Amita Toprani, MD, MPH New York City Department of Health & Mental Hygiene EIS Field Assignments Branch Centers for Disease Control and Prevention CSTE Conference June 4, 2012 Patient Characteristics of Repeat Induced Terminations of Pregnancy — New York City, 2010 Office of Surveillance, Epidemiology, and Laboratory Services Scientific Education and Professional Development Program Office

Why Study Repeat Abortions?  Majority of abortions result from unintended pregnancy  Repeat abortion = repeat unintended pregnancy  Women undergoing abortion are high risk group for future unintended pregnancy  Little known about women who undergo repeat abortions  Opportunity to provide long-acting reversible contraceptives

Abortions are Reportable to the NYC Bureau of Vital Statistics  NYC Health Code requires abortion reporting  Within 5 days of event  Definition of abortion  Purposeful interruption of intrauterine pregnancy  Intention other than to produce live-born infant  Does not result in live birth  80,000 abortions reported yearly  Estimated to capture 88% of procedures

Abortions are Reportable to the NYC Bureau of Vital Statistics  Healthcare provider or designee completes report form  Self report of past pregnancy outcomes  Abortions, miscarriages, and births  Demographic and socioeconomic data  Patient age  Level of education  Race/ethnicity  Method of payment  Zip code  Marital status

Questions  How common are repeat abortions in New York City?  What characteristics are associated with repeat abortions?

Methods  Inclusion criteria  Procedures among NYC residents  Performed during 2010  Outcome of interest: repeat abortion  Procedure where the patient reported a history of one or more prior abortions  Rates of first and repeat abortion  Age  Race/ethnicity  Neighborhood level poverty

Descriptive Analysis Methods  Proportion of all abortions that are repeat procedures by:  Stratified analysis  Race/ethnicity and neighborhood-level poverty  Patient age  Level of education  Race/ethnicity  Method of payment  Neighborhood-level poverty  Marital status  Number of living children

2010 Abortion Procedures by Total Abortions Obtained Including Current Total AbortionsNumberPercent 132, , , ,1298 ≥56,8959 Total76,614100

2010 Abortion Procedures by Total Abortions Obtained Including Current Total AbortionsNumberPercent 132, , , ,1298 ≥56,8959 Total76, % repeat abortions

Abortion Rates by Age Group New York City, 2010 Repeat First

Abortion Rates by Race/Ethnicity New York City, 2010 Repeat First

Abortion Rates by Race/Ethnicity New York City, 2010 Repeat First 4x Ref

Abortion Rates by Race/Ethnicity New York City, 2010 Repeat First 9x Ref 4x Ref

Abortion Rates by Neighborhood Poverty New York City, 2010 Repeat First

Patient Age and Repeat Abortions

Race/Ethnicity and Repeat Abortions

Poverty and Repeat Abortions

Number of Living Children and Repeat Abortions

Education and Repeat Abortions Among Women Aged ≥25 Years

Payment Method and Repeat Abortions

Marital Status and Repeat Abortions

Percent Repeat Abortions by Race Within Neighborhood Level Poverty Strata

Percent Repeat Abortions by Neighborhood Level Poverty Within Race Strata

 Predictor variables  Outcome: Mean number of prior abortions  Negative binomial regression with single predictor Bivariate Analysis Methods  Patient age  Level of education  Race/ethnicity  Method of payment  Neighborhood-level poverty  Marital status  Number of living children

Bivariate Analyses Variablep value Age< Race/ethnicity< Neighborhood-level poverty< Number of living children< Level of education< Method of payment< Marital status0.7980

 Negative binomial regression  Outcome = mean number of prior abortions  Predictor variables significant in bivariate analyses  Education variable removed due to 21% missing Multivariate Analysis Methods

Multivariate Analysis  All predictors significant after adjustment  Patient age  Number of Living Children  Race/ethnicity  Method of payment  Neighborhood-level poverty

Ratio of Mean Number of Prior Abortions by Patient Age Patient Age (years) Unadjusted Mean Adjusted Ratio < ≥

Ratio of Mean Number of Prior Abortions by Patient Age Patient Age (years) Unadjusted Mean Adjusted Ratio < ≥

Ratio of Mean Number of Prior Abortions by Patient Age Patient Age (years) Unadjusted Mean Adjusted Ratio < ≥

Ratio of Mean Number of Prior Abortions by Race/Ethnicity Race/Ethnicity Unadjusted Mean Adjusted Ratio Asian/Pacific Islander White Non-Hispanic0.821 Other Hispanic Other race Black non-Hispanic Puerto Rican

Ratio of Mean Number of Prior Abortions by Race/Ethnicity Race/Ethnicity Unadjusted Mean Adjusted Ratio Asian/Pacific Islander White Non-Hispanic0.821 Other Hispanic Other race Black non-Hispanic Puerto Rican

Ratio of Mean Number of Prior Abortions by Race/Ethnicity Race/Ethnicity Unadjusted Mean Adjusted Ratio Asian/Pacific Islander White Non-Hispanic0.821 Other Hispanic Other race Black non-Hispanic Puerto Rican

Ratio of Mean Number of Prior Abortions by Neighborhood-level Poverty Neighborhood-level Poverty Unadjusted Mean Adjusted Ratio <10% % % ≥30%

Ratio of Mean Number of Prior Abortions by Neighborhood-level Poverty Neighborhood-level Poverty Unadjusted Mean Adjusted Ratio <10% % % ≥30%

Ratio of Mean Number of Prior Abortions by Neighborhood-level Poverty Neighborhood-level Poverty Unadjusted Mean Adjusted Ratio <10% % % ≥30%

Ratio of Mean Number of Prior Abortions by Number of Living Children Number of Living Children Unadjusted Mean Adjusted Ratio ≥

Ratio of Mean Number of Prior Abortions by Number of Living Children Number of Living Children Unadjusted Mean Adjusted Ratio ≥

Ratio of Mean Number of Prior Abortions by Number of Living Children Number of Living Children Unadjusted Mean Adjusted Ratio ≥

Ratio of Mean Number of Prior Abortions by Payment Method Payment Method Unadjusted Mean Adjusted Ratio Self pay1.001 Medicaid Third-party insurance

Ratio of Mean Number of Prior Abortions by Payment Method Payment Method Unadjusted Mean Adjusted Ratio Self pay1.001 Medicaid Third-party insurance

Ratio of Mean Number of Prior Abortions by Payment Method Payment Method Unadjusted Mean Adjusted Ratio Self pay1.001 Medicaid Third-party insurance

Discussion  Patient age  Number of living children  Race/ethnic disparities  Economic disparities

Limitations  Self report of abortion history  Unit of analysis is abortion event, not woman  Missing values  Cannot exclude medically indicated abortions

Conclusions  Repeat abortions comprised over half of all abortions  Repeat abortion common across all sociodemographic characteristics  Race/ethnicity strongly correlated with repeat abortion

Next Steps  Identify interventions to integrate with abortion visits  Include post-abortion contraception in surveillance  Reduce barriers to provision of long-term contraception  Further research needed on race/ethnic disparities

Office of Surveillance, Epidemiology, and Laboratory Services The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Scientific Education and Professional Development Program Office Acknowledgments New York City Department of Health and Mental Hygiene Centers for Disease Control and Prevention Elizabeth Begier Wenhui Li Sung woo Lim Carolyn Greene Judith Sackoff Cristina Yunzal-Butler Deborah Kaplan Julie Magri Karen Pazol Betsy Cadwell Diana Bensyl

Who is Required to Report?  If event occurs in a hospital or en route thereto  The person in charge of hospital or his or her designee  If event occurs elsewhere than a hospital  The health care practitioner in attendance  or the person in charge of the clinic or hospital with which the practitioner is associated  or the designee of such person in charge  If event is investigated by the Office of the Chief Medical Examiner  A medical examiner within that office

Abortion Rates by Age New York City, 2010 Abortions per 1,000 Women Age (years)1 st AbortionRepeat Abortion < – – – – – – ≥

Abortion Rates by Race/Ethnicity New York City, 2010 Race/Ethnicity Abortions per 1,000 Women 1 st AbortionRepeat Abortion White Non-Hispanic Asian /Pacific Islander Hispanic Black Non-Hispanic

Abortion Rates by Neighborhood Poverty New York City, 2010 Abortions per 1,000 Women Neighborhood Level Poverty1 st AbortionRepeat Abortion <10% –19.9% –29.9% ≥30%

Sensitivity: Number of Terminations Reported NYC Health Department Guttmacher Institute Sensitivity ,673104,53688% ,891103,56586% ,870100,04691% ,469101,75688% Overall360,903409,90388%

VariableMissing Values Prior abortions2,468 (3%) Patient age292 (0.4%) Race/ethnicity4,074 (5%) Neighborhood-level poverty1,460 (2%) Number of living children2,089 (3%) Level of education17,725 (21%) Method of payment3,176 (4%) Marital Status3,253 (4%) Missing Data