Ab borttionss in Arizonna 20 011 Abo ortion Reportt Bureau B of Pu ublic Health Statistics 9/12/2012 9 Heealth and Weellness for alll Arizonans Janice K. Brewer, Govvernor Statte of Arizona Will Humble, Direcctor Arrizona Departtment of Heallth Services MISSION M mote, protect,, and improvee the health an nd wellness oof individuals and communnities in Arizoona. To prom Prrepared by: Th he Bureau off Public Healthh Statistics Arrizona Departtment of Heallth Services 150 N 18 8th Ave, Suitee 550 Phoen nix, AZ 850007 http://www.azdhss.gov/plan/crrr/ar/index.htm m Acknowleedgements: The Departmen nt acknowled dges all the faacilities who rreported aborttion data duriing the reportting period. This publication can bee made availaable in alternaative format. P Please contacct the Bureau of Public Heaalth Statistics at (602) 542-1242 (voice) or 1-800-367 7-8939 (TDD)). Permissio on to quote fro om or reprodu uce materials from this pubblication is grranted if the ssource is acknowledged. Table of Contents Page Executive Summary .......................................................................................................... 1 1. Introduction ................................................................................................................. 2 1.1 Overview of the Arizona Abortion Reporting Requirements ............................... 2 1.2 Trends in Abortions in Arizona and the U.S. ....................................................... 3 2. Methodology .............................................................................................................. 6 2.1 Data sources .......................................................................................................... 6 2.2 Measures .............................................................................................................. 6 2.3 Analytic Procedures .............................................................................................. 8 3. Results ........................................................................................................................ 9 3.1 Characteristics of women receiving abortions ...................................................... 10 3.2 Abortion by gestational age .................................................................................. 21 3.3 Abortions by county of residence ......................................................................... 23 3.4 Reported complications due to abortion ............................................................... 27 3.5 Petitions filed with the Administrative Office of the Courts ................................ 29 4. Conclusions ................................................................................................................. 30 Appendix A. Abortion reporting form........................................................................................ 32 B. Glossary ............................................................................................................... 36 Page | i List of Tables Page 1. Number, rate, and ratio of reported abortions – selected states, United States, 1999-2008 .................................................................................................................. 2. Abortions in 2011 by month and resident status......................................................... 2 9 3. Age-distribution of women receiving abortions in Arizona by state of residence ..... 11 4. Abortions, abortion rates, and abortion ratios by age group and year for Arizona residents during 2000 – 2011 ...................................................................................... 12 5. Proportion of abortions, rates, and ratios by race and ethnicity during 2000-2011 .... 14 6. Pregnancy history of resident women seeking abortions in Arizona in 2011............. 17 7. Method of abortion used by resident women in Arizona 2011................................... 19 8. Distribution of gestational age at time of abortion for Arizona residents................... 21 9. Distribution of gestational age at time of abortion by age-groups.............................. 22 10. Method of abortion and gestational age ...................................................................... 23 11. Arizona 2011, abortions, live births, rates, and ratio by county of residence ............. 24 12. Number of abortions, rates, and ratio by county of residence 2000-2011 .................. 25 13. Abortions by county of residence and age group, Arizona, 2011 ............................... 26 14. Abortions by county of residence and race and ethnicity, Arizona, 2011 .................. 27 15. Complications from an abortion for Arizona resident women ................................... 28 16. Petitions filed in the Arizona Administrative Office of the Courts ............................ 29 Page | ii List of Figures Page 1. Arizona estimates of abortion rates for Arizona 1999-2010 by state of residence ..... 4 2. Guttmacher Institute estimates of abortion rates for the U.S. and Arizona, by state of residence ................................................................................................................ 4 3. Abortion counts and rates for Arizona 1999-2011 by state of residence .................... 10 4. Adolescent abortion rates for Arizona 2000-2011 ...................................................... 13 5. Married and unmarried resident women seeking abortions in Arizona during 2000-2011 ........................................................................................................ 15 6. Educational status of Arizona resident women seeking abortions in 2011 ............... 16 7. Pregnancy history of resident women seeking abortions in Arizona 2011 by age-groups .............................................................................................................. 18 8. Method of abortion among Arizona resident women during 2000-2011 .................. 20 Page | iii Executive Summary The Arizona Department of Health Services collected abortion information from providers within the state on a voluntary basis prior to passage of the federal legislation (Roe v. Wade 1973) permitting a woman to legally obtain an abortion in any of the fifty states within the United States. As required by A.R.S §36-2163, this second annual comprehensive statistical report, presents abortion statistics. It includes data compiled from reports of elective abortion, a list of reported complications, and data about the petitions filed authorizing abortions to unemancipated minors as compiled by the Arizona Administrative Office of the Courts. Data is compiled annually based on calendar year using a secured web-based reporting system. Facilities and providers submit abortion procedure (A.R.S. §36-2161) and complication reports (A.R.S. §36-2162) to the Arizona Department of Health Services on a monthly basis. In the 2011 calendar year, there were a total of 14,401 reported abortions compared to 11,438 abortions in 2010. This represents a 26 percent increase in the count of reported abortions. This increase in the number of abortions is perhaps attributable to more complete reporting of abortion data as well as enhanced surveillance. Ninety-four percent (n = 13,606) of the abortions were to resident women. The majority of the resident women who received abortions were unmarried. Approximately 57 percent of the resident women who received abortion were in the age-group 20 to 29 years. Of the total abortions (n = 14,401), about 63 percent (n = 9,089) abortions were surgical and approximately 37 percent (n = 5,298) were non-surgical procedures used for terminating pregnancies. During 2000-2011 the abortion rates for adolescents declined and there was approximately 36 percent increase in the percent of married women seeking abortions. Incidents of complications from an abortion are not consistently reported at the state or national level. From 1981 to 1991 ADHS reported the count of hospitalization due to complications from abortions; then, as recently as 2009 the reporting of complications probably has been unreliable. Comparisons are therefore based on only two years of data collected on resident women. There were a total of 60 complications reported in 2011, and the most frequently reported complication was excessive hemorrhage. This is the first complete year of data reporting the number of petitions filed with Arizona courts for authorization to obtain an abortion by an unemancipated minor without parental consent. The Arizona Administrative Office of the Courts provides aggregate data to ADHS annually. A total of fifty six (n= 56) petitions were received and an order authorizing the abortion was issued without parental consent for 32 young women and one petition was denied. Page | 1 Introduction Abortion surveillance in the U.S. has been conducted by the Centers for Disease Control and Prevention (CDC) since 1969 and the data are collected each year by the CDC through central health agencies of 52 reporting areas (the 50 states, the District of Columbia, and New York City) which provide this information voluntarily.1 According to CDC, since 1973 the total number, rate (number of abortions per 1,000 women aged 15-44 years), and ratio (number of abortions per 1,000 live births) of reported abortions increased rapidly in the U.S. and reached its highest levels in the 1980s before decreasing.1 Table 1 displays the number, rate, and ratio of reported abortions from selected states for the U.S for the period 1999-2008. Table 1. Number, rate*, and ratio of reported abortions – selected states, United States, 19992008 Year All reporting areas§ No. 861,789 857,475 853,485 854,122 848,163 839,226 820,151 No. 1999 836,119 2000 824,023 2001 819,681 2002 821,527 2003 817,586 2004 809,257 2005 799,084 †† 2006 825,604 852,385 2007 827,609 810,582 2008 825,564 808,528 * Number of abortions per 1,000 women aged 15--44 years. † Number of abortions per 1,000 live births. Continuously reporting areas %** Rate 97 96.1 96 96.2 96.4 96.4 97.4 96.9 97.9 97.9 ¶ Ratio 16.6 16.4 16.2 16.2 16.2 16 15.8 16.2 16 16 261 251 251 252 247 243 238 238 231 234 § Excludes states that did not report abortion numbers to CDC: Alaska (1999--2002), California (1999--2008), Louisiana (2005), Maryland (2007--2008), New Hampshire (1999--2008), Oklahoma (1999), and West Virginia (2003--2004). ¶ Only includes areas that reported abortion counts every year during the period of analysis (1999--2008). Abortions from areas that reported every year during 1999--2008 as a percentage of all reported abortions. †† This number is greater than reported in the 2006 report because of numbers subsequently provided by Louisiana. ** 1.1 Overview of the Arizona Abortion Reporting Requirements For many years Arizona has been collecting and reporting abortion data in response to administrative rules written by the Arizona Department of Health Services (ADHS) as part of the Vital Records Administrative Code. Beginning in June 1976, as part of the required Report of an Induced Termination of Pregnancy, providers reported to ADHS basic information about abortions and complications. Adherence to the reporting requirement was not enforced but regular reminders along with a standard reporting format were sent to clinics that provided Page | 2 abortion services. ADHS received these forms and used the data to prepare tables for inclusion in the annual Health Status and Vital Statistics (HSVS) report.* The abortion data improved the estimation of total pregnancies in addition to counts of births. In 2010, SB1304 was enacted that statutorily required the reporting of abortions and treatment of complications associated with abortions.2 In addition, the law requires the Arizona Administrative Office of the Courts to report the number of petitions received by the court for authorization to perform abortions on unemancipated minors as prescribed in Arizona Revised Statutes §36-2152. The collection of this information began on July 29, 2010. The 2010 ADHS report about abortions contained a combination of data collected prior to the passage of the law and after the passage of the law. However, starting July 29, 2010 abortion data has been reported through a web-based reporting system. The new reporting system was designed to meet the requirements of the new law and training was offered to all facilities that perform abortions. The data that providers submit to ADHS do not include individually identifiable information about patients, and only authorized entities can enter and submit data through a secure, password protected portal. The 2011 Arizona abortion report is different in several ways. First, the report utilizes complete year’s data for the 2011 calendar year reported uniformly after passage of the law. Second, where feasible, the report is formatted and categorized to suit both legislative requirements as well as CDC reporting standards for comparability. Third, the report includes specific terms associated with abortion, as well as a description of the strengths and limitations of the report. Fourth, the report details the methodology for assessing any ‘statistically significant’ differences as well as including details of how race and ethnicity was enumerated. Finally, the report discusses public health implications. A robust abortion surveillance system facilitates Arizona to monitor long-term changes in the overall incidence of abortion and further facilitates evaluation of programs for preventing unintended pregnancy in the nation as well as in Arizona. 1.2 Trends in Abortions in Arizona and the U.S. In calendar year 2011 there were a total of 14,401 abortions reported in Arizona of which 13,606 abortions were to Arizona residents. The percent increase in total abortions from 2010 was about 26 percent. This increase is perhaps attributable to the law which prompted more complete reporting. Figure 1 below displays Arizona’s abortion rate for the decade. As per ADHS estimates, Arizona’s abortion rates have ranged from 10.2 per 1000 women in 1999 to 8.8 per 1000 women in 2010 with the highest rate in 1999 (10.2) and the lowest in 2001 with 7.3 per 1000 women. As per the Centers for Disease Control and Prevention (CDC) estimate (and the * ADHS. Health Status and Vital Statistics (HSVSR) Report. See section 1D of each annual report for the table of characteristics. Page | 3 most recent data available) during this 1999-2008 period, Arizona’s abortion rate was half (7.8 per 1000 women) compared to the overall nation’s rate (16.0 per 1000 women see figure 1). Independent estimates available from Guttmacher Institute show abortion rates for Arizona that are consistently higher than the rates generated by ADHS (see figure 2). Figure 1. Arizona estimates of abortion rates for Arizona 1999-2010 by state of residence Abortion rates for Arizona 1999-2010 by state of residence 20.0 18.0 16.0 14.0 12.0 10.2 9 8.9 10.0 7.3 8.0 10 8.5 8.8 8.1 8.2 8.1 7.8 * 7.5 2005 2006 2007 2008 2009 6.0 4.0 2.0 0.0 1999 2000 2001 2002 2003 2004 2010 *This rate is the reported rate by Arizona Department of Health Services using population denominators specific to Arizona, while CDC abortion rate for Arizona in 2008 is 8.3 (see table 2 MMWR 2011;60(15):1-41 Figure 2. Guttmacher Institute estimates of abortion rates for the U.S. and Arizona, by state of residence Abortion rates for the U.S. and Arizona residents, 1978-2008 US Arizona 50.0 45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 19.6 15.2 5.0 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 0.0 Page | 4 Differences in the ADHS’s and Guttmacher Institute’s estimates are likely due to differences in methodology. Since 1974, the year after abortion was legalized, abortion incidence estimates have been generated using periodic surveys of all known abortion providers in the United States.5 According to the CDC, the Guttmacher Institute uses numerous active follow-up techniques to increase the completeness of the data obtained through its periodic national survey of abortion providers.1 Keeping this perspective in mind, the following report estimates the incidence of abortion in Arizona for 2011 calendar year. Page | 5 Methodology Collection of accurate information on induced abortion can reveal the level of unwanted and/or unintended pregnancy in a population. Abortion also can affect maternal morbidity and mortality.6 The data presented in this report responds to statutory requirements following the passage of SB1304. The terms induced termination of pregnancy (I-TOP) and abortions in this report are used interchangeably. 2.1. Data sources The primary data source for this report is the web-based reporting system for Arizona providers. The data does not include individually identifiable information of patients, and only authorized entities enter and submit data through a secure password protected portal. A secondary data source captures the number of petitions received by the court for authorization to perform abortions on unemancipated minors as prescribed in Arizona Revised Statutes §36-2152. It is plausible that the number of abortions performed on unemancipated minors is also reported in the web-based reporting system. 2.2. Measures Measures reported here are mostly consistent with CDC categorization and definitions. Aggregate abortion counts are reported for the following variables: • Age in years of the woman (<15, 15–17, 18–19, 20–24, 25–29, 30–34, 35–39, 40-44, ≥ 45+ ); • Gestational age in weeks at the time of abortion (≤ 6, 7–20 by individual week, ≥21); • Race (White, Black, American Indian/Alaska Native Asian and/or Native Hawaiian/Pacific Islander); • Ethnicity (Hispanic or non-Hispanic); • Method type (surgical, non-surgical); • Marital status (married and unmarried); • Number of previous live births (0, 1, 2, 3, or ≥4); • Number of previous abortions (0, 1, 2, 3, or ≥4); • Maternal residence (State, county of residence for resident abortions, border and nonborder region). Some important measures for abortions are: a) the total count of abortions in a given population, b) the percentage of abortions obtained within a given sub-population, c) the abortion rate (number of abortions per 1,000 women aged 15–44 years or other specific group within a Page | 6 given population), and d) the abortion ratio (count of abortions per 1,000 live births within a given population).1 Although total counts and percentages provide an overview of abortions, abortion rates are a more useful measure as they adjust for differences in sub-population size and reflect the likelihood of abortion in subgroups. On the contrary, abortion ratios reflect the relative number of pregnancies in a group and/or population that end in abortion compared with live birth. Abortion ratios change according to the proportion of pregnancies both intended and unintended in a population.1 U.S. Census Bureau and Arizona Vital Statistics estimates of the resident female population of Arizona were used as the denominator for calculating abortion rates. Overall abortion rates were calculated from the population of women aged 15–44 years, with the exception of age-specific rates. To calculate abortion ratios, live birth data were obtained from Arizona natality files and utilized along with the Health Status and Vital Statistics report. The variables for race and ethnicity are based on the instructions for the newly designed webbased reporting changes as well as the Office of Management and Budget (OMB) methodology. It is important to detail how race and ethnicity in this report was handled. Consistent with the OMB methodology3 the web-based reporting allowed for multiple race categorizations consistent with Census enumerations. For instance, women seeking abortions were asked about their ethnicity (namely, as Hispanic or Latino and/or Non-Hispanic or non-Latino) and separately about their race according to five standard race categories (i.e. White, Black, American Indian/Alaska Native, Asian, and/or Native Hawaiian/Pacific Islander). However, this year’s report form allowed additional race choices, with “select one or more option” in addition to “some other race.” With “select one or more option” there can be 31 unique race combinations with five standard race categories, and when combined with ethnicity this type of categorization now can result in 64 different combinations.1,7 This method posed a challenge for capturing data on race and ethnicity in the web-based reporting system as it resulted in accumulation of approximately 40 percent of the abortion records containing multiple race and ethnicity not reflective of Census enumerations. As denominators for multiple races are not readily available, utilizing multiple race and ethnicity categories complicate estimation of abortion rates4 for groups who report multiple races. To meet the requirements of OMB reporting standards for compiling statistics on these sub-groups, Hispanics or Latino irrespective of race were reported as Hispanics or Latino. When single race and ethnicity was reported, those categories were included and when multiple races were reported, multiple races were coded to multiple race categories. Because Arizona is a border state it was important to examine the characteristics of abortions by border categorization. For the purpose of this report, women who reported their county of residence as Cochise, Pima, Santa Cruz, and Yuma were categorized as a ‘border region’ that essentially comprises of the U.S. Mexico border region, consistent with the U.S. Mexico Border Health Commission8 definition. We consider other counties as ‘non-border’ regions. Page | 7 2.3. Analytic Procedures Where applicable both univariate and bivariate statistics are presented. Rates, chi-square tests and tests for linear trends were estimated using SAS v9.3 2008 software. While abortion rates in general are reported for women of child-bearing age (15-44 years), age-specific rates were estimated using Census as well as Arizona Vital Statistics denominators for age-groups 10-14 years, 15-17 years, 18-19 years, 20-24 years, 25-29 years, 30-34 years, 35-39 years, and 40-44 years. Page | 8 Results A total of 25 facilities reported data for calendar year 2011. In calendar year 2011, there were a total of 14,401 abortion incidents reported in Arizona of which 13,606 abortions were to Arizona residents. The percent increase in total abortions from 2010 (n = 11,438) was about 26 percent. This increase is perhaps attributable to greater awareness that the law required enhanced reporting. Almost all (99.02%) of the abortions reported during the calendar year were elective abortions and most of these abortions were performed in clinics (99.65%). Out of the total abortions, about 63 percent (n = 9,089) of the abortions were surgical and approximately 37 percent (n = 5,298) were non-surgical procedures used for terminating pregnancies. Table 2 gives an overview of 2011 abortions by month of termination, by residence and nonresidence status, and the resident live births in those months. Table 2. Abortions in 2011 by month and resident status Month January February March April May June July August September October November December § Non-resident abortions (N = 795) 73 78 105 56 47 59 47 57 51 79 54 89 Resident abortions (N = 13,606) 1,238 1,334 1,399 1,208 1,161 1,158 1,170 1,025 885 941 960 1,127 Resident live births (N = 85,190) 7,127 6,500 7,254 6,498 6,678 7,086 7,222 7,688 7,750 7,361 6,987 7,039 Abortion ratio§ (160 per 1000 births) 174 205 193 186 174 163 162 133 114 128 137 160 Abortion ratio is then number of abortions per 1000 live births The overall abortion ratio for the calendar year 2011 was 160 per 1000 live births compared to 127 per 1000 live births in the year 2010. The overall abortion rate for the calendar year 2011 was 10.7 per 1000 women of child-bearing age (15-44 years). The difference in the 2010 and 2011 rates for abortions was statistically significant. Figure 3 displays Arizona’s abortion rates for the 1999-2011 time-periods. Page | 9 Figure 3. Abortion counts and rates for Arizona residents during1999-2011 Abortion rates for Arizona 1999-2011 Counts Rates 16,000 10.2 8.5 7.8 7.5 8 11,059 10,045 10,396 10,486 10,506 10,446 12,301 10,154 10,397 8,226 9,631 4,000 10,656 8,000 6,000 10 8.8 6 4 Rates per 1000 women 8.1 8.2 8.1 7.3 10,000 Counts 9 8.9 12,000 12 10 13,606 14,000 10.7 2 2,000 0 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 3.1. Characteristics of women receiving abortions in Arizona Characteristics described here examine age of the mother, race and ethnicity, marital status, and education. They also included a description of pregnancy history (i.e. previous pregnancies, previous number of live births, previous induced termination of pregnancy, previous spontaneous termination of pregnancy), type of facility accessed by women, and the method used for terminating a pregnancy (i.e. surgical or non-surgical). Where feasible, comparative statistics for the U.S. and Arizona are shown. Age Age is an important element in all epidemiological analyses, and maternal age is especially critical in determining maternal and child health. The average age of a woman receiving abortion in Arizona in 2011 was 26.45 years (SD = 6.45 years) with age ranges between 10 to 49 years. In general, there were no differences in the average age of a woman seeking abortion by resident status. Table 3 displays the age-distribution of the women receiving abortions in Arizona by resident status. Irrespective of their resident status, the proportion of women in each group receiving abortions in Arizona in 2011 was similar. Page | 10 Table 3. Age-distribution of women receiving abortions in Arizona by state of residence Age-distribution <15 years 15-17 years 18-19 years 20-24 years 25-29 years 30-34 years 35-39 years 40-44 years 45+ years Non-Resident Resident (N = 795) (N = 13,606) Count Percent Count Percent 3 0.38% 49 0.36% 23 2.89% 478 3.51% 59 7.42% 1,258 9.25% 265 33.33% 4,386 32.24% 191 24.03% 3,428 25.19% 144 18.11% 2,153 15.82% 78 9.81% 1,308 9.61% 28 3.52% 512 3.76% 4 0.50% 34 0.25% Table 4 on the following page presents reported abortions, by age group and year for Arizona residents during 2000 – 2011. Women in the youngest and the oldest group accounted for the smallest percentage of abortions (0.36% and 4.06%) in 2011 and during 2000-2011 time-periods. It is evident from the table that the proportion of abortions for women less than 15 years of age declined from 0.59 percent in 2000 to 0.36 percent in 2011. Similarly, among women 15 to 19 years of age, the proportion of abortions declined from 20.05 percent in 2000 to 12.76 percent in 2011 – a 36 percent decline. Decline in the proportion of abortions in women less than 15 years of age (-54%) was highest during the 2005-2009 time-period, while for women 15 to 19 years of age (-15%) the highest decline was during the 2000-2011 time-period. On the contrary, the proportion of abortions increased for all other age-groups increased, with the highest increase in women 40 and older (50%). For instance, the proportion of abortion in 2000 was 2.68 percent of all abortions, however, by 2011 this proportion increased to 4.18 percent – approximately 50 percent increase. Abortion rates for women less than 15 years of age declined (-28%) from 0.31 per 1000 in 2000 to 0.22 in 2011 with the highest decline seen in 2005-2009 time-periods (-58%). Similarly, the abortion rates for women 15 to 19 years of age declined from 10.90 per 1000 in 2000 to 7.69 per 1000 in 2011 (~-30%). There was also an increase in rates of abortion for women in all other age-groups. For instance, the abortion rate for women 40 and older was 1.38 per 1000 women in 2000 and by 2011 this rate increased to 2.43 per 1000 women with a 76 percent increase during 2000-2011 time-frames. As noted earlier, the abortion ratio compares the count of elective terminations to the count of live births, and is expressed as abortions per 1,000 live births. It is evident from the table that Page | 11 abortion ratio for women less than 15 years of age increased from 264 per 1000 live births in 2000 to 485 per 1000 live births in 2011 – an increase of 84 percent. Similarly, the abortion ratio for women 15 to 19 years of age in 2000 was 161 per 1000 live births and this increased to 208 per 1000 live births in 2011 (29%). Abortion ratios for women greater than or equal to 40 years of age also increased between 2000 (165 per 1000 live births) and 2011 (261 per 1000 live births). Table 4. Abortions, abortion rates, and abortion ratios by age group and year for Arizona residents during 2000 – 2011 Age in years % of Abortions <15 yrs 15-19 yrs 20-24 yrs 25-29 yrs 30-34 yrs 35-39 yrs >=40 yrs Abortion rates <15 yrs 15-19 yrs 20-24 yrs 25-29 yrs 30-34 yrs 35-39 yrs >=40 yrs Abortion ratio <15 yrs 15-19 yrs 20-24 yrs 25-29 yrs 30-34 yrs 35-39 yrs >=40 yrs Year 2005 2006 2000 2001 2002 2003 2004 0.59% 20.05% 31.58% 20.64% 13.08% 7.56% 2.68% 0.56% 18.02% 31.90% 20.53% 13.37% 7.31% 2.74% 0.42% 18.77% 32.37% 19.63% 13.27% 7.59% 2.94% 0.59% 17.80% 34.12% 20.35% 13.48% 7.26% 3.20% 0.36% 17.69% 34.16% 21.12% 13.12% 7.88% 2.89% 0.52% 17.60% 33.40% 21.01% 12.72% 7.63% 2.97% 0.31 10.90 17.70 11.12 7.12 3.77 1.38 0.24 8.10 14.77 9.13 6.01 3.01 1.16 0.22 10.33 18.36 10.69 7.31 3.83 1.53 0.30 9.31 18.38 10.52 7.05 3.48 1.58 0.20 10.06 19.40 11.66 7.37 4.24 1.64 264 161 127 86 77 93 165 232 128 108 74 65 78 137 214 173 134 87 78 99 186 284 157 135 83 74 89 183 234 186 163 101 84 110 182 % Change 2000 to 2004 2005 to 2009 2010 to 2011 2000 to 2011 2007 2008 2009 2010 2011 0.66% 17.61% 33.57% 21.35% 13.14% 8.34% 4.25% 1.35% 17.52% 32.93% 22.75% 12.72% 7.91% 4.66% 0.64% 16.79% 33.98% 22.33% 12.22% 8.01% 2.89% 0.24% 14.88% 33.55% 23.72% 13.75% 8.66% 2.80% 0.40% 13.27% 33.10% 23.67% 15.33% 9.44% 3.38% 0.36% 12.76% 32.24% 25.19% 15.82% 9.61% 4.01% -40% -12% 8% 2% 0% 4% 8% -54% -15% 0% 13% 8% 14% -6% -9% -4% -3% 6% 3% 2% 19% -39% -36% 2% 22% 21% 27% 50% 0.25 8.83 17.13 10.34 6.33 3.49 1.40 0.31 8.66 16.45 10.40 6.50 4.31 2.06 0.64 8.54 16.44 10.35 6.26 3.89 2.23 0.30 7.99 16.54 9.86 5.79 3.84 1.35 0.11 6.78 15.59 9.98 6.20 3.92 1.25 0.20 6.54 17.18 12.21 8.29 5.08 1.86 0.22 7.69 20.45 15.87 10.45 6.32 2.43 -35% -8% 10% 5% 3% 12% 19% -58% -23% -9% -4% -2% 12% -11% 11% 17% 19% 30% 26% 24% 31% -28% -30% 15% 43% 47% 67% 76% 292 156 132 83 67 89 163 406 145 125 78 68 89 223 789 144 124 83 63 83 235 416 146 135 82 62 83 150 182 138 141 90 70 92 140 415 157 165 105 88 115 193 485 208 202 141 111 143 261 -11% 16% 28% 18% 9% 18% 11% -38% -12% 7% 9% 4% 4% -14% 17% 32% 22% 34% 27% 25% 35% 84% 29% 58% 64% 44% 53% 58% † ‡ § † Percents do not add up to a 100 due to rounding errors as well as unknown age-categories in some reporting years ‡ Number of abortions obtained by women in a given age group per 1,000 women in that same age group. Adolescents aged 10–14 years were used as the denominator for the group of adolescents aged <15 years, and women aged 40–44 years were used as the denominator for the group of women aged ≥40 years. § Number of abortions obtained by women in a given age group per 1,000 live births to women in that same age group. Adolescents Figure 4 on the following page displays adolescent abortion rates for residents during 2000-2011 for Arizona. It is evident that during 2000-2011 abortion rates for adolescents in all age-groups declined. For instance, the 2000 abortion rate for adolescents aged 15 to 17 years was 6.56 per Page | 12 1000 women while in 2011 this rate was 3.60 per 1000 women. The percent change in abortion rates during 2000-2011 was highest among 15 to 17 year olds (~45%). Linear regression results for trends indicated that there was a significant decline in trend for adolescents 15 to 17 years. However, between 2010 (3.30 per 1000 women) and 2011 (3.60 per 1000 women) there was approximately a nine percent increase in the rates of abortion for the same age-group. Among the 18 to 19 year olds there was approximately 21% decline in abortion rates from 17.14 per 1000 women in 2000 to 13.52 per 1000 women in 2011. However, between 2010 and 2011 there was a 21 percent increase in abortion rates for this age-group. Figure 4. Adolescent abortion rates for Arizona 2000-2011 Adolescent Abortion Rates for Arizona 2000-2011 <15 years 15-17 years 18-19 years 25.00 20.00 17.83 17.14 Rate per 1000 women 16.06 14.96 14.67 15.00 14.81 15.73 14.46 13.52 13.09 12.52 11.17 10.00 6.56 6.34 5.37 5.01 5.95 4.75 5.00 4.77 4.27 4.14 3.02 3.30 3.60 0.31 0.24 0.22 0.30 0.20 0.25 0.31 0.64 0.30 0.11 0.20 0.22 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 0.00 Race and Ethnicity In nearly 40 percent (n = 4,442) of the cases multiple race categories were reported, and in approximately 17 percent (n = 2,265) there was no indication of any race(s). Of the total 13,606 abortions to resident women in 2011, approximately 38 percent (n = 4,274) of the abortions were Page | 13 for resident Hispanic women followed by approximately 21 percent (n = 2,385) for non-Hispanic White women. African American resident women accounted for approximately one percent (n = 145), followed by American Indian (n = 48), and Asian or Pacific Islanders (n = 47). Table 5 gives an overview of the trends in abortions by race and ethnicity during 2000-2011. The 2011 abortion rates for those other than Hispanics and/or Latinos should be interpreted with caution due to the problems in race categorization noted above. In general, the Hispanic and/or Latino abortions (as a proportion of abortions among all race groups) remained similar throughout this time-period. However, between 2010 and 2011 there was approximately 23 percent increase in the abortion rates and a 29 percent increase in abortion ratios for Hispanics and/or Latinos. Some of the race- and ethnic-specific figures markedly changed beginning in 2010 and this may reflect changes in the way these variables were reported in the new electronic reporting system. Table 5. Proportion of abortions, rates, and ratios by race and ethnicity during 2000-2011 Year Race and Ethnicity 2005 2006 2007 2008 2009 2010 2011¶ White non-Hispanic 49.69% 47.62% 47.22% 48.13% 42.89% 42.42% 48.60% 49.61% 45.57% 47.38% 47.39% 17.53% Hispanic or Latino 31.10% 33.27% 34.30% 33.89% 36.46% 29.79% 30.08% 35.47% 30.05% 32.88% 30.94% 31.41% 5.53% 6.44% 7.16% 7.33% 4.30% 1.07% 2000 % of Abortions 2001 2002 2003 2004 † Black or African American 5.51% 5.47% 5.35% 4.87% 5.88% 5.60% American Indian 2.63% 2.67% 2.74% 3.52% 2.77% 3.38% 3.26% 2.96% 2.86% 2.99% 1.97% 0.35% Asian or Pacific Islander 2.60% 2.52% 2.63% 2.68% 3.61% 3.63% 3.72% 4.33% 3.96% 3.88% 2.30% 0.35% Multiple races Unknown Abortion rates NA NA NA NA NA NA NA NA NA NA NA 32.65% 0.08 0.08 0.08 0.07 0.08 0.15 0.09 0.01 0.10 0.06 0.13 16.65% 7.40 6.10 7.10 6.90 7.70 5.70 7.21 7.30 6.45 6.38 8.21 3.67 ‡ White non-Hispanic Hispanic or Latino 9.10 8.90 10.90 10.20 12.90 8.60 8.10 9.20 7.59 7.96 8.05 9.95 13.30 12.50 14.50 11.80 17.70 13.00 10.27 12.70 13.81 13.34 8.45 2.48 American Indian 4.20 3.60 4.40 5.10 5.10 5.10 4.38 3.80 3.60 3.59 3.20 0.58 Asian or Pacific Islander NA NA NA 8.30 14.70 11.30 9.27 10.40 9.31 8.73 5.24 0.92 Multiple races NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA White non-Hispanic 120 101 127 126 134 112 119 123 113 115 135 62 Hispanic or Latino 88 78 99 88 110 74 70 81 73 86 100 129 192 165 202 164 225 170 150 162 173 168 110 44 45 41 51 61 56 56 54 48 47 49 38 8 Black or African American Unknown Abortion ratio § Black or African American American Indian Asian or Pacific Islander 123 98 120 108 170 135 125 133 120 115 77 12 Multiple races NA NA NA NA NA NA NA NA NA NA NA NA Unknown NA NA NA NA NA NA NA NA NA NA NA NA † Percents do not add up to a 100 due to rounding errors as well as unknown age-categories in some reporting years ‡ Number of abortions obtained by women in a given race and ethnic group per 1,000 women in that same group. § Number of abortions obtained by women in a given race and ethnic group per 1,000 live births to women in that same age group. ¶ Rates and ratios for 2011 race groups should be interpreted with caution as they are severely underreported due to choice of multiple race and ethnic category selections for which denominators are not available. The reports based on single race selections are the best estimates of rates and ratios. Page | 14 Marital Status In 2011, 16.43 percent (n = 2,169) of the women seeking abortion were married. Figure 5 displays the trend data on the proportion of married and unmarried resident women in Arizona who sought abortion during 2000-2011. The percent of married women during 2000-2011 ranged from 12 percent to 20 percent and has remained consistent similar to unmarried women seeking abortions during the time-period ignoring unknown cases. According to latest available U.S. data, “among the 40 areas that reported marital status for 2008, 15.7% of all women were married, and 84.3% were unmarried.”1 (p7) Between 2000 and 2011 there was an approximately 36 percent increase in the percent of married women seeking abortions. Figure 5. Married and unmarried resident women seeking abortions in Arizona during 2000-2011 Proportion of Married and Unmarried Resident Women Seeking Abortions in Arizona Married Unmarried Unknown 100.0% 17.4% 90.0% 80.0% 10.9% 1.5% 8.7% 3.0% 31.9% 70.0% 60.0% 50.0% 40.0% 64.9% 70.2% 71.2% 81.8% 82.4% 83.2% 85.9% 86.8% 85.6% 82.4% 81.1% 56.5% 30.0% 20.0% 10.0% 11.7% 17.8% 18.8% 20.1% 18.2% 17.6% 16.8% 14.1% 13.2% 14.4% 16.1% 15.9% 2011 (n=13,606) 2010 (n=11,059) 2009 (n=10,045) 2008 (n=10,396) 2007 (n=10,486) 2006 (n=10,506) 2005 (n=10,446) 2004 (n=12,301) 2003 (n=10,154) 2002 (n=10,397) 2001 (n=8,226) 2000 (n=9,631) 0.0% Not surprisingly, the percent of married women increased with age, and of those who were married, almost 90 percent of the married women were in the 20 to 39 years age-group (i.e. Page | 15 ~17% in 20 to 24 years; ~26% in 25 to 29 years; ~27% in 30 to 34 years; ~19% in 35 to 39 years age-groups). Education Figure 6 displays the distribution of educational attainment of Arizona resident women seeking abortions in 2011. The largest proportion had unknown educational status (~48%). Thirty-one percent of the women who sought abortions in 2011 had 12 years of schooling, followed by approximately 14 percent (n = 1,899) women who had 13 to 16 years of schooling. Four percent had less than a high school education. Figure 6. Educational status of Arizona resident women seeking abortions in 2011 Educational Status of Resident Women receiving Abortions in 2011 31.16% 13.96% 2.59% 3.07% 0.24% 0.49% 48.49% < 8 years of schooling (n = 67) 9-11 years of schooling (n = 418) 13-16 years of schooling (n = 1,899) 8 years of schooling (n = 32) 12 years of schooling (n = 4,240) 17+ years of schooling (n = 353) Previous Pregnancy History Previous pregnancy history captures the previous number of pregnancies, previous number of live births, previous induced terminations of pregnancy, and previous spontaneous termination of pregnancy. Previous pregnancy history provides an overview of the risk involved in future pregnancy outcomes. For instance, in the case of abortions, some studies have indicated that “the Page | 16 risk of preterm birth is higher in women who have undergone induced abortion, and that the risk is related to the number of abortions.”9(p.734) More recent meta analytic study by Shah et al. indicated that previous induced terminations of pregnancy (I-TOP) was associated with a significantly increased risk of low birth weight (LBW) and preterm birth (PTB) but not with small for gestational age (SGA) and the risk increased with increase in the number of I-TOP.10 Table 6 shows the previous number of live births, previous induced termination of pregnancy, and previous spontaneous termination. Data from 2011 suggests that one-third (~33%) of the resident women had three or more previous pregnancies and approximately 16 percent had previous live births. Of the women who received abortions during 2011, approximately 12 percent had two or more previous abortions; approximately three percent had two or more previous spontaneous terminations of pregnancies. Table 6. Pregnancy history of resident women seeking abortions in Arizona in 2011 Pregnancy History Number of previous pregnancies 0 1 2 3 or more Unknown Number of previous live births 0 1 2 3 or more Unknown Previous induced termination of pregnancy 0 1 2 3 or more Unknown Previous spontaneous termination of pregnancy 0 1 2 3 or more Unknown 2011 Count (N = 13,606) Percent 3,745 2,844 2,459 4,545 13 27.52 20.90 18.07 33.41 0.10 5,820 3,132 2,521 2,119 14 42.78 23.02 18.53 15.57 0.10 8,382 3,467 1,159 557 41 61.61 25.48 8.52 4.1 0.3 11,257 1,809 368 124 48 82.74 13.3 2.7 0.91 0.35 Page | 17 Of those women who sought abortions in 2011, 7,239 (53%) never had a previous induced termination of pregnancy and never had a previous spontaneous termination (data not shown). Approximately, 8.5 percent (n = 1,148) had at least one or more previous induced termination of pregnancy and had one or more previous spontaneous terminations. Further, about 8.5 percent (n = 1,141) had a previous spontaneous termination but did not have a previous induced termination of pregnancy; and about 30 percent (n = 4,015) had a previous abortion but did not have a previous spontaneous termination. Figure 7 gives an overview of the pregnancy history of resident women who sought abortions in 2011 by age-groups. It is evident that the proportion of pregnancies, previous live births, previous induced terminations of pregnancy, as well as previous spontaneous terminations mostly concentrated in women 20-29 years of age. Figure 7. Pregnancy history of resident women seeking abortions in Arizona 2011 by age-groups Pregnancy History of Resident Women Seeking Abortions in Arizona 2011 by Age-group§ Previous pregnancy(ies) Previous abortion(s) Previous birth(s) Previous spontaneous termination(s) 100 90 80 70 Percent 60 57.07 50 53.71 58.09 51.19 40 30 19.69 20 10 22 20.28 23.95 22.25 17.42 20.14 17.17 5.81 4.14 4.45 2.61 0 <19 yrs §Indicates 20-29 yrs 30-34 yrs 35+ yrs one or more counts for each age-group combination Page | 18 Abortion Method Of those women who had abortions in 2011, approximately 38 percent (n = 5,108) had nonsurgical procedures and approximately 62 percent (n = 8,485) had surgical procedures. Table 7 provides an overview of the method of abortions in 2011. Of the total surgical procedures reported, the most common procedure was suction curettage (~75%), followed by dilation and evacuation (D&E) accounting for approximately 15 percent, and sharp curettage (D&C) accounting for ten percent of the total surgical procedures. Of the total non-surgical procedures that were reported, Mifeprex and/or Misoprostol (~50%) was the most common. Table 7. Method of abortion used by resident women in Arizona 2011 ¶ Method Surgical Procedures Sharp Curettage (D&C) Suction Curettage Insertion/Laminaria Hysterotomy/Hysterectomy Insertion/Intra-amniotic (saline) Insertion/Prostaglandin Dialation and Evacuation (D&E) Other procedure Non-surgical Procedures Methotrexate and misoprostol (Cytotec) Mifepristone (Mifeprex) and misoprostol (Cytotec) Mifeprex and misoprostol Digoxin Other ¶ Count Percent 910 6,327 15 1 0 23 1,204 5 10.72% 74.57% 0.18% 0.01% 0.00% 0.27% 14.19% 0.06% 1 27 2,666 2,351 63 0.02% 0.53% 52.19% 46.03% 1.23% In 13 cases procedures were unknown Figure 8 displays the trends in surgical as well as non-surgical procedures during 2000-2011. It is evident that the number of non-surgical abortions increased until 2009 and then decreased in 2010 and 2011. In 2000, almost all procedures for abortions comprised of surgical procedures; however in 2011, surgical procedures accounted for 62 percent of all abortion procedures. Similarly, in 2001 non-surgical procedures comprised of less than one percent (0.01%) and in 2011 comprised 38 percent. Between 2005-2009 time-period, there was approximately 29 percent decrease for surgical procedures; however, during the same time-frame there almost 70 percent increase in non-surgical procedures. Page | 19 Figure 8. Method of abortion among Arizona resident women during 2000-2011 Method of abortions among Arizona resident women during 2000-2011 Surgical Non-surgical 37.5% 45.1% 70% 50.0% 38.4% 35.9% 29.4% 29.5% 80% 29.0% 90% 24.0% 17.0% 100% 62.4% 53.2% 20% 50.0% 61.6% 2008 (n=10,396) 70.6% 2006 (n=10,506) 64.1% 70.5% 2005 (n=10,446) 2007 (n=10,486) 71.0% 30% 2004 (n=12,301) 76.0% 99.0% 2001 (n=8,226) 40% 83.0% 100.0% 50% 2000 (n=9,631) 60% 10% 2011 (n=13,606) 2010 (n=11,059) 2009 (n=10,045) 2003 (n=10,154) 2002 (n=10,397) 0% Facility and Reason for Termination Of the 13,606 abortions reported for Arizona residents, 13,566 (99.66%) were performed in clinics, followed by 38 in hospitals (0.28%), six in an outpatient surgical center, and two in an outpatient treatment center. The most common reason for pregnancy termination was elective (99.10%), followed by 122 (0.9%) cases reported for medical reasons. Of those 122 cases that indicated terminating pregnancy for medical reasons, approximately 80 percent (n = 97) of the terminations were surgical procedures and 19 percent (n = 23) of the abortions were nonsurgical. Of those 122 cases, approximately 70 percent (n = 86) were performed in clinics and approximately 30 percent (n = 36) were performed in hospitals. Of those 122 cases, approximately 95 percent (n = 116) of the abortions were performed on women age 20 or older. Medical complications occurring during pregnancy are reported on the abortion procedure report. During 2011, 25 women experienced medical complications of pregnancy and 97 experienced complications with the fetus and majority these related to birth defects. The complications noted for the mother were maternal cardiac complications (n = 2), maternal renal complications (n = 2), Page | 20 chorioamnionitis (n = 3), preeclampsia or HELLP syndrome (n = 5), premature rupture of membranes (n = 7), and other unspecified maternal conditions (n = 6). 3.2. Abortions by gestational age Gestational age plays a critical role in an induced termination of pregnancy and some evidence suggests that longer gestational age is perhaps associated with abortion-related mortality.11 Table 8 gives an overview of the gestational ages of the fetus at the time of abortion for 2011. The majority of the abortions (67.10%) to Arizona resident women were performed at less than or equal to 8 weeks of gestation; the comparable U.S. figure was (62.8%).1 Ninety-five percent of the Arizona abortions were performed at less than or equal to 15 weeks of gestation. It is evident from the table that one-third of the abortions were performed at six weeks of gestation, followed by approximately one-fifth at seven weeks of gestation, and slightly more than onetenth of the abortions at eight weeks of gestation. About one percent (n = 141) of the abortions were performed at 21 weeks of gestation and in 23 cases no gestational age was reported. Table 8. Distribution of gestational age at time of abortion of Arizona residents Gestational age (in weeks) Less than or equal to 8 weeks 6 weeks 7 weeks 8 weeks 9 to 13 weeks 9 weeks 10 weeks 11 weeks 12 weeks 13 weeks 14 to 15 weeks 14 weeks 15 weeks 16 to 17 weeks 16 weeks 17 weeks 18 to 20 weeks 18 weeks 19 weeks 20 weeks Greater than or equal to 21 weeks 21 weeks Unknown/Missing Unknown Count ( N = 13,606) 9,130 4,550 2,697 1,883 3,398 1,147 759 671 449 372 408 220 188 271 146 125 235 93 95 47 141 141 Percent 67.10% 33.44% 19.82% 13.84% 24.97% 8.43% 5.58% 4.93% 3.30% 2.73% 3.00% 1.62% 1.38% 1.99% 1.07% 0.92% 1.73% 0.68% 0.70% 0.35% 1.04% 1.04% 23 0.17% Page | 21 Table 9 presents the distribution of age of the women and the gestational age in weeks at the time of abortion. It is evident that irrespective of age, the majority of the abortions were performed at less than or equal to 13 weeks of gestation. However, among women less than15 years of age, approximately 16 percent of the abortions (n = 8), were performed between 14 to 20 weeks of gestation, and in two cases the abortions were performed at 21 weeks of gestation. Similarly, among women 15 to 19 years of age, about nine percent of the abortions (n = 154), were performed at 14 to 20 weeks of gestation, and in about one percent (n = 24) of the cases abortions were performed at 21 weeks of gestation. Table 9. Distribution of gestational age at time of abortion by age-groups ¶ Age in (years) Gestational age (in weeks) <=13 weeks 14 to 20 weeks 21 weeks Count Percent Count Percent Count Percent 39 79.59% 8 16.33% 2 4.08% 15-19 yrs 1,554 89.72% 154 8.89% 24 1.39% 20-24 yrs 4,048 92.42% 281 6.42% 51 1.16% 25-29 yrs 3,166 92.49% 230 6.72% 27 0.79% 30-34 yrs 1,991 92.65% 132 6.14% 26 1.21% 35-39 yrs 1,219 93.41% 79 6.05% 7 0.54% >=40 yrs 511 93.76% 30 5.50% 4 0.73% 12,528 92.23% 914 6.73% 141 1.04% <15 yrs Totals ¶ Totals do not add to 13,606 due to 23 unknown gestational age Table 10 provides an overview of the gestational age and the method of abortion. Irrespective of gestational age, surgical procedure was one of the most utilized methods for terminating pregnancy. In the majority of the cases (n = 5,956; ~80) involving surgical procedure, suction curettage (D&C) was the most common procedure utilized at less than or equal to 13 weeks of gestation. Similarly, Mifeprex and/or misoprostal (n = 2,658; ~52%), followed by Digoxin (n = 2,346; ~46%) was the most common non-surgical procedure utilized at less than or equal to 13 weeks of gestation. At 14 to 20 weeks of gestation, dilation and evacuation (D&E) accounted for approximately 65 percent (n = 585) of the surgical procedures, followed by suction curettage accounting for one-third (n = 301; ~33%) of the surgical procedures. Page | 22 Table 10. Method of abortion and gestational age ¶ Gestational age (in weeks) § Method Surgical Sharp Curettage (D&C) Suction Curettage Insertion/Laminaria Insertion/Prostaglandin Dialation and Evacuation (D&E) Other procedure/Unknown Non-surgical Methotrexate and misoprostol (Cytotec) Mifepristone (Mifeprex) and misoprostol (Cytotec) Mifeprex and misoprostol Digoxin Other procedure/Unknown ¶ <=13 weeks (n = 12,528) Count Percent (n = 7,450) 898 5,956 14 16 562 4 (n = 5,074) 27 2,658 41 2,346 2 12.05% 79.95% 0.19% 0.21% 7.54% 0.05% 0.53% 52.36% 0.81% 46.22% 0.04% 14 to 20 weeks (n = 914) Count Percent (n = 904) 9 301 0 7 585 2 (n = 10) 0 1 3 0 6 1.00% 33.30% 0.00% 0.77% 64.71% 0.22% 0.00% 10.00% 30.00% 0.00% 60.00% 21 weeks (n = 141 ) Count Percent (n = 126) 1 67 1 0 57 0 (n = 15) 1 0 0 0 14 0.79% 53.17% 0.79% 0.00% 45.24% 0.00% 6.67% 0.00% 0.00% 0.00% 93.33% In about 23 cases gestational age was unknown § In about 13 cases method of abortion was unknown 3.3. Abortions by patient’s county of residence Table 11 on the following page gives an overview of the abortions, number of live births, abortion rates, and ratio by county of residence as well as border and non-border region. The border region consists of Cochise, Pima, Santa Cruz, and Yuma counties while the remaining counties are considered non-border counties. The overall Arizona rate for abortions in 2011 was 10.7 per 1000 women and 13 out of the 15 counties had abortion rates below the state rate. Greenlee (26.50 per 1000 women) and Maricopa (12.88 per 1000 women) exceeded the state rate. Similarly, 12 out of the 15 counties had abortion ratios below the state ratio (159.71) while Greenlee (344.50 per 1000 births), Maricopa (192.65 per 1000 births) and Pima (171.72 per 1000 births) exceeded the overall state abortion ratio. When comparing border and non-border regions, the overall abortion rate for the border region was 9.13 per 1000 women compared to 11.11 per 1000 women in the non-border region. And, the overall abortion ratio for border region was 138.15 per 1000 births compared to 165.26 per 1000 births in the non-border region. Both abortion rates as well as the abortion ratio for the border region was below the state rate. Page | 23 Table 11. Arizona 2011 abortions, live births, rate, and ratio by county of residence ¶ Resident county Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma † Abortions Count % 15 0.11% 162 1.19% 184 1.35% 41 0.30% 12 0.09% 41 0.30% 11 0.08% 10,280 75.55% 43 0.32% 77 0.57% 2,039 14.99% 313 2.30% 35 0.26% 181 1.33% 172 1.26% 2,408 17.70% Border region Non-border region 11,198 82.30% Arizona 13,606 100% ¶ Residence indicates women's place residence Live Births Count % 1,071 1.26% 1,664 1.95% 1,771 2.08% 620 0.73% 606 0.71% 119 0.14% 172 0.20% 53,361 62.64% 1,962 2.30% 1,642 1.93% 11,874 13.94% 4,607 5.41% 694 0.81% 1,829 2.15% 3,198 3.75% 17,430 67,760 85,190 20.46% 79.54% 100% Abortion Rate ‡ Abortion Ratio 1.12 7.26 5.86 5.38 1.76 26.50 4.42 12.88 1.48 4.04 10.54 4.58 3.77 6.05 4.43 14.01 97.36 103.90 66.13 19.80 344.54 63.95 192.65 21.92 46.89 171.72 67.94 50.43 98.96 53.78 9.13 11.11 10.70 138.15 165.26 159.71 § † Border region in Arizona include Cochise, Pima, Santa Cruz, and Yuma ‡ Number of abortions obtained by women per 1,000 women of child-bearing age (15-44 years of age) § Number of abortions obtained by women per 1,000 live births Table 12 on the following page displays the trends in abortions, rates, ratios, and percent change by county of residence for 2000-2011. During 2000-2011, the number of abortions increased in most counties, except for Cochise, Coconino, Graham, Pima, and Santa Cruz. The percent change in the number of abortions in Arizona during 2000-2011 was 41 percent. During 2000-2011, Mohave (617%) Greenlee (583%), Pinal (175%) and Yuma (126%) had the highest percent change. The high percentage change in Mohave and Greenlee may be due to the small number of cases (possibly undercount in previous years). Graham (47%), Santa Cruz (33%), Coconino (19%), Cochise (17%), and Pima (15%) saw a decline in the count of abortions during this time-period. The same pattern was true for abortion rates and abortion ratios. Page | 24 Table 12. Number of abortions, rates, and ratio by county of residence 2000-2011 County of Residence # of Abortions ARIZONA Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Unknown Abortion Rates ARIZONA Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Abortion Ratio ARIZONA Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma 2000 2001 2002 2003 2004 Year 2005 2006 9,631 11 196 226 23 21 6 4 6,082 6 46 2,394 106 52 122 76 - 8,226 12 144 190 29 17 8 8 4,697 4 45 2,422 147 45 132 84 - 10,397 15 201 239 27 20 7 8 6,371 11 73 2,764 110 70 144 112 - 10,154 17 150 233 15 18 4 3 7,027 5 54 2,080 83 45 100 133 - 12,301 43 181 291 29 21 4 9 8,178 20 70 2,965 131 50 190 119 - 10,446 46 136 266 10 9 6 6,541 6 51 3,018 85 36 208 28 - 10,506 47 176 299 27 15 4 6 6,496 16 47 2,636 277 81 263 81 - 8.88 0.77 8.74 7.97 2.73 3.26 3.51 1.38 9.01 0.23 2.38 13.12 3.49 6.35 4.41 2.47 7.33 0.85 6.34 6.61 3.43 2.65 4.82 2.75 6.69 0.15 2.27 12.98 4.60 5.32 4.56 2.64 8.98 1.04 8.51 7.81 3.10 3.05 4.06 2.67 8.79 0.40 3.62 14.35 3.38 8.23 4.84 3.43 8.53 1.17 6.25 7.41 1.70 2.71 2.33 0.98 9.41 0.18 2.62 10.56 2.43 5.15 3.24 3.94 9.97 2.93 7.42 9.24 3.27 3.00 2.38 2.88 10.55 0.66 3.27 14.70 3.51 5.56 5.79 3.39 8.14 3.03 5.42 8.37 1.11 1.27 3.27 0.00 8.14 0.19 2.31 14.49 1.99 3.81 6.07 0.75 8.24 3.10 7.16 9.73 3.02 2.19 2.66 1.92 8.21 0.47 2.05 13.01 5.46 8.57 7.26 2.19 8.06 2.82 3.24 9.02 3.89 1.68 4.61 3.94 8.97 1.26 2.13 9.35 7.26 7.86 6.59 1.99 7.84 0.98 4.98 9.17 2.84 1.96 4.26 1.99 8.79 0.88 2.47 9.94 4.04 3.67 5.99 1.91 7.47 1.23 5.66 8.47 2.75 2.89 5.13 0.64 8.14 0.58 1.66 10.20 2.51 3.53 4.61 3.99 8.76 1.43 4.77 8.70 3.67 2.23 14.22 2.47 9.81 0.76 3.62 9.59 3.25 3.38 6.83 3.99 113 9 113 122 34 46 56 22 112 3 27 191 41 65 69 25 97 11 88 101 45 38 84 43 84 2 29 200 58 59 76 28 119 14 118 128 118 128 39 35 113 6 45 222 41 92 75 37 112 14 85 121 22 42 46 14 119 2 32 163 28 57 54 42 132 32 100 144 43 47 39 39 135 9 39 228 43 62 95 36 109 36 77 129 15 20 61 0 105 3 27 233 23 46 98 9 103 40 97 145 41 28 36 26 98 7 25 189 62 108 111 24 102 37 44 129 52 21 51 52 109 19 25 138 80 99 104 23 105 12 71 142 39 23 53 24 114 14 30 152 45 45 106 22 109 15 80 140 38 36 62 12 117 10 21 165 31 46 89 48 127 17 60 154 42 28 210 30 143 11 40 152 44 45 112 47 2007 2008 2009 10,486 10,396 43 15 81 127 275 281 36 27 12 15 7 7 6 12 7,188 7,166 45 32 51 59 1,908 2,054 420 257 76 36 251 234 76 74 6 10,045 19 147 266 27 23 8 2 6,732 21 40 2,124 163 35 183 156 - 2010 % Change 2011 2000 to 2004 2005 to 2009 2010 to 2011 2000 to 2011 11,059 13,606 19 15 107 162 274 184 28 41 15 12 22 41 6 11 7,774 10,280 22 43 69 77 1,844 2,039 217 313 31 35 204 181 151 172 276 - 28% 291% -8% 29% 26% 0% -33% 125% 34% 233% 52% 24% 24% -4% 56% 57% NA -4% -59% 8% 0% 170% 156% 33% 0% 3% 250% -22% -30% 92% -3% -12% 457% NA 23% -21% 51% -33% 46% -20% 86% 83% 32% 95% 12% 11% 44% 13% -11% 14% NA 41% 36% -17% -19% 78% -43% 583% 175% 69% 617% 67% -15% 195% -33% 48% 126% NA 10.70 1.12 7.26 5.86 5.38 1.76 26.50 4.42 12.88 1.48 4.04 10.54 4.58 3.77 6.05 4.43 12% 280% -15% 16% 20% -8% -32% 109% 17% 185% 38% 12% 1% -12% 31% 37% -8% -59% 4% 1% 147% 128% 57% 0% 0% 204% -28% -30% 26% -8% -24% 429% 22% -22% 52% -33% 46% -21% 86% 79% 31% 95% 12% 10% 41% 11% -11% 11% 20% 45% -17% -26% 97% -46% 655% 221% 43% 537% 70% -20% 31% -41% 37% 80% 160 14 97 104 66 20 345 64 193 22 47 172 68 50 99 54 16% 279% -11% 18% 28% 2% -29% 80% 21% 168% 43% 19% 5% -5% 37% 42% 0% -57% 4% 9% 149% 79% 1% 0% 11% 252% -21% -29% 32% 0% -10% 467% 26% -19% 62% -33% 58% -30% 64% 113% 34% 101% 18% 13% 56% 13% -12% 15% 41% 65% -14% -15% 94% -57% 520% 195% 72% 545% 72% -10% 67% -23% 43% 113% † § † Number of abortions obtained by women per 1000 women of child-bearing age (15-44 yrs) § Number of abortions obtained by women per 1000 live births Page | 25 Table 13 displays the county of residence and the age of women who sought abortions in 2011. The majority of the women resided in Maricopa county irrespective of age. Within Maricopa County the proportion of women age 30 or older receiving abortion was slightly higher (at 3014/10280 or 30% of the Maricopa women) compared to Pima county’s proportion (536/2039 or 26%) of women age 30 or older. Table 13. Abortions by county of residence and age group, Arizona, 2011 <=19 years Count Percent 3 0.17% 27 1.51% 35 1.96% 8 0.45% 2 0.11% 5 0.28% 2 0.11% 1,285 71.99% 6 0.34% 14 0.78% 300 16.81% 43 2.41% 8 0.45% 19 1.06% 28 1.57% County Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma † 363 20.34% Border region 1422 79.66% Non-border region ARIZONA 1,785 100% ¶ Residence indicates women's county of residence 20-29 years Count Percent 7 0.09% 94 1.20% 108 1.38% 24 0.31% 5 0.06% 25 0.32% 5 0.06% 5,891 75.39% 31 0.40% 45 0.58% 1,203 15.40% 153 1.96% 21 0.27% 98 1.25% 104 1.33% 30+ years Count Percent 5 0.12% 41 1.02% 41 1.02% 9 0.22% 5 0.12% 11 0.27% 4 0.10% 3,104 77.46% 6 0.15% 18 0.45% 536 13.38% 117 2.92% 6 0.15% 64 1.60% 40 1.00% 1422 6392 7,814 623 3384 4,007 18.20% 81.80% 100% 15.55% 84.45% 100% † Border region in Arizona include Cochise, Pima, Santa Cruz, and Yuma Table 14 on the following page displays the residence county and the race and ethnicity of resident women who sought abortions in Arizona in 2011. As noted earlier, the majority of the respondents selected more than two race categories and therefore, race and ethnicity data for 2011 need to be interpreted with caution. Page | 26 Table 14. Abortions by county of residence and race and ethnicity, Arizona, 2011 County White Hispanic Black or African American Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma 0 34 60 6 3 8 0 1,704 11 9 408 41 2 76 23 1 51 30 11 4 12 4 3,116 9 22 773 84 24 28 105 0 2 1 0 0 0 0 120 0 0 18 3 0 1 0 American Indian or Alaskan Native 3 1 5 0 0 0 0 30 0 4 4 0 0 1 0 467 1,918 2,385 953 3,321 4,274 20 125 145 5 43 48 ¶ † Border region Non-border region ARIZONA Asian or Pacific Islander Multiple race Unknown 0 0 3 0 0 0 0 36 1 0 6 0 0 1 0 8 47 64 16 3 21 4 3,511 17 31 535 117 3 52 13 3 27 21 8 2 0 3 1763 5 11 295 68 6 22 31 6 41 47 598 3,844 4,442 359 1,906 2,265 ¶ Residence indicates women's county of residence † Border region in Arizona include Cochise, Pima, Santa Cruz, and Yuma 3.4. Complications from abortion procedures. The way ADHS assesses and reports the complications of abortion has changed over time. Beginning in June 1976, as part of the required Report of an Induced Termination of Pregnancy, providers reported to ADHS basic information about the complication. Specifically, the providers reported whether the patient was hospitalized for complications which occurred during the abortion procedure. Between 1982 and 2003 the ADHS annual Health Status and Vital Statistics Report (HSVSR, Table D1-1) used these provider-submitted reports to list a count of patients who received abortion and who were hospitalized for complications. Beginning with 1986 data, the table of complications included only Arizona residents. From 2004 to 2009 the ADHS HSVSR continued to report the general characteristics of women receiving abortions but did not list the count of complications. Following passage of SB1304 in 2010, Arizona Revised Statutes §36-2162 added new requirements for reporting the complications of abortion procedures. Since July 2010, healthcare professionals who provide medical treatment to women experiencing complications Page | 27 from an abortion or an attempted abortion are required to file a report of the complications. The information below presents statistics compiled from analysis of those reports. There were a total of 60 reported complications in 2011 to Arizona resident women. Table 15 lists complications from an abortion by key variables. Table 15. Complications from an abortion for Arizona resident women Complications from an abortion for Arizona resident women by key variables Age (in years) <15 yrs 15-19 yrs 20-24 yrs 25-29 yrs 30-34 yrs 35-39 yrs >=40 yrs Gestational age (in weeks) <= 13 weeks 14 to 20 weeks 21 weeks Unknown Patient's county of residence Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma Unknown Description of complications 639.0 Complicated by genital tract and pelvic infection 639.1 Complicated by delayed or excessive hemorrhage 639.2 Complicated by damage to pelvic organs 639.6 Complicated by embolism 639.8 Without mention of complication Urinary tract infection following conditions classifiable to 630-638 Count (n = 60) Percent 0 11 19 24 3 2 1 0.00% 18.33% 31.67% 40.00% 5.00% 3.33% 1.67% 29 5 1 25 48.33% 8.33% 1.67% 41.67% 0 1 0 0 0 0 0 37 2 0 15 0 1 0 2 2 0.00% 1.67% 0.00% 0.00% 0.00% 0.00% 0.00% 61.67% 3.33% 0.00% 25.00% 0.00% 1.67% 0.00% 3.33% 3.33% 6 34 3 1 7 9 10.00% 56.67% 5.00% 1.67% 11.67% 15.00% Page | 28 Of the case reports that contained race and ethnicity approximately 28 percent (n = 17) were nonHispanic White, followed by 22 percent (n = 13) Hispanic, and seven percent (n = 4) African Americans. In approximately 43 percent (n = 26) of the cases, no race and/or ethnicity information was available. 3.5 Petitions filed with the Arizona Administrative Office of the Courts As specified in A.R.S. § 36-2163 subsection C, the Arizona Administrative Office of the Courts collects data and reports aggregate statistics on the number of petitions filed with Arizona courts to obtain authorization for unemancipated minors to undergo abortion without parental consent. Following is the summary provided by the Arizona Administrative Office of the Courts. The dates of petitions filed range from January 1, 2011 to December 31, 2011. Although not specified in statute, the total number of petitions issued an order are included for context. A total of 56 petitions were filed, of which 45 (82%) were issued an order authorizing an abortion: 32 without parental consent and 13 with parental consent. It should be noted that while a petition may be filed during a specific period, resolution may be in the following period. Table 16. Petitions filed in the Arizona Administrative Office of the Courts Reporting Category # of petitions 1. Number of petitions filed pursuant to A.R.S.§ 36-2152 Subsection B 56 2. Of the petitions filed pursuant to A.R.S.§ 36-2152 Subsection B, the number in which the judge appointed a guardian ad litem or court-appointed counsel for the minor pursuant to A.R.S.§ 36-2152 Subsection D. 51 3. Of the petitions filed pursuant to A.R.S.§ 36-2152 Subsection B, the number in which the judge issued an order authorizing an abortion without parental consent. Note: A total of 45 petitions were issued however, 13 were issued with parental consent. 32 4. Of the petitions filed pursuant to A.R.S.§ 36-2152 Subsection B, the number in which the judge issued an order denying the petition. Note: In addition, 8 petitions were withdrawn or otherwise terminated. 3 5. Of the petitions denied, the number appealed to the court of appeals. 1 6. The number of those appeals that resulted in the denials being affirmed. 0 7. The number of those appeals that resulted in the denial being reversed. 1 Page | 29 Conclusion The true incidence of abortions is difficult to estimate as the reporting of abortions to ADHS has been subject to the variable requirements of the abortion providers. For instance, in Arizona prior to the expanded reporting of abortions required by ARS §36-2161 and 36-2162, varying compliance in provider reporting may have underestimated the incidence rates. This is clearly evidenced through the trends and recent increases (post SB1304) in the number of reported abortions. In calendar year 2011, providers reported a total of 14,401 abortions in Arizona compared to 11,438 abortions in 2010, an increase of about 26 percent. Some of the increase in the count of abortions might be attributable to better reporting of abortion data as well as enhanced surveillance. For instance, ADHS held several training events for web-based reporting as well as the use of specific abortion reporting forms at ADHS. Over 20 facilities and 60 attendees participated at these events. Further, ADHS partnered with the Arizona Medical Board to post the notification about the requirements of abortion reporting on their website as well as collaborated with the Division of Licensing at ADHS to field questions about reporting requirements. In addition to these efforts, ADHS sent letters to OB-GYNs as well as outpatient treatment and surgical centers and developed the Abortion Reporting information website http://www.azdhs.gov/plan/crr/ar/ with a telephone number that allows providers for feedback. This URL is also emailed with their registration confirmation. Nonetheless, the estimate of abortion incidence is still below other independent estimates such as that of the Guttmacher Institute report, which reports higher incident rates of abortion. According to CDC, the Guttmacher Institute uses numerous active follow-up techniques to increase the completeness of the data obtained through its periodic national survey of abortion providers.1 While there are differences in methodology, one plausible reason for the difference between the State estimates and independent estimates of the incidence of abortions is perhaps due to lack of awareness about mandatory reporting among providers; however, it is a complex proposition to test. Of the 14,401 abortions reported in 2011, 13,606 abortions were to Arizona resident women compared to 11,059 abortions to resident women in 2010. There was a 23 percent increase in abortion incidence for resident women from 2010 and 41 percent increase during 2000-2011. Almost all abortions reported (99.02%) in 2011 were elective abortions and most of these abortions were performed in clinics (99.65%). In 2011, there were a total of 85,190 live births of Arizona residents and the overall abortion ratio was 160 per 1000 live births compared to 127 per 1000 live births in the year 2010. The overall abortion rate in calendar year 2011 was 10.7 per 1000 women of child-bearing age (15-44 years) compared to 8.8 per 1000 women in 2010. The difference in 2010 and 2011 rate for abortions was statistically significant (p < 0.01). Abortion rates for women 15 to 19 years of age declined from 10.90 per 1000 to 7.69 per 1000 during Page | 30 2000-2011 time-periods, representing a 30 percent decline in abortion rates. The proportion of abortions and abortion rates for 19 and younger declined and this trend has been consistent with declines in the number of pregnancies for 19 and younger. While this report provides a comprehensive overview of the incidence of abortion in Arizona it is limited by the descriptive nature. It cannot draw inferences about increases and/or declines in abortion rates in specific sub-groups because there have been differences in the collection of abortion data across time. Trend comparisons should be interpreted with the caveat of the varying provider reporting that was in effect prior to 2010, and the expanded reporting requirements that went in to effect in July 2010. Moreover, there are no data available to assess the extent of any underreporting of incidences. Analysis of abortion data has public health implications, as ongoing abortion surveillance can facilitate efforts at preventing unintended pregnancies.1 Abortion surveillance provides an important measure of pregnancies that are unintended and/or unwanted. Abortions are a key element in compilation of pregnancy statistics because the numerator for ‘pregnancy rate’ is comprised of the count of live births, abortions, and spontaneous fetal losses. Another important element of abortion surveillance is to assess the complications resulting from abortions. The 2011 data show that surgical procedures were the most common procedures for terminating pregnancy irrespective of gestational age, and the most common complication resulting from an abortion was excessive hemorrhage. In conclusion, the 2011 report provides a comprehensive overview of the abortions in the State of Arizona following the passage of SB1304. In April of 2012, a new abortion law HB203612 was signed that restricts abortions being performed at 20 weeks of gestational age or greater and expands the scope of parental consent for unemancipated minors. One implication of this law would be a decline in the number of abortions performed at 20 weeks of gestation or greater (~188 cases and/or 1.5% of the abortions in 2011). Another implication of this law would be a decline in the number of abortions to unemancipated minors (527 cases and/or ~4.0% of the abortions in 2011). Irrespective of the effect of the new law, this report highlights the importance of continuing public health prevention messaging about unintended pregnancies and the risks associated thereof in women of child-bearing age, especially in the adolescent teen population. Page | 31 App pendix A – Abortion Repporting Form m Pagge | 32 Pagge | 33 Pagge | 34 Pagge | 35 Appendix B- Glossary Abortion or Induced termination of pregnancy (ITOP) – Abortion means the use of any means to terminate the clinically diagnosable pregnancy of a woman with knowledge that the termination by those means will cause, with reasonable likelihood, the death of the unborn child. Abortion does not include birth control devices, oral contraceptives used to inhibit or prevent ovulation, conception or the implantation of a fertilized ovum in the uterus or the use of any means to save the life or preserve the health of the unborn child, to preserve the life or health of the child after a live birth, to terminate an ectopic pregnancy or to remove a dead fetus. (A.R.S. 36-2151) Abortion rate – The number of abortions per 1,000 women aged 15-44 year or other specific group within a given population. Abortion ratio – The number of abortions per 1,000 live births within a given population. The ratio reflects the relative number of pregnancies in a population that end in abortion compared to live birth. Birth or Live birth – The complete expulsion or extraction from its mother of a product of human conception, irrespective of the duration of pregnancy which, after such expulsion or extraction, breathes or shows any other evidence of life such as beating of the heart, pulsation of the umbilical cord or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached. Heartbeats are to be distinguished from transient cardiac contractions; respirations are to be distinguished from fleeting respiratory efforts or gasps. Epidemiology - Epidemiology is the study of the distribution and determinants of disease, injury, and other health outcomes in human populations. Gestational age – Gestational age means the age of the unborn child as calculated from the first day of the last menstrual period of the pregnant woman. Pregnancies – Pregnancies are the sum of live births, spontaneous terminations of pregnancy (fetal deaths or stillbirths) and induced terminations of pregnancy (abortions) Proportion – A proportion is a ratio in which those in the numerator are also in the denominator. Rate – A rate is a ratio in which those in the numerator are also in the denominator, and those in the denominator are "at risk" of being in the numerator. The denominator is the sum of "at risk" person-time or, by convention, the count of individuals "at risk" in a given time period. Ratio – A ratio is any division of one number by another; the numerator and denominator do not have to be mutually exclusive. Page | 36 Standard Deviation – Standard deviation (SD) indicates the variation or “dispersion” in a variable especially from the average (mean). A low SD implies there is little variation and the data points are close to the average and a high SD implies that data points are spread out. In a normally distributed population 68% of the data points lie between +1SD. Unemancipated minor – Unemancipated minor means a minor who is subject to the control, authority, and supervision of his or her parents or guardians, as determined under State law (See Title 42. The Public Health and Welfare; Chapter 6a USCS §300z-1). End notes: 1. Centers for Disease Control and Prevention. Abortion Surveillance — United States, 2008. MMWR 2011;60(15):1-41 2. SB1304 State of Arizona Senate Forty-ninth Legislature Second Regular Session 2010. http://www.azleg.gov/legtext/49leg/2r/bills/sb1304p.pdf 3. Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity: Federal Register Notice. Retrieved from http://www.whitehouse.gov/omb/fedreg_1997standards/ accessed on July 16, 2012. 4. Abortion rate is essentially denoted as number of abortions per 1000 women. Race specific abortion rates are obtained by estimating the number of abortions (numerator) by women in a given racial group per 1,000 women in that same racial group. 5. Methodologies for Estimating Abortion Incidence and Abortion-Related Morbidity: A Review. Retrieved from http://www.guttmacher.org/pubs/compilations/IUSSP/abortionmethodology.html accessed on July 16, 2012. 6. Sedgh G, Henshaw S. Measuring the Incidence of Abortion in Countries With Liberal Laws. In: Singh S, Remez L, Tartaglione eds. Methodologies for Estimating Abortion Incidence and Abortion-Related Morbidity: A Review New York: Guttmacher Institute; and Paris: International Union for the Scientific Study of Population, 2010. 7. Subcommittee on Standardized Collection of Race/Ethnicity Data for Healthcare Quality Improvement, Institute of Medicine. "Front Matter." Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement. Washington, DC: The National Academies Press, 2009. 8. United States-México Border Health Commission. Border Region. Available at http://www.borderhealth.org/border_region.php Website. Accessed on July 16, 2012. 9. Ancel Pierre-Yevel et al., History of induced abortion as a risk factor for preterm birth in European countries: results of the EUROPOP survey. Human Reproduction, 2004, 19(3):734740. 10. Shah P, Zao J. Induced termination of pregnancy and low birthweight and preterm birth: a systematic review and meta-analyses. BJOG 2009;116:1425–1442. 11. Bartlett LA et al., Risk factors for legal induced abortion-related mortality in the United States, Obstetrics & Gynecology, 2004, 103(4):729–737. 12. Arizona State Legislature. House Bill No. 2036. Available at http://www.azleg.gov/DocumentsForBill.asp?Bill_Number=HB2036 Website. Accessed on September 8, 2012.