Amita Toprani, MD, MPHNew York City Department of Health & Mental

HygieneEIS Field Assignments Branch

Centers for Disease Control and PreventionCSTE Conference

June 4, 2012

Patient Characteristics of Repeat Induced Terminations of Pregnancy — New York

City, 2010

Office of Surveillance, Epidemiology, and Laboratory ServicesScientific 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 Abortions Number Percent

1 32,944 432 19,154 253 11,492 154 6,129 8

≥5 6,895 9Total 76,614 100

2010 Abortion Procedures by Total Abortions Obtained Including Current

Total Abortions Number Percent

1 32,944 432 19,154 253 11,492 154 6,129 8

≥5 6,895 9Total 76,614 100

57%repeat abortions

Abortion Rates by Age GroupNew York City, 2010

Repeat

First

<15 15–17 18–19 20–24 25–29 30–34 35–39 ≥400

5

10

15

20

25

30

35

40

45

Age Group

Abor

tion

Rat

e pe

r 10

00

Wom

en

Abortion Rates by Race/Ethnicity New York City, 2010

0102030405060

Race/Ethnicity

Abor

tion

Rat

e pe

r 10

00

Wom

en

Repeat

First

Abortion Rates by Race/Ethnicity New York City, 2010

0102030405060

Race/Ethnicity

Abor

tion

Rat

e pe

r 10

00

Wom

en

Repeat

First

4x

Ref

Abortion Rates by Race/Ethnicity New York City, 2010

0102030405060

Race/Ethnicity

Abor

tion

Rat

e pe

r 10

00

Wom

en

Repeat

First9x

Ref

4x

Ref

Abortion Rates by Neighborhood Poverty

New York City, 2010

<10% 10 to 19.9% 20 to 29.9% ≥30%0

10

20

30

40

50

60

Neighborhood Level Poverty

Abor

tion

Rat

e pe

r 10

00

Wom

en

Repeat

First

Patient Age and Repeat Abortions

<15 15–17 18–19 20–24 25–29 30–34 35–39 ≥400

2,000

4,000

6,000

8,000

10,000

12,000

14,000

Age Group

Repe

at A

bort

ions

(N

umbe

r)

Patient Age and Repeat Abortions

<15 15–17

18–19

20–24

25–29

30–34

35–39

≥400

2,000

4,000

6,000

8,000

10,000

12,000

14,000

0%10%20%30%40%50%60%70%80%90%100%

Age Group

Repe

at A

bort

ions

(N

umbe

r)

Repe

at A

bort

ions

(Per

cent

)

Patient Age and Repeat Abortions

<15 15–17

18–19

20–24

25–29

30–34

35–39

≥400

2,000

4,000

6,000

8,000

10,000

12,000

14,000

0%10%20%30%40%50%60%70%80%90%100%

Age Group

Repe

at A

bort

ions

(N

umbe

r)

Repe

at A

bort

ions

(Per

cent

)

Patient Age and Repeat Abortions

<15 15–17

18–19

20–24

25–29

30–34

35–39

≥400

2,000

4,000

6,000

8,000

10,000

12,000

14,000

0%10%20%30%40%50%60%70%80%90%100%

Age Group

Repe

at A

bort

ions

(N

umbe

r)

Repe

at A

bort

ions

(Per

cent

)

Race/Ethnicity and Repeat Abortions

05,000

10,00015,00020,00025,000

0%20%40%60%80%100%

Race/Ethnicity

Repe

at A

bort

ions

(Num

ber)

Repe

at A

bort

ions

(Per

cent

)

Poverty and Repeat Abortions

<10% 10 to 19.9%

20 to 29.9%

≥30%02,0004,0006,0008,000

10,00012,00014,00016,00018,00020,000

0%10%20%30%40%50%60%70%80%90%100%

Neighborhood Level Poverty

Repe

at A

bort

ions

(Num

ber)

Repe

at A

bort

ions

(Per

cent

)

Number of Living Children and Repeat Abortions

0 1 2 3 4 ≥50

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

0%10%20%30%40%50%60%70%80%90%100%

Number of Living Children

Repe

at A

bort

ions

(Num

ber)

Repe

at A

bort

ions

(Per

cent

)

Education and Repeat Abortions Among Women Aged ≥25 Years

0

2,000

4,000

6,000

8,000

10,000

12,000

0%10%20%30%40%50%60%70%80%90%100%

Level of Education

Repe

at A

bort

ions

(Num

ber)

Repe

at A

bort

ions

(P

erce

nt)

Payment Method and Repeat Abortions

Self Medicaid Other 3rd Party

0

5,000

10,000

15,000

20,000

25,000

0%10%20%30%40%50%60%70%80%90%100%

Payment Method

Repe

at A

bort

ions

(N

umbe

r)

Repe

at A

bort

ions

(P

erce

nt)

Marital Status and Repeat Abortions

Married Not Married0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

0%10%20%30%40%50%60%70%80%90%100%

Marital Status

Repe

at A

bort

ions

(N

umbe

r)

Repe

at A

bort

ions

(P

erce

nt)

Percent Repeat Abortionsby Race Within Neighborhood Level Poverty

Strata

<10% 10 to 19.9% 20 to 29.9% ≥30%0%10%20%30%40%50%60%70%80%90%

100%Black Non-Hispanic

Puerto Rican

Other Hispanic

White non-Hispanic

Asian-Pacific Is-landers

Neighborhood Level Poverty

Perc

ent

Repe

ats

Percent Repeat Abortionsby Neighborhood Level Poverty Within Race

Strata

0%10%20%30%40%50%60%70%80%90%

100% <10%10 to 19.9%20 to 29.9%≥30%

Race/Ethnicity

Perc

ent

Repe

ats

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

Variable p valueAge <0.0001Race/ethnicity <0.0001Neighborhood-level poverty <0.0001Number of living children <0.0001Level of education <0.0001Method of payment <0.0001Marital status 0.7980

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 AgePatient Age (years)

Unadjusted Mean

Adjusted Ratio

<15 0.18 0.1815-17 0.29 0.2718-19 0.56 0.4920-24 1.06 0.7925-29 1.56 130-34 1.77 1.0635-39 1.72 0.99≥40 1.61 0.95

Ratio of Mean Number of Prior Abortions

by Patient AgePatient Age (years)

Unadjusted Mean

Adjusted Ratio

<15 0.18 0.1815-17 0.29 0.2718-19 0.56 0.4920-24 1.06 0.7925-29 1.56 130-34 1.77 1.0635-39 1.72 0.99≥40 1.61 0.95

Ratio of Mean Number of Prior Abortions

by Patient AgePatient Age (years)

Unadjusted Mean

Adjusted Ratio

<15 0.18 0.1815-17 0.29 0.2718-19 0.56 0.4920-24 1.06 0.7925-29 1.56 130-34 1.77 1.0635-39 1.72 0.99≥40 1.61 0.95

Ratio of Mean Number of Prior Abortions

by Race/Ethnicity

Race/Ethnicity

Unadjusted

Mean

Adjusted

RatioAsian/Pacific Islander 0.77 0.79White Non-Hispanic 0.82 1Other Hispanic 1.10 1.09Other race 1.10 1.15Black non-Hispanic 1.52 1.46Puerto Rican 1.56 1.49

Ratio of Mean Number of Prior Abortions

by Race/Ethnicity

Race/Ethnicity

Unadjusted

Mean

Adjusted

RatioAsian/Pacific Islander 0.77 0.79White Non-Hispanic 0.82 1Other Hispanic 1.10 1.09Other race 1.10 1.15Black non-Hispanic 1.52 1.46Puerto Rican 1.56 1.49

Ratio of Mean Number of Prior Abortions

by Race/Ethnicity

Race/Ethnicity

Unadjusted

Mean

Adjusted

RatioAsian/Pacific Islander 0.77 0.79White Non-Hispanic 0.82 1Other Hispanic 1.10 1.09Other race 1.10 1.15Black non-Hispanic 1.52 1.46Puerto Rican 1.56 1.49

Ratio of Mean Number of Prior Abortions

by Neighborhood-level Poverty

Neighborhood-level Poverty

Unadjusted

MeanAdjusted

Ratio<10% 0.99 110-19.9% 1.20 1.1020-29.9% 1.28 1.10≥30% 1.45 1.17

Ratio of Mean Number of Prior Abortions

by Neighborhood-level Poverty

Neighborhood-level Poverty

Unadjusted

MeanAdjusted

Ratio<10% 0.99 110-19.9% 1.20 1.1020-29.9% 1.28 1.10≥30% 1.45 1.17

Ratio of Mean Number of Prior Abortions

by Neighborhood-level Poverty

Neighborhood-level Poverty

Unadjusted

MeanAdjusted

Ratio<10% 0.99 110-19.9% 1.20 1.1020-29.9% 1.28 1.10≥30% 1.45 1.17

Ratio of Mean Number of Prior Abortions

by Number of Living Children

Number of Living Children

Unadjusted

MeanAdjusted

Ratio0 0.56 11 1.56 2.032 1.93 2.323 2.11 2.474 2.21 2.50≥5 2.50 2.78

Ratio of Mean Number of Prior Abortions

by Number of Living Children

Number of Living Children

Unadjusted

MeanAdjusted

Ratio0 0.56 11 1.56 2.032 1.93 2.323 2.11 2.474 2.21 2.50≥5 2.50 2.78

Ratio of Mean Number of Prior Abortions

by Number of Living Children

Number of Living Children

Unadjusted

MeanAdjusted

Ratio0 0.56 11 1.56 2.032 1.93 2.323 2.11 2.474 2.21 2.50≥5 2.50 2.78

Ratio of Mean Number of Prior Abortions

by Payment Method

Payment Method

Unadjusted

MeanAdjusted

RatioSelf pay 1.00 1Medicaid 1.39 1.16Third-party insurance 1.44 1.19

Ratio of Mean Number of Prior Abortions

by Payment Method

Payment Method

Unadjusted

MeanAdjusted

RatioSelf pay 1.00 1Medicaid 1.39 1.16Third-party insurance 1.44 1.19

Ratio of Mean Number of Prior Abortions

by Payment Method

Payment Method

Unadjusted

MeanAdjusted

RatioSelf pay 1.00 1Medicaid 1.39 1.16Third-party insurance 1.44 1.19

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

AcknowledgmentsNew York City

Department of Health and Mental Hygiene

Centers for Disease Control and Prevention

Elizabeth BegierWenhui Li

Sung woo LimCarolyn GreeneJudith Sackoff

Cristina Yunzal-ButlerDeborah Kaplan

Julie MagriKaren Pazol

Betsy CadwellDiana 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 AgeNew York City, 2010

Abortions per 1,000 WomenAge (years) 1st Abortion Repeat Abortion<15 3.9 0.5715–17 21.1 5.918–19 39.2 23.820–24 29.7 37.525–29 16.5 32.030–34 11.0 25.035–39 7.0 16.1≥40 3.0 6.2

Abortion Rates by Race/Ethnicity New York City, 2010

Race/Ethnicity

Abortions per 1,000 Women1st

Abortion Repeat Abortion

White Non-Hispanic 6.8 5.6Asian /Pacific Islander 8.6 6.6

Hispanic 18.1 25.9

Black Non-Hispanic 27.6 52.5

Abortion Rates by Neighborhood Poverty

New York City, 2010

Abortions per 1,000 WomenNeighborhood Level Poverty 1st Abortion Repeat Abortion

<10% 9.22 9.39

10–19.9% 14.24 18.08

20–29.9% 16.15 22.96

≥30% 22.06 37.12

Sensitivity: Number of Terminations Reported

NYC Health Department

GuttmacherInstitute

Sensitivity

2004 91,673 104,536 88%2005 88,891 103,565 86%2007 90,870 100,046 91%2008 89,469 101,756 88%Overall 360,903 409,903 88%

Variable Missing Values

Prior abortions 2,468 (3%)Patient age 292 (0.4%)Race/ethnicity 4,074 (5%)Neighborhood-level poverty 1,460 (2%)Number of living children 2,089 (3%)Level of education 17,725 (21%)Method of payment 3,176 (4%)Marital Status 3,253 (4%)

Missing Data