Questionnaire Content and Fielding
The census of abortion providers described here, the 15th in a series dating back to 1973, was conducted in 2009; follow-up of nonrespondents extended into 2010. The questionnaire was modeled on the instrument used in the previous census, which collected data for 2004 and 2005.1 All respondents were asked the number of induced abortions that were performed in their facilities in 2007 and 2008, minimum and maximum gestations at which abortions were offered, and whether early medication abortion was offered.* The data represent abortions according to the state in which they occurred, not the state of residence of women having the abortions. Clinics and physician providers (but not hospital providers) were also asked about the number of medication abortions performed (with separate items for mifepristone and methotrexate), charges for surgical and medication abortions, experience of harassment and the proportion of provider services accounted for by abortions. Questions about gestational limits, charges and proportion of client services for abortion referred to the time when the questionnaire was completed, so this information applies to 2009, since the majority of responses came in that year. We asked fewer questions of hospitals because the individuals answering the questionnaires in these settings typically have access to less information about clients. Information restricted to nonhospital facilities represents the experience of most women having abortions, since these providers perform the vast majority of all abortions (95% in 2005).1
All nonhospital facilities known to have performed abortions in 2005 were surveyed, and possible new providers were identified through various sources: provider listings on the Internet, newspaper ads, telephone directories, and the membership directories of the National Abortion Federation and the Abortion Care Network. Additional providers were identified and surveyed throughout the data collection process.
In May 2009, we mailed questionnaires to all potential providers, and two additional mailings were sent at three-week intervals to nonrespondents. In July and August 2009, the distributor of mifepristone (the drug used for most early medication abortions) sent the same questionnaire to a subset of approximately 1,200 providers (most of which we had likely already identified) that had purchased mifepristone. Twenty-nine providers that were not previously in our database responded to these surveys.
We also obtained information about abortion incidence from state health departments in 45 states and the District of Columbia. Many departments obtain only incomplete data from abortion providers, but we sometimes found the information useful even if it was incomplete. We used the health department figures only if the providers did not respond to any of our mailings or, in a few instances, if the number from the state was very different from the providers’ report and we had reason to believe the provider-supplied information was inaccurate (e.g., if the provider caseload differed substantially from that in the prior census and the facility was in a state with strict reporting requirements).
Intensive telephone follow-up of nonrespondents was carried out between September 2009 and June 2010, and particular effort was made to obtain the total number of abortions performed. During this phase of data collection, more than 7,100 contacts were made with approximately 1,000 providers.
Of the 2,344 facilities surveyed, 1,024 responded to the mailed questionnaire, 501 responded during nonresponse follow-up and health department data were used for 451 facilities. We determined that 14 providers had closed or stopped offering abortion services during the survey period, and excluded 15 facilities that we could not confirm provided abortions. For 109 facilities, we obtained estimates of the number of abortions performed from knowledgeable sources in the area, including other providers of reproductive health services and organizations that worked on reproductive health issues. We made our own estimates for the remaining 230 facilities, usually on the basis of information obtained in prior abortion censuses. If a provider had not previously participated in the census, our estimates were based on informal data, such as information from the provider’s Web site, caseloads of other providers in the immediate area and information obtained from telephone calls to the provider (e.g., hours of operation, gestations at which abortions were provided).
In the prior census, California’s health department provided information about hospitals, but only for inpatient abortions (typically procedures performed late in the second trimester). For the current survey, we obtained hospital data on both inpatient and outpatient procedures; this allowed us to identify 65 additional hospital providers in the state in 2008. These facilities performed 470 abortions in 2008, and we expect many of them had provided small numbers of abortions in previous years as well.
Of the abortions that occurred in 2008, some 82% were reported by providers, 9% came from health department data, 6% were estimated by knowledgeable sources and 3% were projections or internal estimates. By comparison, in 2005, some 76% of abortions were reported by providers, 12% came from health departments, 9% were external estimates and 3% were estimated internally.1
We distinguished among four types of providers: abortion clinics, other clinics, hospitals and physicians’ offices. Abortion clinics are defined as nonhospital facilities in which half or more of patient visits are for abortion services. Other clinics are sites in which fewer than half of patient visits are for abortion services; these include physicians’ offices that provide 400 or more abortions per year. Physicians’ offices are facilities that perform fewer than 400 abortions per year and have names suggesting that they are physicians’ private practices.
We obtained information on other aspects of abortion care from a majority of nonhospital facilities: Sixty-six percent provided information on the number of early medication abortions, 67% on gestational limits and 66% on charges for abortion services. Because response rates varied by facility type and caseload, we constructed weights that accounted for these differences. Item-specific weights were applied to medication abortion, gestational limits, charges and harassment. Unless otherwise noted, all abortion data presented include both surgical and medication abortions.
Census Bureau data on the population of women aged 15–44 for July 1, 2007, and July 1, 2008, were used as denominators for calculating abortion rates for the entire United States and for each state and the District of Columbia.5 We estimated the national abortion ratio as the proportion of pregnancies (excluding those ending in miscarriages) that ended in abortion; to do this, we combined our abortion counts with National Center for Health Statistics data on the number of U.S. births in the one-year periods beginning on July 1 of 2007 and 2008 (to match conception times for births with those for abortions).6–8