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Research Article|Articles in Press, 110011

Classification of periviable pregnancy-ending interventions for maternal life endangerment as induced abortion1

      Abstract

      Objective

      To explore how U.S. OB/GYNs classify periviable pregnancy-ending interventions for maternal life endangerment.

      Study Design

      From May-July 2021, we performed an explanatory sequential mixed methods study of U.S. OB/GYNs, recruited through social media and professional listservs. We administered a cross-sectional survey requesting institutional classification of labor induction or surgical evacuation of a 22-week pregnancy affected by intrauterine infection, using chi-square tests and logistic regression to compare determinations by physician and institutional factors. We then conducted semi-structured interviews in a diverse nested sample to explore decision-making, merging quantitative and qualitative data in a mixed methods analysis.

      Results

      We received 209 completed survey responses, with 101 (48.3%) current abortion providers and 48 (20.1%) never-providers, and completed 21 qualitative interviews. Fewer than half of respondents reported that pregnancy-ending intervention for 22-week intrauterine infection would be classified as induced abortion at their institution (induction: 21.1%, dilation & evacuation: 42.6%, p<0.001). In addition to procedure method, decision-making factors for classification as abortion included personal experience with abortion (with more experienced participants more likely to identify care as abortion) and state and institutional abortion regulations (“I have to call it a medical [induction]…I’m not allowed to use the word abortion”).

      Conclusions

      Most OB/GYNs do not classify periviable pregnancy-ending interventions for life-threatening maternal complications as induced abortion, especially when physicians and institutions have less abortion expertise. Differential classification of pregnancy-ending care may lead to under-counting of later abortion procedures, masking the impact of abortion restrictions.

      Keywords

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      References

        • Creanga A.A.
        • Syverson C.
        • Seed K.
        • Callaghan W.M.
        Pregnancy-Related Mortality in the United States, 2011-2013.
        Obstet Gynecol. 2017; 130: 366-373https://doi.org/10.1097/aog.0000000000002114
        • Addante A.N.
        • Eisenberg D.L.
        • Valentine M.C.
        • Leonard J.
        • Maddox K.E.J.
        • Hoofnagle M.H.
        The association between state-level abortion restrictions and maternal mortality in the United States, 1995-2017.
        Contraception. 2021; 104: 496-501https://doi.org/10.1016/j.contraception.2021.03.018
      1. H.H.S. Press Office. Following President Biden’s Executive Order to Protect Access to Reproductive Health Care, HHS Announces Guidance to Clarify that Emergency Medical Care Includes Abortion Services [press release]. July 11, 2022 2022. Accessed from: 〈https://www.hhs.gov/about/news/2022/07/11/following-president-bidens-executive-order-protect-access-reproductive-health-care-hhs-announces-guidance-clarify-that-emergency-medical-care-includes-abortion-services.html〉

        • Raju T.N.K.
        • Mercer B.M.
        • Burchfield D.J.
        • Joseph Jr., G.F.
        Periviable birth: executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists.
        Obstet Gynecol. 2014; 123: 1083-1096https://doi.org/10.1097/aog.0000000000000243
        • American College of Obstetricians and Gynecologists
        reVITALize: Gynecology Data Definitions (version 1.0).
        American College of Obstetricians and Gynecologists. Washington, DC, 2018
        • Heuser C.C.
        • Sagaser K.G.
        • Christensen E.A.
        • Johnson T.C.
        • Lappen J.R.
        • Horvath S.
        Society for Maternal-Fetal Medicine Special Statement: A critical examination of abortion terminology as it relates to access and quality of care.
        Am J Obstet Gynecol. 2022; https://doi.org/10.1016/j.ajog.2022.12.302
        • ACOG
        ACOG Practice Bulletin No. 200: Early Pregnancy Loss.
        Obstet Gynecol. 132. 2018: e197-e207https://doi.org/10.1097/aog.0000000000002899
        • Cunningham F.G.
        • Leveno K.J.
        • Bloom S.L.
        • Dashe J.S.
        • Hoffman B.L.
        • Casey B.M.
        • et al.
        Abortion. Williams Obstetrics, 25e.
        McGraw-Hill Education, New York, NY2018
        • Hoeldtke N.J.
        • Calhoun B.C.
        Perinatal hospice.
        Am J Obstet Gynecol. 2001; 185: 525-529https://doi.org/10.1067/mob.2001.116093
      2. Guttmacher Institute. Induced Abortion in the United States. Guttmacher Institute: 2020 . Accessed: November 9 2020. Available from: 〈https://www.guttmacher.org/sites/default/files/factsheet/fb_induced_abortion.pdf〉.

      3. Guttmacher Institute. An Overview of Abortion Laws. Guttmacher Institute: 2022 . Accessed: June 17 2022. Available from: 〈https://www.guttmacher.org/state-policy/explore/overview-abortion-laws〉.

        • Bearak J.M.
        • Burke K.L.
        • Jones R.K.
        Disparities and change over time in distance women would need to travel to have an abortion in the USA: a spatial analysis.
        Lancet Public Health. 2017; 2: e493-e500https://doi.org/10.1016/s2468-2667(17)30158-5
        • Jerman J.
        • Jones R.K.
        Secondary measures of access to abortion services in the United States, 2011 and 2012: gestational age limits, cost, and harassment.
        Womens Health Issues. 2014; 24: e419-e424https://doi.org/10.1016/j.whi.2014.05.002
        • Jones R.K.
        • Witwer E.
        • Jerman J.
        Abortion Incidence and Service Availability in the United States.
        Guttmacher Institute, New York2017: 2019
        • Joffe C.
        • Schroeder R.
        COVID-19, health care, and abortion exceptionalism in the United States.
        Perspect Sex Reprod Health. 2021; 53: 5-12https://doi.org/10.1363/psrh.12182
      4. Pew Research Center. Methodology: The American Trends Panel survey methodology. 2022 . Accessed: Available from: 〈https://www.pewresearch.org/religion/2022/05/06/methodology-49/〉.

      5. Nash E. State Abortion Policy Landscape: From Hostile to Supportive. Guttmacher Institute: 2020 . Accessed: Feburary 28, 2022 Available from:

        • Patton M.Q.
        Qualitative Research and Evaluation Methods. 4th edition. Sage Publications, Thousand Oaks, CA2014
      6. Zernike K. What Does ‘Abortion’ Mean? Even the Word Itself Is Up for Debate. The New York Times. 2022 10/18/2022 Retrieved from 〈https://www.nytimes.com/2022/10/18/us/abortion-roe-debate.html〉.

      7. Tabrizy N. , Bracken K. , Boyer M. , Dwedar M. 'Do No Harm': OB-GYNs Weigh the Legal Impact of Abortion Bans. The New York Times. 2022 September 10, 2022 Retrieved from 〈https://www.nytimes.com/video/us/100000008489880/abortion-bans-maternal-health.html〉.

        • Grimes D.A.
        • Cates Jr, W.
        Dilatation and Evacuation.
        in: Gary S. Berger W.E.B. Louis G.Keith Second-Trimester Abortion: Perspectives After a Decade of Experience. The Hague. Martinus Nijhoff Publishers, Boston, London1981: 119-133
        • Grimes D.A.
        • Smith M.S.
        • Witham A.D.
        Mifepristone and misoprostol versus dilation and evacuation for midtrimester abortion: a pilot randomised controlled trial.
        BJOG. 2004; 111: 148-153https://doi.org/10.1046/j.1471-0528.2003.00044.x-i1
        • Lohr P.A.
        • Hayes J.L.
        • Gemzell-Danielsson K.
        Surgical versus medical methods for second trimester induced abortion.
        Cochrane Database Syst Rev. 2008; 1: Cd006714https://doi.org/10.1002/14651858.CD006714.pub2
      8. Guttmacher Institute. Later Abortion. 2019. Accessed: November 9 2020. Available from: 〈https://www.guttmacher.org/evidence-you-can-use/later-abortion〉.

        • Foster D.G.
        • Kimport K.
        Who seeks abortions at or after 20 weeks.
        Perspect Sex Reprod Health. 2013; 45: 210-218https://doi.org/10.1363/4521013
        • Kulczycki A.
        Dobbs: Navigating the New Quagmire and Its Impacts on Abortion and Reproductive Health Care.
        Health Educ Behav. 2022; 49: 924-928https://doi.org/10.1177/10901981221125430
        • Zeldovich V.B.
        • Rocca C.H.
        • Langton C.
        • Landy U.
        • Ly E.S.
        • Freedman L.R.
        Abortion Policies in U.S. Teaching Hospitals: Formal and Informal Parameters Beyond the Law.
        Obstet Gynecol. 2020; 135: 1296-1305https://doi.org/10.1097/aog.0000000000003876
        • Watson K.
        Scarlet A: The Ethics, Law, & Politics of Ordinary Abortion.
        Oxford University Press, New York2018
        • Maguire M.
        • Light A.
        • Kuppermann M.
        • Dalton V.K.
        • Steinauer J.E.
        • Kerns J.L.
        Grief after second-trimester termination for fetal anomaly: a qualitative study.
        Contraception. 2015; 91: 234-239https://doi.org/10.1016/j.contraception.2014.11.015
        • Kerns J.L.
        • Light A.
        • Dalton V.
        • McNamara B.
        • Steinauer J.
        • Kuppermann M.
        Decision satisfaction among women choosing a method of pregnancy termination in the setting of fetal anomalies and other pregnancy complications: A qualitative study.
        Patient Educ Couns. 2018; 101: 1859-1864https://doi.org/10.1016/j.pec.2018.06.012
      9. Swenson A. Posts falsely claim abortion is never medically necessary. AP News. 2022 July 11, 2022 Retrieved from 〈https://apnews.com/article/fact-check-abortion-medically-necessary-342879333754〉.

      10. Uribe M.R. Abortions done under legal exceptions are still abortions. The Poynter Institute: July 15, 2022. Accessed: August 31, 2022 Available from: 〈https://www.politifact.com/factchecks/2022/jul/15/catherine-glenn-foster/abortions-done-under-legal-exceptions-are-still-ab/〉.

        • Nambiar A.
        • Patel S.
        • Santiago-Munoz P.
        • Spong C.Y.
        • Nelson D.B.
        Maternal morbidity and fetal outcomes among pregnant women at 22 weeks' gestation or less with complications in 2 Texas hospitals after legislation on abortion.
        Am J Obstet Gynecol. 2022; 227 (e1): 648-650https://doi.org/10.1016/j.ajog.2022.06.060
        • Stulberg D.B.
        • Dude A.M.
        • Dahlquist I.
        • Curlin F.A.
        Abortion provision among practicing obstetrician-gynecologists.
        Obstet Gynecol. 2011; 118: 609-614https://doi.org/10.1097/AOG.0b013e31822ad973
        • Grossman D.
        • Grindlay K.
        • Altshuler A.L.
        • Schulkin J.
        Induced Abortion Provision Among a National Sample of Obstetrician-Gynecologists.
        Obstet Gynecol. 2019; 133: 477-483https://doi.org/10.1097/aog.0000000000003110
        • UW CORE Collaborative for Reproductive Equity
        Physician Support of Unrestricted Abortion Services in Wisconsin.
        Department of Obstetrics and Gynecology. University of Wisconsin, 2021
        • MacDonald A.
        • Gershengorn H.B.
        • Ashana D.C.
        The Challenge of Emergency Abortion Care Following the Dobbs Ruling.
        JAMA. 2022; 328: 1691-1692https://doi.org/10.1001/jama.2022.17197
        • Stevenson A.J.
        The Pregnancy-Related Mortality Impact of a Total Abortion Ban in the United States: A Research Note on Increased Deaths Due to Remaining Pregnant.
        Demography. 2021; 58: 2019-2028https://doi.org/10.1215/00703370-9585908