ajog.
org
facilities. It is anticipated that these restrictions will reduce the
ability of individuals to freely decide if or when they wish to
give birth and may increase unwanted births and Medicaid
costs. The limitations of this study included its reliance on
administrative data, which were subject to classification errors.
We did not capture patient-reported outcomes or preferences.
Our datasets for Medicaid claims and abortion access covered
different periods, which affected our accuracy. However, the
overall proportion of reproductive-aged women using
contraception in the United States seems to have remained
relatively constant over time.7 Moreover, increased travel
distance for abortion restricted access to abortion. This will
likely exacerbate disparities in unintended pregnancies
among US Medicaid recipients.
Maria I. Rodriguez, MD, MPH
Department of Obstetrics and Gynecology
Oregon Health & Science University
Portland, OR
Center for Health Systems Effectiveness
Oregon Health & Science University
Portland, OR
rodrigma@ohsu.edu
Thomas H. A. Meath, MPH
Kelsey Watson, MPH
Ashley Daly, MPH
Center for Health Systems Effectiveness
Oregon Health & Science University
Portland, OR
Caitlin Myers, PhD
Middlebury College
Middlebury, VT
K. John McConnell, PhD
Center for Health Systems Effectiveness
Oregon Health & Science University
Portland, OR
Exploring the impact of COVID-19 on gestational age
at the time of abortion: an interrupted time series
analysis among patients receiving abortions in
Southwest California
OBJECTIVE: The COVID-19 pandemic has rapidly
changed healthcare delivery, including abortion services.
Nationwide data demonstrated that 33% of patients
reported delays in reproductive healthcare because of
COVID-19,1 and requests for self-managed abortions
increased 27% nationally.2 On March 20, 2020, California
issued shelter-in-place orders and limited healthcare to
essential services. Despite institutional and governmental
Research Letters
M.I.R. reported receiving grants from the National Institute on Minority
Health and Health Disparities during the conduct of the study and
personal fees from the American College of Obstetricians and
Gynecologists and Bayer outside the submitted work. These potential
conflicts of interest were managed by the institutional review board at
Oregon Health & Science University.
This work was conducted with the support of an award from an
anonymous donor.
The sponsors had no role in the design and conduct of the study;
collection management, analysis, and interpretation of the data;
preparation, review, or approval of the manuscript; or decision to submit
the manuscript for publication.
-
REFERENCES
1. Thompson KMJ, Sturrock HJW, Foster DG, Upadhyay UD. Associa-
tion of travel distance to nearest abortion facility with rates of abortion.
JAMA Netw Open 2021;4:e2115530.
2. Supreme Court of the United States: Dobbs, State Health Officer of
the Mississippi Department of Health, et al. v. Jackson Women’s Health
Organization et al. 2022. Available at: https://www.supremecourt.gov/
opinions/21pdf/19-1392_6j37.pdf. Accessed July 1, 2022.
3. Bearak JM, Burke KL, Jones RK. Disparities and change over time in
distance women would need to travel to have an abortion in the USA: a
spatial analysis. Lancet Public Health 2017;2:e493–500.
4. Guttmacher Institute. Abortion policy in the absence of ROE. 2023.
Available at: https://www.guttmacher.org/state-policy/explore/abortion-
policy-absence-roe. Accessed July 28, 2022.
5. Office of Population Affairs. Measure CCW: Contraceptive care e all
women ages 15e44. 2020. Available at: https://opa.hhs.gov/sites/default/
files/2020-07/MME-and-LARC-2016-Measure-Specifications-for-All-
Women.pdf. Accessed August 19, 2021.
6. Myers C. Myers abortion facility database. 2021. Available at: https://
osf.io/8dg7r/. Accessed May 5, 2022.
7. Kavanaugh ML, Jerman J. Contraceptive method use in the United
States: trends and characteristics between 2008, 2012 and 2014.
Contraception 2018;97:14–21.
ª 2023 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ajog.
2023.01.032
efforts to maintain access, we hypothesized that concerns
over infection exposure, confusion about the availability of
services, financial hardship, or decreased childcare would
impact the gestational age (GA) at which people presented
for abortion.1
STUDY DESIGN: We conducted an interrupted time series
analysis (ITSA) of abortion patients between August 1, 2019
JUNE 2023 American Journal of Obstetrics & Gynecology 753
Research Letters ajog.org

TABLE
Demographic and patient characteristics stratified by date of presentation before and after California statewide
March 20, 2020 shelter-in-place mandate
Demographic or patient Prepandemica n[11, Pandemicb n[10,
characteristic Total n[21,880 612 (53.1%) 268 (46.9%) P value
Age (y) 26 (22e31) 26 (22e31) 26 (22e31) .654
Gravidity 2 (1e4) 2 (1e4) 2 (1e4) .04
Parity 0 (0e2) 0 (0e2) 0 (0e2) .37
Race and ethnicity <.001
Asian Pacific Islander 978 (4.5) 494 (4.3) 484 (4.7)
African American or Black 2030 (9.3) 1005 (8.7) 1025 (10)
Hispanic or Latinx 10,600 (48.4) 5567 (47.9) 5033 (49)
White 5198 (23.8) 2656 (22.9) 2542 (24.8)
Multiracial 47 (0.2) 32 (0.3) 15 (0.1)
Other 491 (2.2) 231 (2) 260 (2.5)
Declined to specify 2536 (11.6) 1627 (14) 909 (8.9)
Insurance .002
Commercial 4064 (18.6) 2182 (18.8) 1882 (18.3)
Cash 4422 (20.2) 2240 (19.3) 2182 (21.3)
Medi-Cal 13,394 (61.2) 7190 (61.9) 6204 (60.4)
Abortion location .004
San Diego County 12,894 (58.9) 6912 (59.5) 5982 (58.3)
Riverside County 8167 (37.3) 4235 (36.5) 3932 (38.3)
Imperial County 819 (3.7) 465 (4) 354 (3.4)
Abortion type <.001
Medication abortion 12,815 (58.6) 6578 (56.6) 6237 (60.7)
Dilation and curettage 7772 (35.5) 4309 (37.1) 3463 (33.7)
Dilation and evacuation 1293 (5.9) 725 (6.2) 568 (5.5)
GA by trimester .004
First trimester 20,835 (95.2) 11,012 (94.8) 9823 (95.7)
Second trimester 1045 (4.8) 600 (5.2) 445 (4.3)
GA in wk 7.2 (2.9) 7.3 (2.9) 7.0 (2.8) <.001
GA by type
Medication abortion 6.2 (1.2) 6.3 (1.2) 6.2 (1.2) <.001
Dilation and aspiration 7.3 (2.2) 7.4 (2.2) 7.2 (2.2) .001
Dilation and evacuation 15.7 (3.9) 15.9 (3.8) 15.4 (4.0) .023
All data are presented as number (percentage), meanstandard deviation, or median (interquartile range).
GA, gestational age.
a b
Prepandemic reflects the period from August 1, 2019 to March 19, 2020; Pandemic reflects the period from March 20, 2020 to October 31, 2020.
Zachek. The impact of COVID-19 on gestational age at the time of abortion. Am J Obstet Gynecol 2023.

and October 31, 2020, at the Planned Parenthood of the
Pacific Southwest in Imperial, Riverside, and San Diego
counties where abortion services were minimally disrupted by
COVID-19. Site selection was based on convenience with
these counties encompassing the abortion care provided by
the Planned Parenthood of the Pacific Southwest affiliate.
We compared the monthly mean GA at the time of
abortion during the 8 months before and the 8 months
after March 20, 2020. This analysis was conducted in early
2021 after data validation, and although the statewide
mandate was gradually lifted during the study period, it
marked the beginning of pandemic-related societal

754 American Journal of Obstetrics & Gynecology JUNE 2023

ajog.org Research Letters

disruption. GA was determined by the last menstrual period needed to ensure safe and uninterrupted access to essential
and was confirmed with an ultrasound.3 Participants reproductive healthcare. -
without a recorded GA or a calculated GA <4 weeks or
24 weeks were excluded (Supplemental Figure 1). We ACKNOWLEDGMENTS
used Fisher exact tests and t tests to examine statistical The authors would like to acknowledge the Planned Parenthood affiliate
differences. The ITSA used segmented linear regression with health centers for providing data for this study and for their commitment
the interruption point of March 20, 2020, and compared to reproductive justice.
the slope change in GA. This study was determined to be
exempt by the institutional review board at the University Christine Zachek, MD, MPH
of California, San Diego. Sheila Mody, MD, MPH
Department of Obstetrics, Gynecology and Reproductive Sciences
University of California San Diego
RESULTS: The total number of abortions provided (medi-
San Diego, CA
cation and procedural) remained stable. No meaningful
clinical difference was noted in the mean GA before and Nawal Siddiqui, MD
after the mandate (7.54 vs 7.32 weeks; P<.001; Supplemental School of Medicine
University of California San Diego
Figure 2), however, the ITSA model showed a slight
San Diego, CA
decrease in GA (trend, e0.24 weeks; standard error, 0.004;
P<.001; Supplemental Figure 3). Demographic factors like Selina Sandoval, MD, MPH
age, race, and obstetrical history were largely unchanged; Department of Obstetrics, Gynecology and Reproductive Sciences
however, differences in payor status and procedure type University of California San Diego
San Diego, CA
showed divergence between pre- and postpandemic levels
(Table). We observed small shifts toward cash payments as Kyle Bukowski, MD
opposed to insurance payments and toward medication Planned Parenthood of the Pacific Southwest
abortion as opposed to surgical abortion in the pandemic San Diego, CA
period. When stratified by procedure type, the mean GA Marni Jacobs, PhD
decreased across all categories after the mandate. Department of Obstetrics, Gynecology and Reproductive Sciences
University of California San Diego
San Diego, CA
CONCLUSION: Our data suggest that abortion care was not
delayed in Southern California where services were not heavily Sarah Averbach, MD, MAS
restricted. We found that people who needed abortion care pre- Department of Obstetrics, Gynecology and Reproductive Sciences
University of California San Diego
sented earlier in pregnancy after the mandate, although this dif-
9300 Campus Point Dr #7433,
ference was not clinically meaningful. Planned Parenthood
San Diego, CA 92037
affiliates put forth immense effort to continue abortion access, School of Medicine
including adopting screening protocols and community outreach University of California San Diego
regarding abortion accessibility during the early pandemic. San Diego, CA
Alternating provider teams were designated to reduce the risk of saverbach@health.ucsd.edu
abortion care interruptions owing to potential team-wide The authors report no conflict of interest.
exposures. Preventive and other nonurgent services were
temporarily suspended to ensure abortion availability, and This study was presented at the annual meeting of the Society of Family
procurement processes were rapidly altered to secure personal Planning, held virtually, October 1e2, 2021.
protective equipment and other necessary supplies. In addition,
The findings and conclusions in this article are those of the authors and
state and local government communications and actions do not necessarily reflect the views of Planned Parenthood Federation of
supported continuing abortion services as essential healthcare. America, Inc.
Our findings may not be generalizable to settings where
abortion services were significantly altered during COVID-19
or to those with more extensive abortion restrictions.4
In-person abortion remains a necessity, because delays in REFERENCES
this time-sensitive care leads to an increased risk for com- 1. Lindberg LD, VandeVusse A, Mueller J, Kristein M. Early impacts of the
plications and further limits abortion access.5 Our findings COVID-19 pandemic: findings from the 2020 Guttmacher Survey of
Reproductive Health Experiences. New York: Guttmacher Institute; 2020.
suggest that unrestricted abortion access and prompt systems-
2. Aiken ARA, Starling JE, Gomperts R, Tec M, Scott JG, Aiken CE.
level responses can support timely access to abortion care Demand for self-managed online telemedicine abortion in the United
during public health crises. Research on best practices for States during the coronavirus disease 2019 (COVID-19) pandemic.
clinics to remain operational during disease outbreaks is Obstet Gynecol 2020;136:835–7.

JUNE 2023 American Journal of Obstetrics & Gynecology 755

Research Letters ajog.org

3. Committee Opinion No 700: Methods for estimating the due date.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2017;129:e150–4.
4. Berglas NF, White K, Schroeder R, Roberts SCM. Geographic dis-
parities in disruptions to abortion care in Louisiana at the onset of the
COVID-19 pandemic. Contraception 2022;115:17–21.
5. Upadhyay UD, Desai S, Zlidar V, et al. Incidence of emergency
department visits and complications after abortion. Obstet Gynecol
2015;125:175–83.
ª 2023 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ajog.
2023.01.033

Association of a large-for-gestational-age infant and

maternal prediabetes mellitus and diabetes mellitus
10 to 14 years after delivery in the Hyperglycemia
and Adverse Pregnancy Outcome Follow-up Study
OBJECTIVE: Gestational diabetes mellitus (GDM) is a well-
recognized risk factor for developing prediabetes mellitus and
type 2 diabetes mellitus after delivery.1,2 Although GDM is
associated with having a large-for-gestational-age (LGA) infant,
it is uncertain whether having an LGA infant without GDM is
associated with an increased risk of subsequent maternal
diabetes mellitus.3e5 We hypothesized that having an LGA
infant even without GDM may be a precursor to postpartum
dysglycemia.
We estimated the association of having had an LGA infant
with developing maternal prediabetes mellitus and type 2
diabetes mellitus 10 to 14 years after delivery among in-
dividuals without GDM.
STUDY DESIGN: This was a secondary analysis of the pro-
spective Hyperglycemia and Adverse Pregnancy Outcome
Follow-up Study (HAPO FUS).2 The current analysis
included all individuals in the HAPO FUS except those
diagnosed with GDM. A diagnosis of GDM was made in
the HAPO Study following the International Association of
Diabetes and Pregnancy Study Group (IADPSG) criteria.
The primary exposure was birthweight category (LGA [birth-
weight of 90th percentile], small for gestational age [SGA;
birthweight of <10th percentile], and appropriate for gestational
age [AGA] as the reference), accounting for gestational age at birth
and infant sex, following the International Fetal and Newborn
Growth Consortium for the 21st Century standard. The outcome
was having developed either prediabetes mellitus or type 2
diabetes mellitus by 10 to 14 years after delivery, consistent with
definitions used in the original HAPO FUS.2
Poisson regression with robust error variance was used and
adjusted for baseline maternal covariates assessed at the oral
glucose tolerance test (OGTT) during pregnancy (approxi-
mately 28 weeks of gestation): age, HAPO field center, parity,
body mass index (BMI), height, family history of diabetes
mellitus, mean arterial pressure, smoking status, and alcohol
use. Covariates for model inclusion were identified according
to the study design, known potential confounders, and ad-
justments used for the analyses in the HAPO Study. Because

TABLE
Frequency and association between birthweight and prediabetes mellitus and diabetes mellitus 10 to 14 years
after delivery in HAPO FUSa
Frequency of prediabetes
mellitus or diabetes mellitus
Variables (row percentage) Adjusted analyses
n n (%) aRR (95% CI)b aRR (95% CI)c
AGA 3176 613 (19.3) 1.00 (reference) 1.00 (reference)
SGA 314 47 (15.0) 0.78 (0.60e1.02) 0.81 (0.62e1.07)
LGA 535 131 (24.5) 1.31 (1.11e1.56) 1.21 (1.02e1.44)
There are 4025 participants in the unadjusted model and 3946 participants in the adjusted model. Because of limited missing data (2%), imputation for missing data was not performed.
AGA, appropriate for gestational age; aRR, adjusted risk ratio; CI, confidence interval; HAPO FUS, Hyperglycemia and Adverse Pregnancy Outcome Follow-up Study; LGA, large for gestational age;
SGA, small for gestational age.
a
Poisson regression with robust error variance was used; b Model 1 was adjusted for study field center; c Model 2 was adjusted for study field center and maternal variables at pregnancy visit
with oral glucose tolerance test during pregnancy: age (continuous), body mass index (continuous), height (continuous), family history of diabetes mellitus (yes or no), mean arterial pressure
(continuous), smoking status (yes or no), alcohol use (yes or no), and parity (0 or 1).
Venkatesh. Gestational diabetes mellitus and large-for-gestational-age infant in the Hyperglycemia and Adverse Pregnancy Outcome Follow-up Study. Am J Obstet Gynecol 2023.

756 American Journal of Obstetrics & Gynecology JUNE 2023

Research Letters ajog.org

SUPPLEMENTAL FIGURE 1 SUPPLEMENTAL FIGURE 3

Study participant enrollment flowchart Trends in monthly mean gestational age before and
after statewide mandate

GA, gestational age.

Zachek. The impact of COVID-19 on gestational age at the time of abortion. Am J Obstet
Gynecol 2023.

Vertical dotted line represents March 20, 2020, the date that statewide
orders went into effect.
GA, gestational age.
Zachek. The impact of COVID-19 on gestational age at the time of abortion. Am J Obstet
Gynecol 2023.

SUPPLEMENTAL FIGURE 2
Density plot of gestational age during prepandemic
(August 1, 2019eMarch 19, 2020) and pandemic
(March 20, 2020eOctober 31, 2020) periods

GA, gestational age.

Zachek. The impact of COVID-19 on gestational age at the time of abortion. Am J Obstet
Gynecol 2023.

756.e1 American Journal of Obstetrics & Gynecology JUNE 2023