logistical issues, system navigation issues, limited clinic options, financial issues, and state or clinic restrictions. Consequences were delays in care, negative mental health impacts and considering self-induction. The experience of barriers complicated the process of obtaining an abortion, but the effect of any individual barrier was unclear. Instead, the experience of multiple barriers appeared to have a compounding effect, resulting in negative consequences for women traveling for abortion. CONCLUSION The amalgamation of barriers to abortion care experienced simultaneously can have significant consequences for patients.

Births resulting from an unintended pregnancy affect individuals differentially, and some may experience more negative consequences than others. In this study, we sought to describe the mechanisms through which the severity of effects may be mitigated or exacerbated. We conducted in-depth interviews with 35 women and 30 men, all with a youngest child born resulting from an unintended pregnancy, in two urban sites in the United States. Respondents described both negative and positive effects of the child's birth in the areas of school; work and finances; partner relationships; personal health and outlook on life trajectories. Mechanisms through which unintended pregnancies mitigated or exacerbated certain effects fell at the individual (e.g. lifestyle modification), interpersonal (e.g. partner support) and structural (e.g. workplace flexibility) levels. These qualitative findings deepen understanding of the impact of unintended childbearing on the lives of women, men and families.

Objective Many patients may wish to receive contraceptive counseling and services during an abortion visit, but a 2009 study documented challenges faced by abortion clinics, especially independent ones, in providing contraceptive care. Since then, the Affordable Care Act (ACA) has made contraception more accessible by expanding coverage to millions of individuals and by eliminating out of pocket costs. This paper aims to update this previous work and describe recent challenges in providing contraceptive care in independent abortion settings following the ACA, as well as the strategies used to address these challenges. Methods We conducted two focus groups and 19 semi-structured interviews with clinic administrators and directors at independent abortion clinics. Results Challenges to providing contraceptive care in independent abortion clinics included navigating new guidelines under the Affordable Care Act for establishing coverage agreements with health insurance plans and receiving timely and sufficient reimbursement for services provided. Study respondents described strategies related to adjusting clinic flow and protocols to address patient needs regarding receiving contraception during abortion care. Conclusion Staff working in independent abortion clinics in the United States experience a tension between trying to provide holistic, patient-centered care – including contraceptive care – and navigating restrictive political and healthcare contexts for the delivery of abortion care.

Intrauterine devices (IUDs) are one of the most effective forms of reversible contraception and can reduce unintended pregnancy rates. We explored practice characteristics associated with IUD services across a network of primary care practices in New York City during 2010-2013.Data were extracted from electronic health records (EHRs) for 253 primary care practices participating in an EHR quality improvement program in New York City. We used diagnostic and procedure codes to count IUD insertions and removals among females aged 10-49 years during 2010-2013. Logistic regression models predicted the likelihood of IUD insertion, removal or no activity for 2013, based on practice characteristics. We stratified trends in IUD services over time by practice type and specialty.From 2010 to 2013, the proportion of practices that inserted IUDs increased slightly from 4.7% to 6.3% (p=0.17), and the proportion removing IUDs increased from 8.3% to 12.3% (p0.01). More than 60% of obstetricians/gynecologists and midwives performed insertions or removals each year; fewer than 10% of internal medicine and pediatric providers did so. Community health centers had higher odds of performing removals than independent practices (adjusted odds ratio=10.24, 95% confidence interval: 3.37-31.17). Practices seeing66% female patients had higher odds of performing both insertions and removals.From 2010 to 2013, IUD services increased but remained low among primary care practices in this network. Provider training and system readiness programs should include independent primary care practices, which rarely provide IUDs, to ensure that women can receive IUDs or IUD service referrals in the primary care setting.Much of primary care in the United States takes place in independent practices with one or two providers. Our study of a major urban area found that these types of practices are much less likely to offer IUD services than community health centers. Ensuring that small practices know where to refer women for IUD insertion and removal services is warranted to ensure women's access to IUDs.

Background The Affordable Care Act (ACA) requires that privately insured women can obtain contraceptive services and supplies without cost sharing. This may substantially affect women who prefer an intrauterine device (IUD), a long-acting reversible contraceptive, because of high upfront costs that they would otherwise face. However, imperfect enforcement of and exceptions to this provision could limit its effect. Study design We analyzed administrative data for 417,221 women whose physicians queried their insurance plans from January 2012 to March 2014 to determine whether each woman had insurance coverage for a hormonal IUD and the extent of that coverage. Results In January 2012, 58% of women would have incurred out-of-pocket costs for an IUD, compared to only 13% of women in March 2014. Differentials by age and region virtually dissolved over the period studied, which suggests that the ACA reduced inequality among insured women. Conclusions Our findings suggest that the cost of hormonal IUDs fell to US$0 for most insured women following the implementation of the ACA. Implications Financial barriers to one of the most effective methods of contraception fell substantially following the ACA. If more women interested in this method can access it, this may contribute to a decline in unintended pregnancies in the United States.

Objective: To examine associations between health insurance coverage, income level and contraceptive use — overall and most/moderately effective method use — among women ages 18–44 at risk of pregnancy, within and across 41 United States jurisdictions in 2017. Study design: Using data from the 2017 Behavioral Risk Factor Surveillance System, we calculated the proportions of women using any contraceptive method and using a most or moderately effective method for each state/territory and across all jurisdictions, categorized by health insurance coverage and income groups. For both contraceptive use outcomes, we ran simple and multivariable logistic regression models to test for significant differences in outcomes between insured and uninsured individuals. Results: Across jurisdictions, compared to uninsured women, those who had health care coverage had higher levels of contraceptive use (65% versus 59%; p

Objective For individuals traveling significant distances for time-sensitive abortion care, accurate information about service options and locations is critical, but little is known regarding information barriers that individuals may encounter and strategies for circumventing these barriers. Study design In early 2015, we conducted in-depth interviews with 29 patients who had traveled for abortion care at six facilities in Michigan and New Mexico. We identified information-related barriers that respondents encountered in understanding their pregnancy options and/or where to obtain an abortion between the time of pregnancy discovery, including any contact with a crisis pregnancy center, to the day of the abortion procedure through inductive and deductive analysis. Results We identified two logistical information-related barriers — a general lack of reproductive-related knowledge and unhelpfulness on the part of perceived members of the healthcare community — and one broader barrier of perceived stigma within respondents' narratives. Of the seven respondents who did not encounter a logistical information-related barrier, having previous personal or close experience with abortion and internet savviness were both identified as strategies enabling them to circumvent the barriers. Conclusion Lack of clear, easy-to-find and accurate information about abortion services and availability represents a key barrier to obtaining an abortion; health care providers play a crucial role in ensuring pregnant patients' right to informed consent within reproductive health care delivery. Implications Women's health care providers should provide their patients with the full spectrum of resources and referrals for pregnancy and abortion care; recent federal guidelines proposing to restrict abortion counseling and referral at Title X-funded facilities would only exacerbate the current challenges that pregnant patients encounter when seeking abortion-related information and further decrease linkages to timely, desired abortion care.

OBJECTIVE: To examine current levels, current correlates of, and changes in long-acting reversible contraceptive (LARC) use, including intrauterine devices and implants, among females aged 15–44 years using contraception between 2008–2010 and 2011–2013 with specific attention to associations between race, income, and age and their LARC use. METHODS: We analyzed data from two rounds of the National Survey of Family Growth, nationally representative samples of females aged 15–44 years, consisting of 6,428 females in 2008–2010 and 5,601 females in 2011–2013. We conducted simple and multivariable logistic regression analyses with adjustments for the sampling design to identify demographic characteristics predictive of LARC use and changes in these patterns between the two time periods. In this cross-sectional, descriptive study, our primary outcome of interest was current prevalence of LARC use among all contraceptive users at the time of the interview. RESULTS: The prevalence of LARC use among contracepting U.S. females increased from 8.5% in 2009 to 11.6% in 2012 (P,.01). The most significant increases occurred among Hispanic females (from 8.5% to 15.1%), those with private insurance (7.1–11.1%), those with fewer than two sexual partners in the previous year (9.2–12.4%), and those who were nulliparous (2.1–5.9%) (all P,.01). In multivariable analyses adjusting for key demographic characteristics, the strongest associations with LARC use in 2012 were parity (adjusted odds ratios [ORs] 4.3–5.5) and having a history of stopping non-LARC hormonal use (adjusted OR 1.9). Women aged 35–44 years (adjusted OR 0.3) were less likely to be LARC users than their counterparts (all P,.001). Poverty status was not associated with LARC use. There were no differences in discontinuation of LARC methods resulting from dissatisfaction between minority women and nonHispanic white women. CONCLUSION: During the most recent time period surveyed, use of LARC methods, particularly intrauterine devices, increased almost uniformly across the population of users.

CONTEXT As federal initiatives aim to fundamentally alter or dismantle the Affordable Care Act (ACA), evidence regarding the use of insurance among clients obtaining contraceptive care at Title X–funded facilities under ACA guidelines is essential to understanding what is at stake. METHODS A nationally representative sample of 2,911 clients seeking contraceptive care at 43 Title X–funded sites in 2016 completed a survey assessing their characteristics and insurance coverage and use. Chi‐square tests for independence with adjustments for the sampling design were conducted to determine differences in insurance coverage and use across demographic characteristics and facility types. RESULTS Most clients (71%) had some form of public or private health insurance, and most of these (83%) planned to use it to pay for their services. Foreign‐born clients were less likely than U.S.‐born clients to have coverage (46% vs. 75%) and to use it (78% vs. 85%). Clients with private insurance were less likely than those with public insurance to plan to use their insurance (75% vs. 91%). More than one‐quarter of clients not planning to use existing insurance for services indicated that the reason was that someone might find out. CONCLUSION Coverage gaps persist among individuals seeking contraceptive care within the Title X network, despite evidence indicating increases in health insurance coverage among this population since implementation of the ACA. Future research should explore the impact of altering or eliminating the ACA both on the Title X provider network and on the individuals who rely on it.

Introduction Given the recent reforms in the United States health care system, including the passage and implementation of the Affordable Care Act, as well as anticipated upcoming changes to health care coverage, it is critical that publicly funded health care providers understand how to effectively work with their states' Medicaid programs and the private health insurance plans in their service areas to provide high-quality contraceptive care to the millions of women relying on services at these sites annually. Methods We collected survey data from a nationally representative sample of 535 clinics providing family planning services that received Title X funding and conducted semistructured interviews with 23 administrators at a subsample of surveyed clinics to explore provider-reported experiences working with health plans and to identify barriers to, and practices that lead to, adequate reimbursement for services provided. Results Providers report that knowledgeable staff are crucial to securing contracts with both public and private insurance plan issuers, and that the contracts they secure often include coverage restrictions on methods or services clinics offer their clients. Good staff relationships with issuers are key to obtaining adequate and consistent reimbursement for all covered services. Conclusions Providers are trying to understand how insurance programs in their area knit together. Regardless of how U.S. health policies and delivery systems may change in the coming years, it is imperative that publicly funded family planning centers continue to work with health plans and maximize their third-party revenue to provide services to those in need.

In settings of high fertility and high HIV prevalence, individuals are making fertility decisions while simultaneously trying to avoid or manage HIV. We sought to increase our understanding of how individuals dually manage HIV risk while attempting to achieve their fertility goals as part of the project entitled HIV Status and Achieving Fertility Desires conducted in Zambia in 2011. Using multivariate regression to predict fertility patterns based on socio-demographic characteristics for respondents from facility-based and community-based surveys, we employed Anomalous Case Analysis (ACA) whereby in-depth interview respondents were selected from the groups of outliers amongst the survey respondents who reported lower or higher fertility preferences than predicted as well as those who adhered to predicted patterns, and lived in Lusaka ( n = 45). All of the facility-based respondents were HIV-positive. We utilize the Theory of Conjunctural Action (TCA) to categorize domains of influence on individuals' preferences and behavior. Both community-based and facility-based right-tail respondents (outliers whose fertility intentions indicated that they wanted a/nother child when we predicted that they did not) expressed comparatively less control over their fertility and gave more weight to pressures from others to continue childbearing. Partner communication about fertility desires was greater among left-tail respondents (outliers whose fertility intentions indicated that they did not want a/nother child when we predicted that they did). HIV-positive right-tail respondents were more likely to see anti-retroviral therapies (ARTs) which prevent mother to child transmission of HIV as highly effective, mitigating inhibitions to further childbearing. Drug interactions between ARTs and contraceptives were identified as a limitation to HIV-positive individuals' contraceptive options on both sides of the distribution. Factors that should be taken into account in the future to understand fertility behavior in high HIV-prevalent settings include couples' communication around fertility and perception of the efficacy of ARTs.

Background The objective of this research was to examine individuals' knowledge about abortion in the context of their knowledge about other sexual and reproductive health (SRH) issues, including contraception, abortion, pregnancy, and birth. Methods During August 2012, we administered an online questionnaire to a randomly selected sample of 639 men and women of reproductive age (18–44 years) in the United States. Findings Respondents reported the highest levels of perceived knowledge about SRH in general (81%), followed by pregnancy and birth (53%), contraception (48%), and abortion (35%); knowledge of specific items within each of these areas paralleled this pattern. Respondents who believe that abortion should be allowed in at least some circumstances were more likely to be correct regarding the safety and consequences of contraception and abortion. Characteristics associated with higher levels of knowledge regarding abortion-related issues included having higher levels of knowledge about non–abortion-related SRH issues and having less restrictive abortion beliefs. Conclusions Women and men are not well-informed about the relative safety and consequences of SRH-related experiences. Many overestimate their knowledge, and personal beliefs about abortion restrictions may influence their knowledge about the safety and consequences of abortion and contraception. Providers of SRH services should provide comprehensive evidence-based information about the risks and consequences of SRH matters during consultations, particularly in the case of abortion providers serving women who hold more restrictive abortion beliefs.

Study Objective To describe and explore provider- and patient-level perspectives regarding long-acting reversible contraception (LARC) for teens and young adults (ages 16-24). Methods Data collection occurred between June and December 2011. We first conducted telephone interviews with administrative directors at 20 publicly funded facilities that provide family planning services. At 6 of these sites, we conducted a total of 6 focus group discussions (FGDs) with facility staff and 48 in-depth interviews (IDIs) with facility clients ages 16-24. Results Staff in the FGDs did not generally equate being a teen with ineligibility for IUDs. In contrast to staff, one-quarter of the young women did perceive young age as rendering them ineligible. Clients and staff agreed that the “forgettable” nature of the methods and their duration were some of LARC's most significant advantages. They also agreed that fear of pain associated with both insertion and removal and negative side effects were disadvantages. Some aspects of IUDs and implants were perceived as advantages by some clients but disadvantages by others. Common challenges to providing LARC-specific services to younger patients included extra time required to counsel young patients about LARC methods, outdated clinic policies requiring multiple visits to obtain IUDs, and a perceived higher removal rate among young women. The most commonly cited strategy for addressing many of these challenges was securing supplementary funding to support the provision of these services to young patients. Conclusion Incorporating young women's perspectives on LARC methods into publicly funded family planning facilities' efforts to provide these methods to a younger population may increase their use among young women.

Although stigma towards HIV-positive women for both continuing and terminating a pregnancy has been documented, to date few studies have examined relative stigma towards one outcome versus the other. This study seeks to describe community attitudes towards each of two possible elective outcomes of an HIV-positive woman's pregnancy - induced abortion or birth - to determine which garners more stigma and document characteristics of community members associated with stigmatising attitudes towards each outcome. Data come from community-based interviews with reproductive-aged men and women, 2401 in Zambia and 2452 in Nigeria. Bivariate and multivariate analyses revealed that respondents from both countries overwhelmingly favoured continued childbearing for HIV-positive pregnant women, but support for induced abortion was slightly higher in scenarios in which anti-retroviral therapy (ART) was unavailable. Zambian respondents held more stigmatising attitudes towards abortion for HIV-positive women than did Nigerian respondents. Women held more stigmatising attitudes towards abortion for HIV-positive women than men, particularly in Zambia. From a sexual and reproductive health and rights perspective, efforts to assist HIV-positive women in preventing unintended pregnancy and to support them in their pregnancy decisions when they do become pregnant should be encouraged in order to combat the social stigma documented in this paper.

Abortion availability and accessibility vary by state. Especially in areas where services are restricted or limited, some women travel to obtain abortion services in other states. Little is known about the experience of travel to obtain abortion.In January and February 2015, in-depth interviews were conducted with 29 patients seeking abortion services at six facilities in Michigan and New Mexico. Eligible women were 18 or older, spoke English, and had traveled either across state lines or more than 100 miles within the state. Respondents were asked to describe their experience from pregnancy discovery to the day of the abortion procedure. Barriers to accessing abortion care and consequences of these barriers were identified through inductive and deductive analysis.Respondents described 15 barriers to abortion care while traveling to obtain services, and three major consequences of experiencing those barriers. Barriers were grouped into five categories: travel-related logistical issues, system navigation issues, limited clinic options, financial issues, and state or clinic restrictions. Consequences were delays in care, negative mental health impacts and considering self-induction. The experience of barriers complicated the process of obtaining an abortion, but the effect of any individual barrier was unclear. Instead, the experience of multiple barriers appeared to have a compounding effect, resulting in negative consequences for women traveling for abortion.The amalgamation of barriers to abortion care experienced simultaneously can have significant consequences for patients.

Objectives To examine whether race and reported history of abortion are associated with abortion stigma and miscarriage stigma, both independently and comparatively. Study design Self-administered surveys with 306 new mothers in Boston and Cincinnati, United States. Main outcome measures Abortion stigma perception (ASP); miscarriage stigma perception (MSP); and comparative stigma perception (CSP: abortion stigma perception net of miscarriage stigma perception). Results Regardless of whether or not they reported having an abortion, white women perceived abortion (ASP) to be more stigmatizing than Black and Latina women. Perceptions of miscarriage stigma (MSP), on the other hand, were dependent on reporting an abortion. Among those who reported an abortion, Black women perceived more stigma from miscarriage than white women, but these responses were flipped for women who did not report abortion. Reporting abortion also influenced our comparative measure (CSP). Among those who did report an abortion, white women perceived more stigma from abortion than miscarriage, while Black and Latina women perceived more stigma from miscarriage than abortion. Conclusions By measuring abortion stigma in comparison to miscarriage stigma, we can reach a more nuanced understanding of how perceptions of reproductive stigmas are stratified by race and reported reproductive history. Clinicians should be aware that reproductive stigmas do not similarly affect all groups. Stigma from specific reproductive outcomes is more or less salient dependent upon a woman's social position and lived experience.

Background High risk for additional unintended pregnancies among abortion patients makes the abortion care setting an ideal one for facilitating access to contraception. This study documents attitudes of abortion patients about contraceptive services during their receipt of abortion services and identifies patient characteristics associated with desire for contraception and interest in using a long-acting reversible contraceptive method (LARC). Study Design Structured surveys were administered to 542 patients at five US abortion-providing facilities between March and June of 2010. Supplementary information was collected from 161 women who had had abortions in the past 5 years through an online survey. Results Among abortion patients, two thirds reported wanting to leave their appointments with a contraceptive method and 69% felt that the abortion setting was an appropriate one for receiving contraceptive information. Having Medicaid and having ever used oral contraceptives were predictive of wanting to leave with a method. Women having a second or higher-order abortion were over twice as likely as women having a first abortion to indicate interest in LARC, while black women were half as likely as white women to indicate this interest. Conclusion Many women are interested in learning about and obtaining contraceptive methods, including LARC, in the abortion care setting.

OBJECTIVE: To examine characteristics of U.S. women that are associated with use of long-acting reversible contraception and changes in these characteristics between 2002 and 2006-2008. METHODS: We analyzed data from two nationally representative samples of women aged 15-44 in the National Survey of Family Growth including 7643 women in 2002 and 7356 women in 2006-2008. We conducted simple and multinomial logistic regression analyses to identify demographic and reproductive health characteristics associated with use of long-acting reversible contraception. RESULTS: Long-acting reversible contraception (intrauterine devices and subdermal implants) use among U.S. women using contraception increased from 2.4% in 2002 to 5.6% in 2006-2008. The largest increases in long-acting reversible contraception use during this time occurred among the youngest and oldest age groups non-Hispanic white and non-Hispanic African American women foreign-born women and those in the highest income group. High prevalence of long-acting reversible contraception use in 2006-2008 was seen among women who had given birth once or twice (10%) foreign-born women (8.8%) and Hispanic women (8.4%). After adjusting for key demographic and reproductive health characteristics in comparison with users of other contraceptive methods and with those not using contraception who were at risk for unintended pregnancy foreign-born women and women who experienced coitarche before age 18 were approximately twice as likely to be using long-acting reversible contraception as women without those characteristics. CONCLUSION: A more diverse population of women used long-acting reversible contraception in 2006-2008 compared with 2002. However there is likely more potential for increased uptake especially among populations historically not considered to be candidates for these methods.

Background Abortion facilities represent a potentially convenient setting for providing contraception to women experiencing unintended pregnancies. This analysis examines a range of factors that may act as barriers to integrating contraceptive and abortion services and documents abortion providers’ perspectives on their role in their patients’ contraceptive care. Methods Administrators from 173 large, nonhospital facilities that provide abortions in the United States responded to a structured survey between May and September 2009. We used chi-square tests to assess differences in categorical outcomes. Results Although the majority of U.S. abortion facilities offer a range of contraceptive methods on site, facility staff identified multiple barriers to full integration of the two services, in particular, insurance, patient, and cost barriers. Few of these perceived barriers, however, were associated with differences in the actual provision of most contraceptive methods. Specialized abortion clinics that do not accept health insurance were less likely to have highly effective methods, such as intrauterine devices and implants, on site. Facilities located in Medicaid states were more likely to accept both public and private health insurance for contraceptive services. Conclusion Increased access to contraceptive services during abortion care is one strategy for reducing repeat unintended pregnancy, and stakeholders at all levels—including abortion providers, insurance companies, and policy makers—have a role to play in achieving this goal.

Stigmatization is a deeply contextual, dynamic social process; stigma from abortion is the discrediting of individuals as a result of their association with abortion. Abortion stigma is under-researched and under-theorized, and the few existing studies focus only on women who have had abortions. We build on this work, drawing from the social science literature to describe three groups whom we posit are affected by abortion stigma: Women who have had abortions, individuals who work in facilities that provide abortion, and supporters of women who have had abortions, including partners, family, and friends, as well as abortion researchers and advocates. Although these groups are not homogeneous, some common experiences within the groups--and differences between the groups--help to illuminate how people manage abortion stigma and begin to reveal the roots of this stigma itself. We discuss five reasons why abortion is stigmatized, beginning with the rationale identified by Kumar, Hessini, and Mitchell: The violation of female ideals of sexuality and motherhood. We then suggest additional causes of abortion stigma, including attributing personhood to the fetus, legal restrictions, the idea that abortion is dirty or unhealthy, and the use of stigma as a tool for anti-abortion efforts. Although not exhaustive, these causes of abortion stigma illustrate how it is made manifest for affected groups. Understanding abortion stigma will inform strategies to reduce it, which has direct implications for improving access to care and better health for those whom stigma affects.

Recently, the hypothesis that state-level political context influences individuals' cultural values – the ‘red states v. blue states’ hypothesis – has been invoked to explain the hyper-polarisation of politics in the USA. To test this hypothesis, we examined individuals' knowledge about abortion in relation to the political context of their current state of residence. Drawing from an internet-survey of 586 reproductive-age individuals in the USA, we assessed two types of abortion knowledge: health-related and legality. We found that state-level conservatism does not modify the existing relationships between individual predictors and each of the two types of abortion knowledge. Hence, our findings do not support the ‘red states’ versus ‘blue states’ hypothesis. Additionally, we find that knowledge about abortion's health effects in the USA is low: 7% of our sample thought abortion before 12 weeks gestation was illegal.

Objective To examine trends in the use of long-acting reversible contraceptive (LARC) methods—the intrauterine device (IUD) and implant—and the extent to which these methods have replaced permanent sterilization and less effective short-acting methods. Design We tabulated data from female survey respondents overall and by demographic subgroups. We performed t -tests of the differences in the proportions of female contraceptors using LARC in 2007 and 2009. We also looked at use of LARC, sterilization, other methods, and no method among women at risk of unintended pregnancy. Setting In-home survey. Patient(s) All female respondents to the surveys. Intervention(s) None. Main Outcome Measure(s) Current use of LARC methods in 2009, and change in use from 2007. Result(s) The proportion of contraceptors using LARC increased significantly from 2.4% in 2002 to 3.7% in 2007 and 8.5% in 2009. The increase occurred among women in almost every age, race, education, and income group. Among women at risk of unintended pregnancy, increases in LARC use more than offset decreases in sterilization. Conclusion(s) LARC methods (primarily IUDs) are contributing to an increase in contraceptive effectiveness in the United States.

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.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.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.Abortion is becoming increasingly concentrated among poor women, and restrictions on abortion disproportionately affect this population.

Background Involving women's partners in family planning services may be one avenue by which rates of unplanned pregnancies can be reduced. Study Design In 2009, we surveyed a nationally representative sample of 2113 women aged 18–49 years receiving services from Title X family planning clinics in the United States about their contraceptive use and their current partner, including partners' past involvement in seeking and obtaining contraceptive services. Results More than half of the women in the sample (56%) indicated that their partners were at least partially involved in their contraceptive services. In the multivariable analysis, race/ethnicity, union status and relationship satisfaction were all significant predictors of partner involvement in contraceptive services. Women reporting that their partners interfere with their birth control were nearly twice as likely as women without interfering partners to report those partners being involved in their contraceptive services. Contraceptive use at last sex was not associated with partner involvement in contraceptive services in either bivariable or multivariable analyses. Conclusion In designing future couple-focused programs, clinics may need to focus on the interpersonal dynamics of couple-based decision-making and behaviors and tailor their programs given the characteristics of clients most likely to avail themselves of these services.

Analysis of data from the 2006–2008 National Survey of Family Growth indicates that use of emergency contraception in the United States has increased after changes in its prescription status in 2006. However, clinicians continue to play a pivotal role in ensuring that women have accurate information about emergency contraception.

Background: About half of US women having abortions have already had at least one prior abortion. Facilitating access to contraception may help these women avoid subsequent unintended pregnancies. Information is needed to document the availability of contraceptive services in abortion care settings in the United States. Study Design: Data for this cross-sectional mixed-methods study were collected between December 2008 and September 2009 and come from two sources: 15 semistructured telephone interviews and 173 structured questionnaires administered to a nationally representative sample of eligible facilities. Respondents were administrators at large (400+ abortions per year), nonhospital facilities that provide abortion services in the United States. Results: Virtually all (96%) abortion clinics incorporate contraceptive education into abortion care, and the three most common methods reported to be distributed are the birth control pill (99%), the vaginal ring (61%) and Depo-Provera (58%). Almost one-third reported being able to offer post-abortion intrauterine device insertion. Most facilities (82%) accept some form of insurance for either contraceptive or abortion services, and those with a broader family planning focus are significantly more likely to do so. Administrators at the majority of facilities (56%) report that patients most commonly do not pay additional fees for contraceptive services because they are included in the cost of abortion services. Conclusion: Although almost all large, non-hospital abortion providers in the United States are able to provide some level of contraceptive care to their abortion patients, the degree to which they are able to do so is influenced by a wide range of factors.

Among industrialized countries, the United States continues to have the highest rate of unintended pregnancy; approximately half of all American women aged 15–44 have experienced at least one unintended pregnancy.1 These pregnancies have well-documented health and economic consequences for mothers, children and society as a whole, including an increased risk of morbidity among women who experience unintended pregnancies and economic and social costs in education and child welfare.2 Rates of unintended pregnancy and of abortion are disproportionately high among young women, minority women and low-income women.3 Given the public health impact of unintended pregnancy, the U.S. government’s Healthy People 2010 initiative focuses on its prevention as part of the broader goals of eliminating health disparities and improving quality of life.4 Current discourse regarding unintended pregnancy, reflected in reproductive health policies and programs, often takes the stance that the concept of unintended pregnancy is uncomplicated and self-evident, despite growing evidence that the measurement and conceptualization of unintended pregnancy has significant limitations.5–11 Some of these limitations result from interchangeable use of terms related to the “intendedness,” “wantedness” and “planning status” of pregnancies;6–8 dichotomous categorization of these concepts (as unintended or intended, unwanted or wanted, and unplanned or planned) and the universal application of the concept of unintended pregnancy to different subpopulations of women;9 others stem from significant differences between researchers and policymakers on the one hand and the women being researched on the other regarding the definitions and values of planned and unplanned pregnancies.10 In response to the drawbacks of divergent definitions of existing measures, Barrett, Smith and Wellings developed and validated a simple question sequence, the London Measurement of Unplanned Pregnancy (LMUP), to measure pregnancy planning as a multidimensional concept across diverse groups of women.11 Several studies indicate that dichotomous measures of intention do not capture the experiences of the large portion of women who are ambivalent about becoming pregnant. For example, Schwarz and colleagues demonstrated that more women were willing and able to express their ambivalence toward becoming pregnant when presented with five possible responses to a pregnancy intention question than when presented with three.12 This finding is of clinical significance, because women characterized as being ambivalent toward pregnancy use less effective contraceptive methods than nonambivalent women.12,13 In addition, the retrospective approach to assessing pregnancy intention significantly limits the accuracy of its measurement.14–16 Rates of unintended pregnancy fluctuate broadly, depending on whether pregnancy intentions are measured during a pregnancy or after a birth. Most commonly, women tend to become more accustomed to a pregnancy over time, and reports of both intention and desire for pregnancy increase with time from conception. 15–17 Only two studies12,13 have prospectively assessed pregnancy intentions, and both did so in populations of nonpregnant women. An analysis of National Survey of Family Growth data in conjunction with subsequent respondent interviews, which found that correlates of unintended births differ somewhat between prospective and retrospective studies, provides evidence for the need for more prospective studies addressing pregnancy intentions in diverse populations of women.18 Prospective assessment of pregnancy intention as a multidimensional concept may increase health care providers’ ability to identify women who are ambivalent toward pregnancy and to tailor contraceptive and preconception messages to improve population-level pregnancy outcomes. Our goal was to prospectively assess pregnancy intentions in a population of women at high risk for unintended pregnancy using two measurement strategies, and to describe the relationship between these measures, decisions regarding the outcome of the potential pregnancy and the women’s pregnancy test results.