Abortion Surveillance in the United States:

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					Abortion Surveillance in the
United States:
Future Directions and Challenges
                    Karen Pazol, PhD, MPH
                    Maternal and Infant Health Branch
                      Division of Reproductive Health
   National Center for Chronic Disease Prevention and Health Promotion
                Centers for Disease Control and Prevention



                                   Gateway to the Future:
                       Improving the National Vital Statistics System
                        St. Louis, MO    June 6th – June 10th, 2010
Abortion data are important for
monitoring reproductive health
   Combined with data on births and fetal losses
    to calculate pregnancy rates
   Monitor clinical practice patterns and
    changes in use of procedures over time
   Guide efforts to reduce unintended
    pregnancy and assess the impact of changes
    in policy and the implementation of family
    planning programs

                              Gateway to the Future:
                  Improving the National Vital Statistics System
                   St. Louis, MO    June 6th – June 10th, 2010
    Organizations collecting abortion
    data in the United States
                                                         Information
 Organization Data Source Origin of Data                 Obtained           Dates
CDC, NCCDPHP State Vital     Individual records Aggregate                   Annually, 1969 -
Division of Rep. Statistics  from abortion               report: N’s +      present
Health           Agencies    providers                   basic traits
Guttmacher       Abortion    Counts from                 Total N’s          Periodically,
Institute        Provider    abortion providers                             1974 -present
                 Survey
                 Abortion    Responses from              Basic traits       1987, 1994,
                 Patient     women seeking                                  2000, 2008
                 Survey      abortion
NCHS             National    Responses from              N’s + basic        1982, 1988,
                 Survey of   reproductive aged traits                       2001, & 2006 -
                 Family      women                                          2008
                 Growth
                 State Vital Individual records N’s + basic                 1978 -1994
                 Statistics  from abortionthe Future:
                                        Gateway to       traits
                 Agencies Improving the National Vital Statistics ,System
                             providers June 6th – June 10th 2010
                             St. Louis, MO
Talk overview
   CDC’s Abortion Surveillance System and its
    strengths
   Challenges of combining data collected
    through independent state-run systems
   Efforts to facilitate work carried out in the
    states and integrate data collected through
    independent systems


                               Gateway to the Future:
                   Improving the National Vital Statistics System
                    St. Louis, MO    June 6th – June 10th, 2010
CDC’s Abortion Surveillance System
   Each year CDC requests aggregate data from
    the 50 states, NY City and DC
   Legally mandated and voluntary elements
       Most states (N=47) require provider reporting
       States submit data to CDC voluntarily, yet
        participation is high (N=49 areas in 2007)
   Most but not all states have a reporting system
       Prior to 1997, five states had no system
       Prior to 1998, CDC conducted surveys in
        hospitals and other abortion facilities
                                Gateway to the Future:
                    Improving the National Vital Statistics System
                     St. Louis, MO    June 6th – June 10th, 2010
CDC compiles abortion data on a
consistent annual basis
       Calendar years with abortion counts

0.61

0.59

0.57

0.55

0.53

0.51

0.49

0.47

0.45




       Guttmacher Institutethe Future:CDC
                         Gateway to
               Improving the National Vital Statistics System
                        St. Louis, MO   June 6th – June 10th, 2010
CDC compiles information on a wide
range of variables
   Information collected by CDC:
       Gestational age                ●   Maternal ethnicity
       Procedure type                 ●   Marital status
       Place of Residence             ●   Number prior births
       Maternal age                   ●   Number prior
       Maternal race                      abortions
   CDC proportions are applied to Guttmacher
    Institute total counts to estimate the incidence
    of abortion within population subgroups

                                Gateway to the Future:
                    Improving the National Vital Statistics System
                     St. Louis, MO    June 6th – June 10th, 2010
CDC counts closely track results from
the Guttmacher Patient Survey
        Percentage distribution of abortions - measured
  50%     by CDC and the Guttmacher Institute, 2000

  40%

  30%

  20%

  10%

  0%
         <15 15-19 20-24 25-29 30-34 35-39 ≥ 40                  0       1     ≥2

                        maternal age (yrs)                       prior live births
                                    Gateway to the Future:
                        Improving the National Vital Statistics System
                  CDC                        Guttmacher Institute
                         St. Louis, MO    June 6th – June 10th, 2010
Talk overview
   CDC’s Abortion Surveillance System and its
    strengths
   Challenges of combining data collected
    through independent state-run systems
   Efforts to facilitate work carried out in the
    states and integrate data collected through
    independent systems


                               Gateway to the Future:
                   Improving the National Vital Statistics System
                    St. Louis, MO    June 6th – June 10th, 2010
CDC does not obtain abortion counts
from all 52 reporting areas
   % contribution of areas that reported to CDC
        # the Guttmacher Institute totals
        toareas contributing to CDC totals
  52
 100%

  42
 80%

  32
 60%
  22
 40%
  12

 20%
   2

             1978 1983 1988 to1993 1998 2003
                                  Gateway the Future:
                      Improving the National Vital Statistics System
                                        June 6th – & other abortion facilities
   Central reporting agency MO Hospitals June 10th, 2010
                       St. Louis,
States vary considerably in the
completeness of reporting
CDC counts by state as a percentage of Guttmacher Institute counts
     Voluntary reporting                            69%
      2000 (N=4)

                                   35%
     2005 (N=3)

     Mandatory reporting                                                96%
     2000 (N=44)

                                                                        96%
     2005 (N=45)



               0%           25% Gateway to50%Future:
                                          the                  75%       100%
                       Improving the National Vital Statistics System
                        St. Louis, MO    June 6th – June 10th, 2010
Active outreach to abortion providers
can improve reporting
                                                Reported abortions, 1993-2006
                                    12                                                                        1,000



                                    10
                                                                                                              800
   # reported in Colorado x 1,000




                                                                                                                      # reported in the US x 1,000
                                    8
                                                                                                              600

                                    6

                                                                                                              400
                                    4


                                                                                                              200
                                    2



                                    0                                                                         0

                                         1993    1995     1997       1999       2001
                                                                    Gateway to the Future: 2003        2005
                                                        Improving the National Vital Statistics System
                                           Colorado            Continuously reporting areas in the US
                                                         St. Louis, MO    June 6th – June 10th, 2010
States vary in the amount of
information they collect




                        Gateway to the Future:
            Improving the National Vital Statistics System
             St. Louis, MO    June 6th – June 10th, 2010
States vary in the amount of
information they collect
                          Number of reporting areas and percentage
                              of abortions categorized, 2007
                     60                                                               100%




                                                                                             % of total abortions categorized
                     50
                                                                                      80%
 # reporting areas




                     40
                                                                                      60%
                     30
                                                                                      40%
                     20

                                                                                      20%
                     10


                     0                                                                0%




                                                 Gateway to the Future:
                                     Improving the National Vital Statistics System
                                      St. Louis, MO    June 6th – June 10th, 2010
States vary in the level of detail
provided for each variable
        Number areas reporting by procedure and
       with medical abortion as a separate category
  50

  40


  30


  20
                              FDA approval of
                              medical abortion
  10

   0
         1997          1999                        2003
                                       2001 to the Future:
                                        Gateway
                                                                  2005          2007
                        Improving
       reported by procedureLouis, the National Vital Statistics ,System
                         St.
                             typeMO medical abortion 2010
                                           June 6th – June 10th
                                                                   separate category
States vary in the level of detail
provided for each variable
                                 Level of detail - residence status, 2007
                          100%
                                            87%
                          80%
% of reported abortions




                          60%


                          40%


                          20%
                                                                                                      12%
                                                                         1%
                           0%
                                 Assigned to 1 of 50 states, Out-of-state but exact               Unknown residence
                                   District of Columbia,                   the specified
                                                               Gateway tonot Future:
                                                               residence
                                                     Improving the National Vital Statistics System
                                     Canada or Mexico Louis, MO June 6th – June 10th, 2010
                                                       St.
Talk overview
   CDC’s Abortion Surveillance System and its
    strengths
   Challenges of combining data collected
    through independent state-run systems
   Efforts to facilitate work carried out in the
    states and integrate data collected through
    independent systems


                               Gateway to the Future:
                   Improving the National Vital Statistics System
                    St. Louis, MO    June 6th – June 10th, 2010
Analyses of trends over time based
on continuously reporting areas




                        Gateway to the Future:
            Improving the National Vital Statistics System
             St. Louis, MO    June 6th – June 10th, 2010
Analyses of trends over time based
on continuously reporting areas




                        Gateway to the Future:
            Improving the National Vital Statistics System
             St. Louis, MO    June 6th – June 10th, 2010
Revised analyses retain
compatibility with current reporting




                        Gateway to the Future:
            Improving the National Vital Statistics System
             St. Louis, MO    June 6th – June 10th, 2010
Revised analyses retain
compatibility with current reporting
Medical (Nonsurgical) Abortion:
A procedure (that) involves the administration of a
medication or medications to induce an abortion.
Medications (e.g., methotrexate, mifepristone,
misoprostol, etc.) are used most frequently early in
the first trimester of pregnancy. However, some
medications (e.g., prostaglandin suppositories,
injectable prostaglandins, etc.) may be administered
during the second trimester of pregnancy to induce
abortion.
                              Gateway to the Future:
                  Improving the National Vital Statistics System
                   St. Louis, MO    June 6th – June 10th, 2010
Revised analyses retain compatibility
with current reporting
                                                 Medical Abortions, 2007
                                         Total # and percentage of all abortions
                                            reported by weeks of gestation
                               50,000                                                                     50%




                                                                                                                % of all abortions reported as medical
# medical abortions reported




                               40,000                                                                     40%


                               30,000                                                                     30%


                               20,000                                                                     20%


                               10,000                                                                     10%


                                   0                                                                      0%
                                        ≤6   7   8   9          Gateway to 15 16
                                                         10 11 12 13 14 the Future:17 18 19 20 ≥21
                                                         Improving the National Vital Statistics System
                                                                   weeks of gestation
                                                          St. Louis, MO    June 6th – June 10th, 2010
Revised analyses retain compatibility
with current reporting




                        Gateway to the Future:
            Improving the National Vital Statistics System
             St. Louis, MO    June 6th – June 10th, 2010
Revised analyses retain
compatibility with current reporting




                        Gateway to the Future:
            Improving the National Vital Statistics System
             St. Louis, MO    June 6th – June 10th, 2010
Revised analyses retain compatibility
with current reporting
                                Abortions cross-classified by race-ethnicity,
                          # of reporting areas and percentage of total abortions
                     25                                                                   100%



                     20                                                                   80%




                                                                                                 % of reported abortions
 # reporting areas




                     15                                                                   60%



                     10                                                                   40%



                     5                                                                    20%



                     0                                                                    0%
                                      2006           Gateway to the Future:2007
                                         Improving the National Vital Statistics System
                                                  reporting yearth
                                          St. Louis, MO    June 6 – June 10th, 2010
CDC efforts to understand state
systems and enhance collaboration
   Establish improved dialogue with state
    vital statistics departments
   Increase the compatibility of CDC data
    requests with state data systems
   Develop more efficient methods for
    transferring aggregate reports to CDC


                             Gateway to the Future:
                 Improving the National Vital Statistics System
                  St. Louis, MO    June 6th – June 10th, 2010
Conclusions
 CDC has compiled the most consistent
  annual record of abortions
 CDC collects important information on
  maternal demographics, procedure type
  and gestational age
 CDC faces many challenges in combining
  data from 52 independent sources

                          Gateway to the Future:
              Improving the National Vital Statistics System
               St. Louis, MO    June 6th – June 10th, 2010
Conclusions
   Attempts to overcome variation and
    improve surveillance:
       Trends based on continuously reporting areas
       Revisions to analyses compatible with current
        reporting formats
       Increase communication and understanding of
        state systems to enhance collaboration


                                Gateway to the Future:
                    Improving the National Vital Statistics System
                     St. Louis, MO    June 6th – June 10th, 2010
Acknowledgements
   Douglas Cook, CDC                       Elizabeth Nash,
                                             Guttmacher
   Sonya Gamble, CDC                        Institute
   Laura Hall, CDC                         Mary Chase,
   Saeed Hamdan, CDC                        Colorado
                                             Department of
   Wilda Parker, CDC                        Public Health &
   Suzanne Zane, CDC                        Environment



                            Gateway to the Future:
                Improving the National Vital Statistics System
                 St. Louis, MO    June 6th – June 10th, 2010

				
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