Abortion and Repeat Abortion in Grampian

Abortion and Repeat Abortion In Grampian

A report for the Sexual Health and Blood Borne Virus Managed Care Network (MCN) NHS Grampian March 2015

This document is also available in large print and other formats and languages upon request. Please call NHS Grampian Corporate Communications on (01224) 551116 or (01224) 552245.

Contents

Page Acknowledgements 1 Glossary 2 Foreword 3 Recommendations 4 Introduction 5

Section 1: Abortions in Grampian (2009-2013) 6 1. Background 6 2. Overview of abortion rates in Grampian: ISD Data 6 2.1 Grounds for abortion 7 2.2 Abortion rates and deprivation 8 3. Abortion rates by age and local authority area 9 3.1 Aberdeen City 9 3.2 Aberdeenshire 9 3.3 Moray 11 4. Abortion rates by intermediate zone 11 4.1 Aberdeen City 11 4.2 Aberdeenshire 12 4.3 Moray 13 5. Abortion rates by deprivation 15 5.1 Aberdeen City 15 5.2 Aberdeenshire 15 5.3 Moray 15 6. Abortion rates by GP cluster zone 17 6.1 Aberdeen 17 6.2 Aberdeenshire 17 6.3 Moray 17 7. Travel times to Aberdeen Royal Infirmary and Dr Grays 19 8. Key Findings 22

Section 2: Repeat abortions in Grampian (2010-2013) 23 1. Background 23 2. Results: Analysis of the Grampian TOP Database 23 2.1 Comparison of characteristics of women with 24 single and multiple abortions 2.2 Multivariate analysis 24

Section 3: International Systematic Review – Determinant 29 factors of repeat abortion

1. Background 29 1.1 Definitions 30 2. Systematic review 30 2.1 Systematic review methods 30 2.2 Scope of the review 30 2.3 Search strategy 31 2.4 Inclusion Criteria 31 2.5 Exclusion Criteria 31 2.6 Data extraction and assessment for study inclusion 31 3. Results 32 4. Data synthesis 38 4.1 Familial factors 38 4.1.1 Socioeconomic status 38 4.1.2 Ethnicity 39 4.1.3 Education 39 4.2 Urbanisation and rurality 40 4.3 Individual level factors 40 4.3.1 Age 40 4.4 Age at first pregnancy 41 4.5 Marital status 41 4.6 Relationship 42 4.7 Previous obstetric history 42 4.8 Contraception usage 43 4.8.1 Comparison with one abortion 43 4.8.2 Contraceptive method 43 4.8.3 Comparison with no abortion 44 4.8.4 Emergency contraception 45 4.8.5 Contraceptive usage post abortion 45 4.9 Sexual behaviour 45 4.9.1 Intentions and motivations 45 4.10 Psychosocial 46 4.10.1 Mental illness 46 4.10.2 Abuse 46 4.10.3 Substance abuse 47 4.10.4 Smoking 47 4.10.5 Adverse life events 47 4.10.6 Sexual health and past medical history 48 4.10.7 Intervention studies 48 5. Discussion 48 5.1 Principle findings 48 5.1.1 Systematic review 48 5.1.2 Secondary data analysis 50

5.2 Strengths and limitations 50 5.2.1 Systematic review 50 5.2.2 Secondary data analysis 51 5.3 Context of findings from secondary analysis 51

References 53

Appendices

Acknowledgements

This report is produced on behalf of the Grampian Managed Care Network for Sexual Health and Blood Borne Viruses led by Executive Lead, Dr Emmanuel Okpo. Data on Abortions in Grampian were compiled by Rochelle Morgan, Senior Analyst, NHS Grampian and Sarah Shanks, Public Health Locum Associate Specialist, NHS Grampian.

Data on repeat abortions and investigation into the determinants of repeat abortion were compiled by a team based at the University of Aberdeen. Thanks are therefore expressed to the principle investigator Dr Sohinee Bhattacharya and co-investigators Dr Mari Imamura and Dr Gillian Flett. Mr Stephen McCall, Dr Umi Nursheila Nur Ibrahim and Dr Emmanuel Okpo are also noted for their contribution as authors.

Finally, special thanks to Dr Sue Brechin, Consultant in Sexual and Reproductive Health for reviewing the report and Lisa Allerton, Public Health Researcher for reviewing and compiling the final report.

Glossary

AOR Adjusted Odds Ratio ARI Aberdeen Royal Infirmary BBV(s) Blood Borne Virus(es) CI Confidence Interval CMO Chief Medical Officer COC Combined Oral Contraception EMBASE Excerpta Medica dataBase ISD Information Services Division HIS Health Improvement Scotland IUD Intrauterine Device IUS Intrauterine System LARC Long Acting Reversible Contraception MEDLINE Medical Literature Analysis and Retrieval System Online MeSH Medical Subject Heading NHS National Health Service RCOG Royal College of Obstetrics and Gynaecology SH&BBV(s) Sexual Health and Blood Borne Virus(es) SIMD Scottish Index of Multiple Deprivation SMR1 Scottish Morbidity Record STI(s) Sexually Transmitted Infection(s) TOP Termination of Pregnancy UK United Kingdom US United States WHO World Health Organization

Foreword

The Managed Care Network (MCN) for Sexual Health and Blood Borne Viruses in Grampian brings together partners from across the NHS, local authorities and the third sector. The overall objective of the MCN is to plan and review actions to promote health, prevent, diagnose and treat ill health as a result of sexually transmitted infections, blood borne viruses and unintended pregnancies. Abortion and repeat abortion are a direct consequence of unintended and unwanted pregnancy.

In order to better understand the current patterns and trends of abortion and repeat abortion in Grampian, a review, culminating in this report, was undertaken. In Grampian, we are fortunate to have excellent data collection on abortions locally through the Grampian Termination of Pregnancy (TOP) Database. This database collects rich data which allows us to look further than nationally collected data which is published annually by NHS Information Services Division (ISD). Moreover, our academic colleagues at the University of Aberdeen have also assisted us with adding to our knowledge base by looking at factors associated with repeat abortions, something which is of particular concern to us here in Grampian.

Our review has confirmed that abortion is linked to deprivation and younger women (15-24) are more likely to attend for abortion. We also know that the contextual factors surrounding abortion and repeat abortion are multifaceted with family stability, education, contraceptive use, relationship stability and psychosocial factors all impacting on increased risk of abortion. However, this report provides us with an evidence base from which we can set our direction for the future starting with the recommendations for improvement and further investigation.

There is a lot of information contained in this report and it is the responsibility of the MCN, within the context of the Grampian Sexual Health and Wellbeing and Blood Borne Virus Strategy, to consider this and take forward the recommendations. The MCN manager can be contacted on (01224) 558569.

We would like to thank everyone who contributed to this needs assessment and all those who gave freely of their time.

Susan Webb, Emmanuel Okpo, Deputy Director of Public Health Consultant in Public Health Medicine

Recommendations

1. Results suggest that some intermediate zones have increased rates of abortion which is at odds with our local knowledge of population demographics and deprivation. Therefore rates of abortion by intermediate zone warrants further investigation.

2. In Grampian, abortion rates are highest in the age group 15-24 years and women are more likely to have a repeat abortion if they had their first abortion at a young age (under 20 years old). Being sexually active at a younger age therefore may expose women to an increased risk of conception and subsequent abortions during their reproductive years. Consideration should be given to how best to engage with young women who are sexually active at a young age to assist them in planning pregnancies and to reduce the risk of unplanned pregnancy.

3. Literature suggests that there is a strong association between older age and repeat abortion. It is unclear whether this is because by definition women at a repeat abortion will be older or if this represents a group of women who are more likely to attend for further abortion(s) due to other factors such as increased parity which has been shown to increase repeat abortion. This requires further investigation.

4. Results indicate that most women use a form of contraception prior to their repeat abortion. Although ‘self-reported method failure’ is collected locally, detailed information on the circumstances of failure and whether the repeat abortion was due to ‘true method failure’ or ‘ presumed user failure’ would be useful to collect to assist in developing tailored contraceptive advice and counselling following repeat abortion.

5. There was some evidence in the literature that the use of LARC post abortion reduces the risk of further abortions. Evidence from our local dataset contradicted this. Women attending for repeat abortion in Grampian who had left with a LARC method following a first abortion were significantly more likely to have a repeat abortion. Investigation into LARC uptake, continued use and reasons for discontinuation following abortion in Grampian is required.

6. There appears to be an association between psychosocial factors and repeat abortion. At present psychosocial factors are not recorded in the TOP database. This should be considered for future research purposes.

7. Studies suggest that women from lower socioeconomic quintiles have an increased likelihood of repeat abortion. This is consistent with our own local data and ISD data. This has public health implications in terms of addressing inequalities in health and wellbeing in addition to accessing sexual health services. As such, careful thought should be given to how best to target women who are considered to be at increased risk of repeat abortion, particularly those who live in the most deprived quintiles.

8. Further clarification and investigation is required to establish actual versus indicated travel time to specialist sexual health services for women undergoing an abortion.

Introduction

Reducing the number of abortions is central to achieving the national outcomes as outlined in the Sexual Health and Blood Borne Virus (SH& BBV) Framework for Scotland (Scottish Government, 2011).

Induced abortion is carried out under the terms of the Abortion Act 1967 which applies to England, Scotland and Wales. There is a legal requirement to notify the Chief Medical Officer (CMO) of all terminations carried out in Scotland. The Information Services Division (ISD) is responsible for the collation of data derived from notifications of abortions. ISD data indicates that abortion rates in Grampian are higher than the Scottish national average.

Whilst current information published by ISD on abortions provides an overall Grampian and local authority area perspective, further analysis of the data is required in order to understand the epidemiology of abortion within the Grampian area. Analysis of the data by intermediate zones, postcode areas and age groups would enable interventions to be targeted to where the potential impact would be greatest and ensure effective services are being provided where required. Section 1 of this report concentrates on providing localised data on abortion in Grampian using data from the Grampian Termination of Pregnancy (TOP) Database.

Repeat abortions in Grampian are an increasing area of concern. Recent ISD data suggests that approximately 33% of all abortions occurring in Grampian are among women who have had one or more previous abortions. Using two methodologies, this report aims to investigate the determinant factors for repeat abortion by analysing the local dataset to explore factors associated with repeat abortion specifically in the Grampian region of Scotland and by systematically reviewing the published literature worldwide. Section 2 reports the findings of our local dataset (TOP) on repeat abortions; Section 3 concentrates on reviewing the literature around determinant factors for repeat abortions.

Section 1: Abortions in Grampian (2009-2013) [Authors: Sarah Shanks, Lisa Allerton, Emmanuel Okpo]

1. Background Currently, data at the local level is available from NHS Grampian Termination of Pregnancy (TOP) database. This database is hosted by the University of Aberdeen. In order to obtain a more in depth picture of abortion within Grampian, an analysis was carried out on data from 2009 to 2013. The data was obtained from:

• NHS Grampian TOP Database for all abortions in Aberdeen City and Aberdeenshire • Scottish Morbidity Record One (SMR1) data for all abortions in Moray as the TOP database only contains a small number of abortions from Moray. Data requested included year of abortion, Community Health Index (CHI) number, age at time of abortion and postcode. The postcode information was used to identify the patients and their local authority area of residence and intermediate zone and to determine Scottish Index of Multiple Deprivation (SIMD) quintile. Furthermore the patients’ GP practices were identified using CHI numbers in combination with postcode of residence. Crude abortion rates were calculated using female population at risk for each age category where possible. Abortion numbers are presented as well. However, caution should be employed when interpreting abortion numbers. This is because the number of abortions in any given population reflects the changing size of that population, such that if the population grows, the number of abortions will grow. Thus more women having abortions does not necessarily mean that women are having more abortions. Travel times from patients’ residence to Aberdeen Royal Infirmary (ARI) and Dr Grays Hospital in Elgin have been estimated.

Using available data from the TOP database and SMR1 data, this report describes all abortions in Aberdeen City, Aberdeenshire and Moray.

2. Overview of abortion rates in Grampian: ISD data Overall the abortion rates in Grampian have remained stable over the past 10 years, albeit with slight increased rates in 2007 and 2008. The rate for Grampian has consistently been higher than the overall Scottish rate for the past 10 years with the exception of 2011(Figure 1).

Figure 1: Abortion rate in Grampian 2004-2013, per 1000 females aged 15-44 years. 16 14 12 10 8

44 6 4 2 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Rate per 1000 females aged 15- aged females 1000 per Rate Year

Grampian Scotland

Source ISD, Abortion Statistics Report, 2014

2.1 Grounds for abortion A full outline of the categories pertaining to ‘grounds for abortion’ is given in Appendix 1. In 2013 the vast majority of abortions in Grampian and Scotland were carried out under Ground C (97.3% and 98.6% respectively), where ‘the pregnancy has not exceeded its 24 th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, or injury to the physical or mental health of the pregnant woman’ (Table 1). A small percentage of abortions in Grampian (2.4%) were carried out under Ground E, where ‘there is substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped’. The percentage of abortions across Scotland carried out under the same ground was 1.2%.

Table 1: Abortions performed by Grounds, 2013 Grounds for Scotland Grampian

abortion Number % Number %

A, B, F,G * * * *

C 11614 98.6 1352 97.3

D 18 0.2 * *

E 142 1.2 34 2.4

Source ISD, Abortion Statistics Report 2014 * Indicates that values that have been suppresses due to potential risk of disclosure

2.2 Abortion rates and deprivation There is a strong association between abortion and level of deprivation. In 2013 the rate of abortion across Scotland in areas of high deprivation was 75% higher than the rate for the least deprived areas; 14.4 per 1,000 women compared to 8.2 per 1,000 women respectively (Figure 2).

The trend in Grampian is similar. In 2013 the highest rate of abortion was seen in the most deprived area (19.7 per 1,000 women). This was double the lowest rate seen in the second least deprived area (9.7 per 1,000 women).

The rate of abortion in Grampian was higher than the rate across Scotland in all quintiles in 2013. The biggest difference in rates was seen in the second most deprived quintile where the rate in Grampian was 49% greater than the rate in Scotland at 18.9 per 1,000 women and 12.7 per 1,000 women respectively.

Figure 2: Abortions in Grampian by SIMD Quintiles, 2013. Rate per 1000 women (15-44 years).

25.0

20.0

15.0

10.0 aged 15-44 aged

5.0 Rate per 1000 women 1000 per Rate

- 1 - Most 2 3 4 5 -Least deprived deprived National SIMD Quintiles Scotland Grampian

Source ISD, Abortion Statistics Report, 2014

3. Abortion rates by age and local authority area Abortion rates in Aberdeen City and Aberdeenshire have been decreasing since 2009 (Figure 3). In Moray, after an initial increase in the abortion rate in 2010, it has declined over the following 4 years; however this trend should be interpreted with caution due to small numbers. The abortion rate in Aberdeen City has remained consistently higher than the rate in Aberdeenshire and Moray throughout the 5 year period.

3.1 Aberdeen City The rate of abortions from 2009-2013 has been consistently highest in younger women, aged 15-19 and 20-24 with lower rates seen in the older age groups, 30-34, 35-39 and 40-44 (Figure 4). The rate of abortion has decreased across the 5 year period from 2009-2013 in all but the 35-39 and the 40-44 age group, which have shown a 9.5% and 20% increase respectively. The fall in abortion rates between 2009 and 2013 has been greatest in the youngest women, with a 37.3% reduction in the 15-19 age group. In 2013 the highest rate of abortion was seen in the 20-24 age group (18.3 per 1,000 women). This is lower than the overall average rate across Scotland for the same age group (19.1 per 1,000 women).

3.2 Aberdeenshire The rate of abortion has been consistently highest in the 20-24 age group across the 5 year period from 2009 to 2013 (Figure 5). This age group has seen a decrease in rate of abortion in this time from 20.9 per 1,000 in 2009 to 17.5 per 1,000 in 2013. The older women, aged 30-34, 35-39 and 40-44 have consistently had the lowest rates of abortion with the rates remaining fairly consistent in the 35-39 and 40-44 age groups and a 22% decrease in rate from 2009 to 2013 in the 30-34 age group. The biggest decrease in rate from 2009 to 2013 was seen in the youngest women, aged 15-19, with a 38% reduction in rates.

Figure 3: Abortion rate by Local Authority Area 2009-2013. Rate per 1000 females aged 15-44 years.

16.0 14.0 12.0 10.0 8.0

aged 15-44 aged 6.0 4.0

Rate per 1000 females 1000 per Rate 2.0 0.0 2009 2010 2011 2012 2013 Aberdeen City 14.5 13.9 12.9 12.8 12.1 Aberdeenshire 11.3 11.3 10.1 9.8 9.2 Moray 6.5 9.2 8.8 9.6 8.7

Year

Source: Aberdeen University TOP database

Figure 4: Abortion rate by age group, Aberdeen City 2009-2013. Rate per 1000 females aged 15-44 years.

30.0

25.0

20.0

15.0 aged 15-44 aged 10.0

Rate per 1000 females 1000 per Rate 5.0

0.0 2009 2010 2011 2012 2013 15-19 24.1 22.8 18.6 19.1 15.1 20-24 20.1 22.3 19.4 15.8 18.3 25-29 17.2 13.4 15.0 13.7 14.2 30-34 14.1 11.3 11.1 12.7 9.6 35-39 7.4 7.1 7.0 9.9 8.1 40-44 1.5 2.0 2.0 2.1 1.8 Year

Figure 5: Abortion rate by age group, Aberdeenshire. Rate per 1000 females aged 15-44 years.

30.0

25.0

20.0

15.0

aged 15-44 aged 10.0

5.0 Rate per 1000 females 1000 per Rate

0.0 2009 2010 2011 2012 2013 15-19 17.9 16.4 15.1 12.6 11.1 20-24 20.9 21.7 15.6 19.0 17.5 25-29 15.3 16.1 13.8 14.2 11.6 30-34 11.9 11.5 11.6 8.7 9.3 35-39 7.3 7.0 6.6 7.0 7.5 40-44 1.7 1.7 2.2 1.7 1.8 Year

Source for Figures 4,5: Aberdeen University TOP database, 2014

3.3 Moray The rate of abortion has been highest in the 20-24 age group throughout the 5 year period from 2009-2013 (Figure 6). The older women, 35-39 and 40-44 have consistently had the lowest rates of abortion. The rates of abortion have increased in all age groups from 2009 to 2013 however this trend should be interpreted with caution due to low numbers.

Figure 6: Abortion rate by age group, Moray 2009-2013. Rate per 1000 females aged 15-44 years.

30.0 25.0 20.0 15.0 aged 15-44 aged 10.0

Rate per 1000 females 1000 per Rate 5.0 0.0 2009 2010 2011 2012 2013 15-19 6.8 12.1 9.1 11.8 7.4 20-24 13.0 15.9 21.9 20.0 19.4 25-29 8.7 15.9 9.2 14.4 12.5 30-34 7.6 11.0 10.8 8.1 7.7 35-39 4.8 6.2 5.2 4.4 5.6 40-44 1.7 0.0 1.2 2.8 2.3 Year

Source: Aberdeen University TOP database 2014

4. Abortion rates by Intermediate Zone 4.1 Aberdeen City Analysis of the data by intermediate zone in 2013 showed that the abortion rate was highest in Sheddocksley (31.3 per 1,000). This was more than double the overall average rate for Aberdeen City (13.2 per 1,000) and almost 3 times more than the Scottish average rate for females ages 15-44 (11.2 per 1,000) for the same year. Garthdee, Braeside, Mannofield, Broomhill and Seafield East and Ferryhill North had the lowest rate with no abortions in 2013 (Figure 7).

Figure 7: Abortion rate of Aberdeen City Intermediate Zones 2013. Rate per 1000 females aged 15-44 years.

35.0

30.0

25.0

20.0

15.0

10.0

5.0

0.0 … … Rate per 1000 females aged 16-44 aged females 1000 per Rate Dyce Hilton Culter Seaton Mastrick Hanover Denmore Garthdee Ashgrove Northfield Tillydrone Woodside Stockethill Torry East Torry Kingswells Midstocket Hazlehead Danestone Torry West Torry City Centre City Summerhill Cove North Cove Rosemount Cove South Cove Old Aberdeen Old Sheddocksley Ferryhill North Ferryhill Street George Ferryhill South Ferryhill West End North End West Cummings Park Cummings Oldmachar East Oldmachar West End South End West Oldmachar West Oldmachar North Bucksburn Bucksburn South Bucksburn Braeside East etc East Braeside Braeside North etc North Braeside Braeside South etc South Braeside Heathryfold and Middlefield and Heathryfold Cults, Bieldside and Milltimberand Bieldside Cults, Milltimberand Bieldside Cults, Balgownie and Donmouth East Donmouth and Balgownie Balgownie and Donmouth West Donmouth and Balgownie Froghall, Powis and Sunnybank and Powis Froghall, Kincorth, Leggart and Nigg North Nigg and Leggart Kincorth, Kincorth, Leggart and Nigg South Nigg and Leggart Kincorth, Intermediate Zones

4.2 Aberdeenshire In Aberdeenshire, analysis of the data by intermediate zones showed that Stonehaven South had the highest rate of abortion in 2013 at 21.2 per 1,000 (Figure 8). This was more than double the average rate of abortion in Aberdeenshire (8.9 per 1,000) and approximately double the Scottish average rate for females ages 15-44 (11.2 per 1,000) for the same year. The lowest abortion rate during 2013 was recorded in East Cairngorms, Aberchirder and Whitehills and Portsoy, Fordyce and Cornhill with no abortions recorded in these intermediate zones in 2013.

Figure 8: Abortion rate of Aberdeenshire Intermediate Zones 2013. Rate per 1000 Females aged 15-44 years.

35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Rate per 1000 females aged 16-44 aged females 1000 per Rate Banff Turriff Ythsie Huntly Cruden Mintlaw Macduff Kemnay Barrahill Banchory Ythanside Ellon East Ellon Portlethen Newtonhill Ellon West Ellon Auchnagatt New Pitsligo New Fyvie Rothie Fyvie Howe of Alford of Howe Peterhead Bay Peterhead North Inverurie Clashindarroch Inverurie South Inverurie Westhill Central Westhill Peterhead Links Peterhead East Cairngorms East Stonehaven North Stonehaven Stonehaven South Stonehaven Garlogie and Elrick and Garlogie Peterhead Harbour Peterhead Deer and Mormond and Deer Peterhead Ugieside Peterhead Crathes and Torphins and Crathes Longside and Rattray and Longside Fraserburgh Lochpots Fraserburgh Kintore and Blackburn and Kintore Cromar and Kildrummy and Cromar Smiddyhill Fraserburgh Balmedie and Potterton and Balmedie Newmachar and Fintray and Newmachar Westhill North and South and North Westhill Durno Chapel of Garioch of Chapel Durno Mearns and Laurencekirk and Mearns Rosehearty and Strathbeg and Rosehearty Aberchirder and Whitehills and Aberchirder Aboyne and South Deeside South and Aboyne Insch, Oyne and Ythanwells and Oyne Insch, Mearns and South Benholm South and Mearns Auchterless and Monquhitter and Auchterless Portsoy, Fordyce and Cornhill and Fordyce Portsoy, Mearns North and Inverbervie and North Mearns Dunecht, Durris and Drumoak and Durris Dunecht, Fraserburgh Central Academy Central Fraserburgh Gardenstown and King Edward King and Gardenstown Banchory Devenick and Findon and Devenick Banchory Fetteresso, Netherley and Catter and Netherley Fetteresso, Fraserburgh Harbour and Broadsea and Harbour Fraserburgh Intermediate Zones

4.3 Moray Analysis of the data by intermediate zone in 2013 revealed that the abortion rate was highest in New Elgin East at 20.6 per 1,000 (Figure 9). This was approximately double the overall average rate for Moray (9.0 per 1,000) and almost double the Scottish average rate for females ages 15-44 (11.2 per 1,000) for the same year. Rural Keith and Strathisla had the lowest abortion rate with no abortions in 2013.

Figure 9: Abortion rate by Intermediate Zone, Moray 2013. Rate per 1000 Females aged 15-44 years.

35.0

30.0

25.0

20.0

15.0

10.0 Rate per 1000 females ages 16-44 ages females 1000 per Rate

5.0

0.0 New Elgin East ElginNew North Speyside North New Elgin West ElginNew Lossiemouth West Lossiemouth Elgin Central West CentralElgin Keith andFifeKeith Keith Buckie CentralEast Buckie Rural KeithandStrathisla Rural Rafford, Dallas, Dyke to Dava DykeDallas, Rafford, Burghead, Roseisle andLaich Roseisle Burghead, Lossiemouth EastandSeatown Lossiemouth South Speyside and the Cabrach andtheSpeyside South CentralEastandseaward Forres Buckie West and Mains of WestBuckie and Mains Buckie Elgin Bishopmill EastandLadyhill Bishopmill Elgin Heldon West,Inchberry Fogwatt to Heldon Forres SouthWestandMannachie Forres Elgin Bishopmill WestandNewfield BishopmillElgin Mosstodloch, Portgordon and seaward PortgordonandMosstodloch, Findhorn, Kinloss andPluscardenValley Kinloss Findhorn, Elgin Cathedral to AshgroveandCathedralPinefield to Elgin Fochabers, Aultmore,ClochanandOrdiquish Fochabers, Lhanbryde, Urquhart, PitgavneyUrquhart, andseaward Lhanbryde,

Cullen, Portknockie,Findochty,DrybridgeandBerr Cullen, Intermediate Zones

Source: Aberdeen University TOP database, 2014

5. Abortion rates by deprivation 5.1 Aberdeen City A snapshot of abortion rates in 2013 (Figure 10) showed the highest rate to be in the 20-24 age group in the most deprived quintile (44.6 per 1,000). This was more than double the average rate across Scotland for this age group (19.1 per 1,000) and 4 times greater than the rate for the 20-24 age group in the least deprived area of Aberdeen City (10.6 per 1,000). In all but the most deprived quintile the rate of abortion is highest in the under 20 age group.

5.2 Aberdeenshire A snapshot of abortion rates in 2013 showed that the rate was highest in the under 20 age group in the most deprived quintile (48.5 per 1,000). This is 5 times greater than the rate for the same age group in the least deprived quintile at 9.5 per 1,000. The highest rate for every age group was seen in the most deprived quintile. The 20-24 age group had the highest rate of abortion in all but the most deprived quintiles (Figure 11).

5.3 Moray In 2013 the highest rates of abortion were seen in the under 20, 20-24 and 30-34 age groups in the most deprived quintile (Figure 12). This result should however be interpreted with caution as the rates are based on very small numbers.

Figure 10: Abortion rate by deprivation quintile, Aberdeen City 2013. Rate per 1000 females 15-44 years.

50.0 45.0 40.0 35.0 30.0 25.0 20.0 Rate per 1000 females 1000 per Rate 15.0 10.0 5.0 0.0 1 2 3 4 5 <20 16.5 31.7 18.2 18.1 10.7 20-24 44.6 21.5 17.6 13.1 10.6 25-29 23.4 20.5 13.2 9.0 10.4 30-34 16.2 9.0 9.4 5.9 10.3 35-39 10.1 12.0 15.0 4.5 4.7 40-44 0.0 3.2 3.9 2.2 1.0 2012 National SIMD Quintiles

Figure 11: Abortion rate by deprivation quintile, Aberdeenshire 2013. Rate per 1000 females 15-44 years.

50.0 45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0

Rate per 1000per Rate females 0.0 1 2 3 4 5 <20 48.5 17.9 15.6 14.3 9.5 20-24 32.4 18.8 16.4 16.0 18.3 25-29 22.0 17.8 10.9 10.7 11.0 30-34 6.1 11.9 7.0 11.2 9.1 35-39 15.0 8.0 4.6 7.7 7.9 40-44 0.0 5.2 1.1 1.6 1.9 2012 National SIMD Quintiles

Figure 12: Abortion rate by deprivation quintile, Moray 2013. Rate per 1000 females 15-44 years.

90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 Rate per 1000 population 1000 per Rate 10.0 0.0 1 2 3 4 5 <20 66.7 22.3 5.5 11.1 0.0 20-24 69.8 26.3 21.4 16.9 11.9 25-29 0.0 11.0 22.4 5.9 3.0 30-34 80.0 7.0 7.4 6.0 10.1 35-39 0.0 10.0 4.3 6.4 3.2 40-44 27.8 0.0 2.8 2.5 0.0

2012 National SIMD Quintiles

Source: Aberdeen University TOP database, 2014

6. Abortion rates by GP cluster zone 6.1 Aberdeen Throughout the 5 year period from 2009-2013 the rate of abortion has been consistently highest in the Central North Cluster and lowest in the Central South Cluster (Figure 13). In 2013 the rates in the Central North Cluster (13.1 per 1,000) and the North Cluster (11.7 per 1,000) were both higher than the overall average rate of abortion across Scotland (11.2 per 1,000). The Central South Cluster and South Cluster were both lower than the Scottish average, both at 9.1 per 1,000.

6.2 Aberdeenshire Since 2009, Marr has had the lowest rate of abortion in Aberdeenshire (Figure 14). Prior to 2013, Buchan consistently had the highest rate of abortion, with Kincardine& Mearns having the highest rate in 2013 (10.6 per 1,000). In 2013 all GP Clusters had a lower rate of abortion than the overall average rate across Scotland at 11.2 per 1,000.

6.3 Moray In 2013 the highest rate of abortion was in Elgin (10.0 per 1,000) and lowest in Speyside (5.0 per 1,000). (Figure 15). The rate for all Moray GP clusters was lower than the overall average rate across Scotland in 2013 (11.2 per 1,000).

Figure 13: Abortion rate by Aberdeen City GP Cluster 2009-2013. Rate per 1000 females aged 15-44 years.

18.0 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 aged 15-44 aged 0.0 Central North Central South North South

Rate per 1000 females1000per Rate Cluster Cluster Cluster Cluster 2009 14.9 6.5 12.1 13.1 2010 16.1 9.7 10.8 11.0 2011 14.9 7.9 10.6 11.0 2012 14.3 9.7 9.8 10.7 2013 13.1 9.1 11.7 9.1

Aberdeen City GP Clusters

Source: Aberdeen University TOP database, 2014

Figure 14: Abortion rate by Aberdeenshire GP Cluster 2009-2013

18.0 16.0 14.0 12.0 10.0 8.0 aged 14-55 aged 6.0

Rate per 1000 females 1000 per Rate 4.0 2.0 0.0 Banff and Kincardine Buchan Formartine Garioch Marr Buchan & Mearns 2009 8.0 13.1 9.7 12.3 10.4 8.9 2010 9.9 14.2 11.6 9.8 10.1 8.6 2011 7.3 11.6 8.6 10.9 10.2 6.8 2012 8.4 11.7 9.7 10.3 9.3 7.7 2013 7.5 9.9 9.6 8.8 10.6 6.2

Aberdeenshire GP Clusters

Figure 15: Abortion rate by Moray GP Cluster 2009-2013. Rate per 1000 females 15-44 years.

18.0 16.0 14.0 12.0 10.0 8.0 6.0 4.0

aged 15-44 aged 2.0 0.0 Buckie Elgin Forres Speyside Rate per 1000 females 1000 per Rate 2009 3.7 6.3 6.0 4.1 2010 7.1 7.3 10.5 9.4 2011 7.1 8.6 6.4 5.4 2012 12.2 9.3 11.4 3.5 2013 8.3 10.0 9.6 5.0

Moray GP Clusters

Source: Aberdeen University TOP database, 2014

7. Travel times to Aberdeen Royal Infirmary and Dr Grays Women requesting an abortion are given high priority in NHS Scotland, under Health Improvement Scotland (HIS) [Previously Quality Improvement Scotland] Sexual Health Standard 1. Furthermore, Standard 1.2 states ‘ there is a minimum of 2 full days per week of integrated local specialist sexual health service provision available within 30 minutes travel time from each settlement of over 10,000.

Data suggests that of those women who had an abortion between 2009-2013, 4877 women resided within 30 minutes travel time of either ARI or Dr Gray’s in Moray, (n=4249 and n= 628) respectively (Figure 16). Of the remaining women who had an abortion during this period, 5265 resided within 60 minutes travel time of ARI and 733 within 60 minutes travel time of Dr Gray’s (Figure 17). This indicates that approximately 24% of women undergoing an abortion between 2009-2013 did not live within 30 minutes travel time from a local specialist sexual health service. That said, they did live within 30-60 minutes travel time.

There are however additional issues with this in that this data is prepared based on the women’s postcodes and does not take into account the ‘actual’ travel time which may be longer or shorter dependent on mode of travel, speed of travel, traffic conditions etc. Further clarification and investigation is therefore required to establish actual versus indicated travel time to specialist sexual health services for women undergoing an abortion.

Figure 16: Women residing within 30 minutes travel time of ARI and Dr Grays

Figure 17: Women residing within 60 minutes travel time of ARI and Dr Grays

8. Key findings

Abortion rates by age

• The rate of abortions in Aberdeen City is highest in younger women aged 15- 19 and 20-24. The lowest rates are seen in the 40-44 age group. • In Aberdeenshire the highest rate of abortion is seen in the 20-24 age group. The rate of this group is gradually decreasing. The lowest rate is seen in the 40-44 age group. • The rate of abortion in Moray is highest in the 20-24 age group and lowest in the 40-44 age group. Abortion rate by Intermediate zone

• In Aberdeen City the abortion rate was highest in Sheddocksley and lowest in Garthdee, Braeside, Mannofield, Broomhill and Seafield East and Ferryhill North. • In Aberdeenshire the abortion rate was highest in Stonehaven South and lowest in East Cairngorms, Aberchirder and Whitehills and Portsoy, Fordyce and Cornhill. • In Moray the rate of abortion was highest in New Elgin Eat and lowest in Rural Keith and Strathisla. Abortion rate by deprivation

• The rate of abortion shows a clear link with deprivation level. • In Aberdeen City the highest rate of abortion was seen in the 20-24 age group in the most deprived quintile. • In Aberdeenshire the highest rate of abortion for every age group was seen in the most deprived quintile, with the <20 age group showing the highest rate of all the age groups. • In Moray the highest rates of abortion for the <20, 20-24, 30-34 and 40-44 age groups were seen in the most deprived quintile. Abortion rate by GP Cluster zone

• In Aberdeen City the highest rate of abortion is in the Central North Cluster. The lowest rate is in the Central South Cluster. • In Aberdeenshire the highest rate of abortion in 2013 was seen in Kincardine& Mearns with Buchan having the highest rate for 4 years prior to that time. The lowest rate was found in Marr. • In Moray the highest rate of abortion was in Elgin and the lowest rate in Speyside. Travel times

• Around 24% of women attending for abortion between 2009 and 2013 did not live within 30 minutes travel time of specialist sexual health service provision. • All women attending for an abortion between 2009-2013 lived within 60 minutes travel time of specialist sexual health service provision. • Further investigation is required to establish actual versus indicated travel time to specialist sexual health services for women undergoing an abortion. 22

Section 2: Repeat abortions in Grampian 2010-2013 [Authors: Dr Sohinee Bhattacharya, Dr Gillian Flett. Mr Stephen McCall, Dr Emmanuel Okpo]

1. Background Ethical approval was given by the North of Scotland Research Ethics Service and NHS Research and Development approval was given for non-commercial use of NHS data (REC Ref no: 14/NS/0034). This study followed the ISD Scotland recommendations on the dissemination of sensitive information to prevent identification of individuals. This was a retrospective study using routinely collected data from the TOP database in Grampian from January 1997 to December 2013. The year 2010 was chosen as the cut off for women with the first abortion, allowing a three year follow up period to 2013 in order to identify any woman who had a subsequent abortion. The database collects data on all induced abortions occurring in ARI. Data were extracted and an anonymised data set was given to the researchers for analysis. The extracted variables included age, SIMD, contraceptive choice post abortion, method of abortion, date of abortion, gestation age, sexually transmitted infection (STI) status, previous miscarriage, ectopic pregnancy, self-reported contraceptive use at conception, previous live births, self-reported method failure and self-reported emergency contraceptive usage at the time of the first abortion. The outcome measure was repeat abortions and was defined as women who had two or more abortions within the specified time period. These were obtained by matching women using the CHI number; a unique identifier available for all persons registered with a general practice in Scotland. The total number of abortions contained in the database over the study time period was 14973. Complete case analysis was used in the analysis and as a result, the final sample size in the final model was 12933. All statistical analysis used SPSS software and suitable methods were used to clean the dataset. The descriptive associations between repeat abortions and one abortion for each explanatory variable were tested using Chi square tests. A multivariate logistic regression model was used to assess which factors were associated with repeat abortion while adjusting for other variables, using repeat abortion as the dependant variable. Each explanatory variable was presented with 95% confidence intervals and odds ratios. 2. Results: Analysis of the Grampian TOP Database There were 14978 unique women who had one or more abortions recorded in the database. The number of women who had had at least one further abortion recorded was 3422 (22.8%). Table 1 presents the baseline characteristics of the whole cohort. Figure 1 highlights that Grampian has consistently had a higher proportion of repeat abortions than the Scottish average. Although the Scottish rate has been increasing over time, the Grampian rate appears to be decreasing since 2000.

2.1 Comparison of characteristics of women with single and multiple abortions Bivariate analysis comparing women with repeat abortion to women with one abortion is presented in Table 2. Women with repeat abortions, at the time of their first abortion, were more likely to be younger in comparison to women with one abortion. A larger proportion of women with repeat abortion were from the most deprived quintile (31.4% vs. 30.4%, p ≤ 0.001). Women with repeat abortions were more likely to have a positive Chlamydia result (8.1% vs. 6.1%, p ≤ 0.001) and were more likely to have been tested for BBVs (8.4 vs. 5.1, p ≤ 0.001). A larger proportion of women in the repeat abortion group in comparison to women with one abortion had Long Acting Reversible Contraceptive (LARC) as their post abortion contraceptive method (25.5 vs. 18.5, p ≤ 0.001).

2.2 Multivariate analysis Table 3 shows the results of the multivariate analysis. After mutually adjusting for all other factors included in the logistic regression model, women aged below 20 years at the initial termination showed increased odds of having a repeat abortion {AOR4.75 (95% CI 3.63 – 6.21)} . Women with two previous live births at the time of their initial abortion had an increased likelihood of a repeat abortion {AOR 1.47 (95% CI 1.10 to 1.96)}. Women in the most socially deprived categories had increased odds of a repeat abortion {AOR 1.19 (95% CI: 1.02-1.39)}. There was no significant association with the trimester of the abortion. Women with a surgical abortion in comparison to medical abortions had a decreased likelihood of a repeat abortion with an odds ratio of AOR 0.85 (95% CI: 0.77-0.94). Women who were tested for a BBV had an increased likelihood of a repeat abortion with an odds ratio of AOR 1.62 (95% CI: 1.37-1.91). When examining contraception use at conception at the time of initial abortion, there was no statistically significant association for any of the methods used. Post first abortion contraception methods showed a similar trend, as there was no statistically significant association found between any of the methods and repeat abortion apart from LARC. Women who were fitted with LARC after their index abortion had increased odds of a repeat abortion {AOR 1.53 (95% CI: 1.31-1.79)}.

Table 1. Baseline characteristics of all women at the time of the first abortion

Characteristics table n (%) <20 4580 (30.6) 20-24 3388 (22.6) 25-29 2825 (18.9) Age n=14961 30-34 2021 (13.5) 35-40 1462 (9.8) >40 685 (4.6) Least deprived 1589 (10.9) 2 2432 (16.2) SIMD Quintiles n=13194 3 2191 (14.6) 4 2936 (19.6) Most deprived 4046 (27.0) 1 7788 (52.0) Pregnancy number n=14927 2 2631 (17.6) >3 4508 (30.1) 0 9036 (60.3) 1 2573 (17.2) Live-births n=14978 2 2225 (14.9) >3 1144 (7.6) 1 11556 (77.2) Number of abortions n=14978 2 2546 (17.0) ≥3 876 (5.8) History of a ectopic n= 14301 Yes 111 (0.7) History of a miscarriage n=14302 Yes 1634 (10.9) 1 13503 (90.2) Trimester n=14973 2 1465 (9.8) 3 * MTOP 8864 (59.2) Method of abortion n=14978 STOP 4542 (30.3) Other 1572 (10.5) Chlamydia n=14722 Yes 966 (6.4) BBV tested n=14978 Yes 877 (5.9) None/ Natural/ Not known 4901 (32.7) Barrier 6239 (42.0) Contraception at the time of Depo Provera 52 (0.3) conception n=14978 LARC 153 (1.0) Other 1012 (6.8) Hormonal 2567 (17.1) None/ Natural/ Not known 1828 (12.2) Barrier 681 (4.5) Planned contraception after an Depo Provera 1790 (12.0) abortion n= 14978 LARC 3006 (20.1) Other 1409 (9.4) Hormonal 6264 (41.8) Yes 2642 (17.6) Method Failure n= 7735 No 5093 (34.0)

Table 2: Comparison of baseline characteristics between women with one or repeat abortions One abortion Repeat abortion P-value n (%) n (%) Total 11556 (77.2) 3422 (22.8) <20 2729 (23.6) 1851 (54.1) 20-24 2803 (24.3) 585 (17.1) 25-29 2479 (21.5) 346 (10.1) Age p ≤ 0.001 30-34 1717 (14.9) 304 (8.9) 35-40 1235 (10.7) 227 (6.6) >40 578 (5.0) 107 (3.1) 1 6659 (57.6) 2163 (63.4) 2 2107 (18.3) 524 (15.3) p ≤ 0.001 Pregnancy number ≥3 3781 (32.8) 727 (21.3) 0 6659 (57.6) 2377 (69.5) 1 2086 (18.1) 487 (14.2) Live birth p ≤ 0.001 2 1847 (16.0) 378 (11.0) ≥3 964 (8.3) 180 (5.3) 0 9626 (88.0) 3042 (90.5) Previous miscarriage 1 1008 (9.2) 253 (7.5) p ≤ 0.001 ≥2 305 (2.8) 68 (2.0) 0 10845 (99.1) 3345 (99.5) Ectopic P = 0.041 ≥1 94 (0.9) 17 (0.5) Least deprived 1236 (12.3) 353 (11.4) 2 1905 (18.9) 527 (17.0) SIMD quintile 3 1657 (16.4) 534 (17.2) p ≤ 0.053 4 2217 (22.0) 719 (23.1) Most deprived 3070 (30.4) 976 (31.4) Negative 10676 (6.1) 3080 (92.0) Chlamydia 0.000 Positive 698 (6.1) 268 (8.0) Negative 1423 (99.7) 795 (99.6) Gonorrhoea 0.699 Positive 4 (0.3) 3 (0.4) Negative 10965 (94.9) 3136 (91.6) STI_BBV bloods 0.000 Positive 591 (5.1) 286 (8.4) First trimester 10438 (90.4) 3065 (89.7) Trimester of pregnancy p = 0.34 Second trimester 1113 (9.6) 352 (10.3) MTOP 6708 (58.0) 2156 (63.0) Method of abortion STOP 3544 (30.7) 998 (29.2) p ≤ 0.001 Other 1304 (11.3) 268 (7.8) None/ Natural and Not known 3748 (32.4) 1153 (33.7) Barrier 4828 (41.8) 1465 (42.8) Contraceptive use at Depo Provera 37 (0.3) 15 (0.4) P<0.0001 conception LARC 121 (1.0) 32 (0.9) Other 884 (7.6) 128 (3.7) Hormonal 1938 (16.8) 629 (18.4) None/ Natural/ Not known 1461 (12.6) 367 (10.7) Barrier 588 (5.1) 93 (2.7) Post-abortion Depo Provera 1401 (12.1) 389 (11.4) P<0.0001 contraception LARC 2133 (18.5) 873 (25.5) Other 1176 (10.2) 233 (6.8) Hormonal 4797 (41.5) 1467 (42.9) Yes 1853 (34.3) 789 (33.9) Method Failure No 3556 (30.8) 1537 (44.9) p <0.001 Missing 6147 (53.2) 1096 (32.0)

Table 3. Multivariate analysis

Adjusted Model n= 12933 OR 95% CI P value <20 4.64 (3.55-6.06) 0.000 20-24 1.31 (1.00-1.72) 0.048 25-29 0.78 (0.60-1.03) 0.075 Age 30-34 1.00 (0.76-1.30) 0.983 35-40 1.12 (0.85-1.47) 0.426 >40 1 1 1 Pregnancy number 2 0.90 (0.74-1.09) 0.278 ≥3 0.77 (0.58-1.03) 0.074 0 1 1 1.16 (0.94-1.44) 0.165 Live birth 2 1.43 (1.08-1.91) 0.014 ≥3 1.33 (0.97-1.83) 0.074 Least deprived 1 2 1.01 (0.86-1.19) 0.890 SIMD quintile 3 1.16 (0.98-1.37) 0.079 4 1.16 (0.99-1.35) 0.072 Most deprived 1.18 (1.02-1.38) 0.031 0 1 Previous miscarriage 1 1.20 (1.01-1.44) 0.044 ≥2 1.26 (0.93-1.72) 0.132 0 1 Ectopic ≥1 1.04 (0.84-1.16) 0.989 Trimester 1 1 2 0.89 (0.77-1.03) 0.901 Negative 1 Chlamydia Yes 0.99 (0.84-1.16) 0.896 MTOP 1 Method STOP 0.84 (0.76-0.93) 0.001 Other 1.02 (0.93-1.26) 0.845 None 1 Barrier 0.94 (0.85-1.04) 0.241 Contraception at the time of Depo Provera 1.14 (0.58-2.25) 0.700 conception LARC 1.13 (0.69-1.84) 0.628 Other 0.83 (0.66-1.04) 0.111 Hormonal 1.05 (0.93-1.19) 0.435 None 1 Barrier 0.80 (0.62-1.05) 0.106 Planned contraception after an Depo Provera 0.86 (0.72-1.04) 0.115 abortion LARC 1.59 (1.36-1.85) 0.000 Other 1.18 (0.91-1.52) 0.205 Hormonal 1.02 (0.88-1.18) 0.806

Figure 1. The proportion of repeat abortions across time in Aberdeen, NHS Grampian and Scotland.

45 TOPs database ISD Scotland

40 ISD Grampian

20 Proportionof repeat abortions per year 15

10 28 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year

Aberdeen data provided by the TOP database, Scottish and NHS Grampian data provided by the Infor mation Service Division (Information Service Division 2013).

Section 3: International Systematic Review – Determinant factors of repeat abortion [Authors: Dr Sohinee Bhattacharya, Dr Mari Imamura, Dr Gillian Flett. Mr Stephen McCall, Dr Umi Nursheila Nur Ibrahim, Dr Emmanuel Okpo]

1. Background This research was undertaken to investigate the determinant factors of repeat abortion as part of a Sexual Health and Blood Borne Virus Framework (The Scottish Government 2011), invited by the SH&BBV Managed Care Network and funded by NHS Grampian. The research aims to guide the understanding of unplanned pregnancies manifest to the health services as repeat abortions, in order to reduce the proportion of these in Grampian as part of the key strategies of Respect and Responsibility (Scottish Government 2005).

Global abortion rates were estimated at 28 per 1,000 women of reproductive age in 2008 (Sedgh, Singh et al. 2012). It is estimated that approximately 30% of all pregnancies in Europe (last estimate 4.2million) will end in abortion (Singh et al. 2012). Trend data shows that abortion rates globally have declined and remained stable in recent years. However, in the United States, recent statistics suggest that about 50% of all abortions are in women who have had a previous abortion and the rate of repeat abortions appears to be rising steadily (Cohen 2007, Department of Health 2011, Sedgh, Singh et al. 2012).

In Scotland, rates of abortion have also been gradually declining in recent years from 13.3 per 1,000 women in 2008 to 12.0 in 2012 for women aged 15-44 (Information Service Division 2013). England and Wales showed similar trends between 2007 and 2011; abortion rates decreased slightly from 17.6 per 1,000 women to 17.2, but the proportion of repeat abortion increased from 32% to 36% (Department of Health 2011).These figures indicate that repeat abortion of unwanted pregnancies is a significant and growing public health problem worldwide. Current strategies in Scotland, England and Wales aimed at preventing unplanned pregnancies i.e. improved provision and access to a full range of contraception and emergency contraception services across a range of providers have shown not to have impacted on repeat abortion rates (Das, Adegbenro et al. 2009). More complex factors may be influencing repeat abortion and the distribution of these factors in different populations. Identification of these factors could provide a clearer picture of the interplay between determinant factors of repeat abortion, sexual health service provision and policies. A similar report by the Guttmacher Institute was previously published on characteristics of women with repeat abortion in the United States (Jones, Singh et al. 2006).

The Royal College of Obstetrics and Gynaecology (RCOG) advocates that medical abortion is safe and has a low risk of major medical complications. However, in terms of maternal and foetal outcomes, it is associated with a slight increased risk of preterm birth in subsequent pregnancies (RCOG 2011). Notably, repeat abortion is associated with preterm birth, foetal loss, low birth weight and ectopic pregnancies (Thapa, Neupane 2013). The greater the number of repeat abortions, the greater the likelihood of poor foetal outcomes and particularly preterm birth and low birth weight (Klemetti, Gissler et al. 2012).

At present, there are limited comprehensive reviews concerning factors associated with repeat abortion among women globally. In general, available research evidence, the majority of which has been conducted in the United States, suggests that repeat abortion compared to a single abortion is associated with older age, contraception use at the time of conception, being unmarried, having more children and being non- white (Westfall, Kallail 1995, Berger, Gold et al. 1984, Steinhoff, Smith et al. 1979, Bracken, Hachamovitch et al. 1972). Better understanding of the determinant factors associated with repeat abortion can lead to the development of more effective interventions through the recognition of women most at risk. Similarly, the examination of determinants at a local level using a local database will provide the evidence to aim interventions at a local level. These targeted interventions applicable in the United Kingdom will facilitate the reduction of unintended pregnancies as well as prevent the hazards of repeat abortions. Additionally, it affords a platform for the change in societal perception of women who have more abortions from punitive to a more supportive and non-stigmatising approach.

1.1 Definitions For the purposes of this report, the term abortion represents only the termination of a continuing, unwanted pregnancy using surgical or medical methods in a clinical setting and repeat abortion refers to having more than one induced abortion. The World Health Organization (WHO) recognises determinant factors as an individual’s or a population’s socio-economic environment, physical environment, and any characteristics or behaviours which impact on health outcomes (WHO, 2014). This review measures the association between these factors and repeat abortion.

2. Systematic Review

2.1 Systematic review methods The methodology for the systematic review of the literature was drawn from the recommended approach developed by the Centre for Reviews and Dissemination, York. A review protocol was devised a priori from the following review question: “What are the determinant factors of repeat abortions?”

2.2 Scope of the review The systematic review investigates determinant factors for repeat abortion by comparing socio-demographics, obstetric history, sexual behaviours, sexual health knowledge, sexual attitudes, psychosocial and contextual factors associated with the likelihood of repeat abortion between groups of women who have had none, one or more abortions.

Focus is on the differentiation in factors between women who have experienced more than one abortion with women who have had only one or no abortion. The review does not include publications reporting comparison of women with only one abortion with those who have had none.

All study designs including observational studies such as cohort case control or cross-sectional are included in the analysis. Case series or case reports without comparison groups have been excluded.

2.3 Search strategy EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials and Cochrane Database for Systematic Reviews databases were searched for eligible studies using combined MeSH terms and search terms with Boolean operators. This search strategy for MEDLINE can be seen in Appendix 2. References of previously published reviews and primary studies were searched for eligible papers. No language or time restrictions were applied.

2.4 Inclusion criteria All quantitative studies that included a comparison group i.e. women who have had one or more induced abortion compared with women who have had fewer or no abortions, were included. The primary outcome examined in this review was repeat medical or surgical abortion irrespective of whether there was a live birth between any two episodes of termination.

2.5 Exclusion criteria Studies that only examined the determinants of a single abortion, had no comparison group and did not explore any determinant factors were excluded.

2.6 Data extraction and assessment for study inclusion There were seven stages to the review process: 1. Titles of all studies were screened by one reviewer; 2. Abstracts of studies were screened independently by two reviewers for relevance to repeat abortion and determinant factors. Disagreements were settled by discussion or a third independent opinion; 3. Full texts of studies were examined by two reviewers for relevant data on determinant factors and comparison groups. Disagreements were settled by discussion or a third independent opinion; 4. Data was extracted from selected studies and was summarised in a study characteristics table; 70% checked independently. A data extraction form was developed based on the recommendations of the Cochrane Collaboration and piloted by two reviewers. The data extraction form collected information on the following: study details, study characteristics, factors and methodology, results, comments and conclusions; 5. Quality assessment for the included studies was guided by a modified quality assessment checklist by Downs and Black (Downs, Black 1998). The checklist was not used as a quality threshold as studies were not excluded on the basis of an overall quality rating; 6. Results were mainly presented as a narrative synthesis and tabulated in a conceptual framework; 7. Some associations were measured using a meta-analysis; a meta-analysis was only appropriate for selected determinants, where there was consistency amongst the studies.

3. Results The search strategy identified 3933 references from the various bibliographic databases searched for possible inclusion in the review. After studies which had no relevant data were excluded, 45 papers remained for data extraction and quality assessment. The results from the study selection process are summarised in a Figure 1 and Tables 1 to 4 below.

Figure 1: Flow diagram of study selection process

Titles of papers screened (n =3933)

Citations excluded (n = 3593); no abortion focus

STEP 2 Titles and abstracts of papers screened for retrieval (n = 340)

Citations excluded (n = 214); no repeat abortion focus, no data on factors

STEP 3 Studies selected for full-text evaluation (n =126)

Full text unavailable for ILL 56 studies excluded request: 10 (no relevant data) ILL Foreign: 13 Total ILL request: 23

STEP 4 Studies included for data extraction (n=47)

Excluded at data extraction (n=2)

STEP 5 Studies included for data extraction and quality assessment (n=45)

Table 1: Setting of included studies by risk factors examined

UK US N R EU Z A NZ ∑

A Socio-demographics 4 20 11 1 2 1 3 2 44

B Obstetric history 4 16 8 0 2 1 3 2 36

C Sexual health knowledge and attitudes 1 3 1 1 0 0 1 0 7

D Sexual behaviour 5 15 7 1 1 0 3 2 34

E Psychosocial 3 11 6 1 1 0 0 0 22

F Contextual 1 1 1 0 0 1 2 0 6

Number of studies in location 5 20 11 1 2 1 3 2 45

*Key: UK = United Kingdom, US = United States and Canada, N = Nordic (Denmark, Norway, Sweden, Finland), R = Russia, EU = European Union (Spain, Switzerland), Z = Zimbabwe, A = Asia (Nepal, Vietnam), NZ = New Zealand The majority of these studies were cross-sectional studies using either data from medical records, official government records, self-reported questionnaires or interviews; there were a limited number of cohort and randomised controlled studies. Using a narrative synthesis approach a number of themes were apparent in the literature such as socio-demographic, sexual behaviour, obstetric history and psychosocial factors.

Table 2: Summary of the quality of included studies (n=45)

Quality criteria No. of studies (%)

Overall quality, full score = 27 Low (<10) 5/45 (11%) Medium ( ≥10 to <19) 24/45 (53%) High ( ≥19) 16/45 (37%) Reporting score, full score = 10 Low (<6) 25/45 (56%) High ( ≥6) 20/45 (44%) External validity score, full score = 10 Low (<6) 36/45 (80%) High ( ≥6) 9/45 (20%) Internal validity score, full score = 6 Low (<4) 38/45 (84%) High ( ≥4) 7/45 (16%) Power calculation, score = 1 Yes 5/45 (11%) No/Unable to determine 40/45 (89%)

Table 3: Determinant factor categories

Socio-demographic factors Sexual behaviour Age Contraceptive use Ethnicity Number of sexual partners Education Marital status Psychosocial factors Deprivation group Smoking Rural/urban residence Alcohol and drug use Mental health Obstetric history Social support Parity Number of abortions Contextual factors Affordability of contraceptives Sexual health knowledge and attitude Availability of abortion advice Reason for non-use of contraceptives

Table 4. Quality assessment of studies by country and ascending in date

STUDIES REPORTING EXTERNAL INTERNAL POWER TOTAL (10) VALIDITY VALIDITY (6) (1) (27) (10) UK 2011 Stone & Ingham UK 6 3 3 0 12 2009 Das UK 5 4 2 0 11 2006 Schunmann et al. UK 10 8 4 1 23 2005 St John et al. UK 7 4 3 0 14 2001 Garg UK 5 3 1 0 9 US & CANADA 2013 Steinberg & Tschann USA 6 5 1 0 12 2011 Bleil et al. USA 7 3 3 0 13 2008 Goodman et al. USA 8 5.5 3.5 0 17 2007 Prager et al. USA 5 1 2 0 8 2005 Fisher et al. Canada 5.5 3 3.5 0 12 2005 Coleman et al. USA 5 3 1 0 9 2001 Steinberg & Finer USA 7 4 3 0 14

1995 Westfall et al. USA 5 4 2 0 11 1984 Berger et al. Canada 5 2 3 0 10 1980 Freeman et al. USA 4 3 1 0 8 1980 Aguirre USA 5 5 2 0 12 1979 Steinhoff et al. USA 3 4 1 0 8 1979 Howe et al. USA 5 7 2 0 14 1978 Tietze USA 2 2 1 0 5 1977 Leach USA 6 2 2 0 10 1976 Schneider USA 4 0 1 0 5 1975 Bracken et al. USA 4 2 1 0 7 1974 Grauer Canada 4 3 1 0 8 1973 Daily et al. USA 2 2 1 0 5 1972 Bracken et al. USA 5 1 2 0 8 NORDIC 2013 Frandsen et al. Denmark 5 5 3 0 13 2012 Leppalahti Finland 8 6 3 1 18 2010 Mentula Finland 8 7 4 1 20 2009 Niinimäki Finland 9 6 3 0 18 2009 Heikinheimo et al. Finland 8 7 3 0 18 2006 Raatikainen Finland 7 5 2 0 14 1994 Skjedestad Norway 7 5 2 0 14 1992 Osler et al. Denmark 5 2 2 0 9 1981 Niemela Finland 3 3 0 0 6 1977 Somers Denmark 3 0 4 0 7 1976 Jacobsson Sweden 3 2 1 0 6 RUSSIA 2007 David et al. Russia 9 7 4 1 21 EUROPEAN UNION 2009 Falcon et al. Spain 5 2 2 0 9 2003 Addor et al. Switzerland 4 2 2 0 8 ZIMBABWE 2002 Johnson Zimbabwe 8 6 1 0 15 ASIA 2013 Thapa Nepal 5 4 4 1 14 2012 Nguyen et al. Vietnam 6 2 2 0 10

2000 Nguyen et al. Vietnam 6 3 2 0 11 NEW ZEALAND 2012 Rose et al. New Zealand 9 6 4 0 19 2010 Roberts et al. New 8 5 4 0 17 Zealand *scores: 19-27 = Green, 10-18 = No colour, 1-9 = Red

Structural Familial Individual factors factors Level

Policy Socio-economic Age status •Abortion laws •Contraceptive policy Childhood adverse Marital status/ •Management of health events services Relationship quality •NICE guidlines •Health inequalities Education Parity Abortion Repeat abortion Service delivery Ethnicity Contraceptive usage •Sexual health services at conception •GP services Risk taking •Contraceptive availability behaviour and •Enhanced services Health problems contraceptive useage

Sexual behaviour Social and Cultural •Women's empowerment •Information and choice Adverse life events, •Neo-liberalism. substance abuse and mental Ilness

37 •Relgious beliefs

Time Figure 2. Conceptual framework of Repeat abortion. Adapted from Benson (2005) .

4. Data synthesis A summary of results including data extraction and excluded studies can be found in Appendix 3. Repeat abortions are not a consequence of one determinant but many interrelated determinants. This is shown through the conceptual framework illustrated in Figure 2 on the previous page. The thematic synthesis of this report enables each determinant to be understood within the causal framework of the conceptual model.

4.1 Familial factors

4.1.1 Socioeconomic status The majority of studies indicated that lower socioeconomic status was associated with repeat abortion (St John, Critchley et al. 2005, Steinhoff, Smith et al. 1979, Addor, Narring et al. 2003, Das, Adegbenro et al. 2009, Stone, Ingham 2011, Osler, Morgall et al. 1992, Niemela, Lehtinen et al. 1981, Niinimaki, Pouta et al. 2009, Mentula, Niinimaki et al. 2010, Freeman, Rickels et al. 1980). A number of studies used unemployment and social class as the measure of socioeconomic status (Osler, Morgall et al. 1992, Das, Adegbenro et al. 2009, Addor, Narring et al. 2003). Osler et al . (1992) showed women with repeat abortions were less likely to be students, and Addor et al. (2003) showed these women were more likely to be on social benefit. Stone and Ingham (2011) showed that women with repeat abortions were more likely to live in rented accommodation rather than owning their homes. Niemela et al. (1981) showed that women with repeat abortions are more likely to have lower quality housing and lower prestige jobs. Niinimaki et al. (2009) showed that women with repeat abortions were more likely to be from lower social classes. Mentula et al. (2010) showed that women with repeat abortions were more likely to come from any social class other than white collar workers. One study found that a higher socioeconomic status increased the odds of a repeat abortion, although this paper did not use multivariate analysis (Aguirre Zozaya, Iglesias et al. 1980). Skjeldestad (1994) showed that there was no increase in the likelihood of a repeat abortion for unemployed women, although this study had a small sample size. Two studies showed through bivariate analysis that the majority of repeat abortions were from women who were employed (Osler, Morgall et al. 1992, Jacobsson, Von Schoultz et al. 1976). Falcon et al . (2010) showed that women with repeat abortions were more likely to have their own income than women with one abortion. Seven studies found that there was no significant association between socioeconomic status or economic income and repeat abortion (Rose, Lawton 2012, Steinberg, Tschann 2013, Westfall, Kallail 1995, Prager, Steinauer et al. 2007, Nguyen, Chongsuvivatwong et al. 2000, Nguyen, Budiharsana 2012, Steinberg, Finer 2011). The studies by Westfall et al. and Prager et al. were located in clinics within the United States. As a result of private healthcare, this study population may be more wealthy. Both studies by Nguyen et al. 2000 and 2012 were located in Vietnam therefore the population may not be comparable to the United Kingdom population. Skjeldestad (1994) showed that there was no difference in the likelihood of a repeat abortion for unemployed women.

4.1.2 Ethnicity Ethnicities that were associated with repeat abortion were dependant on the study location. The majority of studies found that women with repeat abortions were more likely to be black or non-white (Westfall, Kallail 1995, Bleil, Adler et al. 2011, Stone, Ingham 2011, Prager, Steinauer et al. 2007, Steinberg, Finer 2011). Similarly, one study found that women with repeat abortions were less likely to be white (Steinberg, Tschann 2013). A study in the UK using multivariate analysis showed that in comparison to women with one abortion, woman with repeat abortions were more likely to be black or Chinese rather than white (Stone, Ingham 2011). In contrast, a study situated in the United States examining associations between repeat abortions against one abortion, found women with repeat abortions were more likely to be white (Steinberg, Finer 2011). However, another US study showed that women with repeat abortions were more likely to be of African American origin rather than Latin origin (Prager, Steinauer et al. 2007). A number of studies identified that foreign nationals were at increased risk of a repeat abortion in comparison to nationals. Addor et al. (2003) showed that women who were foreign nationals rather than Swiss had increased odds of a repeat abortion. Fisher et al . (2005) showed women with repeat abortions were more likely to be born outside of Canada. Robert et al .(2010) found that indigenous New Zealanders had increased odds of a repeat abortion. A number of studies found that ethnicity did not have a significant association with repeat abortion (Rose, Lawton 2012, Bracken, Hachamovitch et al. 1972, Nguyen, Budiharsana 2012, Leach 1977). However two of these studies were undertaken in the 1970s, thus the population studied may not be comparable to the modern population of the UK (Bracken, Hachamovitch et al. 1972, Leach 1977). Nguyen and Budiharsana (2012) study was situated in Vietnam so may not be applicable to the UK. Rose et al. (2012) had a very small sample of repeat abortion increasing the likelihood of a type 2 error. Prager et al . (2007) showed that there was no significant difference between white women, Asian women and women of other ethnicities in comparison to Latino women. Most studies highlighted that non-white woman were highly associated with repeat abortions.

4.1.3 Education A number of studies indicated lower level education in women was associated with repeat abortions (Steinberg, Tschann 2013, Thapa, Neupane 2013, Bleil, Adler et al. 2011, Addor, Narring et al. 2003, Stone, Ingham 2011, Frandsen, Rørbye et al. 2014). Steinburg and Tschann (2013) showed that women with repeat abortions were more likely to have less high school education and less likely to have any college education. Similarly, a study in Nepal found that women with repeat abortions were more likely to have secondary education or primary education than college or higher education. Stone and Ingham (2011) showed that women with repeat abortions in comparison to women with one abortion were more likely to have left school aged 16 with some or no qualifications than left school at age 17. Addor et al . (2003) suggested that women with repeat abortions were more likely to have non- university education than university education. Bleil et al . (2011), using bivariate analysis, showed that women who had repeat abortions in comparison to women with no abortion had a significantly lower education in years, although the

relationship was non-significant when comparing women with repeat abortion and one abortion. This suggests that the educational status of women with abortions as a whole were similar. Eight studies showed that there was no significant association in the level of education between women with repeat abortions and one abortion (David, Reichenbach et al. 2007, Prager, Steinauer et al. 2007, Bracken, Kasl 1975, Nguyen, Chongsuvivatwong et al. 2000, Leach 1977, Jacobsson, Von Schoultz et al. 1976). A number of these studies were situated in the US during the 1970s and one study was located in Vietnam, so the population that had access to these clinics may be entirely different to those people accessing healthcare in the United Kingdom (Prager, Steinauer et al. 2007, Bracken, Kasl 1975, Nguyen, Chongsuvivatwong et al. 2000, Leach 1977). In contrast, one study showed that women with repeat abortions in comparison to women with one abortion were more likely to have a higher level of education, probably indicating a higher level of access to abortion care with increasing education levels as this study was conducted in the US during the late 1970s (Howe, Kaplan et al. 1979). 4.2 Urbanisation and rurality Two studies found that living in an urban area increased the likelihood of repeat abortions (Niinimaki, Pouta et al. 2009, Leppalahti, Gissler et al. 2012). However, two studies found a non-significant relationship between location and the number of abortions (Westfall, Kallail 1995, Mentula, Niinimaki et al. 2010). One of these studies was located in Kansas which may limit the relevance (Westfall, Kallail 1995). 4.3 Individual level factors 4.3.1 Age The majority of studies found an association between older age and repeat abortion. Many of these studies had their own definition of older age (Westfall, Kallail 1995, Thapa, Neupane 2013, St John, Critchley et al. 2005, Bleil, Adler et al. 2011, Berger, Gold et al. 1984, Fisher, Singh et al. 2005, Falcon, Valero et al. 2010, Howe, Kaplan et al. 1979, Prager, Steinauer et al. 2007, Bracken, Kasl 1975, Roberts, Silva et al. 2010, Somers 1977, Nguyen, Chongsuvivatwong et al. 2000, Nguyen, Budiharsana 2012, Raatikainen, Heiskanen et al. 2006, Garg, Singh et al. 2001, Leppalahti, Gissler et al. 2012, Freeman, Rickels et al. 1980). A number of studies identified that women at the extremes of age were less likely to have repeat abortions, for example Skjeldestad (1994) showed that women aged 20-34 years were more likely to have a repeat abortion in comparison to women with no abortions. Similarly, Tietze (1978) indicated that women in their twenties were at increased risk of repeat abortion, while women who were less than 20 years old and more than 30 years old were at lower risk of repeat abortion. Falcon et al . (2010) using bivariate analysis showed these women were less likely to be younger than 20 years old. Many studies have shown that extremes of age are protective of repeat abortion. While younger women have not yet had the time to have more than one abortion, older women are less likely to conceive because of declining fertility and therefore less likely to need abortions. In contrast only five studies identified younger aged mothers at increased odds of a repeat abortion (Roberts, Silva et al. 2010, David, Reichenbach et al. 2007, Niinimaki, Pouta et al. 2009, Mentula, Niinimaki et al. 2010, Goodman, Hendlish et al. 2008). Mentula et al (2010) identified that women aged under 20 – 39 years old 40

were at greater risk of a repeat abortion than women aged 40 years and above. Similar results were found in a study by David et al . (2007). Niinimaki et al. (2009) is the only study that showed that women aged less than 20 years old were at increased risk of a repeat abortion; however the study noted that young parous women with a lower socioeconomic status who were either single or cohabiting were at increased risk of repeat abortion. A number of studies found that age did not have a significant association with repeat abortion (Rose, Lawton 2012, Steinberg, Tschann 2013, Aguirre Zozaya, Iglesias et al. 1980, Das, Adegbenro et al. 2009, Bracken, Kasl 1975, Niemela, Lehtinen et al. 1981, Leach 1977, Jacobsson, Von Schoultz et al. 1976). It was highlighted that women who had repeat abortions and one abortion were of similar age (St John, Critchley et al. 2005, Steinberg, Finer 2011, Frandsen, Rørbye et al. 2014). St John and Critchley (2005) found that age was a confounder in the analysis. Addor et al. (2003) adjusted for age in the analysis but did not present the results. Aguirre et al. (1980) noted that age was not an important predictor of repeat abortion. 4.4 Age at first pregnancy A number of studies showed an association between young age at index abortion and repeat abortion (Bleil, Adler et al. 2011, Osler, Morgall et al. 1992, Grauer 1974, Heikinheimo, Niinimaki et al. 2009), again because of the increased follow up time. Multivariate analysis by Heikinheimo et al . (2009) showed that women of younger age at the index abortion showed increased likelihood of a repeat abortion. Similarly this study showed that women of older age at the index abortion were less likely to have a repeat abortion and more likely that the next pregnancy would result in delivery. Goodman et al . (2008) showed that increased age decreased the risk of repeat abortion over time. Similarly, one study showed that women with repeat abortions in comparison to women with one abortion were more likely to have a lower age of first sexual experience (Stone, Ingham 2011). 4.5 Marital status A number of studies using bivariate analysis showed that women with repeat abortions were more likely to be divorced or separated (Somers 1977, Steinhoff, Smith et al. 1979, Berger, Gold et al. 1984, Howe, Kaplan et al. 1979, Westfall, Kallail 1995). Bleil et al . (2011) and Addor et al . (2003) using multivariate analysis showed that women with repeat abortions were more likely to be divorced, separated or widowed than single. Berger et al . (1984) showed that women with repeat abortions were less likely to be married. Osler et al . (1992) showed that these women were less likely to have a partner and more likely to live alone. Two studies showed that these women were more likely to be single or cohabiting rather than married (Niinimaki, Pouta et al. 2009, Mentula, Niinimaki et al. 2010). Goodman et al . (2008) showed that being married decreased the risk of repeat abortion. Two studies showed that women with repeat abortions were more likely to be married than divorced or separated (Leppalahti, Gissler et al. 2012, Grauer 1974). However this finding in Grauer’s study was not statistically tested. This study was completed in the 1970s thus had a very different sample population, as abortion users were likely to have a different demographic (Grauer 1974). Leppalahti, Gissler et al. 2012 found that women with repeat abortions were more likely to be married or cohabitating than single. Similarly, Westfall and Kallail (1995) showed that women with repeat abortions were less likely to be single than married.

Some studies found no difference in marital status between women with repeat abortions compared to women with no or one abortion (Steinberg, Tschann 2013, David, Reichenbach et al. 2007, Frandsen, Rørbye et al. 2014, Prager, Steinauer et al. 2007, Steinberg, Finer 2011, Freeman, Rickels et al. 1980, Jacobsson, Von Schoultz et al. 1976). Despite having a statistically non-significant result, some studies showed a trend as women who had repeat abortions were less likely to be married and more likely to be divorced or separated than women with one abortion (Steinberg and Finer 2011), or with no abortions (Steinberg, Tschann 2013). David et al . (2007) showed that being single or divorced was not a predictor of a repeat abortion, however being in an unregistered marriage increased the likelihood of a repeat abortion. Similarly, Skjeldestad (1994) showed that marriage was not an independent risk factor for repeat abortion. 4.6 Relationship A number of studies identified unstable relationships as a risk factor for repeat abortion. One very good quality study identified that women with repeat abortions were more likely to be in an unstable relationship (Niemela, Lehtinen et al. 1981, Fisher, Singh et al. 2005). These women were likely to be in short term relationships, with frequent divorce or breakups, and the men in the relationship were less likely to be faithful (Jacobsson, Von Schoultz et al. 1976). Similarly, Berger et al . (1984) showed that women with repeat abortions were more likely to have poor self- reported quality relationships and less likely to live with their partner. However, two studies showed that being in a stable relationship was not significantly associated with repeat abortion, however these studies only examined this association at a bivariate level with relatively small sample sizes (Das, Adegbenro et al. 2009, Jacobsson, Von Schoultz et al. 1976). 4.7 Previous obstetric history Increased parity is strongly associated with repeat abortion (St John, Critchley et al. 2005, Steinberg, Tschann 2013, Steinhoff, Smith et al. 1979, Roberts, Silva et al. 2010, Thapa, Neupane 2013, Bleil, Adler et al. 2011, Stone, Ingham 2011, Falcon, Valero et al. 2010, Heikinheimo, Niinimaki et al. 2009, Goodman, Hendlish et al. 2008, Nguyen, Budiharsana 2012, Niinimaki, Pouta et al. 2009, Raatikainen, Heiskanen et al. 2006, Somers 1977). Roberts et al . (2010) showed that a larger parity increased the odds of a repeat abortion by 20%. Howe et al . (1979) showed that women with repeat abortions were less likely to have a lower number of children, and had an increased number of unintended pregnancies. Multiple studies found a larger number of pregnancies in women with repeat abortions than women with no or one abortions (Steinberg, Tschann 2013, Thapa, Neupane 2013, Bleil, Adler et al. 2011, Howe, Kaplan et al. 1979, Bracken, Kasl 1975). There is very little evidence to suggest otherwise but one study did find very similar percentages of previous live births in both the repeat and the one abortion group (Somers 1977). Another study found a lower number of live births among women with repeat abortions than women with no abortions (Steinberg, Finer 2011). Additionally, Aguirre et al . (1980) showed that among married and divorced women with repeat abortions there was a lower level of parity, however as discussed previously this study may lack the rigour to provide a reliable result. Three studies found a non-significant association between parity and repeat abortion (Rose, Lawton 2012, Steinberg, Tschann 2013, Jacobsson, Von Schoultz et al.

1976). Rose and Lawton (2012) showed a non-significant result with a very small sample of repeat abortions. A number of studies consider parity as a confounder (St John, Critchley et al. 2005, Bracken, Kasl 1975). Additionally, Skjeldestad (1994) showed that parity was not an independent risk factor for repeat abortion. 4.8 Contraception usage 4.8.1 Comparison with one abortion Figure 3 shows that there was no evidence to suggest there was a difference in the contraceptive usage at conception between women with one abortion and repeat abortions. A random effects model was chosen as there was statistical heterogeneity between the studies shown by the large I 2 value. Figure 3

4.8.2 Contraceptive method There is evidence to suggest that women with repeat abortions were more likely to use non-reliable methods of contraception such as rhythm and withdrawal (Nguyen, Chongsuvivatwong et al. 2000, Stone, Ingham 2011, Niemela, Lehtinen et al. 1981). Similarly, a number of studies showed women with repeat abortions were more likely to use barrier methods than any other method (Osler, Morgall et al. 1992). However, two studies found that there was not a significant difference in the use of condoms (Addor, Narring et al. 2003, Jacobsson, Von Schoultz et al. 1976). Similarly, another study found there was a non-significant difference in the use of coitus interruptus (Thapa, Neupane 2013).

On the other hand the literature suggests that woman with repeat abortions in comparison to woman with one abortion are more likely to use reliable methods. Schneider and Thompson (1976) showed these women were less likely to use coitally related methods (douche, rhythm and withdrawal). Similarly, Howe et al . (1979) showed that women with repeat abortions were less likely to use rhythm and withdrawal methods. Grauer (1974) and Bracken et al. (1975) identified that these women were less likely to use rhythm methods; however, Grauer did not use any statistical test for these relationships. Furthermore a number of studies suggest that women with repeat abortions were more likely to use reliable methods of contraception. Two studies showed that women with repeats were more likely to use IUD before their pregnancy (Raatikainen, Heiskanen et al. 2006, Jacobsson, Von Schoultz et al. 1976). One study showed that women with repeats were more likely to use Depo Provera before their pregnancy (Prager, Steinauer et al. 2007). In contrast, another study showed that women with one abortion were more likely to use IUD than women with repeat abortions (Leach 1977). Many studies show that the combined oral contraceptive (COC) pill was widely used at the time of conception in women with repeat abortions (Schneider, Thompson 1976, Howe, Kaplan et al. 1979, Addor, Narring et al. 2003, Niinimaki, Pouta et al. 2009, Garg, Singh et al. 2001, Jacobsson, Von Schoultz et al. 1976). Schneider and Thompson (1976) showed that women with repeat abortions were more likely to use the pill or IUD. One study shows that women with repeat abortions were more likely to be using COC than women with one abortion; however this was not tested statistically (Osler, Morgall et al. 1992). Similarly, Grauer (1974) and Daily (1973) showed that women with repeat abortions were more likely to use the pill; however no statistical test was performed to test this relationship. Howe et al . (1979) showed an increase in the likelihood in the use of COC, IUD and diaphragm. However, one study showed that women with one abortion were more likely to use COC than women with repeat abortions (Leach 1977). A number of studies showed there was no significant difference between the use of the pill and other methods (Prager, Steinauer et al. 2007, Westfall, Kallail 1995). Similarly, Thapa and Neupane showed there was no significant difference between women having repeat abortion and their use of no method or the pill (Thapa, Neupane 2013) . There are a number of studies that showed there was no significant difference in the use of contraceptive methods between women with repeat abortions and one abortion (David, Reichenbach et al. 2007, Bracken, Hachamovitch et al. 1972, Grauer 1974, Leppalahti, Gissler et al. 2012). However, despite there being a lack of an association Bracken et al. noted that women with repeat abortions were more likely to be using contraception at the time of conception. Grauer (1974) as discussed had a very small sample size. 4.8.3 Comparison with no abortion One study identified that women with repeat abortions in comparison to women with no abortion were less likely to use contraception (Schneider, Thompson 1976). Evidence also suggested that in comparison to women with no abortion, women with repeat abortion were more likely to use coitally related methods (rhythm, douche and withdrawal) (Schneider, Thompson 1976). Nguyen and Budiharsana (2012) showed that women with repeat abortions in comparison to women with no abortions were more likely to use oral pills,

intrauterine device (IUD), injectables, implants, and female sterilization. There is only one study that found women with repeat abortions were more likely to use reliable methods (IUD) before their pregnancy than women with no abortion (Raatikainen, Heiskanen et al. 2006). 4.8.4 Emergency contraception A number of studies found that women with repeat abortions were less likely to use emergency contraception. St John et al. (2005) found this association but it was non- significant. Das et al. (2009) highlighted that only 5% of women with repeat abortions had access to emergency contraception. 4.8.5 Contraceptive usage post abortion Some studies examined the subsequent abortion rate depending on the usage of contraception. There is some evidence to suggest that post abortion usage of LARC reduces the likelihood of a repeat abortion. Roberts et al . (2010) illustrated that woman who left with an IUD and Depo Provera in comparison to leaving with the Combined Oral Contraceptive (COC) pill had significantly reduced odds of a subsequent repeat abortion within a 3 year follow up period. Rose and Lawton (2012) found that women who chose a LARC method post abortion compared to all other methods of contraception were less likely to return for a subsequent abortion within a 24 month follow up period. Depo Provera reduced the likelihood of a repeat abortion; however the association was not significant. Similarly, one study showed that women who used an IUD or IUS after their initial abortion were less likely to have another abortion (Heikinheimo, Niinimaki et al. 2009). Goodman et al . (2008) showed that women who used an IUD had a lower repeat abortion rate than women who used other non-IUD methods. Planned usage of a copper releasing IUD reduced the risk of a repeat abortion (Niinimaki, Pouta et al. 2009). However there was no significant difference in the planned usage of other contraceptives and the risk of a subsequent abortion. 4.9 Sexual Behaviour 4.9.1 Intentions and motivations Women with repeat abortions were more likely to have no intention for a future child (Thapa, Neupane 2013). Although two studies showed there was no significant difference (Nguyen, Chongsuvivatwong et al. 2000, Jacobsson, Von Schoultz et al. 1976). Two studies showed that coital frequency was higher in women with repeat abortions (Howe, Kaplan et al. 1979, Berger, Gold et al. 1984). Howe et al . (1979) and Bracken (1975) showed that women with repeat abortions were more likely to plan to have coitus. Two studies showed that women with repeat abortions were more likely to have a greater number of sexual partners than women with one abortion (Stone, Ingham 2011, Jacobsson, Von Schoultz et al. 1976). In contrast one study found no difference in the number of sexual partners in both groups (Bracken, Kasl 1975). However, two studies found a non-significant relationship between coital frequency and repeat abortions (Bracken, Kasl 1975, Jacobsson, Von Schoultz et al. 1976). As sexual attitudes and behaviours have been changing over the past number of decades it may not be appropriate to use findings of studies from the 1970s to summarize the number of sexual partners (Mercer, Tanton et al. 2013). Stone et al. (2011) conducted a robust population survey which was representative of the UK and highlighted a larger number of partners in the repeat abortion group. 45

A number of studies examined the reasons for future non-use of contraception after a repeat abortion; the main reasons for non-use were that these women were not planning to have sexual intercourse, sexual intercourse was to be avoided and the discontinuation of a relationship (Bracken, Hachamovitch et al. 1972). Daily (1973) highlighted that running out of supplies or having experienced negative side effects of contraception may have been factors that resulted in the discontinuation of contraceptive methods. Women were more likely to attribute repeat abortions to method failure (Daily, Nicholas et al. 1973, Howe, Kaplan et al. 1979). Using a bivariate analysis, St John et al . (2005) showed that women with repeat abortions were less likely to be discharged with contraception or have had a follow up arranged after previous abortion. Similarly women who planned to use contraception after an initial abortion were less likely to have a subsequent abortion (Steinhoff, Smith et al. 1979). Women with a repeat abortion compared to first abortion were less likely to have received Depo Provera. David et al . (2007) showed that women who had a repeat abortion were significantly less likely to have thought about a future method of contraception. These women were also less likely to know when their fertility returned following abortion. Another study showed that women with repeat abortion were less likely to have a positive attitude towards birth control (Niemela, Lehtinen et al. 1981). Thapa (2013) showed that women with a repeat abortion compared to first abortion were more likely to have received barrier methods at time of discharge. 4.10 Psychosocial 4.10.1 Mental illness Using multivariate analysis Steinburg and Finer (2011) highlighted that women with repeat abortions were more likely to have an anxiety disorder; this became non- significant after adjusting for prior risk factors. In this study there was no association with mood disorders. One study examined the personalities of women with repeat abortions; using bivariate analysis it showed that these women more likely to have lower self-esteem, emotional balance, stable life and higher anxiety levels (Niemela, Lehtinen et al. 1981). Two studies showed that there was an increased likelihood of a psychiatric history among those with a repeat abortion; however this relationship was non-significant (St John, Critchley et al. 2005). This relationship was not significantly tested (Grauer 1974). Both of these studies had very small sample sizes so may be unable to detect a significant effect.

4.10.2 Abuse Two studies indicated that having a history of abuse increased the likelihood of having a repeat abortion in comparison to women with one abortion (Bleil, Adler et al. 2011, Fisher, Singh et al. 2005). These studies found that physical abuse from a partner and sexual abuse were associated with repeat abortion in comparison to women with one abortion. The relationship with physical abuse became non- significant when compared to women with no abortions but the relationship with sexual abuse remained significant (Bleil, Adler et al. 2011).

One study found a non-significant relationship with physical abuse, sexual abuse and neglect, when comparing women with repeat abortions to women with no or one abortion (Steinberg, Tschann 2013). 4.10.3 Substance abuse Two studies noted that substance abuse was a risk factor for repeat abortion (Steinberg, Finer 2011, Prager, Steinauer et al. 2007). One study found that women with repeat abortions in comparison to women with no abortion were more likely to consume alcohol during pregnancy (Raatikainen, Heiskanen et al. 2006). This was also the case for women with a repeat abortion in comparison to women with one abortion, although it became non-significant when all risk factors were adjusted for (Steinberg, Finer 2011). One study showed that there was not a significant relationship between repeat abortions and substance misuse (Coleman, Reardon et al. 2005). 4.10.4 Smoking Four studies showed that women with repeat abortions in comparison to women with single abortions were more likely to smoke (Heikinheimo, Niinimaki et al. 2009, Frandsen, Rørbye et al. 2014, Coleman, Reardon et al. 2005). One study found that women with repeat abortions in comparison to women with no abortion were more likely to smoke (Raatikainen, Heiskanen et al. 2006). 4.10.5 Adverse life events One study examined unstable childhood events of women with repeat abortions. Using bivariate analysis, this study illustrated that women with repeat abortions were more likely to have parental loss at a younger age, siblings from multiple parents, frequent change of municipality, poor economic circumstances or poor relationship with parents (Niemela, Lehtinen et al. 1981). Another study found that women with repeat abortions were more likely to report family disruption than women with one or no abortions (Bleil, Adler et al. 2011). However, one study showed that opinion of childhood was not associated with repeat abortion, although this study did not specifically ask about abuse events and adverse events may have been underreported at interview due to the sensitivity of this topic (Jacobsson, Von Schoultz et al. 1976). A personal safety threat was shown to have an association with repeat abortion. One study showed two or more personal safety threats were found to be associated with repeat abortion when compared to one or no abortions (Steinberg, Tschann 2013). Stressful life events were indicated to be significantly associated with women with repeat abortions in comparison to women with no and one abortion (Bleil, Adler et al. 2011). A stressful life event included abuse, death of parent, parental mental illness, violence or conflict, living with a relative who has a substance abuse problem, and it also included having threats to personal safety. Bleil et al.(2011) found that women with a repeat abortion were more likely to report family disruption and have had issues with personal safety in comparison to women with one or no abortions. This study also showed that women who had an increase in non-abusive events were more likely to have a repeat abortion compared to no or one abortions. However, one study found a non-significant relationship between repeat abortion and one personal safety threat, parental divorce, criminal behaviour and violence (Steinberg, Tschann 2013).

4.10.6 Sexual health and past medical history Fisher et al . (2005) showed that women with repeat abortions were more likely to have a history of a sexually transmitted infection. A previous medical of history of maternal diabetes, pre-gravid hypertension and chronic illness did not increase the likelihood of a repeat abortion in comparison to no abortion. One study found that obesity was not significantly associated with repeat abortion (Prager, Steinauer et al. 2007). One study found that women with repeat abortions were more likely to have a BMI greater than 25 than women who have had no abortion (Raatikainen, Heiskanen et al. 2006). However, one study showed a non- significant relationship with obesity (Prager, Steinauer et al. 2007) 4.10.7 Intervention studies Schunmann and Glasier (2006), a UK study, showed that specialist post abortion contraceptive services increased the uptake of contraception after an abortion. However this intervention did not reduce repeat abortions after a two year period.

5. Discussion 5.1 Principal findings 5.1.1 Systematic Review This review of published studies found that individual, family as well as contextual level factors were important in determining who was likely to have a repeat abortion. Individual determinant factors included younger age at first abortion, lower level of education, unstable relationships, adverse life events, history of sexual abuse and poor uptake of LARC post abortion. The most important family level determinants were lower socio-economic status; disruptive family environment such as parental divorce and living in an urban area. Although no study actually measured contextual factors every study’s setting influenced the results. These contextual or ecological factors such as abortion laws, access and availability of contraceptives, sexual health service delivery, women’s decision making empowerment and status in society were the unmeasured variables influencing all other determinant factors. Time as a separate determinant factor was not evaluated by any published reports but obviously played a crucial role at all levels, especially at the contextual level. Although the evidence was sometimes conflicting, the conclusions of this review drew from the best available evidence in the published literature. The majority of studies examining the familial factors suggested that lower socioeconomic status, belonging to an ethnic minority group and living in an urban area were the main determinants of repeat abortion at a familial level. Jones et al. (2006) argued that the evidence surrounding socioeconomic status was uncertain, but studies included in this literature review that were conducted in the United States (US) and were a couple of decades old did report a strong association with lower socioeconomic status. At the individual level the evidence highlighted that women who had their initial abortion at a younger age were at increased risk of a repeat abortion. By having an abortion at a younger age these women increased the likelihood of having another unplanned pregnancy during their reproductive lifetime. These findings were mirrored in a UK prevalence study which showed that younger people commonly had

unplanned pregnancies (Wellings, Jones et al. 2013). Age had an interesting relationship with repeat abortion as there was wide diversity between studies on how age was measured; as while there appeared to be a strong association between older age and repeat abortion, women at their repeat abortion by definition will be older than women at their first abortion. However, these older women may highlight a different group of women who also have a larger parity, as these women have reached their optimum family size so any additional pregnancies will be aborted. There is evidence to suggest that women who conceive soon after a live birth are at increased likelihood of an induced abortion (Vikat, Kosunen et al. 2002). The majority of the evidence indicated that non-married women and women in unstable relationships had an increased likelihood of a repeat abortion. Previous research has highlighted a similar association between unplanned pregnancies and non-long term relationships (Wellings, Jones et al. 2013). The literature surrounding unplanned pregnancy has highlighted that the population is becoming sexually active at a younger age with a larger number of sexual partners but also postponing a stable cohabiting relationship, leaving a larger amount of time for an unplanned pregnancy and risky sexual behaviours (Johnson, Mercer et al. 2001, Wellings, Jones et al. 2013). Although only one study measured an association between STIs and repeat abortion the women at risk of an STI may be a very similar to those at risk of a repeat abortion. These women were younger at their sexual debut, had a larger number of sexual partners, were from deprived areas and were engaging in unprotected sexual intercourse (Sonnenberg, Clifton et al. 2013). This review highlights that there is much contrasting evidence surrounding the use of contraception preceding the abortion. It is not very clear from the evidence whether the use of reliable (IUD, IUS and Depo Provera) or non-reliable methods (Barrier, natural methods) was different between the first and repeat abortion group. Jones et al. (2006) contested that women with repeat abortions were more likely to use contraception than women who had only aborted one previous pregnancy; however this article did not complete a meta-analysis. This study also highlighted that the repeat abortion group were more likely to use COC at the time preceding the pregnancy and less likely to use LARC methods; despite a number of studies in this review showing this relationship we feel there is not a coherent trend in the literature. The evidence from this review would suggest that these two groups were more similar than different in respect to contraceptive usage at conception or time leading up to conception. As the outcome in both groups was abortion, both groups must have used less effective methods or no method at all. There was strong evidence from the literature to suggest that women who left with LARC as their post abortion contraception had a reduced likelihood of repeat abortion. The literature also highlights that women in the repeat abortion group were less likely to leave with a contraceptive method, or to have planned a contraceptive method or have chosen a LARC method. There appears to be an association between psychosocial factors and repeat abortions. The literature has highlighted associations between repeat abortion and previous psychiatric history, anxiety, depression, alcohol misuse, smoking, adverse life events and history of sexual abuse. These results were consistent with other studies on unplanned pregnancy as the results from the NATSAL-3 highlighted that women with unplanned pregnancies were likely to use drugs other than cannabis,

have been depressed and currently smoke (Wellings, Jones et al. 2013). The evidence in this review surrounding mental illness, abuse and substance misuse is not very strong; as the small numbers of studies that measured these associations had very small sample sizes and the self-reported nature of these studies may be susceptible to recall bias. However, the included studies appear to show an association between these psychosocial factors and repeat abortion. 5.1.2 Secondary data analysis We found that 22.8% of women who had one abortion had at least one further abortion during the study time period. By comparing the characteristics of the women at the time of the first abortion, it was possible to predict groups of women who would subsequently go on to have another abortion. Women with repeat abortions were more likely to be younger at their initial abortion, have had two live births, belong to a lower SIMD quintile, have been tested for an STI or BBV and had a medical abortion. This study showed that at the initial abortion there was no difference in the contraceptive choice at conception however women with repeat abortions were more likely to use LARC as their post abortion method. 5.2 Strengths and limitations 5.2.1 Systematic review This systematic review offers the first comprehensive synthesis of the available evidence on the determinant factors for repeat abortions. The review protocol was devised a priori with a focussed review question and strict inclusion and exclusion criteria. The rigorous search strategy and extensive bibliographic search add robustness to the review. The qualitative synthesis of identified factors into a framework of determinants is an added strength. The population-based design of the majority of the included studies promotes generalisability within countries as well as transferability of findings to other countries with similar contextual factors. Although of good quality there were measurable differences in the reporting of the included studies. Primary studies differed considerably in their definition of repeat abortion and therefore in the measurement of this outcome. The measures of the determinant factors, especially social class varied considerably between studies. In view of this considerable diversity between studies, a meta-analysis was not considered suitable for most determinants. A further issue was the lack of consistency in addressing the effects of confounding and co linearity. However, residual confounding by poor measurement of relevant confounders or unknown confounders could still explain at least part of the associations reported Finally, publication bias and selective reporting were possible limitations for any systematic review, more so systematic reviews of observational studies. This may be particularly the case for very sensitive topics such as sexual abuse, mental illness and substance abuse. Many of the studies identified by the inclusion criteria were conducted a number of decades ago limiting their generalisability to the sexual attitudes and lifestyles of the UK in the 21 st Century. Around half of the papers scored higher than 6 on the reporting score; many of the studies used self-reported measures for either the outcome or determinants which made these studies susceptible to recall or social desirability bias.

5.2.2 Secondary data analysis This study had one of the largest sample sizes of repeat abortions in the published literature, reducing the likelihood of a type II error. The quality of the data collected by dedicated coding staff in the TOP database adds validity to the study. As the database collects all abortions in the geographically defined area of Grampian region in Scotland, selection bias is likely to be minimal. The ability to link abortions occurring in the same woman is a special advantage of using this database as valid reproductive histories can be constructed automatically without taking recourse to case note review or self-reported history. We have presented repeat abortions as a proportion of women rather than the total number of abortions and compared their characteristics at the time of the initial abortion to build a prediction model of repeat abortions. This enables the development of targeted interventions following the first abortion to prevent repeats. This database may have underreported the number of repeat abortions as women may have had another abortion in a different health board or hospital and women who have moved into this health board may have had a previous abortion in another region. Similarly, we have analysed data from 1997 as recorded in this database, therefore it is possible that we may have misclassified some women who had an abortion prior to this time period. We were unable to examine some risk factors implicated in the literature such as smoking, substance misuse, marital status and domestic abuse as this database did not collect information on these variables. Furthermore, it is an observational study so the result may be prone to residual confounding and there may be other factors that may be associated with repeat abortion that are not recorded in this database. 5.3 Context of findings from secondary analysis This study has found that the rates of repeat abortions recorded in the TOP database are higher than the Scottish average (ISD, 2013). Despite using the same method this highlights that ISD may have been underreporting the proportion of repeat abortions in Scotland. A possible explanation for this may be the data collection method, as the women in this database are matched on their patient number while ISD’s data is collected through a self-reported measure. Other studies found that women with repeat abortions were younger at their index pregnancy which is consistent with this study as our results show that women who are younger at their index abortion have an increased likelihood of a repeat abortion (Bleil, Adler et al. 2011, Osler, Morgall et al. 1992, Heikinheimo, Niinimaki et al. 2009). One possible explanation for this is women who have an index abortion at younger age increase the amount of time they may be exposed to unprotected sexual intercourse during their reproductive years, thus increase the likelihood of having a subsequent conception and abortion. Interestingly many studies showed that parity increased the likelihood of a repeat abortion (Thapa, Neupane 2013, Stone, Ingham 2011, St John, Critchley et al. 2005). Similarly, this study found that having two previous live births at the index abortion increased the risk of a repeat abortion. Although three or greater previous live births were not associated with a repeat abortion, neither was pregnancy number which is contrary to other studies (Skjeldestad 1994). With the average family size being around 1.7 live births in the UK, many mothers may not desire any more than two children as they have completed their family unit (Office for National Statistics 2013, Kirkman, Rowe et al. 2009). Additionally, prior to the two live births the woman 51

may have had an abortion as it was the wrong timing as these women deem themselves too young or do not have a partner or a stable partner for a live birth. Once these factors have been modified these women will have the desired family size but another unplanned pregnancy post pregnancy could have led to a repeat abortion (Kirkman, Rowe et al. 2009). Although the results cannot identify whether the abortions occurred before or after the live birth this is an important issue for future research. This study showed that women from a lower socioeconomic quintile had an increased likelihood of a repeat abortion, which is consistent with previous research (Osler, Morgall et al. 1992, Niemela, Lehtinen et al. 1981, Niinimaki, Pouta et al. 2009, Mentula, Niinimaki et al. 2010, Das, Adegbenro et al. 2009). Furthermore, these women were more likely to have been tested for an STI and in the bivariate analysis had a chlamydial infection. This result is supported by the limited literature that has examined the association with STIs and found a positive association (Fisher, Singh et al. 2005). Previous research has shown that women from deprived areas and who are younger at first sexual intercourse are more likely to engage in risky sexual behaviours, for example this group may engage in unprotected sexual intercourse which increases the risk of an STI (Vukovic, Bjegovic 2007, Edgardh 2000). The contraceptive usage at conception at the index abortion of both groups of women was very similar. However the post abortion usage was different as women who used LARC methods had an increased likelihood of a repeat abortion. A number of studies have highlighted that use of LARC after an initial abortion may be high; however among women who have repeat abortions, there is a high discontinuation rate (Das, Adegbenro et al. 2009, Schunmann, Glasier 2006). This illustrates the need for woman who are discharged with LARC to be followed up to ensure that they have access to an alternative contraceptive method should they discontinue their usage of LARC. This study depicts that young women with two live births at the index abortion, who partake in risky sexual behaviour and leave their first abortion with LARC had an increased risk of a subsequent abortion.

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APPENDIX 1:

Grounds for termination

Non Emergency

A - the continuance of the pregnancy would involve risk to the life of the pregnant women greater than if the pregnancy were terminated. B - the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman. C - the pregnancy has NOT exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman. D - the pregnancy has NOT exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the existing child(ren) of the family of the pregnant woman. E - there is substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.

Emergency

F - it was necessary to save the life of the woman. G - it was necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman.

Source: http://www.isdscotland.org/Health-Topics/Sexual-Health/Abortions/

APPENDIX 2: Search strategy Ovid MEDLINE(R) < 1946 to November Week 3 2013>

1. exp Abortion, Induced/ 2. ((unwanted or terminat$) adj10 (pregnan$ or conception$1)).tw. 3. Abortion$1.tw. 4. peri-abortion#.tw. 5. or/1-4 6. Multiple.tw 7. repeat$3.tw 8. frequen$3.tw 9. previous$2.tw 10. recur$5.tw 11. numerous.tw 12. various.tw 13. Duplicate.tw 14. Or/ 6-13 15. History.tw 16. Prior.tw 17. Previous.tw. 18. Second.tw. 19. Third.tw 20. Or/ 15-19 21. Or/ 20 and 14 22. 1 and 20 23. 3 ADJ3 20 24. 2 ADJ3 2 25. Or/ 22, 23 and 24 26. exp Risk factors/ 27. exp sexual behaviour/ 28. exp Reproductive Behavi?or/ 29. exp attitude/ 30. exp Attitude to Health/ 31. exp birth control/ 32. exp health behaviour 33. exp Substance-Related Disorders/ 34. exp Alcohol Drinking/ 35. exp Smoking/ 36. exp sex factors/ 37. exp risk taking/ 38. exp risk reduction behavior/ 39. exp age factors/ 40. determinant$.tw. 41. caus$5.tw. 42. association.tw. 43. reason$.tw.

44. characteristics$2.tw. 45. predict$5.tw. 46. explants$3.tw. 47. (conception adj3 behavio?r).tw. 48. exp Reproductive techniques/ 49. (conception adj 3 practices).tw. 50. (birth adj3 control).tw 51. (contraceptive$ or contraception$).tw. 52. exp contraception/or exp contraception behaviour/ or exp contraceptive, barrier 53. (sex$ adj5 (education or knowledge)).tw. 54. (barrier adj5 method$).tw. 55. ((safe or unsafe) adj5 (sex$ or intercourse$)).tw. 56. (reproductive adj4 behavio?r$).tw. 57. ((protected or unprotected or protection$) adj2 (sex$ or intercourse$)).tw. 58. (sex$ adj10 (behavio?r$ or experience$ or activ$4 or relation$ or practice$)).tw. 59. ((drug or substance or alcohol) adj5 (usage or misuse or abuse or addiction or dependence or disorder$)).tw. 60. (alcohol adj5 (drink$ or drank or drunk$)).tw. 61. smoking.tw 62. social environment/ or exp life style/ or exp morale/ or exp psychosocial deprivation/ or exp social values/ or exp social class/ or exp social problems/ or exp social welfare/ or exp social work/ or exp socialization/ or exp socioeconomic factors/ or exp Psychology, Social/ 63. exp Domestic Violence/ exp Sex Offense/ exp battered woman/ or exp family conflict 64. (physical adj3 abuse).tw. 65. (partner adj3 (violence or abuse or coercion)).tw. 66. (sexual adj3 abuse).tw. 67. (relationship adj3 conflict).tw. 68. exp Reproductive Health Services/ or exp Health services 69. /Or 26-68 70. 25 and 69

APPENDIX 3:

Summary of results

Familial factors

Studies that Association Studies agreed

St John, Critchley et al. 2005, Steinhoff, Smith et al. 1979, Addor, Narring et al. 2003, Das, Adegbenro et al. 2009, Stone, Ingham 2011, Lower socioeconomic status 9 Osler, Morgall et al. 1992, Niemela, Lehtinen et al. 1981, Niinimaki, Pouta et al. 2009, Mentula, Niinimaki et al. 2010,

Higher socioeconomic status 1 Aguirre Zozaya, Iglesias et al. 1980 Socioeconomic status Not clear (More likely to Skjeldestad 1994, Osler, Morgall et al. 1992, 4 employed, or have own income) Falcon et al. 2010, Jacobsson et al. 1976

Rose, Lawton 2012, Steinberg, Tschann 2013, Westfall, Kallail 1995, Prager, Steinauer et al. No significant association 7 2007, Nguyen, Chongsuvivatwong et al. 2000, Nguyen, Budiharsana 2012, Steinberg, Finer 2011

Westfall, Kallail 1995, Bleil, Adler et al. 2011, Stone, Ingham 2011, Prager, Steinauer et al. Non-white 7 2007, Steinberg, Finer 2011, Steinberg and Tschann, 2013, Freeman, Rickels et al. 1980

Ethnicity Addor 2003, Fisher et al. 2005 and Roberts et Foreign nationals 3 al. 2010

Rose, Lawton 2012, Bracken, Hachamovitch No significant association 4 et al. 1972, Nguyen, Budiharsana 2012, Leach 1977

Steinberg, Tschann 2013, Thapa, Neupane 2013, Bleil, Adler et al. 2011, Addor, Narring et Lower education level 6 al. 2003, Stone, Ingham 2011, Frandsen, Rørbye et al. 2014

Education David, Reichenbach et al. 2007, Prager, Steinauer et al. 2007, Bracken, Kasl 1975, Nguyen, Chongsuvivatwong et al. 2000, Leach No significant association 8 1977, Jacobsson et al. 1976, Freeman, Rickels et al. 1980, Niemela, Lehtinen et al. 1981

Higher education level 1 Howe, Kaplan et al. 1979

Adverse life Unstable childhood Niemela, Lehtinen et al. 1981, Bleil, Adler et al. 2 events events/family disruption 2011

Steinberg, Tschann 2013, Jacobsson et al. No significant association 2 1976

Individual factors

Westfall, Kallail 1995, Thapa, Neupane 2013, St John, Critchley et al. 2005, Bleil, Adler et al. 2011, Berger, Gold et al. 1984, Fisher, Singh et al. 2005, Falcon, Valero et al. 2010, Howe, Kaplan et al. 1979, Prager, Steinauer et al. 2007, Bracken, Hachamovitch 1972, Older ages (20-39) 21 Roberts, Silva et al. 2010, Somers 1977, Nguyen, Chongsuvivatwong et al. 2000, Nguyen, Budiharsana 2012, Raatikainen, Heiskanen et al. 2006, Garg, Singh et al. 2001, Leppalahti, Gissler et al. 2012, Freeman, Rickels et al. 1980, Falcon et al. 2010, Tietze 1978, Skjeldestad 1994

Roberts, Silva & Xu 2010, David et al. 2007, Younger age in repeat vs. 1 or 0 4 Niinimaki et al. 2009, Mentula et al. 2010 Age Less likely to be older Goodman et al. 2007

St John, Critchley & Glasier 2005, Steinberg, Similar age vs. one abortion 3 Finer 2011, Frandsen, Rørbye & Nilas 2014

Rose, Lawton 2012, Steinberg, Tschann 2013, Aguirre Zozaya et al. 1980, Das et al. 2009, Non-significant 8 Bracken, Kasl 1975, Niemela et al. 1981, Leach 1977, Jacobsson et al. 1976

Not stated 2 Addor et al. 2003, Aguirre et al. 1980

Bleil, Adler et al. 2011, Osler, Morgall et al. Index abortion younger in the 4 1992, Grauer 1974, Heikinheimo, Niinimaki et repeat abortion group al. 2009

Somers 1977, Steinhoff, Smith et al. 1979, More likely to be divorced or Berger, Gold et al. 1984, Howe, Kaplan et al. 6 separated 1979, Westfall, Kallail 1995, Goodman et al. Marital 2008 status

More likely to be single or Niinimaki, Pouta et al. 2009, Mentula, 3 cohabiting Niinimaki et al. 2010, Osler et al. 1992

More likely to be married 2 Grauer, 1974; Leppalahti, Gissler et al. 2012

Steinberg, Tschann 2013, David, Reichenbach et al. 2007, Frandsen, Rørbye et al. 2014, No statistical association 7 Prager, Steinauer et al. 2007, Steinberg, Finer 2011, Jacobsson et al. 1976, Freeman, Rickels et al. 1980

Marriage is not an independent 2 David et al. 2007; Skjeldestad 1994 predictor

Niemela, Lehtinen et al. 1981, Berger et al. Poor 2 1984 Relationship quality Das, Adegbenro et al. 2009, Jacobsson et al. Non-significant 2 1976

St John, Critchley et al. 2005, Steinberg, Tschann 2013, Steinhoff, Smith et al. 1979, Roberts, Silva et al. 2010, Thapa, Neupane 2013, Bleil, Adler et al. 2011, Stone, Ingham 2011, Falcon, Valero et al. 2010, Heikinheimo, Increased parity 16 Niinimaki et al. 2009, Goodman, Hendlish et al. 2008, Nguyen, Budiharsana 2012, Niinimaki, Pouta et al. 2009, Raatikainen, Heiskanen et al. 2006, Somers 1977, Roberts et al. 2010, Howe et al. 1979

Obstetric Lower number or similar number 2 Steinberg, Finer 2011, Aguirre et al. 1980 history live births

Rose, Lawton 2012, Steinberg, Tschann 2013, No statistical association 3 Jacobsson et al. 1976

St John, Critchley et al. 2005, Bracken, Kasl Not an independent predictor 3 1975, Skjeldestad 1994

Steinberg, Tschann 2013, Thapa, Neupane Larger number of previous 5 2013, Bleil, Adler et al. 2011, Howe, Kaplan et pregnancies al. 1979, Bracken, Kasl 1975

Fisher, Singh et al. 2005, , Howe, Kaplan et al. More likely to use contraception 1979, Garg, Singh et al. 2001, Westfall, Kallail 10 than first time abortion 1995, Leach 1977, Daily et al. 1973; Niemela, Contraceptio Lehtinen et al. 1981; Berger 1984 n usage at conception/ Osler, Morgall et al. 1992, Stone, Ingham Before Less likely to use contraception 6 2011, Grauer 1974, Skjeldestad 1994, abortion (vs. one abortion) Schneider, Thompson 1976

6 Increased likelihood of using non Thapa, Neupane 2013, Nguyen,

reliable methods (Rhythm, Chongsuvivatwong et al. 2000, Stone, Ingham withdrawal and condom) 2011, Niemela, Lehtinen et al. 1981, Osler, Morgall et al. 1992, Grauer 1974

No difference in the usage of 2 Addor et al. 2003, Jacobsson et al. 1976 barrier

Schneider and Thompson 1976, Howe et al 1979, Grauer, 1974, Bracken et al. 1975, (By any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)(By Reliable methods 7 any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)(By any other name: feticide. 2013)Raatikainen, Heiskanen et al. 2006, Prager et al. 2007, Jacobsson et al. 1976

Less likely to use LARC and Depo 1 Leach 1977 Provera

Schneider, Thompson 1976, Howe, Kaplan et al. 1979, Addor, Narring et al. 2003, Nguyen, Budiharsana 2012, Niinimaki, Pouta et al. More likely to use COC 7 2009, Garg, Singh et al. 2001, Osler, Morgall et al. 1992, Grauer 1974, Daily 1973, Jacobsson et al. 1976

Less likely to use COC 1 Leach 1977

Prager, Steinauer et al. 2007, Westfall, Kallail No difference in usage of COC 3 1995, Thapa 2013

David, Reichenbach et al. 2007, Bracken, No significant different with one Hachamovitch et al. 1972, Grauer 1974, 6 abortion Leppalahti, Gissler et al. 2012, Freeman, Rickels et al. 1980, Berger et al. 1984

Less likely to use contraception or use less reliable methods (vs. no 1 Schneider, Thompson 1976 abortion)

More likely to use a variety of Nguyen and Budiharsana 2012, Raatikainen, 2 methods Heiskanen et al. 2006

Increased usage of COC post 1 Das et al. 2009 abortion Contraceptio n post Roberts et al. 2010, Rose and Lawton 2012, abortion Less likely to use or continue using 4 Heikinheimo, Niinimaki et al. 2009, Goodman LARC 2008

Less likely to be discharged with contraception/ reliable methods/ St John et al. 2 005; Steinhoff, Smith et al. planned method/ fertility cycle 5 1979; David et al. 2007, Niemela et al. 1981. knowledge/ Positive attitude toward Thapa, 2013 contraception Sexual knowledge More likely to have poor access to 1 Das et al. 2009 EC

Non-significant association with 1 St John et al. 2005 access to EC

Howe, Kaplan et al. 1979, Berger, Gold et al. Increased frequency of coitus/ 4 1984, Stone and Ingham 2011, Jacobsson et partners/ al. 1976

Bracken, Kasl 1975, Jacobsson, Von Schoultz No difference in coital frequency 2 et al. 1976

No difference in number of 1 Bracken, Kasl 1975 Sexual partners behaviour

Thapa, Neupane 2013, Jacobsson, Von No intention for child 2 Schoultz et al. 1976

No significant association for child 1 Nguyen, Chongsuvivatwong et al. 2000 intentions

Increased likelihood of STI 1 Fisher et al. 2005

Increased likelihood of previous mental illness/anxiety disorder/ self 1 Niemela, Lehtinen et al. 1981 esteem Mental illness Increased likelihood of previous 1 Steinberg and Finer, 2011 mental illness- NS

Increased likelihood mental - NS 2 Grauer 1974, St John, Critchley et al. 2005

History abuse 2 Bleil et al. 2011, Fisher et al. 2005 Abuse Non-significant association 1 Steinberg and Tschann 2013

Steinberg, Finer 2011, Prager, Steinauer et al. Alcohol -Increased the likelihood 2 2007

Substance Substance misuse - NS 1 Coleman, Reardon et al. 2005 abuse Heikinheimo, Niinimaki et al. 2009, Frandsen, Smoking 4 Rørbye et al. 2014, Coleman, Reardon et al. 2005, Raatikainen, Heiskanen et al. 2006

Adverse life Steinberg, Tschann 2013, Bleil, Adler et al. Stressful life event/adverse event/ 2 events 2011

APPENDIX 4:

Data extraction from each study Study Key Factor(s) Sample Size Population source Data source Analysis Investigated Addor et al. Socio-demographics, Repeat = 175 Requests made by Abortion request Multivariate 2003, previous obstetric 1 = 740 residents (aged 14- figures, questionnaires Switzerland history, contraceptive 0 = 3208 49) for an abortion to filled by appointed (Repeat + 1) vs. 0: use the Health physicians, medical More likely Longitudinal Department of records and official - divorced, separated, widowed; OR1.9 Canton Vaud registry records, 1997 - unemployed i.e. also includes on social benefits; – 1999 OR1.8 - non-university education; OR1.6 - foreign national; OR1.5 - used oral contraception; OR1.4

Repeat abortion: NS – marital status, no. of living children, condom use

Aguirre 1980, Marital status Repeat = 129 Abortion patients in a Medical records from a Multiple classification USA 1= 960 clinic in Columbus, privately owned, Socio-demographics, Ohio single-service clinic Repeat vs. 1: Cross- contraceptive use, between June 1973 – More likely sectional social support January 1974 - single 30-34 year olds - higher education - white collar occupation - married students

Less likely - divorced students - roman catholic or Methodist - previous live births for married/divorced women

*birth control method and girlfriend support for singles were important factors

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated NS – single students, marital/social support from family

Berger et al. Socio-demographics, Repeat = 126 Early 1 st trimester Self-reported Multivariate 1984, previous obstetric 1 = 454 vacuum aspiration questionnaires, July Canada history, contraception abortions in Quebec 1977 – June 1978 Repeat vs. 1: use, relationship with Province performed More likely Cross- partner, desire to be at the abortion clinic, - older sectional pregnant Montreal General - increased coitus frequency Hospital - poor quality relationships - insomnia

Less likely - living with partner - physical complaints

Bleil et al. Abuse in childhood, Repeat = 43 Participants (aged Self-reported Multivariate 2011, USA non-abuse adverse 1 = 46 25-45) of an ongoing questionnaires and events 0 = 170 population-based interviews using an Repeat vs. 0: Cross- study in northern adapted Life Events More likely to have: sectional Socio-demographics, California Checklist (Tennant - stressful life events; OR1.59 previous obstetric and Andrew 1977), - abuse history; OR2.56 history June 2007 – May 2008 - sexual abuse; OR3.41 - family disruption history; OR1.75 - threatened personal safety history; OR2.74

NS – physical abuse alone

Repeat vs. 1: More likely to have: - stressful life events; OR5.83 - abuse history; OR5.83 - sexual abuse; OR9.12 - threatened personal safety history; OR2.23

NS – physical abuse alone, family disruption history

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated Bracken et al. Contraceptive use Repeat = 70 Patients (aged 14- Self-reported Bivariate 1972, USA 1 = 873 44) of an abortion questionnaires Socio-demographics, clinic, New York City Repeat (n=69) vs. 1 (n=69), matched age/parity; Cross- previous obstetric suburb Shorter gestation period, mean: 8.2 vs. 9.8 sectional history NS – ethnicity, religion, contraceptive use

Bracken et al. Reasons for delaying Repeat = 39 Abortion patients in Self-reported Bivariate 1975, USA decision to abort 1 = 306 their 1 st or 2 nd questionnaires, August trimester at a free- 1972 – January 1973 Repeat vs. 1, matched parity/marital status: Cross- Socio-demographic, standing New York More likely sectional previous obstetric clinic - younger by 2.5years history, sexual - shorter gestation period by 3 weeks behaviour, psychosocial - suspected chance of pregnancy sooner by ~1 week - located abortion clinic sooner by 1 week - higher level of support for decision making

NS – age of menarche, sexual partners, coital frequency, duration of relationship, internal locus of control

Coleman et Substance use Total = 1020 Women who gave Public released Multivariate al. 2005, *Abortion = 426 birth in Washington version of the USA Socio-demographic, DC hospitals Washington DC Repeat vs. 0: previous obstetric (*does not Metropolitan Area More likely: smokes cigarettes Cross- history specify Drug Study sectional proportion of (DC*MADS) NS – marijuana, alcohol and cocaine use Repeat vs. 1 conducted via abortion) interviews and consolidated with medical records, January – December 1992

Daily et al. Contraceptive use Repeat = 2812 Abortion patients Certificates of Bivariate 1973, USA 1 = 111890 who are residents of termination of

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated Socio-demographic, New York City pregnancy ≤24 weeks Repeat vs. 1: Cross- previous obstetric (socio-demographics, More likely sectional history, sexual health obstetric history), July - uses contraceptive methods in general: 74.1% vs. knowledge 1970 – June 1972 46.5% - uses pill/IUD: 41.1% vs. 29.3%/10.1% vs. 5.1% - report contraceptive method failure to use Self-reported according to instructions: 28.7% vs. 15.5% interviews - attributes non-use of contraceptive to previous bad (contraceptive use), experience of methods or March 1972 – August unavailability/inaccessible: 31.0% vs. 17.9% 1972 Less likely - no contraceptive method: 47.3% vs. 66.2% - poor sexual attitude i.e. anticipates chance of pregnancy or that it could be prevented: 5.4% vs. 23%

NS – contraceptive use not affected by ethnicity/age/pregnancy order

Das 2009, Socio-demographic, Repeat = 40 Abortions at Computerised medical Bivariate UK previous obstetric 1 = 1987 Pregnancy database, April 2001 – history, acceptance of Termination service, March 2006 Repeat vs. 1: Retrospective LARC after at first TOP, district general More likely unemployed: 16 (40.0%) vs. 489 (24.6%); record-based stable relationship, hospital in England presence of partner at NS – age, stable relationship, acceptance of LARC abortion after first TOP

David et al. Socio-demographic, 2000: Abortion patients Self-reported Multivariate 2007, Russia contraceptive use, *Repeat = 91 attending women’s questionnaires, sexual health 1 = 106 health clinic facilities February – March Repeat vs. 1: Cohort knowledge, reason for in three Russian 2000, December 2001 More likely abortion 2001 – 2002: cities – February 2002, - younger 15-24 (vs. 25-34): OR 5.88 *Repeat = 332 January – February - unregistered marriage (vs. married): OR 2.19 1 = 227 2003 - does not know when fertility returns: OR 2.91 - not thought about future contraceptive method: OR 2003: 4.14

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated *Repeat = 314 1 = 213 NS – education, intention to have future birth, contraception status, report socio-economic status *repeat abortion within last 12 months

Falcon et al. Substance use, smoking Repeat = 50 Abortion patients at Blood serum and hair Bivariate 20010, Spain 1 = 92 12 weeks gestation samples for testing Socio-demographic, at an and self-reported Previous abortion vs. drug use: more likely cocaine & Cross- previous obstetric obstetric clinic in questionnaires on cannabinoids use sectional history Murcia substance use, September 2007 – Repeat vs. 1: March 2009 More likely - partner cohabitation: 75.6% vs. 50.0% - own income: 70.0% vs. 43.5% - previous children: 65.0 vs. 22.8

Less likely - younger <20 years old: 28.0% vs. 47.7%

Fisher et al. Physical abuse by a Repeat = 358 Abortion patients at Self-reported Multivariate 2005, male partner and history 1 = 769 London Health questionnaires, August Canada of sexual abuse Sciences Centre, 1998 – May 1999 2nd abortion vs. 1 st : Ontario More likely Cross- Socio-demographic, - older OR 1.08 sectional contraceptive use and - born outside of Canada OR 1.83 STD history - using contraceptives OR 2.17 - abused by male partner OR 2.04 - sexually abused by male partner OR 1.58 - history of sexually transmitted infection OR 1.50

*OR increases for 3 rd vs. 1 st , except being born outside of Canada

Frandsen, Method of abortion Repeat = 330 Medical or surgical Medical notes, August Bivariate

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated Rorbye and 1 = 1049 legal abortion at 1999 – June 2001 Nilas 2013, Socio-demographic, ≤63days gestation Repeat vs. 1: Denmark previous obstetric carried out in More likely history, smoking Copenhagen - smokes 41% vs. 33% Cohort Municipality - surgical abortion 68.5% vs. 31.5%,

Less likely - educated 39% vs. 47%

NS – age, parity, marital status

Freeman et Emotional distress Repeat = 65 1st trimester abortion Self-reported Bivariate al. 1980, 1 = 125 patients (aged 14-40) questionnaires (SCL- USA Socio-demographic, at an outpatient unit 90), December 1977 – Repeat vs. 1(%): previous obstetric in a university April 1978 More likely Cross- history, contraceptive hospital, - older, 20-40years: 86 vs. 67 sectional use Pennsylvania - black ethnicity 92 vs. 70 - ≥1 living children 78 vs. 45

Less likely - younger, 14-19years: 14 vs. 33 - white ethnicity 8 vs. 30 - no children 22 vs. 55

Repeat, 61 vs. 1, 125 Higher mean score: - interpersonal sensitivity - phobic anxiety - paranoid ideation - sleep disturbance

NS – education, marital status, contraceptive use, pre- abortion emotional symptoms, somatisation, obsessive compulsive, depression, anxiety, hostility, psychosis, guilt

Garg, 2001, Contraceptive use, peri- Repeat = 50 Abortion patients at Self-administered Bivariate

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated UK abortion advice 1 = 83 abortion clinic, questionnaires and hospital in Newcastle case notes Repeat vs. 1: Cross- Socio-demographic, More likely sectional previous obstetric - older: median age 26 vs. 22 history, sexual health - OCP use 37% vs. 25% and attitude Less likely - no contraceptive use 2% vs.17% - *received information about emergency contraception NS – reasons for not using emergency contraception

(*unspecified significance)

Goodman et Contraceptive use Cases: Aspiration abortion Retrospective billing Multivariate al. 2008, Repeat = 41 patients who initiated data from the InfoPoint USA Socio-demographics, 1 = 632 IUD (cases) or practice management Repeat vs. 1: previous obstetric received other non- system, November More likely Case-control history Control: IUD methods 2002 – October 2005 - large family size Repeat = 206 (controls) at planned - black ethnicity 1 = 1140 parenthood clinics in Northern California Less likely - older - married

Grauer 1974, Contraceptive use, Repeat = 25 Two or more abortion Interview by routine Bivariate Canada psychiatric evaluation 1 = 100 patients (cases) and staff psychiatrist, April only one abortion 1969 – October 1973 Repeat vs. 1: Case-control Socio-demographic patients (control) at (cases) and December More likely the Jewish General 1970 – October 1973 - younger at time of 1 st abortion: mean age 26.9 vs. Hospital (control) 28.5 - married 64% vs. 50% - no contraception 68% vs. 59% - primary psychiatric disorder 76% vs. 52%

Less likely - putative father was the woman’s husband 48% vs.

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated 64% - rhythm method 8% vs. 23%

(unspecified significance for all results)

Heikinheimo Subsequent pregnancy Repeat = 169 Medical abortion Registry of Induced Multivariate et al. 2009, outcome 1 = 1099 patients at index Abortion, Medical Birth Finland TOP, 2000 – 2002, Registry, National Risk of subsequent Repeat after index abortion: Socio-demographics, hospital in Finland Hospital Discharge More likely Cohort previous obstetric Registry (failed - parous HR 3.42 history, contraceptive pregnancies) and - history of abortion HR 1.60 use, smoking status follow-up interview - smoker HR 1.36 (contraceptive use), 2005 – 2006 Less likely - older (>25 years old) 25-29 yrs vs. <20yrs HR =0.46 (HR value decreases with increasing age) - chose IUD contraception after index abortion (Cu- IUD HR0.45, LNG-IUS HR0.36)

NS – delaying initiation of contraception after index abortion

Howe et al. Socio-demographics, Repeat = 255 1st trimester vacuum Self-reported Bivariate 1979, USA previous obstetric 1 = 1250 aspiration abortion questionnaires, March history, sexual health patients at a – June 1975 Repeat vs. 1: Survey attitude, sexual freestanding abortion More likely behaviour, contraceptive clinic in western New - older use York - separated/divorced/widowed - higher education - higher number of previous pregnancies - using contraception 51.7% vs. 32% - using effective method 47.7% vs. 23.3% - higher weekly frequency of intercourse 2.6 vs. 1.8 times - aware of contraceptives but did not use contraception because of fear of medical contraindications or lack of supply 65.8% vs. 38.3%

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated - attributes pregnancy to method failure23.7% vs. 5.2%

Less likely - higher number of children - rhythm/withdrawal method 11% vs. 36.1% - report that they did not plan to have sex/ thought they would not get pregnant 15.8% vs. 30.2% - did not know or never thought about contraception 2.6% vs. 13.4% - attribute pregnancy to not using contraception 20% vs. 30% - identifies as Catholic

Jacobsson, Socio-demographics, Repeat = 45 Women with one or Self-reported Bivariate 1976 Sweden previous obstetric 1 = 92 more previous legal structured interviews; history, sexual Pregnant = 118 abortions applying first abortion Repeat vs. 1 Cross- behaviour, sexual health for repeat abortion Nov 1972 – Feb 1973; More likely sectional attitude and knowledge, and consecutive repeat abortion - employed 55.6% vs. 20.6% psychosocial, contextual women applying for Jan – July 1973 - ≥4 sexual partners 71.7% vs. 40.2% factors first abortion at a Jan – Feb 1974 - severe pregnancy symptoms 48% vs. 32.6% family advice/ - experience with ≥3 contraceptive methods 73.3% gynaecological clinic vs. 39.1% at the university hospital; pregnant Less likely women - housewife (11.1% vs. 18.5%), student/vocational (22.2% vs. 37.0%) or unemployed/other (11.1% vs. 23.9%) - ≤3 sexual partners 28.9% vs. 52.2% - no pregnancy symptoms 6.7% vs. 23.9%

NS – age, civil status, education, number of children, previous obstetric history, relationship with partner, psychosocial background, sexual/dating debut, contraception – condom/coitus interruptus

Johnson, Socio-demographics, Intervention: Women treated for Self-reported Fewer women had repeat abortion in intervention group

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated 2002, previous obstetric Repeat = 2.5% incomplete abortion questionnaires, (received ward-based family planning service) vs. Zimbabwe history, sexual *Index = 276 who desired to pregnancy test and control group. behaviour, contraceptive postpone their next follow-up interviews Non- use, contextual factors Control: pregnancy for at June 1996 – Feb 1997 Multivariate: randomised Repeat = 5.3% least two years and No statistical significance after adjusting for modern controlled *Index = 281 kept at least one contraceptive use. trial follow-up (*does not appointment at specify range of Harare hospital previous (intervention) or abortions) Mpilo Hospital (control)

Leach, 1977 Socio-demographics, Repeat = 61 1st trimester abortion Self-reported Bivariate USA previous obstetric 1 = 61 patients at private questionnaires, May – history, contraception and public clinics in July 1974 Repeat vs. 1: Cross- use Atlanta More likely sectional - white ethnicity in public clinic 28.6% vs. 9.5% - any contraceptive use34.4% vs. 24.5% - pill/IUD use14.8% vs. 8.2% - plan to use effective contraception 98% vs. 93% - attitude: would like to change self a lot 29.5% vs. 19.7% - attitude: believe things frequently go wrong for self24.6% vs. 14.8% - attitude: feels negative about abortion 27.9% vs. 13.1%

Less likely - religious affiliations - previous pregnancies 0.9 vs. 2.3

NS – age, ethnicity in private clinic, education, number of living children

(unspecified significance for all results)

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated Leppalahti, Socio-demographics, Repeat = 5423 Women (aged <20) National Registry on Multivariate 2012, Finland previous obstetric 1 = 52968 with abortions and Induced Abortions and history, contraceptive births in Finland Sterilizations and Repeat vs. 1: Longitudinal use Medical Birth Register, More likely 1987 – 2009 - married/cohabitating OR 1.64 - 2nd trimester abortion OR 1.46

Less likely - younger, 13 -15 OR 0.16, 16 -17 OR 0.49 - rural residence OR 0.62

NS – contraception

Mentula, Socio-demographics, Repeat = 5905 1st trimester Finnish register of Multivariate 2010, Finland previous obstetric 1 = 35845 abortions (January induced abortions and history, indication for 2000 – December sterilizations, repeat Had Index TOP during 1 st trimester Retrospective primary/index abortion 2005) in Finland abortion or up to Repeat vs. 1: cohort December 2006 More likely - younger <20 HR 6.84 - single HR 1.59 - blue collar worker HR 2.03 - age <17 years old was the indication for index TOP HR 1.26

Less likely - Previous deliveries HR 0.83

NS – previous miscarriages, residence

Had Index TOP during 2 nd trimester Repeat vs. 1: More likely younger <20 HR 12.00 and have one previous delivery HR 1.55

Nguyen et al. Socio-demographics, Repeat =185 Married abortion Interview using Multivariate 2000, previous obstetric 1 = 75 patients at the structured Vietnam history, sexual health Institute for the questionnaires, April – Repeat vs. 1:

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated knowledge and attitude, Protection of the June 1997 More likely Cross- contraceptive use Mother and - using modern contraception OR 4.11 sectional Newborn, Hanoi, - traditional methods (vs. none): OR 2.57 leading research - knowledgeable about sexual health OR 1.32 institute in Vietnam Less likely - positive attitudes about abortion i.e. prefers contraception rather than TOP OR 0.63

NS – education, economic status, previous contraception experience, desire for more children

Nguyen & Contextual factors Total = 935 Women married or Interview using Multivariate Budiharsana, living with a partner structured 2012, Socio-demographics, (comparison of (aged 18-49) with questionnaires, Repeat vs. 0: Vietnam previous obstetric repeat, 1, and 0 complete birth, at 4 February – March More likely history – distribution of out of 9 districts of a 2011 - older 35-49 (vs. 18-24): OR 2.78 Cross- cases not province in Northern - has >1 child: 3+ OR 3.57, 2 OR 2.36 sectional identifiable) Vietnam - pills/IUD/implants/female sterilization use OR 3.41

Less likely - delivered a baby girl before current abortion OR 0.62

NS – ethnicity, occupation, couple methods (abstinence/condom/withdrawal) of contraception, counselling, contraception information, access/availability

Niemela, Personality factors Repeat = 30 Abortion patients in Psychological Bivariate 1981, Finland 1 = 29 1971 at Turku interviews using scale Socio-demographics, University Central measure tests, winter Repeat vs. 1: Cross- contraceptive use, Hospital/City Hospital 1975 More likely sectional childhood, relationship of Turku - younger age<20 3 vs. 0 with male partner - low prestige occupation - partner has low income - lower housing condition

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated - reverts to less effective contraception method - low self-esteem, mean score 2.71 vs. 3.66 - less emotional balance, mean score 2.61 vs. 3.62 - less realism of attitudes, mean score 2.93 vs. 3.90 - less stable life, mean score 2.83 vs. 3.12 - less personal values in modernity, socialisation, femininity, mean score 19.97 vs. 23.2 - higher avoidance of monotony, mean score 25.21 vs. 22.66 - higher level of anxiety, mean score 51.11 vs. 42.10 - >3 siblings 50% vs. 27.5% - siblings from parents’ other relationships - parental loss at younger age - frequent change of municipality and residence within municipality - poorer adjustment to change in environment - poorer economic status - leave home at a younger age 62% vs. 12% - poorer relationship with parents - frequent history of divorce/break-up - male partners have outside sexual relationships - satisfied with male partner’s expression of tenderness and admired male partners more - women left more responsibility to male partners for contraception

Less likely - positive attitude towards birth control 36.6% vs. 65.5% - longer current relationship - male partner confident in their partner - solidarity between partners - male partners were responsible for contraception - open to discuss relationship problems with partner

NS – education, income, honesty and openness in interview, childhood home location, marital status,

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated number of children, sexual education, age of menarche, frequency of coitus, sexual satisfaction

Niinimäki, Abortion method Repeat = 5751 Women ≤63 days National health Multivariate 2009, Finland *Index = 40360 gestation with no registries, January Socio-demographics, simultaneous 2000 – December Repeat vs. 1: Cohort previous obstetric (*0, 1, 2, or ≥3 sterilisation at time of 2006 More likely history, planned previous abortion from - single HR 1.25 or cohabitating HR 1.14 contraceptive use post abortions) January 2000 – - occupation “others” HR1.22 index abortion December 2005, - parous HR 1.99 Finland - previous abortion HR 1.70

Less likely - older 20-24 vs. <20: HR 0.72 (HR value decreases with increasing age) >40 vs. <20years: HR 0.10 - rural residence HR 0.87 or live in densely populated area HR 0.90 - sterilisation/IUD vs. COC HR 0.66/ HR 0.85

NS – occupation “student/blue collar/lower white collar”, method of abortion

Osler et al. Socio-demographics, Repeat = 50 Abortion patients Interview using Bivariate 1992, contraceptive use, 1 = 50 (aged 18-44) at a structured Denmark reaction to being hospital, questionnaires Repeat vs. 1: pregnant Copenhagen More likely Cross- - younger at first abortion 76 vs. 56 sectional - ≥ 25 at current abortion 60 vs. 44 - single 67 vs. 43 - employed 64 vs. 52 - unemployed 16 vs. 6 - using no contraception 38 vs. 32 - using condom 38 vs. 36 or diaphragm 16 vs. 12

Less likely - have a partner 33 vs. 57 - student 20 vs. 42

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated - using contraceptive 2 vs. 10/IUD 0 vs. 4 - using rhythm method 0 vs. 4

NS – reason for abortion, reaction to abortion

Prager et al. Substance (alcohols Repeat = 234 1st or 2 nd trimester Audio computer Multivariate 2007, USA and drugs) use, 1 = 164 abortion patients at assisted self- domestic violence, San Francisco interviewing Repeat vs. 1: Cross- obesity General Hospital questionnaires, More likely sectional Women’s Options medical notes and - older 20-29years OR 2.86, 30-44years OR 6.65 Socio-demographics, Centre clinic charts - African American ethnicity (vs. Latina) OR 2.8 previous obstetric - use depot contraceptive OR 3.2 history, contraceptive - alcohol/drug abuse OR 2.6 use Less likely - lived outside of the country OR 0.25 - present for abortion in 2 nd trimester OR 0.6

NS – white/Asian/other ethnicity (vs. Latina), income, insurance, education, marital status, nulliparity, obesity

Raatikainen, Pregnancy and delivery Repeat = 355 Singleton Self-reported Bivariate 2006, Finland history, pregnancy 1 = 2364 pregnancies at questionnaires, nurse outcome 0 = 24248 Kuopio University interviews and clinical Repeat vs. 0: Population Hospital records, January 1989 More likely database Socio-demographic, – December 2001 - older ≥36years: 15.5% vs. 11.7% analysis previous obstetric - 2nd pregnancy in 12 months 23.8% vs. 14.4% history, maternal health, - prior foetal demise 2.3% vs. 1.9% contraceptive use, - BMI>25kg/m 2 24.9% vs. 20.2% smoking, alcohol - using IUD before pregnancy 13.5% vs. 9.8% - smokes >5/day during pregnancy 22.0% vs. 5.2% - consume alcohol during pregnancy 2.9% vs. 3.3% - low birth weight baby 7.0% vs. 4.7%

Less likely - primiparous 33.2% vs. 41.7%

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated - chorioamnionitis 0.3% vs. 1.4%

NS – younger age, >7 deliveries, time since previous delivery >6years, surgically scarred uterus, previous miscarriage, prior foetal demise, history of infertility, maternal diabetes, pre-gravid hypertension and chronic illness, method of delivery and other complications, all other pregnancy outcomes

Multivariate

Repeat vs. 0: No statistically significant risk for adverse obstetric outcome

Roberts et al. Contraceptive method Repeat = 236 1st trimester surgical Auckland District Multivariate 2010, New used at the time of 1 = 1186 abortion at a public Health Board's Clinical Zealand conception and post abortion clinic, Records Information Repeat vs. 1: abortion, sexually Auckland System (CRIS) and More likely Prospective transmitted infection patient medical - younger < 19 (vs. 40-45) OR 6.9 (OR value cohort status records, November decreases with increasing age) 2004 – December - maori OR 2.0 /pacific OR 1.8 /Asian Indian OR 2.4 Socio-demographic, 2007 ethnicity (vs. European) previous obstetric - leaves clinic with IUD (vs. COC) post previous history abortion OR 1.5

Risk of subsequent Repeat vs. Index: More likely - increased parity OR 1.2

Less likely - other ethnicity OR 0.6 - use of IUD OR 0.3 /depo OR 0.6 /other OR 0.9 (vs. COC) post index abortion

NS – previous abortion

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated

Rose et al. Rate of return for repeat Repeat = 49 Women from a Hospital notes and Multivariate 2012, New abortion in relation to *Total = 510 previous intervention self-reported Zealand post-abortion study (which contraceptive use Risk of subsequent Repeat vs. Index: contraceptive method (*0, 1, or ≥2 promoted the use of Less likely: used LARC methods (vs. non LARC) post Prospective choice 24 months previous LARC methods) index abortion 6.45% vs. 14.5% cohort onward from abortions) followed up 24 intervention months after an NS – age, ethnicity, socioeconomic status, previous abortion at a public abortion, parity Socio-demographic, hospital abortion previous obstetric clinic that provides a history free service to New Zealand residents

Schneider, Socio-demographic, Repeat = 116 Patients from two Self-reported Bivariate 1976, USA previous obstetric 1 = 116 hospitals, an questionnaires Repeat vs. 1: history, contraceptive Pregnant = 116 antenatal clinic and a At conception: More likely to use coitally unrelated 15 Cross- use Not pregnant = family planning clinic vs. 4 sectional 116 Pill 4 vs. 2, IUD 9 vs. 3

Less likely to use coitally related 36 vs. 39 Less likely to use none 49 vs. 57

Schunmann Contraceptive use and Intervention: Abortion patients Self-reported Bivariate et al. 2006, continuation rate Repeat = 44 given specialist questionnaires UK *Index = 302 contraceptive advice (contraceptive use) Intervention vs. Control: (intervention) or and hospital records - more likely to have repeat abortion in intervention Randomised Control: standard care group 44 (14.6%) vs. 27 (10%) controlled Repeat = 27 (control) at Royal - (difference between groups NS) trial *Index = 268 Infirmary of Edinburgh Repeat vs. Index: (* ≥ 1 previous More likely abortions) - used LARC 141 vs. 78 - contraception use increased with intervention 271 vs. 115

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated

Skjedestad Socio-demographic, Repeat = 235 First abortion Pre-coded medical Multivariate 1994, contraceptive use 1 = 2690 patients at a records January 1987 Norway university hospital, – December 1991 More likely Trondheim - younger 25-34 (vs. 15-24) aRR 1.3 Population - single housewife aRR 1.7 record-based - uses contraceptives aRR 1.7

Less likely - older 35-44 (vs. 15-24) aRR 0.6 - employed and students aRR 0.7

NS – parity and marital status (not independent risk factors for repeat abortion), unemployed

Somers Socio-demographics, Repeat = 810 Women with legal Public record report Bivariate 1977, previous obstetric 1 = 26885 abortions in Denmark forms October 1973 – Denmark history December 1974 Repeat vs. 1: More likely Cross- - 20 – 34 age group rather than <20 or >34 sectional & - divorced/separated 19 vs. 10 record - ≥1 pregnancies linkage - has had previous abortion

Less likely - >1 live births 53 vs. 57 - 0 pregnancies 18 vs. 23

NS – single/married

St John et al. Socio-demographic, Repeat = 96 Abortion patients at Case notes, October – Multivariate 2005, UK previous obstetric 1 = 262 Royal Infirmary of November 2000 history, contraceptive Edinburgh Repeat vs. 1: Cross- use, presence of More likely sectional psychiatric history - older than 25 RR 1.59 - parous (>1) RR 1.83

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated - most deprived RR 1.63

Less likely - ongoing relationship RR 0.66

NS – psychiatric history, emergency contraceptive use

Steinberg Mood, anxiety, or Repeat = 63 Women with and US National Co Bivariate and Finer, substance use disorder 1 = 284 without abortion morbidity Survey 2011, USA 0 = 1706 (aged 15-54) (NCS) and structured Repeat vs. 0+1: Socio-demographic, psychiatric More likely Cross- previous obstetric interview,1990 – 1992 - white ethnicity sectional history - lower number of births - prior anxiety disorder Less likely - black ethnicity NS – age, income, marital status, miscarriages, prior mood disorder, prior substance use disorder

Repeat vs. 0: more likely have prior physical violence 21.8 vs. 10.0.

Repeat vs. 1: more likely ever experienced intimate partner violence 40.7 vs. 24.3

Multivariate

Repeat vs. 0: More likely substance use disorder OR 5.2 (Adjusting for all risk factors: OR 3.7)

NS – mood and anxiety disorders (repeat vs. 0/1), substance use disorder (repeat vs. 1)

Steinberg Childhood adversities Repeat = 67 Women with data on US National Co Bivariate and Tschann, and subsequent mental 1 = 190 childhood adversity morbidity Survey- 2013, USA health 0 = 1264 and abortion history Replication (NCS-R) Repeat vs. 0/1:

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated (aged 18-41) and computer assisted More likely Cross- Socio-demographic, personal interview - non-white ethnicity 63.8 vs. 40.6 sectional previous obstetric method, February - less educated 32.7 vs. 13.6 history 2001 – April 2003 - large number of pregnancies 4.5 vs. 1.6/2.9

NS – age, childhood income, current marital status, current marital status, current economic status

Repeat vs. 0: more likely to have more births and miscarriages

Repeat vs. 1: more likely lower age at first abortion

Multivariate

Repeat vs. 0/1: More likely - parental mental illness OR 3.67/2.17 - personal safety threats OR 9.87/13.33

NS – parental death/divorce/separation, parental criminal behaviour, parental violent conflict, physical/sexual abuse and neglect

Steinhoff et Socio-demographic, Repeat = 2632 Women presenting Hospital records and Bivariate al. 1979, previous obstetric 1 = 16961 for first time abortion self-administered USA history, contraceptive questionnaires linked Repeat vs. 1: plans with state’s vital More likely Cross- statistics records, - divorced/separated/widowed sectional & March 1970 – - lowest SES category record December 1976 - parous linkage - ≥1 child

Less likely - single before marriage - higher economic status

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated - planned to use contraception

Stone and Socio-demographic, Repeat = 193 Women in a national Self-reported National Multivariate Ingham, previous obstetric 1 = 810 survey (aged 16-44) Survey of Sexual 2011, UK history, sexual living in Britain Attitudes and Repeat vs. 1: behaviour, contraceptive Lifestyles. (NATSAL2), More likely Cross- use, smoking, interviews and - black OR 3.76 or Chinese OR 2.80 ethnicity sectional substance use, body computer assisted - left school at 16 with no OR 2.61 or some OR 2.36 mass index self-reported survey qualifications tool, 2000 – 2001 - lived in rented accommodation OR 1.96 - more children OR 1.33 - used unreliable method (rhythm/withdrawal) OR 1.96 or not use any method OR 2.04 - have ≥5 sexual partners OR 2.13 - last abortion at ages greater than 25years old: 25- 29, OR 2.49, 30-34, OR 6.2, 35-39, OR 7.53

Less likely - least deprived OR 0.51 or third OR 0.36 quintile - used reliable contraceptive method OR 0.76 - last abortion at less than 19 years old OR 0.87

NS – other ethnicity, other SES quintiles,

Thapa 2013, Socio-demographic, Repeat = 378 Surgical abortion Interviews, December Multivariate Nepal previous obstetric 1 = 794 patients ≤12 weeks 2009 – March 2010 history, contraceptive gestation at public Repeat vs. 1: Cross- use, contextual factors maternity hospital More likely sectional and non- - older 25–29: OR 1.56 (increasing OR value with governmental increasing age) abortion clinic in - educated vs. illiterate: Primary (grades 1–5) OR Kathmandu 1.80, secondary (grades 6–10) OR 2.37, high school or higher OR 1.71 - have previous children 2+ OR 2.24 - no intent to have a child OR 2.01 - reason for non-use of contraception: health 1.63 OR

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated - received condom at discharge OR 1.45

Less likely - reason for non-use of contraception: perceived low risk of pregnancy OR 0.46 - received injectable contraceptive at discharge OR 0.62

NS – uncertain about intent to have a child, contraceptive use at conception, other reasons (forgot/disliked method/infrequent sex/youngest child too small), sterilisation/pill/none received at discharge

Tietze, 1978, Age 1974: Women (aged 15-44) Alan Guttmacher Bivariate USA Repeat=133900 with at least one Institute annual survey 1 = 764700 abortion across USA reports of legal Repeat vs. 0: Annual abortions, 1974 – More likely survey 1975: 1976 - 20 – 29 age group Repeat=204800 1 = 829400 Less likely - 30 – 44 age group 1976: - < 20 years old Repeat=271200 1 = 908100 (significance unspecified)

Westfall et al. Socio-demographic, Repeat =34.2% Abortion patients at Self-reported surveys, Bivariate 1995, USA previous obstetric 1 = 65.8% three abortion clinics July 1991 – July 1992 history, contraceptive Total = 2001 in Kansas Repeat vs. 1: Cross- use, contextual factors More likely sectional - older mean current age 22.5 vs. 25.7 - black 16.1 vs. 8.5 ethnicity - married 22.8 vs. 17.4/divorced 15.4 vs. 24.0/widowed 1.1 vs. 0.5/cohabitating 8.9 vs. 4.9 - consistent with contraceptive use 23.8 vs. 20.6 - received contraceptive advice from physician 79 vs. 70

Study Key Factor(s) Sample Size Population source Data source Analysis Investigated

Less likely - white 75.3 vs. 82.8 - single 43.2 vs. 61.8 - used no contraception 35.0 vs. 41.4 - less likely pregnancy confirmed by physician 18.2 vs. 22.0

NS – residence, income, having a personal physician, method of verifying pregnancy

APPENDIX 5:

Studies excluded

REASON(S) FOR STUDIES EXCLUDED EXCLUSION

Abbott J, Feldhaus KM, Houry D, Lowenstein SR. Emergency contraception: what No repeat abortion do our patients know? Ann Emerg Med 2004 Mar;43(3):376-381.

No determinants of repeat Abrams M. Birth control use by teenagers. One and two years post abortion. abortion measured; Journal of Adolescent Health Care 1985 May;6(3):196-200. Teenage abortions

Aktun H, Cakmak P, Moroy P, Minareci Y, Yalcin H, Mollamahmutoglu L, et al. No comparison groups Surgical termination of pregnancy: evaluation of 14,903 cases. Taiwanese Journal with repeat abortion of Obstetrics & Gynecology 2006 Sep;45(3):221-224.

Alouini S, Uzan M, Meningaud JP, Herve C. Knowledge about contraception in women undergoing repeat voluntary abortions, and means of prevention. European No comparison groups Journal of Obstetrics, Gynecology, & Reproductive Biology 2002 Aug 5;104(1):43- with repeat abortion 48.

Aneblom G, Larsson M, Odlind V, Tyden T. Knowledge, use and attitudes towards emergency contraceptive pills among Swedish women presenting for induced No comparison groups abortion. BJOG: An International Journal of Obstetrics & Gynaecology 2002 with repeat abortion Feb;109(2):155-160.

More abortion patients are young, unmarried, non-white; procedures performed No determinants of repeat earlier, and by suction; 1/5 repeats. Fam Plann Perspect 1977 May-Jun;9(3):130- abortion measured 131.

Antai D, Adaji S. Community-level influences on women's experience of intimate partner violence and terminated pregnancy in Nigeria: a multilevel analysis. BMC No repeat abortion Pregnancy & Childbirth 2012;12:128.

Baldwin MK, Edelman AB. The effect of long-acting reversible contraception on Review; No repeat rapid repeat pregnancy in adolescents: a review. Journal of Adolescent Health 2013 abortion Apr;52(4 Suppl):S47-53.

Ban DJ, Kim J, De Silva WI. Induced abortion in Sri Lanka: who goes to providers No determinants of repeat for pregnancy termination?. J Biosoc Sci 2002 Jul;34(3):303-315. abortion measured

Barrett G, Peacock J, Victor CR. Are women who have abortions different from those who do not? A secondary analysis of the 1990 national survey of sexual No repeat abortion attitudes and lifestyles. Public Health 1998 May;112(3):157-163.

Barrett HL, Lust K, Callaway LK, Fagermo N, Portmann C. Termination of pregnancy for maternal medical indications: failings in delivery of contraceptive No repeat abortion advice?. Aust N Z J Obstet Gynaecol 2011 Dec;51(6):532-535.

No repeat abortion; No Berkeley D, Humphreys PC, Davidson D. Demands made on general practice by comparison groups with women before and after an abortion. J R Coll Gen Pract 1984 Jun;34(263):310-315. repeat abortion

Beynon-Jones SM. 'We view that as contraceptive failure': containing the Policy document on 'multiplicity' of contraception and abortion within Scottish reproductive healthcare. abortion Soc Sci Med 2013 Mar;80:105-112.

Bianchi-Demicheli F, Perrin E, Bianchi PG, Dumont P, Ludicke F, Campana A. No repeat abortion; Post Contraceptive practice before and after termination of pregnancy: a prospective abortion effect study. Contraception 2003 Feb;67(2):107-113.

Bianchi-Demicheli F, Ortigue S. Insight of women's sexual function and intimate Review; No relevant data relationships after termination of pregnancy: A review on recent findings and future on repeat abortion perspectives. Current Women's Health Reviews 2007 February 2007;3(1):31-41.

Biggs MA, Gould H, Foster DG. Understanding why women seek abortions in the No determinants of repeat US. BMC Womens Health 2013;13:29. abortion measured

Bitsch M, Jakobsen AB, Prien-Larsen JC, Frolund C, Sederberg-Olsen J. IUD No determinants of repeat (Nova-T) insertion following induced abortion. Contraception 1990 Sep;42(3):315- abortion measured 322.

Blumenfield M. Psychological factors involved in request for elective abortion. J Clin Interview; No relevant Psychiatry 1978 Jan;39(1):17-25. data on repeat abortion

No determinants of repeat Boersma A, Alberts J, Bruijn JD, Meyboom BD, Kleiverda G. Termination of abortion measured; pregnancy in Curacao: need for improvement of sexual and reproductive Incidence of repeat healthcare. Global Journal of Health Science 2012 May;4(3):30-38. abortion

Brewer C. Third time unlucky: a study of women who have three or more legal Risk of complications after abortions. J Biosoc Sci 1977 Jan;9(1):99-105. an abortion

Callan VJ. Repeat abortion-seeking behaviour in Queensland, Australia: knowledge No comparison groups and use of contraception and reasons for terminating the pregnancy. J Biosoc Sci with repeat abortion 1983 Jan;15(1):1-8.

Coleman PK, Reardon DC, Rue VM, Cougle J. A history of induced abortion in No comparison groups relation to substance use during subsequent pregnancies carried to term. American with repeat abortion Journal of Obstetrics & Gynecology 2002 Dec;187(6):1673-1678.

Collier J. The rising proportion of repeat teenage pregnancies in young women No determinants of repeat presenting for termination of pregnancy from 1991 to 2007. Contraception 2009 abortion measured May;79(5):393-396.

Cremer M, Bullard KA, Mosley RM, Weiselberg C, Molaei M, Lerner V, et al. Immediate vs. delayed post-abortal copper T 380A IUD insertion in cases over 12 No repeat abortion weeks of gestation. Contraception 2011 Jun;83(6):522-527.

Curtis C, Huber D, Moss-Knight T. Postabortion family planning: addressing the No repeat abortion cycle of repeat unintended pregnancy and abortion. International perspectives on

sexual & reproductive health 2010 Mar;36(1):44-48.

No determinants of repeat Daling JR, Emanuel I. Induced abortion and subsequent outcome of pregnancy in a abortion; Outcome series of American women. N Engl J Med 1977 Dec 8;297(23):1241-1245. measure - ongoing pregnancy

David HP. Abortion in Europe, 1920-91: a public health perspective. Stud Fam Review Plann 1992 Jan-Feb;23(1):1-22.

Decker MR, Yam EA, Wirtz AL, Baral SD, Peryshkina A, Mogilnyi V, et al. Induced abortion, contraceptive use, and dual protection among female sex workers in No determinants of repeat Moscow, Russia. International Journal of Gynaecology & Obstetrics 2013 abortion measured Jan;120(1):27-31.

Diamond M, Palmore JA, Smith RG, Steinhoff PG. Abortion in Hawaii. Fam Plann No determinants of repeat Perspect 1973;5(1):54-60. abortion measured

Emenike E, Lawoko S, Dalal K. Intimate partner violence and reproductive health of No repeat abortion women in Kenya. Int Nurs Rev 2008 Mar;55(1):97-102.

Escriba-Aguir V, Romito P, Scrimin F, Molzan Turan J. Are there differences in the impact of partner violence on reproductive health between postpartum women and No comparison groups women who had an elective abortion?. Journal of Urban Health 2012 Oct;89(5):861- with repeat abortion 871.

Esen U, Koram K, Doherty E, Orife S, Jones A. Termination of pregnancy in South No determinants of repeat Tyneside. Journal of Obstetrics & Gynaecology 2006 Nov;26(8):791-794. abortion measured

Font-Ribera L, Perez G, Salvador J, Borrell C. Socioeconomic inequalities in No determinants of repeat unintended pregnancy and abortion decision. Journal of Urban Health 2008 abortion measured Jan;85(1):125-135.

Harlap S, Davies AM. Characteristics of pregnant women who report previous No determinants of repeat induced abortions. Bull World Health Organ 1975;52(2):149-154. abortion measured

No comparisons with Henshaw SK, Koonin LM, Smith JC. Characteristics of U.S. women having repeat abortion; Incidence abortions, 1987. Fam Plann Perspect 1991 Mar-Apr;23(2):75-81. and descriptive characteristics of abortion

Henshaw SK, O'Reilly K. Characteristics of abortion patients in the United States, No determinants of repeat 1979 and 1980. Fam Plann Perspect 1983 10-6; Jan-Feb;15(1):5-8. abortion measured

Holmgren K. Repeat abortion and contraceptive use. Report from an Interview Interviews; No relevant Study in Stockholm. Gynecologic & Obstetric Investigation 1994;37(4):254-259. data on repeat abortion

Kavlak O, Atan SU, Saruhan A, Sevil U. Preventing and terminating unwanted No determinants of repeat pregnancies in Turkey. Journal of Nursing Scholarship 2006;38(1):6-10. abortion measured

Li VC, Wong GC, Qiu SH, Cao FM, Li PQ, Sun JH. Characteristics of women having No comparison groups abortion in China. Soc Sci Med 1990;31(4):445-453. with repeat abortion

Macones GA, Odibo A, Cahill A. Discussion: 'Long-acting reversible contraception Roundtable discussion of and repeat abortion' by Rose et al. American Journal of Obstetrics & Gynecology Rose et al. 2012 Jan;206(1):e10-1.

Makenzius M, Tyden T, Darj E, Larsson M. Risk factors among men who have No female participants; repeated experience of being the partner of a woman who requests an induced Comparison of males abortion. Scand J Public Health 2012 Mar;40(2):211-216.

No determinants of repeat Millar WJ, Wadhera S, Henshaw SK. Repeat abortions in Canada, 1975-1993. Fam abortion measured; Plann Perspect 1997 Jan-Feb;29(1):20-24. Incidence of repeat abortion

Misago C, Fonseca W, Correia L, Fernandes LM, Campbell O. Determinants of No determinants of repeat abortion among women admitted to hospitals in Fortaleza, North Eastern Brazil. Int abortion measured J Epidemiol 1998 Oct;27(5):833-839.

Moreau C, Beltzer N, Bozon M, Bajos N, CSF g. Sexual risk-taking following relationship break-ups. European Journal of Contraception & Reproductive Health No repeat abortions Care 2011 Apr;16(2):95-99.

Okereke CI. Assessing the prevalence and determinants of adolescents' unintended No repeat abortion; No pregnancy and induced abortion in Owerri, Nigeria. J Biosoc Sci 2010 comparison groups with Sep;42(5):619-632. repeat abortion

Palanivelu LM, Oswal A. Contraceptive practices in women with repeat termination No comparison groups of pregnancies. Journal of Obstetrics & Gynaecology 2007 Nov;27(8):832-834. with repeat abortion

Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended No determinants pregnancies by providing no-cost contraception. Obstetrics & Gynecology 2012 measured; No Dec;120(6):1291-1297. comparison groups

Petersen DJ, Alexander GR. Seasonal variation in adolescent conceptions, induced No determinants of repeat abortions, and late initiation of prenatal care. Public Health Rep 1992 Nov- abortion measured Dec;107(6):701-706.

No repeat abortion; No Ping T, Smith HL. Determinants of induced abortion and their policy implications in comparison groups with four counties in north China. Stud Fam Plann 1995 Sep-Oct;26(5):278-286. repeat abortion

No comparison groups Potter RG, Ford K. Repeat abortion. Demography 1976 Feb;13(1):65-82. with repeat abortion

No determinants of repeat Salcedo J, Sorensen A, Rodriguez MI. Cost analysis of immediate postabortal IUD abortion measured; Cost- insertion compared to planned IUD insertion at the time of abortion follow up. effectiveness of Contraception 2013 Apr;87(4):404-408. contraceptives

Sarkar NN. The impact of intimate partner violence on women's reproductive health and pregnancy outcome. Journal of Obstetrics & Gynaecology 2008 Apr;28(3):266- Review 271.

Tewari SK, Diaz-Morales O, Urquhart DR, Mahmood TA. Understanding factors No comparison groups influencing request for a repeat termination of pregnancy. Health Bull 2001 with repeat abortion May;59(3):193-197.

Thomson W. Termination of pregnancy. Med J Aust 1978 389; Oct 7;2(8):387. Letter

No determinants of repeat Tietze C. The 'problem' of repeat abortions. Fam Plann Perspect 1974;6(3):148- abortion measured; 150. Probability of repeat abortion

No determinants of repeat Tietze C, Bongaarts J. Repeat abortion in the United States: new insights. Stud abortion measured; Rate Fam Plann 1982 384; Dec;13(12 Pt 1):373-379. of repeat abortion

No determinants of repeat Tietze C, Jain AK. The mathematics of repeat abortion: explaining the increase. abortion measured; Rate Stud Fam Plann 1978 Dec;9(12):294-299. of repeat abortion

Tsakiridu DO, Franco Vidal A, Vazquez Valdes F, Junquera Llaneza ML, Varela Uria JA, Cuesta Rodriguez M, et al. Factors associated with induced abortion in No comparison groups women prostitutes in Asturias (Spain). PLoS ONE [Electronic Resource] with repeat abortion 2008;3(6):e2358. van Roode T, Dickson N, Herbison P, Paul C. Child sexual abuse and persistence of risky sexual behaviors and negative sexual outcomes over adulthood: findings No repeat abortion from a birth cohort. Child Abuse Negl 2009 Mar;33(3):161-172.

Verkuyl DA. Preventing repeat abortions. Aust N Z J Obstet Gynaecol 2009 Letter to editor Oct;49(5):564.