Abortion jabberwocky: the need for better terminology

Explaining sex discrepancies in sterilization rates in the United States: An evidence-informed commentary

CONTEXT

With abortion no longer deemed a constitutional right in the United States (US), the importance of effective contraceptive methods cannot be overstated. Both male sterilization (vasectomy) and female sterilization (tubal ligation) have the lowest failure rates of available means of contraception. Despite the less invasive and reversible nature of vasectomy compared to tubal ligation procedures and even though some healthcare professionals dissuade certain women, especially those who are white and/or economically advantaged, from undergoing a sterilization procedure, female sterilization is approximately three times more prevalent than male sterilization in the US.

PURPOSE

We suggest that the discrepancy in sterilization rates is attributable to the burdens of pregnancy and birth experienced by women, beliefs that pregnancy prevention is a woman's responsibility, a dearth of sex education that results in lack of knowledge and poor understanding of contraception, perceptions of masculinity in which contraception is viewed as feminizing, and the increase in long-term singlehood that shapes the desire of individuals to avoid unwanted pregnancy that may result in single parenting.

IMPLICATIONS

Recent reports suggest that court rulings restricting abortion access and looming threats to contraceptive legality and accessibility may be prompting a national increase in male sterilization.

Later Gestational Age Abortion in Canada: A Scoping Review

Since the decriminalization of abortion in Canada in 1988, there have been no legal restrictions on when in pregnancy an abortion can take place. However, abortion care is only consistently available in Canada up to 23 weeks and 6 days; women, transgender men, and gender non-binary individuals who need abortion care after 24 weeks typically obtain services in the United States. Furthermore, abortion care beyond 16 weeks is unavailable in some regions of the country. The authors undertook this scoping review to explore what is currently known about later gestational age abortion in Canada. Using a six-stage framework, they identified 32 relevant sources that were published in the last 30 years, and they consulted with seven topic experts to validate the findings from our document synthesis. The limited body of literature on abortion after 16 weeks in Canada sheds light on the safety of both medical and instrumentation procedures, the type and training of abortion-providing clinicians, the characteristics of those obtaining abortion care after the first trimester, and geographic disparities in service availability. These topic experts emphasized the need for future research on patient experiences and developing and implementing strategies to help provinces and territories expand abortion care to later gestational ages and improve comprehensive reproductive health services.

Abortion terminology preferences: a cross-sectional survey of people accessing abortion care

BACKGROUND

Abortion stigma likely affects the terminology abortion patients, providers and the public use or avoid using to refer to abortion care. Knowing the terminology people seeking abortion prefer could help inform the language used in clinical interactions and improve patients' experiences with abortion care. However, research in the U.S. has not examined patients' preferences in this area or whether terminology preferences vary by participant characteristics, in the way that experiences of stigma vary across different contexts and communities. This study aims to describe preferred terminology among people presenting for abortion care and to explore the pregnancy-related characteristics associated with these preferences.

METHODS

We surveyed abortion patients about their experiences accessing abortion care, including preferred terms for the procedure. Respondents could mark more than one term, suggest their own term, or indicate no preference. We recruited people ages 15-45 seeking abortion from four U.S. abortion facilities located in three states (California, Illinois, and New Mexico) from January to June 2019. We used descriptive statistics and multivariable multinomial logistic regression to explore associations between respondents' pregnancy-related characteristics and their preferred terminology.

RESULTS

Among the 1092 people approached, 784 (77%) initiated the survey and 697 responded to the terminology preference question. Most participants (57%, n = 400) preferred only one term. Among those participants, "abortion" (43%) was most preferred, followed by "ending a pregnancy" (29%), and "pregnancy termination" (24%). In adjusted multivariable models, participants who worried "very much" that other people might find out about the abortion (29%) were significantly more likely than those who were "not at all" worried (13%) to prefer "ending a pregnancy" over having no preference for a term (adjusted relative risk ratio: 2.68, 95% Confidence Interval: 1.46-4.92).

CONCLUSIONS

People seeking abortion have varied preferences for how they want to refer to their abortions, in particular if they anticipate abortion stigma. Findings can be useful for clinicians and researchers so that they can be responsive to people's preferences during clinical interactions and in the design and conduct of abortion research.

Therapeutic abortion in Iran: an epidemiologic study of legal abortion in 2 years

Objectives

Unsafe abortion is one of the most important causes of death and disability among mothers in countries where abortion is illegal. These conditions have changed since then. The present study has investigated the cases who were referred to the legal medicine organization to receive abortion permission. This country level secondary patient data analysis, investigated all the cases who were referred to the legal medicine centers of Iran for abortion permission during 2015 to 2017.

Results

From 21,477 applicants, 15,617 (72.71%) received permission including 14,367 (91.99%) for fetal abnormalities and 1250 (8.01%) for maternal diseases. The most common fetal abnormalities/disorders were nervous system malformations (26.4%), chromosomal abnormalities (18.4%) and of maternal diseases were circulatory system diseases (43.9%), neoplasms (13.4%) and genitourinary system diseases (9.9%). The most common reasons for not permission were lack of supplementary documents to prove (38.8%), not competency with the criteria (33.9%), and gestational age of more than 19 weeks (25.8%).

Promoting or Undermining Quality Decision Making? A Qualitative Content Analysis of Patient Decision Aids Comparing Surgical and Medication Abortion

OBJECTIVES

To understand, describe, and compare the content of patient decision aids on surgical and medication abortion, including 1) attributes used to describe each method, 2) approaches to clarify patients' values, 3) language used to describe each method, and 4) language used to frame women's decision-making role.

STUDY DESIGN

We analyzed 49 decision aids identified through a previous systematic review and environmental scan. We used summative content analysis for objectives 1 and 2 and directed content analysis for objectives 3 and 4.

RESULTS

We identified 37 method attributes. Overall, the attributes privileged medical over practical and emotional information. One decision aid included an explicit values clarification approach, and others included implicit approaches, which varied in length, information consistency, and organization. We identified four themes-information consistency, subjective claims, emotive or ambiguous descriptions, and medication abortion as not a real abortion-related to the methods' descriptions. We identified three themes-agency in choice, unclear emphasis on women's preferences, and endorsement of clinic services-related to women's decision-making role. Of the nine tools that listed factors influencing women's decision making, patient preferences was often listed last.

CONCLUSIONS

Early abortion method decision aids presented a broad range of information and typically framed the method choice as the woman's. However, their emphasis on medical attributes, use of inconsistent information, and, at times, biased presentation of methods may undermine quality decision making. We recommend adapting an existing decision aid or designing a novel tool based on the content and language that women find most acceptable.

Put a Ring in It: Exploring Women's Experiences with the Contraceptive Vaginal Ring in Ontario

BACKGROUND

Although the contraceptive vaginal ring (CVR) has been available in Canada since 2001, overall use and availability remain low compared with other combined hormonal contraceptive methods. We aimed to explore women's experiences with the CVR in Ontario as well as factors that influenced their decisions to choose the method and continue/discontinue use.

METHODS

We conducted a multimethod qualitative study that consisted of an anonymous online survey and in-depth telephone interviews with a subset of survey participants. We used descriptive statistics to analyze the survey data and analyzed our interviews for content and themes using both deductive and inductive techniques.

RESULTS

From May to July 2015, we received 103 survey responses and conducted 29 in-depth interviews. Many participants described positive experiences with the CVR and found it to be an especially convenient method. Women who discontinued use of the CVR cited high costs, access barriers, and negative media reports as important factors in their decision. Our participants primarily relied on their physicians for contraceptive information but did not feel fully informed about potential side effects. Several women identified the CVR as an "in between" method in the transition from oral contraceptive pills to the intrauterine device.

CONCLUSIONS

Our findings suggest that the CVR represents a convenient and desirable contraceptive option for some women. However, participants expressed a desire for health care providers to provide more comprehensive information about a full range of contraceptive methods. Improving access to a full range of low-cost contraceptives in Ontario seems to be warranted.

"Without any indication": stigma and a hidden curriculum within medical students' discussion of elective abortion

Pregnancy termination is a common, beneficial medical procedure, but abortion care in the United States is stigmatized. Language, including categorization of some abortions as elective, may both reflect and convey stigma. We present a history of the term "elective" in reference to abortion, followed by data demonstrating its use by a sample of contemporary medical trainees and an analysis of the term's relationship to abortion stigma, medical training, and patient access to abortion care. We analyzed interviews with 41 U.S. medical students who had applied to residency programs in obstetrics and gynecology. Participants discussed experiences with, and attitudes toward, abortion before and during medical school, and plans to perform abortions in future practice. We inductively coded participants' use of "elective" in reference to abortion and analyzed their meanings. Participants did not use "elective" according to its medical definition, which conveys an absence of urgency for surgery. Instead, "elective" identified a subset of abortions that lacked maternal or fetal medical indications. "Elective" negatively marked and isolated some abortions, and participants used the term to convey judgment about patients' social and reproductive histories. Participants saw medical and psychosocial indications as mutually exclusive, and became confused when interrelated factors influenced patients' abortion decisions. They ignored the voluntary nature of abortion in the setting of medical illness, sexual violence, or fetal complications, and accepted discrimination against women seeking abortion for psychosocial indications as normal and ethical. The term "elective" enables the creation and perpetuation of abortion stigma, and contributes to a hidden curriculum for abortion training in medical education that distracts from core content, incorporates social judgment of patients into medical practice, and promotes normative gender concepts. Our findings support calls to improve the language of abortion care to ensure policies and training environments are consistent with professional standards.

'Abortion' or 'termination of pregnancy'? Views from abortion care providers in Scotland, UK

BACKGROUND

The phrase 'termination of pregnancy' has recently been adopted by a number of British medical institutions as a preferred descriptor of induced abortion. How it is used by abortion care providers is unclear, although the ongoing stigmatisation of abortion may play a role.

METHODS

A mixed methods study of the views of abortion care providers in Scotland, UK. Self-administered anonymous questionnaires were distributed to abortion care providers at a national conference (Scottish Abortion Care Providers). The main outcomes measured were the proportion of respondents reporting that they found the terms 'abortion' and 'termination of pregnancy' to be distressing, and their preferred terminology for use in consultations with women. In-depth interviews were conducted with 19 providers from a single clinic in Scotland to contextualise use of the terminology.

RESULTS

The questionnaire was completed by 90/118 delegates (76%). More respondents indicated they found the term 'abortion' distressing (28%), compared with those who found 'termination of pregnancy' distressing (6%; P<0.0001). Interview participants reported that 'termination of pregnancy' was the default phrase used in consultations. Some respondents stated that they occasionally purposely used 'abortion' in consultations to emphasise the seriousness of the procedure (morally, physically and/or emotionally).

CONCLUSIONS

'Termination of pregnancy' is the most commonly used term to describe induced abortion in patient consultations in Scotland. This and the term 'abortion' appear to play different roles, with the former being used euphemistically, and the latter as a more emphatic term. Further research is warranted to investigate how this interacts with patient care, service provision, and abortion stigma.

Abortion terminology: views of women seeking abortion in Britain

BACKGROUND

Controversy exists as to whether 'abortion or 'termination of pregnancy' should be used by health professionals during interactions with women and in published works.

METHODS

Self-administered anonymous questionnaires were distributed to women attending 54 abortion clinics in Scotland, England and Wales during a 4-month period in 2015. Responses were coded and analysed using SPSS. Descriptive statistics were generated and responses compared by demographic characteristics. The main outcome measures were the proportion of respondents reporting that they found the terms 'abortion' and 'termination of pregnancy' to be distressing, and women's preferred terminology for referring to induced abortion.

RESULTS

Surveys were completed by 2259 women. The mean age of the respondents was 27(range 13-51) years; 82% identified as white, 51% had children and 36% had previously undergone abortion. Thirty-five percent indicated that they found the word 'abortion' distressing compared with 18% who reported that 'termination of pregnancy' was distressing (p< 0.001). Forty-five percent of respondents expressed a preference for 'termination of pregnancy' and 12% for 'abortion'. Sixteen percent would choose either term. This pattern of results did not vary statistically by age, reproductive history, country of residence, ethnicity or level of deprivation.

CONCLUSIONS

Most women seeking abortion did not find the terms 'abortion' or termination of pregnancy' distressing. When given a choice of terms, more women who expressed a preference chose 'termination of pregnancy'. Healthcare professionals should be sensitive to preferences for terminology when communicating with women seeking abortion.

Comparison Between Sublingual and Vaginal Administration of Misoprostol in Management of Missed Abortion

AIM

The aim of the present study is to compare between sublingual administration of misoprostol and vaginal administration in the management of missed abortion.

MATERIALS AND METHODS

The study was conducted in El-Shatby Maternity Hospital on 160 patients diagnosed as missed abortion by ultrasonographic examination. Cases were divided into two groups according to the methods of misoprostol administration, whether sublingual or vaginal. Patients of the two groups were observed for the times of uterine colic starting, cervical dilation, and conceptus expulsion, along with recording of any side effects.

RESULT

During the follow-up of our cases we found that sublingual route is more effective than vaginal route in the management of missed abortion. The difference between the two groups in percentage of conceptus expulsion was statistically significant. The most common side effects were nausea which was present in 55 % of cases in group I (sublingual) and in 40 % of cases in group II (vaginal) then severe pain in 25 % of cases in group I (sublingual) and in 20 % of cases in group II (vaginal) and hyperpyrexia in 15 % of cases in group I (sublingual) and in 5 % of cases in group II (vaginal).

CONCLUSION

Sublingual administration of misoprostol is more effective than its vaginal administration in missed abortion management. Side effect of misoprostol as nausea, vomiting, fever is more common with sublingual administration in comparison with its vaginal administration.

Public Health Impact of Legal Termination of Pregnancy in the US: 40 Years Later

During the 40 years since the US Supreme Court decision in Doe versus Wade and Doe versus Bolton, restrictions on termination of pregnancy (TOP) were overturned nationwide. The use of TOP was much wider than predicted and a substantial fraction of reproductive age women in the U.S. have had one or more TOPs and that widespread uptake makes the downstream impact of any possible harms have broad public health implications. While short-term harms do not appear to be excessive, from a public perspective longer term harm is conceiving, and clearly more study of particular relevance concerns the associations of TOP with subsequent preterm birth and mental health problems. Clearly more research is needed to quantify the magnitude of risk and accurately inform women with the crisis of unintended pregnancy considering TOP. The current US data-gathering mechanisms are inadequate for this important task.