Research

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GENERAL GYNECOLOGY

Risk factors for repeat elective abortion

Sarah W. Prager, MD, MAS; Jody E. Steinauer, MD, MAS; Diana Greene Foster, PhD; Philip D. Darney, MD, MSc;
Eleanor A. Drey, MD, EdM
OBJECTIVE: Repeat abortions account for 48% of all induced abortions in the United States. This study aims to identify correlates of
repeat abortion in a US clinic.
STUDY DESIGN: This cross-sectional study investigates a consecutive

sample of 398 women who received elective abortion in an urban hospital. All participants answered demographic, reproductive, and other
questions.
RESULTS: Older women were more likely to have had a previous abor-

tion than teenagers (odds ratio for women 20-29 years old, 2.9 [95%
CI, 1.5-5.7]; odds ratio for women 30 years old, 6.7 [95% CI, 2.8-

16.0]). Alcohol/drug abuse (odds ratio, 2.6; 95% CI, 1.3-5.3) also correlated with increased odds of previous abortion. Depo medroxyprogesterone acetate use approached a significant association (odds ratio,
3.2; 95% CI, 1.0-10.5).
CONCLUSION: The associations between both alcohol/drug abuse and
depo medroxyprogesterone acetate use and repeat abortion are new
findings. Future studies are needed to identify modifiable risk factors
for repeat abortion and to identify populations in which interventions,
such as long-term contraception, may lower the risk.

Key words: contraception, repeat abortion, risk factor

Cite this article as: Prager SW, Steinauer JE, Foster DG, Darney PD, Drey EA. Risk factors for repeat elective abortion. Am J Obstet Gynecol 2007;197:575.e1575.e6.

pproximately one-half of the 6 million pregnancies that occur annually

in the United States are unintended, and
almost one-half of those unintended pregnancies end in abortion.1 This results in
approximately 1.3 million abortions annually in the United States, of which 48%
are repeat procedures.2 The rate of repeat
abortion initially increased after legaliza-

From the Department of Obstetrics,

Gynecology and Reproductive Sciences and
the Center for Reproductive Health
Research and Policy, University of
California, San Francisco, School of
Medicine, San Francisco, CA.
Abstract presented at the 54th Annual Clinical
Meeting of the American College of
Obstetricians and Gynecologists, Washington,
DC, May 6-10, 2006.
Received Nov. 9, 2006; accepted April 11,
2007.
Supported by an anonymous foundation and
by the Center for Reproductive Health
Research & Policy.
Reprints: Sarah W. Prager, MD, Department
of Obstetrics and Gynecology, University of
Washington, Harborview Medical Center, 325
9th Ave, Box 359865, Seattle, WA 981042499; pragers@u.washington.edu
0002-9378/$32.00
2007 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2007.04.007

tion of abortion in 1973 and has remained

stable over the last 2 decades.3
Limited research exists concerning the
characteristics of women who obtain repeat abortions, although available research
demonstrates several consistent findings.
Women who obtain repeat abortions are
more likely to have been using some
method of birth control at the time of conception than women who obtain a first
abortion.3,4 They are more likely not to be
married and to report a difficult relationship with their partner.4,5 These women
are also older,3 not white,3,5 and have more
children6 than women who obtain initial
abortions. Previous studies on repeat abortion in the United States are generally 2-3
decades old and are based on data that
were collected immediately after the legalization of abortion. One notable exception
is a recent report on repeat abortion in the
United States that was published by the
Guttmacher Institute.7 However, this report does not have repeat abortion data
available from 8 states, including California, which provides a disproportionate
number of abortions annually.7 To get a
clear picture of repeat abortion, one has to
include data from California, which is the
site of this research project. The availability
of many highly effective birth control
methods also lends this issue new rele-

vance; understanding the factors that may

place women at high risk for repeat abortion may help target interventions to
women at the highest risk.
Because abortion is a safe procedure,
with an overall complication rate of 1%,2
obtaining repeat procedures does not
present a significant health risk. However,
abortion is still riskier than avoiding unintended pregnancy. The positive public
health impact from reducing a need for
procedures and public expenditures are
reasons to explore correlates of repeat
abortion, especially those for which an intervention is possible. Additionally, the
political climate is increasingly unsupportive of abortion; more restrictions to access
are imposed every year. If independent
correlates of repeat abortion can be identified, interventions can be developed in an
attempt to reduce the overall need for
abortion. Our objective in this study was to
identify characteristics of women who currently are seeking repeat elective abortions
in an urban, demographically diverse US
clinic.

M ATERIALS AND M ETHODS

This is a cross-sectional analysis of
women who seek abortions to determine
what characteristics are associated with a
history of 1 previous abortions. The

DECEMBER 2007 American Journal of Obstetrics & Gynecology

575.e1

Research

General Gynecology

data were collected from September

2001-March 2002 for 398 women who
came to the San Francisco General Hospital Womens Options Center for an
elective abortion. Women who were
seeking abortions for fetal anomalies
were excluded from the study sample.
The original dataset was designed to
study risk factors that are associated
with second-trimester abortion8; thus,
women were recruited equally in the
first and second trimesters. The study
was approved by the University of California, San Francisco Institutional Review Board, and informed consent was
obtained from all subjects.
Study subjects used audio computerassisted self-interviewing (ACASI; Senses
Q&A 2.0; Sawtooth Technologies, Evanston, IL) to answer 68 questions regarding
demographic, medical, reproductive, and
other factors. ACASI was used to administer the questionnaire to improve accuracy
of responses to sensitive topics.9 The questions were developed with the assistance of
psychologists who were experts in survey
instrument design and, when possible,
replicated methods that had been used in
similar previous studies. The questionnaires were pretested in both English and
Spanish. After being trained in ACASI and
computer use with sample questions, the
subjects completed the questionnaires in a
private room and were encouraged to request help as needed. Research assistants
abstracted additional information from
medical records.8 Characteristics of the
study population can be found in Table 1.
Bivariable analyses were done with 2
test, the Fisher exact test, and the logistic
regression to find correlates of the dichotomous outcome, repeat or initial abortion.
Variables that were correlated significantly
with the outcome (P .1) were then entered into a multivariable logistic regression model to identify independent correlates of repeat abortion. The final model
also included trimester and insurance for
face validity. STATA software (v 9.0; Stata
Corporation, College Station, TX) was
used to perform all statistical analyses. Age
is a clear confounder, because the longer a
woman has lived, the more opportunities
she has had for both pregnancy and abortion. Thus, all regression models control
for age.
575.e2

Patients in the first and second trimesters represent very different populations
at our clinic. In general, first-trimester
patients are residents of the city of San
Francisco, but second-trimester patients
are from a larger geographic region. This
is because the Womens Options Center
is the primary abortion clinic in Northern California that provides abortions
after 18 weeks gestation for women with
state-funded insurance, and it is also a
referral clinic for patients with any medical complication in the region. Thus, we
assessed interaction between trimester
and the other variables. In this analysis,
trimester was not found to be an important or significant effect modifier. We
also performed a subanalysis to study the
relationship between all variables and
the outcome of repeat abortion after
stratification by trimester; there were no
significant changes in the results between strata. Therefore, we believed that
trimester was not causing significant interaction, and we adjusted for it by including it in our final model.

R ESULTS
Of the 398 women, 234 (59%) were obtaining a repeat abortion. The participants
were young (mean age, 25 6.5 [SD]
years) and primarily African American
(162 women [41%]) or Latina women
(101 [25%]). Teenaged women were more
likely to be seen for a primary abortion
(65% primary vs 35% repeat), whereas
women in their twenties (38% primary vs
62% repeat) and women aged 30-46 years
(23% primary vs 77% repeat) were more
likely to be seen for a repeat abortion. Most
of the women had lived in the United
States only (316 women [79%]).
Two-thirds of the participants had a
household income over $20,000, and 84%
of the women had some type of insurance,
at least for this pregnancy (ie, Medi-Cal).
Approximately 70% of the participants
had at least a high school education, and
most women considered themselves to be
moderately or very religious (249 women
[63%]). Most of the subjects were single
(258 women [65%]), already had at least 1
child (268 women [67%]), and were using
some method of birth control at the time
of conception (278 women [70%]). Some

American Journal of Obstetrics & Gynecology DECEMBER 2007

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subjects reported conflict with their partner (65 women [16%]) and/or friends or
family (124 women [31%]); only 14 women
(3.5%) reported a history of domestic violence and/or sexual abuse (Table 1).
In the final multivariable model, African
American women were more likely than
Latina women to be seeking a repeat abortion (odds ratio [OR], 2.8; 95% CI, 1.3-5.9;
Table 2). Both white and Asian women
had a higher odds of repeat abortion compared with Latinas, although this did not
reach statistical significance (OR, 1.5; 95%
CI, 0.6-3.5; and OR, 2.1; 95% CI, 0.8-5.1,
respectively). Having lived outside of the
country was found to be associated
strongly with a decreased odds of seeking
repeat abortion (OR, 0.3; 95% CI, 0.1-0.6).
Being seen in the second trimester of this
current pregnancy was found to have a decreased association with repeat abortion
(OR, 0.6; 95% CI, 0.3-.97).
We evaluated markers of socioeconomic status for their associations with
the outcome. In a multivariable model,
neither insurance (OR, 0.7; 95% CI, 0.41.4 for private insurance; OR, 0.8, 95%
CI, 0.4-1.8 for no insurance [self-pay], as
compared with Medi-Cal) nor low income (OR, 1.2; 95% CI, 0.7-2.2) was correlated with repeat abortion. Marital status was not associated significantly with
repeat abortion (OR, 1.8; 95% CI, 0.74.8 for cohabiting; OR, 0.9; 95% CI, 0.84.4 for being single as compared with
married). After being controlled for age,
nulliparity did not have a significant effect on the likelihood of repeat abortion
(OR, 0.9; 95% CI, 0.5-1.7).
The use of any birth control was not
associated significantly with repeat abortion. In bivariable analyses, the use of depot medroxyprogesterone acetate and
oral contraceptive pills were the only 2
birth control methods to be associated
with repeat abortion; however, after adjustment for other variables, only the use
of depot medroxyprogesterone acetate
approached significance (OR, 3.2; 95%
CI, 1.0-10.5).
The abuse of alcohol (as defined by
drinking 3 alcoholic drinks in a day) or
drugs (as defined by using heroin, cocaine, or amphetamines in the previous 6
months) was associated significantly
with increased odds of seeking repeat

General Gynecology

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Research

TABLE 1

Baseline characteristics of women who sought abortion that were assessed for repeat abortion risks
Characteristic

First abortion (n)*

Repeat abortion (n)

Age (y)

P value
.000

.......................................................................................................................................................................................................................................................................................................................................................................

15-19

66 (65.3)

35 (34.7)

20-29

76 (37.6)

126 (62.4)

30-46

22 (23.2)

73 (76.8)

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Race/ethnicity

.000

.......................................................................................................................................................................................................................................................................................................................................................................

Latina

59 (58.4)

42 (41.6)

White

23 (37.1)

39 (62.9)

Asian

24 (53.3)

21 (46.7)

African American

45 (27.8)

117 (72.2)

Other

13 (48.1)

14 (51.9)

Lived outside of the country

54 (65.9)

28 (34.1)

Household income $20,000

46 (34.3)

88 (65.7)

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

.000

................................................................................................................................................................................................................................................................................................................................................................................

.047

................................................................................................................................................................................................................................................................................................................................................................................

Education

.000

.......................................................................................................................................................................................................................................................................................................................................................................

Less than high school

75 (61.5)

47 (38.5)

High school diploma

62 (32.0)

132 (68.0)

More than high school

26 (32.1)

55 (67.9)

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Insurance

.746

.......................................................................................................................................................................................................................................................................................................................................................................

State funded (Medi-Cal)

80 (39.2)

124 (60.8)

Private

34 (36.6)

59 (63.3)

None (self-pay)

24 (42.9)

32 (57.1)

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

.746

................................................................................................................................................................................................................................................................................................................................................................................

Marital status

.021

.......................................................................................................................................................................................................................................................................................................................................................................

Single

118 (45.7)

140 (54.3)

Married

16 (41.0)

23 (59.0)

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

Cohabitating

30 (29.7)

71 (70.3)

98 (35.6)

170 (63.3)

................................................................................................................................................................................................................................................................................................................................................................................

Parous

.007

................................................................................................................................................................................................................................................................................................................................................................................

Menstrual characteristics

.......................................................................................................................................................................................................................................................................................................................................................................

Unsure last missed period

52 (43.0)

69 (57.0)

.636

Irregular periods

39 (43.3)

51 (56.7)

.641

Does not track periods

27 (42.2)

37 (57.8)

.862

Thought self infertile

22 (61.1)

14 (38.9)

.011

Spotting/bleeding during pregnancy

33 (33.0)

67 (67.0)

.054

88 (42.5)

119 (57.5)

.582

.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Presenting in the second trimester

................................................................................................................................................................................................................................................................................................................................................................................

Birth control method

................................................................................................................................................................................................................................................................................................................................................................................

Any method user

111 (39.9)

167 (60.1)

.430

78 (42.9)

104 (57.1)

.539

................................................................................................................................................................................................................................................................................................................................................................................

Condom user

................................................................................................................................................................................................................................................................................................................................................................................

Depo medroxyprogesterone acetate user

5 (20.0)

20 (80.0)

.026

14 (28.0)

36 (72.0)

.042

Tubal user

1 (50.0)

1 (50.0)

.655

Intrauterine device user

2 (66.7)

1 (33.3)

.571

15 (39.5)

23 (60.5)

................................................................................................................................................................................................................................................................................................................................................................................

Oral contraceptive pills user

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Other method user

.82

Continued on page 575.e4.

DECEMBER 2007 American Journal of Obstetrics & Gynecology

575.e3

Research

General Gynecology

www.AJOG.org

TABLE 1

Baseline characteristics of women who sought abortion that were assessed for repeat abortion risks
Continued from page 575.e3.
Characteristic

First abortion (n)*

No method user

Repeat abortion (n)

53 (44.2)

67 (55.8)

P value
.43

................................................................................................................................................................................................................................................................................................................................................................................

Medical barriers

.......................................................................................................................................................................................................................................................................................................................................................................

Abuse of drugs/alcohol

27 (32.9)

55 (67.1)

.087

Obesity

35 (27.6)

92 (72.4)

.000

104 (41.8)

145 (58.2)

.769

.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Moderately/very religious

................................................................................................................................................................................................................................................................................................................................................................................

Intrapersonal barriers

.......................................................................................................................................................................................................................................................................................................................................................................

Conflict with partner

29 (44.6)

36 (55.4)

.542

Conflict with friends and/or family

51 (41.1)

73 (58.9)

.983

6 (42.9)

8 (57.1)

.898

.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Domestic violence and/or sexual abuse

................................................................................................................................................................................................................................................................................................................................................................................

* n 164 women (41.2%).

n 234 women (58.8%).

Derived with chi-squared or Fishers exact tests.

Prager. Risk factors for repeat elective abortion. Am J Obstet Gynecol 2007.

abortion (OR, 2.6; 95% CI, 1.3-5.3).

Obesity, as defined by a body mass index
of 30 kg/m2, was not a significant correlate in the multivariate model (OR, 1.6;
95% CI, 0.9-3.0).

C OMMENT
Our cross-sectional study identifies 7
characteristics that are correlated independently with repeat abortion in an urban abortion clinic; some are in agreement and others are in contradiction
with previous studies. The association
between increased age and repeat abortion is consistent with other published
data3,10 and, as mentioned earlier, is
more of a confounder than a true association. The association between race and
repeat abortion is also consistent with
other studies,3 because previous research
has indicated that non-white race/ethnicity usually is associated more highly
with repeat abortion. However, in our
population, Latina women were less
likely to seek repeat abortions than African American, Asian, and white women.
The original study that used these data
found that women with a history of a previous second-trimester abortion were
more likely to be seen in the second trimester for their current abortion.8 However,
the analyses from both studies indicate that
a history of any previous abortion actually
had a decreased association with secondtrimester abortion. There are several pos575.e4

sible explanations for the reason that second-trimester abortion has a decreased
association with repeat abortion. Women
who have had a previous abortion may be
more comfortable with abortion as an option and find it easier to make a decision to
abort. This would enable them to be seen
earlier in their pregnancy for their subsequent abortion. Or it could simply be that,
having accessed abortion care previously,
they now know how to navigate the system
and therefore are seen earlier in pregnancy.
By design, this study included equal
numbers of women who were seeking
first- and second-trimester abortions. This
is discrepant with the overall distribution
nationally, with only approximately 12%
of abortions performed in the second trimester.11 In many instances, the characteristics and/or risk factors for women differ
significantly by trimester. Thus, these data
may be skewed toward better representing
women who are seen in the second
trimester.
The original questionnaire did not ask
specifically whether subjects were born in
the United States, but it did ask subjects
whether they had ever lived outside of the
country. This variable was used as a surrogate marker for being foreign born and,
given the low socioeconomic status of
most of the subjects, was felt to be reasonably accurate. This characteristic was also
associated negatively with repeat abortion,
possibly because the cultural beliefs of

American Journal of Obstetrics & Gynecology DECEMBER 2007

women who are born outside of the country (most commonly Latin America in our
sample) make them less likely to use abortion services and therefore less likely to
have had a previous abortion. They may
also be less likely to report a previous abortion, even if they had obtained one previously. Additionally, subjects who come
from Latin America almost uniformly
would not have had access to safe, legal
abortion in their home country,12 which in
itself may have decreased their likelihood
of a previous abortion.
We found no association between insurance and repeat abortion in this
study. Higher rates of Medicaid use
among women who seek repeat abortion
has been reported previously.7 However,
other studies have not further divided
the non-Medicaid group into the separate components of private insurance
and no insurance (self-pay), as we did. It
is possible that the reason we found no
difference among any of these groups is
that almost all women, regardless of economic status, are able to access abortion
in the state of California. It is known that
there is a significantly higher rate of repeat abortion in states that allow Medicaid to pay for abortion services, as compared with states that do not (53% and
44%, respectively).7 Similarly, it is probable that women without any insurance
would be less likely to obtain a repeat

General Gynecology

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Research

TABLE 2

Odds of repeat abortion that are associated with predictor variables*

Adjusted odds ratio

Predictor variable

95% CI

P value

Age (y)

.......................................................................................................................................................................................................................................................................................................................................................................

20

Reference

Reference

Reference

20-29

2.86

1.45-5.66

.00

30-44

6.65

2.76-16.0

.00

.......................................................................................................................................................................................................................................................................................................................................................................

.......................................................................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................................................................................

Race/ethnicity

.......................................................................................................................................................................................................................................................................................................................................................................

Latina

Reference

Reference

Reference

White

1.46

0.61-3.53

Asian

2.05

0.81-5.14

.13

African American

2.8

1.34-5.85

.00

Other

0.79

0.26-2.41

.68

Lived outside of the United States

0.25

0.11-0.56

.00

Household income $20,000

1.2

0.66-2.18

.56

.......................................................................................................................................................................................................................................................................................................................................................................

.39

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Insurance

.......................................................................................................................................................................................................................................................................................................................................................................

Medi-Cal

Reference

Reference

Reference

Private

0.72

0.37-1.40

.33

None (self-pay)

0.81

0.37-1.79

.61

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Education

.......................................................................................................................................................................................................................................................................................................................................................................

Less than high school diploma

Reference

Reference

Reference

High school diploma

1.59

0.85-3.00

.15

More than high school diploma

1.91

0.83-4.38

.13

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Marital status

.......................................................................................................................................................................................................................................................................................................................................................................

Married

Reference

Reference

Cohabiting

1.78

0.65-4.82

Reference

.......................................................................................................................................................................................................................................................................................................................................................................

.26

.......................................................................................................................................................................................................................................................................................................................................................................

0.91

0.36-2.28

.84

Second trimester of pregnancy

Single

0.56

0.32-0.97

.04

Nulliparity

0.91

0.48-1.74

.78

Spotting/bleeding

1.75

0.92-3.33

.09

Depo medroxyprogesterone acetate user

3.22

0.99-10.5

.05

Oral contraceptive user

1.58

0.73-3.44

.25

Believed self to be infertile

0.8

0.30-2.16

.66

Abuse of drugs/alcohol

2.6

1.28-5.28

.00

Obesity

1.62

0.89-2.96

.11

................................................................................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Bolding indicates significant finding.

* All predictor variables that were statistically significant (P .1) on univariate analysis were included in final model. Trimester and insurance are not significant on univariable analysis but are
included for face validity.

Simultaneously adjusted for all variables.

Statistically significant variables.

Prager. Risk factors for repeat elective abortion. Am J Obstet Gynecol 2007.

abortion in states with more restrictive

laws on abortion.
All previous data have shown a positive association between overall contraception use and repeat abortion (likely

explained by the related facts of women

being more likely to use contraception as
they age and being more likely to seek
repeat abortion). Conversely, in our
dataset, only depot medroxyprogester-

one acetate use approached a significant

association. Women who choose this
method might know they have difficulty
using contraception and are thus selecting a more fool-proof method but are

DECEMBER 2007 American Journal of Obstetrics & Gynecology

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still at higher risk for unintended pregnancy. Or it may be that these women
have an especially strong desire to avoid
an unintended pregnancy, which makes
them more likely to abort if they do become pregnant. It is also possible that
our sample size was too small to find the
expected association between other contraceptive methods and repeat abortion.
Finally, it is important to recognize that
more than two-thirds of the subjects
who sought either a first or repeat abortion were using some method of contraception at the time of conception. This is
higher overall contraception use than the
54% that is usually cited for women seeking abortion.2 It could be that the public
funding for contraception in California
allows for earlier and improved contraception use for all women, even before
they have had 1 unintended pregnancy.
However, this still exemplifies that typical contraception use is not sufficient to
prevent many unintended pregnancies.
This study is the first to find an association between alcohol and/or drug abuse
and repeat abortion. One previous study
looked at this variable and found a positive
association between drug abuse and a history of abortion, as compared with no history of abortion, but there was no difference in the rates of drug abuse in women
who have 1 vs 2 abortions. This association between alcohol and/or drugs and repeat abortion, as found in our study, presents an interesting possibility for targeted
intervention. If women could be convinced to enter treatment programs or to
otherwise decrease their alcohol and drug
use, we might be able to influence their
ability to prevent future unplanned pregnancies. Alternatively, recommending
long-term birth control options for these
higher-risk women would be another possible intervention.
Unlike other studies,4,10 we found no
association between conflict with partner,
family and/or friends, or domestic violence
and/or sexual abuse and repeat abortion.
However, the number of women who reported domestic violence was small (14
women); therefore, we may have missed
an association because of lack of power. In
addition, a history of domestic violence
and/or sexual abuse was elicited by staff
members during their routine counseling
575.e6

sessions and then abstracted by the research assistants from the clinic chart; it
was not a part of the ACASI questionnaire.
This less private method of obtaining the
information may have also contributed to
the low level of reported domestic violence
and/or sexual abuse. The association between domestic violence and/or sexual
abuse and repeat abortion remains of interest for future study, because there is a
potential opportunity for intervention.
Small sample size may explain the lack of
association between repeat abortion and
certain characteristics that displayed significant associations in other studies (ie,
use of birth control). The questionnaire
was not designed originally to study repeat
abortions; thus, other information that
might have been helpful (such as when
previous abortions had occurred, the circumstances that influenced current and
previous decisions, or age at previous pregnancies) was not ascertained. In addition,
there were limited questions about domestic violence and/or sexual abuse, which
may not have been adequate to derive
meaningful results with respect to this
variable. Finally, it is important to realize
that this study was conducted in California, a state where access to abortion is better than in most other states. Repeat abortion in general is more common in states,
such as California, with better access to and
higher rates of abortion.7 However, these
rates may be inflated by women crossing
state borders to access abortion more easily. It is possible that the characteristics of
women who seek repeat abortion may differ, depending on how difficult and expensive it is to access abortion in a specific
state. Therefore, the results from this study
may not be generalizable to states with
more restrictive abortion laws.
To assess more effectively characteristics that are associated with obtaining a
repeat elective abortion, additional studies should be undertaken. Two possible
designs are a cross-sectional analysis of
women who have all had 1 abortion and
are subsequently pregnant again or a
prospective cohort study of women who
are seen for a primary abortion.
It is important to understand risk factors
for repeat abortion so that women who
undergo abortion and who are at higher
risk for repeat abortion can be identified

American Journal of Obstetrics & Gynecology DECEMBER 2007

www.AJOG.org
and targeted for specific interventions.
Studies of interventions, such as counseling techniques, that are directed towards
these high-risk women could then be done
so that we can reduce their chance of needing a future abortion. In part, repeat abortion represents a failure of the medical
community to help women prevent another unintended pregnancy. It is critical
therefore that we understand this complex
issue to help women gain control of their
reproductive lives.
f
ACKNOWLEDGMENT
We thank Dr Mark Pletcher and Dr Steve Shiboski for their help with epidemiologic and biostatistical issues, respectively.

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