Reproductive, Maternal, and Infant Health
Which Policies are Effective in Increasing the Number of Children People Have in Low-Fertility Countries?
Rannveig Kaldager Hart, Janna Bergsvik, Agnes Fauske, and Wookun Kim, July 2024
Many countries in Europe, North America, Oceania and parts of Asia have experienced significant declines in fertility. Long-term low fertility can put a strain on a country’s workforce, pension systems, and old age care, among others. Policymakers in many of these countries have implemented policies to make it easier for people to have and care for children. This brief, from PRC external faculty affiliate Wookun Kim and colleagues, reports on a recent review of dozens of experimental and quasi-experimental studies to evaluate whether policies affecting parental leave, childcare, direct financial incentives, and health insurance caused fertility to increase in low fertility countries. They show that policies that reduced the costs of childbearing were effective in increasing fertility, including policies that introduced, or generously prolonged, maternity leave; expanded public childcare; and implemented or expanded direct financial incentives. The authors argue that, to reduce workplace inequalities for women and inequalities in access to high quality childcare while also addressing policymakers’ goals of increasing fertility, policymakers should prioritize policies to promote lower-cost and higher-quality childcare for all of their inhabitants.
The Supply of Pill Packs for Self-managed Abortion Increased Substantially After the U.S. Supreme Court Eliminated the Constitutional Right to Choose Abortion
Abigail R.A. Aiken, Elisa S. Wells, Rebecca Gomperts, and James G. Scott, April 2024
In the Dobbs v Jackson Women’s Health Organization decision in June 2022, the United States Supreme Court eliminated the constitutional right to choose an abortion. Several states, particularly in the south, immediately imposed total or near-total abortion bans or severely restricted abortion access. In this brief, PRC faculty scholar Abigail Aiken and colleagues identified the number of abortion medications that entities outside of the formal U.S. health care system supplied to people in the U.S. as well as estimated of the number of people who used the medications to self-manage a medication abortion in the 6 months after the Dobbs decision. They found that community networks, telemedicine organizations, and online vendors provided a total of 35,587 medications for self-managed abortion in the 6 months post-Dobbs and that community networks accounted for over half of the total supply post-Dobbs. After accounting for the estimated rate of supplied vs. used medications, as well as estimates of what usage would have been in the absence of the Dobbs decision, the number of self-managed abortions that took place increased by an estimated 26,055 in the 6 months after Dobbs. The authors argue that self-managed abortion will likely continue to be the way many people access abortion in the U.S. post-Dobbs.
State Policies Impact Young People’s Use of Their Preferred Contraceptive Method
Kristine Hopkins, Jennifer Yarger, Irene Rossetto, Audrey Sanchez, Elisa Brown, Sarah Elmes, Thaddeus Mantaro, Kari White, and Cynthia C. Harper, September 2023
When young people can use the contraceptive method of their choice, they are able to exercise reproductive autonomy. State policies can make it easier for young people to access their preferred contraceptive method by increasing insurance coverage and reducing costs barriers. California’s expansion of Medicaid provides insurance coverage to many low-income residents. Its strong family planning safety net helps to provide coverage to many uninsured residents. Texas’s more restrictive health care policy environment, including much more limited access to Medicaid and other programs for low-income and uninsured residents, creates more barriers for young people to access contraception. Using data from a study of community college students in Texas and California, PRC researchers Kristine Hopkins, Irene Rossetto, Audrey Sanchez, PRC faculty scholar Kari White, and colleagues from the University of California San Francisco, explored the impact of insurance coverage on use of preferred contraceptive method. They found that students in Texas were less likely to use their preferred contraceptive method than students in California, with uninsured Texas students being the most disadvantaged. The authors argue that, while it is important to expand access to preferred contraceptive methods in all states, it is especially urgent to improve young people’s access to the contraception they want to use in states with abortion bans.
Texas’ 2021 Ban on Abortion in Early Pregnancy Was Associated with a Decrease in Abortions in Texas, an Increase in Abortions Out of State, and a Decrease in Overall Abortions
Kari White, Gracia Sierra, Klaira Lerma, Anitra Beasley, Lisa G. Hofler, Kristina Tocce, Vinita Goyal, Tony Ogburn, Joseph E. Potter, and Samuel L. Dickman, July 2023
Texas Senate Bill 8 (SB 8) made abortions illegal once embryonic cardiac activity (sometimes incorrectly referred to as a “fetal heartbeat”) can be detected (at about 5-6 weeks of pregnancy), with very limited exceptions. Before SB 8, abortions could be provided in Texas up to 22 weeks of pregnancy. SB 8 was the most restrictive abortion law in the US until June 2022 when the US Supreme Court overturned the Roe v. Wade decision, which allowed Texas to enforce a law that prohibits almost all abortions. In this study, Kari White, PRC faculty scholar and principal investigator of the Texas Policy Evaluation Project (TxPEP), along with PRC and TxPEP researchers Gracia Sierra, Klaira Lerma, Vinita Goyal, and professor emeritus Joseph Potter, and colleagues, compared the abortions Texas residents had in the month before and month after SB 8 went into effect. They also calculated the proportion of abortions that were done out of state for people who were 12 or more weeks pregnant in the six months after the law went into effect, compared to the same six-month period the year before. They found that SB 8 was associated with a decrease in abortions in Texas, an increase in abortions out of state, a decrease in overall abortions, and an increase in abortions after 12 weeks of pregnancy.
Self-managed Medication Abortion Using Misoprostol Provided by an Online Telemedicine Service Has a High Rate of Effectiveness and a Low Rate of Serious Adverse Events
Dana M. Johnson, Mira Michels-Gualtieri, Rebecca Gomperts, and Abigail R. A. Aiken, March 2023
In the wake of the US Supreme Court ruling that ended the constitutional right to abortion, many states have banned or severely restricted abortion access. As a result, women, transgender men, and gender non-binary individuals capable of pregnancy face unprecedented difficulties obtaining abortion care in clinics in those states. Aid Access is an online telemedicine organization that offers low-cost abortion pills to end a pregnancy on one’s own, a process that is also known as self-managed medication abortion. Typically, Aid Access provides the medications mifepristone and misoprostol for self-managed abortion. However, the service temporarily provided prescriptions for misoprostol alone because of challenges shipping mifepristone internationally during the COVID-19 pandemic. In this brief, PRC Graduate Student Trainee Dana Johnson, PRC Faculty Scholar Abigail Aiken and colleagues assessed the safety and effectiveness of self-managed abortion using misoprostol acquired from Aid Access for 568 US residents. They found that self-managed medication abortion using misoprostol had a high rate of effectiveness and a low rate of serious adverse events. These argue that as existing and potential bans substantially limit access to mifepristone, and because misoprostol has far fewer legal constraints, people may increasingly consider misoprostol alone for self-managed abortion.
A Health Education and Patient Navigation Program Increased Breast and Cervical Cancer Screening for Rural and Border Texas Residents
Derek Falk, Catherine Cubbin, Barbara Jones, July 2022
In the Texas-Mexico border region, women who live in lower socioeconomic status areas have lower breast and cervical cancer screening and higher cancer-related mortality than their counterparts in higher socioeconomic status areas. Studies have also reported several barriers to cancer screening in Texas border counties, including cost and transportation challenges. Patient navigation – or programs that provide support to help people overcome barriers to care – has been shown to increase breast and cervical cancer screening rates among different populations. However, few studies have focused on patient navigation to increase breast and cervical cancer screening among rural and border populations. To address this gap in knowledge, former UT Austin School of Social Work T32 recipient Derek Falk, PRC faculty scholar Catherine Cubbin, and UT colleague Barbara Jones, examined the impact of patient navigation services on clinical screening for breast and cervical cancer among women who attended an educational program. They also identified variation in breast and cervical cancer screening rates by rural and border counties in Texas. They found that patient navigation services increased receipt of breast and cervical cancer screening among women reporting barriers to care. They argue for the importance of health care systems to invest in supportive care services to improve outcomes for underserved populations in the United States.
The Pattern and Timing of Weight Changes in Pregnancy Impact Child Growth and Weight Trajectories for Girls but not Boys
Elizabeth M. Widen, Natalie Burns, Michael Daniels, Grant Backlund, Rachel Rickman, Saralyn Foster, Amy R. Nichols, Lori A. Hoepner, Eliza W. Kinsey, Judyth Ramirez-Carvey, Abeer Hassoun, Frederica P. Perera, Radek Bukowski, and Andrew G. Rundle, April 2022
Current obesity prevalence in the U.S. is 14% among preschool aged children, 18% among school aged children, 21% among adolescents, and 40% among adults. Pregnancy is a critical period that can shape later health and obesity risk for both the woman carrying the pregnancy and the eventual child. The Institute of Medicine recommends that researchers explore how the pattern of prenatal weight gain, rather than total prenatal weight gain, impacts children’s health outcomes. Responding to this call, PRC faculty scholar Beth Widen and colleagues designed a study to understand how patterns of weight changes over the course of pregnancy are linked to body composition and growth patterns of the children born of these pregnancies. They found that unlike boys, girls exposed to high prenatal weight changes are likely more vulnerable to excess body fat across childhood and into early adolescence. These findings will likely be included in future Institute of Medicine recommendations for healthy weight changes throughout pregnancy.
What Motivates People in the United States to Seek Medication Abortion Pills Outside of the Clinic Setting?
Dana M. Johnson, Melissa Madera, Rebecca Gomperts, Abigail R.A. Aiken, November 2021
For those wanting to end a pregnancy, the cost of in-clinic abortion care can be a significant barrier. Restrictive abortion laws in the U.S. add further economic burdens to people who would like to obtain an abortion in a clinic. As abortion has become increasingly restricted, evidence is mounting that some people in the U.S. forgo the clinic altogether. Instead, these people attempt to manage their abortion on their own, outside of the formal healthcare setting. In 2018, Aid Access became the first service to provide self-managed medication abortion in the U.S. via an online telemedicine service. In this brief, PRC trainee Dana Johnson, PRC faculty scholar Abigail Aiken, and colleagues report on a recent study of 80 U.S.-based people who self-managed their abortion using medications obtained from Aid Access. They found that the high costs of in-clinic abortion care, made more difficult by restrictive state abortion policies, motivated people to seek medication abortion via online telemedicine. They also found that mothers weighed their family’s economic wellbeing in their decisions. Finally, the suggested donation of $90 for the pills was still too much for many people seeking online medication abortion.
Breastfeeding Is Hard. Can Using an Infant Carrier with Your Baby Make It Easier?
Emily E. Little, Camille C. Cioffi, Lisa Bain, Cristine H. Legare, and Jennifer Hahn-Holbrook, July 2021
The American Academy of Pediatrics recommends that infants be fed only breast milk for the first six months of life. However, in the United States, far from all parents breastfeed their infants. Previous studies have shown that parents who spend more time in physical contact with their infants are more likely to detect early hunger cues and breastfeed more frequently than parents who spend less time in physical contact. This brief by Emily Little, executive director of Nurturely, PRC faculty scholar Cristine Legare, and colleagues, reports on a randomized controlled trial in which pregnant parents were randomly assigned to receive an infant carrier before birth or put on a waitlist to receive the carrier when their child was six months old. They found that, compared to parents in the control group, parents who received an infant carrier were more likely to feed their six-month-old breast milk, either partially or exclusively. To improve lactation, they argue that healthcare and workplace policies must take physical proximity between parents and infants into account.
Who Is Offered and Who Gets an IUD or Implant Before Leaving the Hospital after Having a Baby?
Cristina Wallace Huff, Joseph E. Potter, and Kristine Hopkins, April 2021
The American College of Obstetricians and Gynecologists recognizes that IUDs and implants are a safe and effective contraceptive option for patients right after delivery. It is also a method that many women want. This research brief reports on a recent study in which obstetrician/gynecologist Cristina Wallace, along with PRC faculty research associates Kristine Hopkins and Joseph E. Potter, analyzed who was offered and who received these long-acting contraception (LARC) methods before discharge among 199 women who delivered a baby in a Texas safety net hospital. They found that 52% of the women were offered an immediate postpartum LARC method and that, among those who got the method before leaving the hospital, satisfaction and continuation of the methods was high. However, Spanish-speaking Hispanic women were less likely to be offered the method, perhaps due to limited use of interpretation services during contraceptive counseling. They argue for the importance of health care providers to present the full range of contraceptive options throughout pregnancy to all women to help them come to a patient-centered decision on their contraceptive method of choice.
Evidence From Over 52,000 People in England and Wales Shows Telemedicine Abortion Without Ultrasound Is Safe, Effective and Improves Care
Abigail Aiken, Patricia A Lohr, Jonathan Lord, Nabanita Ghosh, and Jennifer Starling, February 2021
The Covid-19 pandemic prompted the United Kingdom’s Royal College of Obstetricians and Gynaecologists to publish guidelines to safeguard abortion care in the UK. These new guidelines allowed for the delivery of medical abortion via telemedicine for people with pregnancies up to 10 weeks’ gestation. The telemedicine model does not require ultrasound scans unless there are reported symptoms. Based on over 52,000 reports of abortion during the study period, the authors, led by PRC faculty research associate Abigail Aiken, found that telemedicine medical abortion without ultrasound is safe, effective and improves access. They argue that no-test telemedicine should become routine in the provision of abortion care.
Live Births Fell in Brazil after the Link between the Zika Virus and Microcephaly Was Widely Publicized
Letícia J. Marteleto, Gilvan Guedes, Raquel Z. Coutinho, and Abigail Weitzman, June 2020
The Zika virus was first reported in Brazil in 2014. In late 2015, Brazil’s Ministry of Health announced the association between the Zika virus and microcephaly, which was followed by intense national and international media coverage. Government officials subsequently released statements recommending that women postpone pregnancies. In this brief, PRC faculty research associate Letícia Marteleto and colleagues use monthly data on live births and other data sources to show that the number of live births fell in 2016 approximately 9 months after the publicized link between the Zika virus and microcephaly. Declines were observed across all educational groups and all but the oldest age groups and in both the northeastern and southern states examined in more detail.
Texas Family Planning Providers’ Difficulties Offering Adolescents Confidential Services Foreshadows Similar Problems Nationwide as New Title X Rules Go Into Effect
Kate Coleman-Minahan, Kristine Hopkins, and Kari White, February 2020
Texas is one of 24 states that does not explicitly allow minor teens to consent for their own contraceptive care. The federal Title X family planning program historically has guaranteed confidential and low-cost SRH services for all patients, including minor teens. Recent changes to the Title X program guidelines may deter minor teens from getting confidential services, especially in states that require parental consent. Kate Coleman-Minahan, former PRC postdoctoral fellow and co-investigator with the Texas Policy Evaluation Project, along with PRC faculty research associates Kristine Hopkins and Kari White, use in-depth interview data to explore the impact of changing parental consent rules on minor teens’ access to contraceptive care after policy changes in Texas. They find that the availability of confidential services for teens declined after the 2011-2013 changes to publicly funded family planning programs in Texas.
Louisiana Abortion Patients' Current Challenges Accessing Care
Erin Carroll and Kari White, January 2020
In March 2020, the U.S. Supreme Court will hear June Medical Services, LLC v. Gee, the case that will decide whether Louisiana abortion providers need hospital admitting privileges. In a recent study of Louisiana abortion patients, PRC faculty research associate Kari White and colleague Erin Carroll compared patients’ expectations and preferences for care with their actual experiences accessing abortion services. From June 2018 – January 2019, the research team conducted 35 in-depth interviews with patients seeking care at the three in-state facilities. The study found that most women’s expectations and preferences for abortion care are not met in Louisiana’s current service environment and policy setting.
Women’s Experiences with Protestors while Accessing Abortion Care in Louisiana
Erin Carroll and Kari White, December 2019
Women seeking care at free-standing abortion clinics often encounter anti-abortion protestors. While women seeking abortion have reported that the presence of protestors constitutes a negative and even traumatic aspect of care, laws protecting patients from protestor activity vary. From June 2018 – January 2019, PRC faculty research associate Kari White and colleague Erin Carroll led a research team that interviewed 35 women who were seeking abortion care at Louisiana’s three facilities about their experiences accessing services, including any interactions they may have had with people outside the clinics. They found that the presence of protestors was disruptive and unwelcome. In some cases, protestors impeded care.
Repeat Teen Births in the United States Cluster in Poorer Areas with More Limited Reproductive Health Care Access
Julie Maslowsky, Daniel Powers, C. Emily Hendrick, and Leila Al-Hamoodah, October 2019
In 2017, 16.3% of the 194,377 births to adolescent women in U.S. ages 15-19 were repeat teen births. Understanding where first-time and repeat teen births occur, as well as documenting the demographic composition, socioeconomic conditions, density of health care providers, and availability of family planning services in these places, can inform both clinical practice and health services resource allocation. Using 2015-2017 birth certificate data, PRC faculty research associates Julie Maslowsky and Daniel Powers, along with their co-authors, found that first and repeat teen births cluster in geographic areas that are economically worse off than areas with lower levels of teen births. These results demonstrate a need to allocate resources and tailor teen pregnancy prevention programs to the types of teen births that are most common in each area.
Confident, Moderate, Reluctant: Young Women’s Trajectories in Their Willingness to Refuse Unwanted Sex
Abigail Weitzman and Allen B. Mallory, May 2019
Unwanted sex is widely experienced by young women in the United States, and previous research has identified the factors associated with young women agreeing to have unwanted sex. However, much less is known about young women’s willingness to refuse sex. This brief, from PRC faculty research associate Abigail Weitzman and PRC graduate student trainee Allen Mallory, reports on a study that is the first of its kind to examine this willingness to refuse sex and explore how it evolves during the transition to adulthood. They find that young women follow three trajectories in their willingness to refuse unwanted sex: confident, moderate, and reluctant.
Northern Ireland’s Abortion Laws Have Negative Consequences for Women’s Health and Wellbeing
Abigail R.A. Aiken, Elisa Padron, Kathleen Broussard, and Dana Johnson, October 2018
Abortion is not legal in Northern Ireland, except to preserve a pregnant woman’s life or to prevent permanent damage to her physical or mental health. Despite this, women who live in Northern Ireland have abortions. Unless they qualify for one of the few legal exceptions, women obtain a clinic-based abortion by traveling to a country where abortion is legal or they use telemedicine to access medications to self-manage an abortion at home. Reporting on 30 in-depth interviews with women living in Northern Ireland, PRC faculty research associate Abigail R.A. Aiken, undergraduate student Elisa Padron and PRC graduate student trainees Kathleen Broussard and Dana Johnson show that Northern Irish women experience travel barriers, fear and anxiety surrounding the criminalization of self-managed abortion, and a breakdown of the doctor-patient relationship that isolates women and prevents them from seeking care and support through the Northern Irish healthcare system.
Community College Students Want to Use More Effective Birth Control Methods But Can’t Always Get What They Want
Kristine Hopkins, Celia Hubert, Kate Coleman-Minahan, Amanda Jean Stevenson, Kari White, Daniel Grossman, and Joseph E. Potter, April 2018
Female community college students who have a child while in college are 65% more likely to drop out than those who don’t. This brief, from researchers with the Texas Policy Evaluation Project, shows that a large percentage of community college students want to use more effective contraceptive methods, but many aren’t using them, often due to access barriers. Several strategies are recommended to help community college students have children when they are ready for them, thus improving their chances of successfully completing college.
The Impact of Information about Abortion Safety on Texas Voters’ Opinions about Restrictive Laws
Kari White, Daniel Grossman, Amanda Jean Stevenson, Kristine Hopkins, and Joseph E. Potter, February 2018
A substantial gap exists between the scientific evidence demonstrating the safety of abortion in the United States and public opinion about abortion safety. But recent studies suggest that it may be possible to change perceptions about health issues that are based on misinformation. This brief, by researchers from the Texas Policy Evaluation Project, demonstrates that informational statements about the safety of office-based abortion care as currently practiced in Texas significantly reduced perceptions that ambulatory surgical center and admitting privileges requirements would make abortion safer and reduced support for these requirements.
Women’s Empowerment and Contraceptive Method Use in Egypt
Goleen Samari, October 2017
Egypt’s fertility rate reached a 25-year high of 3.5 births per woman in 2014.It is assumed that women’s empowerment plays an important role in women’s choice of a specific contraceptive method. This research brief, by former PRC postdoctoral fellow Goleen Samari, found that use of long-acting methods fell in Egypt between 2005 and 2014, while use of short-acting methods increased. She also found that women’s empowerment increases the likelihood of contraceptive use in Egypt.
The Impact of the Zika Epidemic on Women’s Reproductive Intentions and Behaviors in Brazil
Letícia J. Marteleto, Abigail Weitzman, Raquel Zanatta Coutinho, and Sandra Valongueiro Alves, October 2017
This research brief, by PRC faculty research associates Leticia Marteleto and Abigail Weitzman and co-authors, reports on a focus group study that explores how and why the Zika virus affects reproductive processes in Brazil. The authors found that both reproductive intentions and behaviors changed as a result of the Zika epidemic among women from low and high socioeconomic status groups in two areas of Brazil. They argue that Brazilian health officials and policymakers should reduce barriers to contraceptive use, address longstanding disparities in reproductive health services that put low-income women at disproportionate risk of an unwanted pregnancy, legalize abortion, and show respect and support to women who actively pursue pregnancy during the Zika epidemic.
Improving Women’s Education Improves Maternal Health: Evidence from Peru
Abigail Weitzman, July 2017
Maternal mortality in Peru declined over 70 percent between 1990 and 2015. Women’s education levels rose during the same period. This brief by PRC faculty research associate Abigail Weitzman indicates that Peruvian women’s rising education levels contributed to falling maternal mortality rates by reducing the risk of maternal complications and increasing the use of modern contraception and reproductive healthcare.
How Greater Travel Distance Due to Clinic Closures Reduced Access to Abortion in Texas
Daniel Grossman, Kari White, Kristine Hopkins, and Joseph E. Potter, February 2017
Texas Policy Evaluation Project investigators demonstrate that increases in travel distance to the nearest abortion clinic caused by clinic closures between 2012 and 2014 were closely associated with decreases in the official number of abortions in Texas. Counties where the distance to the nearest facility increased 100 miles or more between 2012 and 2014 saw a 50% decline in abortions. Meanwhile, counties that did not have an abortion provider in 2014 and did not experience a change in distance to the nearest facility had essentially no change in the number of abortions.
Irish and Northern Irish Women's Experiences with At-Home Medical Abortion Using Online Telemedicine
Abigail R. A. Aiken, December 2016
PRC faculty research associate Abigail Aiken reports on work with colleagues in which they analyzed six years of data from Irish and Northern Irish women who requested and accessed abortion pills using the online telemedicine service Women on Web (WoW). The aim of the study was to learn about who requests and accesses abortion using online services and their experiences both with their unwanted pregnancies and their abortions. This brief was submitted to the Irish Citizens' Assembly, where it is currently being considered as key evidence in the decision about whether to call a referendum to repeal the 8th amendment to the Irish Constitution.
