Emotions and decision rightness over five years following an abortion: An examination of decision difficulty and abortion stigma

The ongoing and contentious coverage of abortion in a progressive context: a long-term cross-outlet assessment of Dutch abortion news (2000-2022)

Utilising automated content analysis with transformer-based topic modelling (BERTopic), this study examines cross-outlet variation in volume and topics over two decades (2000-2022) of abortion coverage in seven major daily newspapers in the Netherlands. Our findings reveal an ongoing coverage of abortion. Volume of coverage was notably highest in religious newspapers, indicating that these newspapers constitute a prominent voice in Dutch abortion debate. We discerned four distinct frames used in abortion news coverage. The first emphasised political developments as well as protest and advocacy related to abortion, framing the issue as a controversial political and moral topic. The second emphasised uncommon and problematic aspects of abortion, neglecting to present it as a commonplace and safe reproductive healthcare procedure. Two other frames seek to undermine women's decision-making agency: the marginalisation of women's personal perspectives; and the highlighting of prerequisites for abortion care. The media's emphasis on a hierarchy of deservedness may consequently reduce public support for particular reasons for choosing abortion. Overall, our findings show that abortion remains a regularly covered and contentious issue, even amidst progressive legislation. This study highlights the need for balanced reporting that engages with women's diverse personal experiences and perspectives.

Abortion Law Changes and Occupational Therapy Practice in the United States

IMPORTANCE

The U.S. Supreme Court overturned Roe v. Wade in 2022, changing access to abortion in many states. The impact of these changes on occupational therapy practice has not yet been explored through empirical research.

OBJECTIVE

To explore the perspectives of occupational therapy practitioners on how restrictions to abortion in the United States may have influenced their clients' needs and thus their practice.

DESIGN

This was a qualitative research study. We used an interpretivist epistemological approach and an inductive, thematic content analysis. Participants were recruited through state occupational therapy associations and social media. Two independent researchers coded data and had an initial agreement percentage of 88%. Data trustworthiness was enhanced through documentation of decisions, reflexive thinking about our positionality and the data, and team-based discussions.

PARTICIPANTS

Occupational therapy practitioners (N = 15) working in states with new abortion law changes at the time of interviews.

RESULTS

The four key themes of this study were as follows: (1) abortion restriction laws are affecting some occupational therapy clients' mental health, (2) clients are discussing reproductive health with occupational therapy practitioners across a variety of settings, (3) occupational therapy practitioners are using clinical judgment and their personal beliefs to support clients affected by abortion restrictions, and (4) occupational therapy practitioners are seeking guidance and evidence-based resources to best support clients in the wake of abortion-related legislation changes.

CONCLUSIONS AND RELEVANCE

Our findings underscore the relevance of reproductive health to occupational therapy practice and highlight the importance of preparing occupational therapy practitioners to respond to client needs related to abortion care. Plain-Language Summary: We sought to determine whether occupational therapy practitioners perceive that the 2022 abortion-related restrictions are affecting occupational therapy practice; specifically, we wanted to know whether and how practice is being affected and what resources occupational therapy practitioners might need to address clients' needs. Fifteen occupational therapy practitioners were interviewed and revealed that many of their clients were experiencing stress and anxiety (i.e., mental health challenges) specifically related to abortion access. We also found that occupational therapy practitioners who routinely discuss reproductive health with clients were commonly hearing from clients about abortion-related needs. Overall, this research uncovers a need for resources and guidance from state or national occupational therapy organizations so that occupational therapy practitioners can better support their clients given these new changes in abortion access. Positionality Statement: We are a team of three researchers who identify as cisgender women, and we reside in an urban area in the northeastern United States. Two of us identify as White, and one identifies as a person of color. We have all participated in reproductive health access advocacy and critically examined our own lenses as we engaged in this analysis.

'The abortion gave me my life back': the long-term impact of access to self-managed medication abortion through telemedicine on women's lives in legally restricted countries

Approximately 753 million women (38%) of reproductive age live in countries with restrictive abortion laws. To overcome these legal constraints, women access safe self-managed medication abortions through telemedicine abortion services. This study aimed to explore the long-term impact of accessing a self-managed medication abortion through telemedicine service on women's lives in countries with restrictive abortion laws. We conducted interviews with eleven women (from eleven different countries) who accessed a self-managed medication abortion through online telemedicine between 2014 and 2018 in a legally restricted country. We analysed interviews thematically. Three key themes were developed: (1) access to abortion positively impacted life plans; (2) the negative influence of the legally restricted environment wore off and their well-being improved; (3) participants are now using their own experiences to help others by either sharing information or facilitating access to abortion. In summary, our findings highlight the positive impact of access to self-managed medication abortion and underline the importance of ensuring access to abortion for everyone.

Self-reported elevated pain levels: A coping strategy used by women undergoing medical abortion procedures

PURPOSE

Epidural analgesia alleviates pain during normal labour but women who undergo medical abortion procedures using epidural analgesia continue to express high pain levels. To understand this we assessed if patients undergoing medical abortions, treated with epidural analgesia, use their pain for psychological benefits.

METHODS

This study comprised 105 patients over 13 weeks of gestational age diagnosed with foetal abnormalities after selecting a medical abortion procedure using epidural analgesia. Three questionnaires were handed-out: 1) 'Need for Affect', assessed the motivation to react to emotions; 2) 'Pain-Levels' 3) PANA- 'Positive Affect' (PA), 'Negative Affect' (NA) assessed emotions pre-abortion and post-abortion.

RESULTS

Patients with a strong Need for Affect and high Pain-Levels expressed a stronger PA post-abortion (b = .69, se = .11, β = .68, p < .001, 95%CI [.48,.90]). Patients with a strong NA pre-abortion and high Pain-Levels expressed a higher NA post-abortion (b = .48, se = .11, β = .53, p < .001, 95%CI [.26, .70]).

CONCLUSION

Patients with a strong Need for Affect who express a strong PA pre-abortion intensify their pain to fulfill their Need for Affect, which then helps recovery. Patients with a strong NA pre-abortion and high Pain-Levels indicate a less favourable outcome.

"Maybe if we weren't in the pandemic, I would have reconsidered": Experiences of abortion care-seeking during the COVID-19 pandemic in Maryland

OBJECTIVE

To understand the COVID-19 pandemic's impact on abortion care-seeking in Maryland, a state with Medicaid coverage for abortion, high service availability, and laws supporting abortion rights.

METHODS

We conducted semi-structured telephone interviews with 15 women who had an abortion between January 2021 and March 2022 at a hospital-based clinic in a mid-sized Maryland city. We purposively recruited participants with varied pandemic financial impacts. Interview questions prompted participants to reflect on how the pandemic affected their lives, pregnancy decisions, and experiences seeking abortion care. We analyzed our data for themes.

RESULTS

All participants had some insurance coverage for their abortion; over half paid using Medicaid. Many participants experienced pandemic financial hardship, with several reporting job, food, and housing insecurity as circumstances influencing their decision to have an abortion. Most women who self-reported minimal financial hardship caused by the pandemic indicated they sought an abortion for reasons unrelated to COVID-19. In contrast, women with economic hardship viewed their pregnancies as unsupportable due to COVID-19 exacerbating financial instability, even when they desired to continue the pregnancy. All participants expressed that having an abortion was the best decision for their lives. Yet, when making decisions about their pregnancy, the most financially disadvantaged women weighed their desires against the pandemic's constraints on their reproductive self-determination.

CONCLUSIONS

The pandemic changed abortion care-seeking circumstances even in a setting with minimal access barriers. Financial hardship influenced some women to have an abortion for a pregnancy that-while unplanned-they may have preferred to continue.

A Multidimensional and Longitudinal Exploratory Study of the Stability of Pregnancy Contexts in the United States

Objective

Evaluate the longitudinal stability of six pregnancy contexts, including intention, in a diverse cohort of individuals experiencing delivery, abortion, or miscarriage.

Methods

We enrolled individuals 16-44 years of age with pregnancies <24 weeks gestation in this longitudinal study between June 2014 and June 2015 in four US urban clinics. We assessed six pregnancy contexts (intention, wantedness, planning, timing, desirability, and happiness) at enrollment and 3-month follow-up. We constructed three-level categorical measures for each context defined as favorable, ambivalent, or unfavorable. We used Wilcoxon sign tests to evaluate changes in paired observations between pregnancy context measures over time and by pregnancy outcome.

Results

Among 121 participants at median gestational age of 7 weeks and 3 days, we found intention, wantedness, planning, timing, and happiness remained unchanged from enrollment in early pregnancy to 3-month follow-up. Individuals demonstrated changes in desirability; pregnancy assessments shifted toward less desirable from enrollment to follow-up (p = 0.01) (i.e., desired to ambivalent, or ambivalent to undesired). Among participants choosing delivery (57%), assessments shifted toward more favorable planning (i.e., unplanned to ambivalent, or ambivalent to planned) (p < 0.01), and less favorable desirability (i.e., desired to ambivalent or ambivalent to undesired) (p < 0.01) at follow-up. Among participants choosing abortion (28%), assessments shifted toward more unfavorable planning (i.e., planned to ambivalent, or ambivalent to unplanned) at follow-up (p < 0.01).

Conclusion

In multidimensional, longitudinal assessment, pregnant participants' perspectives on five of six pregnancy contexts remained unchanged between enrollment and 3-month follow-up; only desirability shifted. Pregnancy planning perspectives differed by pregnancy outcome.Human Research Subjects Protection Program: 1310012926.

The "abortion imaginary": Shared perceptions and personal representations among everyday Americans

Drawing upon 217 in-depth interviews and the concept of the "social imaginary," we introduce the "abortion imaginary"-a set of shared understandings regarding abortion and abortion patients. We identify four interrelated facets of the U.S. abortion imaginary pertaining to who gets an abortion and why: maternal inevitability, economic decision-making, relationship precarity, and emotional fragility. We then show how shared perceptions of abortion patients diverge into polarized opinions, revealing how those who know someone who has had an abortion differ from those who do not. Centering personal "exemplars," we integrate conceptual work on social imaginaries with contact theory to illuminate how divergent opinions coexist with shared cultural understandings.

Quality of care from the perspective of people obtaining abortion: a qualitative study in four countries

OBJECTIVE

This qualitative study aimed to identify person-centred domains that would contribute to the definition and measurement of abortion quality of care based on the perceptions, experiences and priorities of people seeking abortion.

METHODS

We conducted interviews with people seeking abortion aged 15-41 who obtained care in Argentina, Bangladesh, Ethiopia or Nigeria. Participants were recruited from hospitals, clinics, pharmacies, call centres and accompaniment models. We conducted thematic analysis and quantified key domains of quality identified by the participants.

RESULTS

We identified six themes that contributed to high-quality abortion care from the clients' perspective, with particular focus on interpersonal dynamics. These themes emerged as participants described their abortion experience, reflected on their interactions with providers and defined good and bad care. The six themes included (1) kindness and respect, (2) information exchange, (3) emotional support, (4) attentive care throughout the process, (5) privacy and confidentiality and (6) prepared for and able to cope with pain.

CONCLUSIONS

People seeking abortion across multiple country contexts and among various care models have confirmed the importance of interpersonal care in quality. These findings provide guidance on six priority areas which could be used to sharpen the definition of abortion quality, improve measurement, and design interventions to improve quality.

Abortion assistance fund staff and volunteers as patient navigators following an abortion ban in Texas

CONTEXT

Abortion assistance funds constitute an important part of the healthcare safety net by covering some of abortion patients' out-of-pocket costs. Few studies have examined the other ways abortion assistance fund staff and volunteers support callers who need help obtaining care.

METHODS

Between June and September 2020, we conducted in-depth interviews with 23 staff and volunteers at 11 local abortion assistance funds that helped Texans seeking abortion care following a March 2020 state executive order that prohibited most abortions. Interviewers explored respondents' experiences with callers whose appointments had been canceled or who traveled out of state and subsequent operational changes. We used both inductive and deductive codes in the thematic analysis.

RESULTS

Abortion assistance fund staff and volunteers bridged callers' information gaps about the services and financial resources available and helped create plans to secure care that accounted for callers' specific needs. They provided emotional support so callers felt it was possible to overcome logistical hurdles to get an abortion, even if that required out-of-state travel. Respondents described greater collaboration between Texas-based abortion assistance funds and out-of-state organizations to support callers' more complex logistical needs and increased costs. Some callers who encountered multiple barriers to care, including interpersonal violence, were unable to obtain an abortion, even with additional supports.

CONCLUSIONS

Local abortion assistance funds worked with Texas callers to co-create person-centered plans for care and expanded inter-organization collaborations. Initiatives that bolster local assistance funds' infrastructure and capacity will be needed as the abortion access landscape becomes further restricted and complex.

Childbearing, abortion and regret: a response to Kate Greasley

Is moral or other regret for abortion an indicator that abortion may not be morally or prudentially choice worthy? This paper examines the work of Kate Greasley in this area, who offers an explanation of any asymmetry in openness to regret between women who have abortions and women who give birth. The latter, not unlike Derek Parfit's 14-year-old who conceives deliberately, may feel duty-bound not to regret their decision (in their case, to continue their pregnancy) and to affirm the life of their child. In response to Greasley, testimonial evidence of one group cannot be dismissed simply because regret may be less available to another group of decision-makers. Moreover, if moral regret for childbearing is uncommon, this is not because mothers have a moral duty, as Greasley argues, not to regret even a morally mistaken choice to conceive. On the contrary, one must separate the evaluation of choices and of the results of these choices, whether positive or negative. Regret, while not infallible, can elucidate values at stake in choices, and testimonial evidence in the form of regret should be taken more seriously in regard to certain kinds of choice.

The end of Roe v. Wade: implications for Women's mental health and care

The Supreme Court decision in Dobbs v. Jackson in June 2022 reversed precedent which had previously protected abortion prior to fetal viability as a universal right within the United States. This decision almost immediately led to abortion restrictions across 25 states. The resulting lack of access to abortion care for millions of pregnant people will have profound physical and mental health consequences, the full effects of which will not be realized for years to come. Approximately 1 in 5 women access abortions in the U.S. each year. These women are diverse and represent all American groups. The Supreme court decision, however, will affect populations that have and continue to be marginalized the most. Forcing pregnant individuals to carry unwanted pregnancies worsens health outcomes and mortality risk for both the perinatal individual and the offspring. The US has one of the highest maternal mortality rates and this rate is projected to increase with abortion bans. Abortion policies also interfere with appropriate medical care of pregnant people leading to less safe pregnancies for all. Beyond the physical morbidity, the psychological sequelae of carrying a forced pregnancy to term will lead to an even greater burden of maternal mental illness, exacerbating the already existing maternal mental health crisis. This perspective piece reviews the current evidence of abortion denial on women's mental health and care. Based on the current evidence, we discuss the clinical, educational, societal, research, and policy implications of the Dobbs v. Jackson Supreme Court decision.

Individual changes in abortion knowledge and attitudes

RATIONALE

Policymakers need to know the abortion attitudes of those they represent. In addition, inaccurate knowledge of or negative attitudes toward abortion may lead to more abortion stigma, which may adversely affect abortion access and women's health.

OBJECTIVE

The first objective was to examine whether individual's abortion knowledge and attitudes changed during 2016-2020 in Delaware and Maryland. The second was to explore whether personally knowing someone who had an abortion in 2020 was associated with knowledge, attitudes, and changes in them from 2016 to 2020.

METHODS

Data were from the Delaware [Maryland] Survey of Women, a probability sample that was self-administered via web and mail (N = 1106). Women aged 18-44 from Delaware and Maryland were followed from 2016/2017 to 2019/2020. Outcomes were each two facets of abortion knowledge (perceived safety and perceived access) and abortion attitudes (acceptability and advocacy self-identification), and changes in these outcomes. The main predictor was whether women personally knew someone who had an abortion. Covariates included state, religiosity, pregnancy history, and sociodemographic factors. We used logistic models with inverse probability weights.

RESULTS

The percentage of respondents who changed between the first and third waves varied: 46% changed their views on safety and accessibility; 21% changed their views on acceptability; and 25% changed their advocacy self-identification. Knowing someone personally who had an abortion was associated with changing toward viewing abortion as very safe and towards pro-choice, and with not changing towards viewing abortion as wrong or identifying as pro-life.

CONCLUSIONS

These findings suggest abortion knowledge and attitudes are not fixed but change over time, and knowing someone who had an abortion or having an abortion oneself was associated with changing toward positive attitudes and accurate knowledge. Sharing one's abortion experience with others one knows may reduce negative attitudes and inaccurate knowledge regarding abortion.

Long-term influence of unintended pregnancy on psychological distress: a large sample retrospective cross-sectional study

This study examined the associations between childbirth decisions in women with unintended pregnancies and long-term psychological distress. An online survey of women selected from a representative research panel was conducted in July 2021. Among participants who experienced an unintended pregnancy, the childbirth decision was categorized: (i) wanted birth, (ii) abortion, (iii) adoption, and (iv) unwanted birth. Participants who made childbirth decisions more than 1 year ago were included. ANCOVA was conducted with psychological distress (Kessler 6) as the dependent variable and education, marital status, years from the decision, age of the first pregnancy, economic situation at the unintended pregnancy, and the number of persons consulted at the unintended pregnancy as covariates. Logistic regression analysis was conducted for high distress (K6 ≥ 13) by adjusting the same covariates. A total of 47,401 respondents participated in the study. Women with an experience of unintended pregnancy experienced more than 1 year before the study were analyzed (n = 7162). Psychological distress was the lowest for wanted birth and increased for abortion, adoption, and unwanted birth. In the adjusted model, abortion was associated with lower distress scores than both adoption and unwanted birth. Compared to the wanted birth, adoption and unwanted birth showed significantly higher levels of distress (adjusted odds ratio [aOR] = 2.03 [95% CI 1.36-3.04], aOR = 1.64 [95% CI 1.04-2.58], respectively). Long-term effects on psychological distress differed according to the childbirth decisions in unintended pregnancy. Healthcare professionals should be aware of this hidden effect of unintended pregnancy experience on women's mental health.

Abortion Stigma: Imagined Consequences for People Seeking Abortion Care in the United States

Prior to and since the 2022 Dobbs decision, U.S. state laws have endorsed individuals surveilling and punishing those associated with abortion care. This practice presents an urgent need to understand the characteristics of abortion stigma, particularly the perspectives of individuals with stigmatizing beliefs. To examine the concept and characteristics of abortion stigma, we interviewed 55 individuals about whether they thought there should be consequences for getting an abortion and, if so, what the consequences should be. Adults from three states (Michigan, Kansas, and Arizona) were purposively sampled to include a range of abortion identities and levels of religious engagement. We used reflexive thematic analysis to code and interpret the data. Participants imagined consequences including financial penalties, incarceration, and forced sterilization. Three themes highlighted how abortion was described as violating the law, women's gender roles, and religious doctrine; accordingly, abortion was imagined as deserving of negative consequences, although abortion was legal in all states during data collection. We argue that these imagined consequences relied on carceral logics and interconnected sexist, racist, and classist stereotypes that reflect and reproduce abortion stigma. This study deepens the understanding of abortion stigma from the perspective of the stigmatizer, underscoring the danger of legislation grounded in stigmatizing beliefs.

Pregnancy scares, pregnancy uncertainty, and abortion attitude change

Women's attitudes towards abortion are often assessed infrequently in their lives. This measurement may not capture how lifetime events, such as reproductive experiences, potentially influence attitudes towards abortion. Although reproductive attitudes can fluctuate with life's circumstances, there is little research on how abortion attitudes may change when a woman suspects she might be pregnant. Using an intensive longitudinal dataset collected in Michigan, the Relationship Dynamics and Social Life (RDSL) study (2008-2012), we test the relationship between the timing of pregnancy scares and uncertainty and abortion attitudes using hybrid effects models. We find that women become less supportive of abortion while experiencing a pregnancy scare or uncertainty; however, this association exists only during a scare or uncertainty. These findings highlight that abortion attitudes may change when a woman suspects she might be pregnant. However, attitudinal change may not last past this period.

The influence of feminist abortion accompaniment on emotions related to abortion: A longitudinal observational study in Mexico

Emotions can reflect how individuals internalize identities, social roles, and broader power structures, including abortion stigma. Abortion accompaniment, in the form of logistical, informational, and emotional support offered by individuals and organizations, takes a person-centered, feminist, and rights-based approach. We tested the extent to which abortion accompaniment may decrease negative and increase positive feelings an individual holds related to their abortion. Using observational longitudinal data collected between January 2017 and mid-2018, we compared negative and positive emotional responses to a personal abortion experience one month and six months following the abortion to emotions immediately prior to the abortion ("baseline"), among women travelling from outside of Mexico City to abortion clinics in Mexico City with and without support of the accompaniment organization, Fondo MARIA. We used doubly robust longitudinal mixed effects models with inverse probability weighting methods. At baseline, accompanied and unaccompanied participants experienced an average of 4.9 and 4.4 negative emotions out of eight respectively (i.e., anguish, nervousness, scared, anxious, sadness, guilt, anger, shame) and 1.7 and 1.9 positive emotions of out 4 respectively (happiness, calmness, decidedness, and relief). From our model results, women accompanied (n = 77) had larger decreases in negative feelings (p < .05) and larger increases in positive feelings (p < .01) toward their abortion compared to those who were not accompanied (n = 119) at six months. These changes led the majority of accompanied respondents to have primarily positive feelings about their abortion by endline. Abortion accompaniment through Fondo MARIA in Mexico City was associated with a larger decrease in negative feelings, particularly those related to stigma, and a larger increase in positive feelings six months after abortion. Accompaniment's focus on person-centered support, self-determination, and autonomy may enable people seeking abortion to view their decision as one that is valid and legitimate, and resist the predominant stigmatizing narratives framing abortion as something that is transgressive.

Why does abortion stigma matter? A scoping review and hybrid analysis of qualitative evidence illustrating the role of stigma in the quality of abortion care

Abortion stigma shapes the environment in which abortion is delivered and received and can have important implications for quality in abortion care. However, this has not previously been clearly articulated and evidenced. We conducted a scoping review of existing qualitative evidence to characterize the relationship between abortion stigma and quality in abortion care. Using a systematic process, we located 50 qualitative studies to include in our analysis. We applied the interface of the WHO quality of care and abortion stigma frameworks to the qualitative evidence to capture manifestations of the interaction between abortion stigma and quality in abortion care in the existing literature. Four overarching themes linked to abortion stigma emerged: A) abortion as a sin and other religious views; B) regulation of abortion; C) judgement, labelling and marking; and D) shame, denial, and secrecy. We further characterized the emerging ways in which abortion stigma operates to inhibit quality in abortion care into seven manifestations of the relationship between abortion stigma and quality in abortion care: 1) poor treatment and the repercussions, 2) gatekeeping and obstruction of access, 3) avoiding disclosure, 4) arduous and unnecessary requirements, 5) poor infrastructure and lack of resources, 6) punishment and threats and 7) lack of a designated place for abortion services. This evidence complements the abortion stigma-adapted WHO quality of care framework suggested by the International Network for the Reduction of Abortion Discrimination and Stigma (inroads) by illustrating specifically how the postulated stigma-related barriers to quality abortion care occur in practice. Further research should assess these manifestations in the quantitative literature and contribute to the development of quality in abortion care indicators that include measures of abortion stigma, and the development of abortion stigma reduction interventions to improve quality in abortion care.

The Adolescent's Right to Confidential Care When Considering Abortion

The American Academy of Pediatrics reaffirms its position that the rights of adolescents under 18 years of age to confidential care when considering legal medical and surgical abortion therapies should be protected. Most adolescents voluntarily involve parents and other trusted adults in decisions regarding pregnancy termination and should be encouraged to do so when safe and appropriate. The legal climate surrounding abortion law is rapidly becoming more restrictive and threatens to adversely impact adolescents. Mandatory parental involvement, the judicial bypass procedure, and general restrictive abortion policies pose risks to adolescents' health by causing delays in accessing medical care, increasing volatility within a family, and limiting their pregnancy options. These harms underscore the importance of adolescents' access to confidential abortion care. This statement presents a summary of pertinent current information related to the impact of legislation requiring mandatory parental involvement in an adolescent's decision to obtain abortion services.

Ritualizing Abortion: A Qualitative Study on Ritual and Its Meanings in The Netherlands

The present study investigates ritualizing abortion in the Netherlands. Explorative, qualitative research was conducted with semi-structured interviews (n = 13) with women who looked for counseling and 43 online personal stories about the abortion from the website of a national care and expertise center. The results reveal three main categories of ritualizing: (1) creating and using symbols privately and online, (2) remembering or honoring the experience and (3) embodied ritualizing. The data reveal that respondents find meaning in the ritualizing through sharing the experience with others, expressing various feelings through symbolic and ritual forms, fostering a connection with the child-to-be, showing respect, seeking closure and transforming the experience in a meaningful way. This research reveals types of ritualizing practices in relation to a meaningful life event such as abortion. For a specific group of women experiencing decision difficulty or existential concerns in relation to the abortion, ritualizing might be an interesting tool to be incorporated into post-abortion care practices.

The impact of mandatory waiting periods on abortion-related outcomes: a synthesis of legal and health evidence

This review follows an established methodology for integrating human rights to address knowledge gaps related to the health and non-health outcomes of mandatory waiting periods (MWPs) for access to abortion. MWP is a requirement imposed by law, policy, or practice, to wait a specified amount of time between requesting and receiving abortion care. Recognizing that MWPs “demean[] women as competent decision-makers”, the World Health Organization recommends against MWPs. International human rights bodies have similarly encouraged states to repeal and not to introduce MWPs, which they recognize as operating as barriers to accessing sexual and reproductive healthcare. This review of 34 studies published between 2010 and 2021, together with international human rights law, establishes the health and non-health harms of MWPs for people seeking abortion, including delayed abortion, opportunity costs, and disproportionate impact. Impacts on abortion providers include increased workloads and system costs.

Comparison of abortion incidence estimates derived from direct survey questions versus the list experiment among women in Ohio

Abortion is highly stigmatized in the United States which prevents its accurate measurement in surveys. The list experiment aims to improve the reporting of abortion history. We evaluated whether a list experiment resulted in higher reporting of abortion experiences than did two direct questions. Utilizing data from a representative survey of adult women of reproductive age in Ohio, we examined abortion history using two direct questions and a double list experiment. Through the double list experiment, we asked respondents to report how many of two lists of health items they had experienced; one list included abortion. We compared weighted history of abortion between these measures and by respondent demographic characteristics (age and socioeconomic status). Estimates of abortion history were similar between direct and list experiment questions. When measured with the two different direct question of abortion history, 8.4% and 8.0% of all respondents indicated ever having an abortion and with the list experiment, 8.5% indicated ever having an abortion. In a Midwestern state-level survey, the list experiment did not lead to increases in abortion reporting as compared to the direct questions. Subgroup analyses require larger samples, and future iterations should incorporate related but non-stigmatized control items to reduce misclassification and under-powering of such subgroup analyses.

The STress-And-Coping suppoRT Intervention (START) for Chinese Women Undergoing Abortion: A Randomized Controlled Trial Protocol

Background: Although undergoing an abortion is stressful for most women, little attention has been given to their psychological wellbeing. This protocol aims to assess the feasibility, acceptability, and primary effects of a complex intervention to promote positive coping behaviors and alleviate depression symptoms among Chinese women who have undergone an abortion. Methods: A two-arm randomized controlled trial design will be used. Participants will be recruited at their first appointment with the abortion clinic and randomly allocated to receive either the Stress-And-Coping suppoRT (START) intervention (in addition to standard abortion care) or standard care only. All participants will be followed-up at two- and six-weeks post-abortion. Approval has been granted by local and university ethics committees. This research was supported by an Australian Government Research Training Program Scholarship. Discussion: The results will assist refinement and further evaluations of the START intervention, contribute to improved abortion care practices in China, and enrich the evidence on improving women’s psychological well-being following abortion in China. Trial registration: Registered at the Chinese Clinical Trials.gov: ChiCTR2100046101. Date of registration: 4 May 2021.

Feeling better: representing abortion in 'feminist' television

Abortion is a common and safe gynaecological procedure. Yet in film and television it is disproportionately represented as risky, violent, requiring hospitalisation, and affecting young, white, wealthy women. This reinforces stigma, fear and misunderstanding surrounding the procedure. While the majority of television storylines still inaccurately portray abortion, a small minority are directly showing abortion and presenting it as a positive decision. This paper analyses four such storylines in the television shows Sex Education, Shrill, GLOW and Euphoria, as well as media discourse around these plotlines, to understand how contemporary, 'feminist' television shows are representing abortion. The paper argues that contemporary television is increasingly representing abortion in an empathetic way that upholds women's choice to access the procedure, but that these portrayals can be read as post-feminist. Individual choice and empowerment are prioritised in these shows at the expense of showing the complex and unequal power structures that affect how women make reproductive choices. 'Feminist' television still prioritises the abortion storylines of young, white women who face no obstacles to abortion access and so the realities of abortion are still not fully represented on screen.

Ohio survey data assessing perceptions of abortion safety

OBJECTIVE

Despite overwhelming data supporting the safety of abortion care in the U.S., public perceptions of abortion safety vary widely. While evidence suggests that the public overestimates abortion risk, few studies have analyzed why people think abortion is safe or unsafe.

STUDY DESIGN

Using data from the Ohio Survey of Women, a representative survey of women aged 18-44 years with a residential address in Ohio, we examined responses to two questions about abortion safety perceptions: the first asked respondents to rate abortion safety in Ohio, and the second asked respondents why they chose this rating of abortion safety. We analyzed these responses with inductive and deductive approaches.

RESULTS

There were 2,529 responses, of which 1,368 (54%) provided a response to the open-ended question about abortion safety. From this subset, 529 gave open-ended responses indicating that they perceive abortion as safe, with 47% attributing this perception to the procedure being performed by a professional in a regulated environment. In contrast, 370 gave open-ended responses indicating that they perceive abortion as unsafe; the most common explanations referred to health risks (19%) and that safety depends on pre-existing health conditions (19%).

CONCLUSION

Many participants perceived abortion as safe because it is performed by professionals in a clinical environment or because of personal experiences with abortion. Those perceiving a lack of safety provided more varied responses, including that abortion was dangerous due to a detrimental effect on mental health or protesters at abortion clinics.

The limitations of patient-centered care: The case of early long-acting reversible contraception (LARC) removal

Patient-centered care (PCC) is frequently recommended to improve healthcare outcomes in the United States. Despite its purported benefits, little research explores how and to what extent providers implement this model in their care. We examine such processes through the case of contraception, specifically, "early" removals of long-acting reversible contraception (LARC). In-depth interviews with 51 healthcare providers reveal that while providers describe embracing patient-centeredness when considering patients' early LARC removal requests, their implementation ironically sidelines patient preferences and needs. Rather than be responsive to patients' requests, all providers in the study resist early LARC removal by: withholding information about self-removal of intrauterine devices (IUDs); negotiating with patients to keep their device longer; setting subjective timelines to prolong LARC use; and/or engaging in delay tactics to wear down patients' resolve for removal. Furthermore, beyond simply resisting LARC removal requests using these strategies, providers purposively employ tenets of PCC to sway patients away from removal. In other words, providers utilize PCC as a means to undermine it. Understanding how providers implement patient-centered care reveals the challenges to doing so, even in cases like early LARC removal where providers indicate patient-centeredness is a priority. It also elucidates the need for enhanced training, specificity, and institutionalization around patient-centered models of care; informs interventions that promote LARC use among patients; as well as offers opportunities for improving patient-provider exchanges generally.

Differences in Financial and Social Burdens Experienced by Patients Traveling for Abortion Care

OBJECTIVE

We compared perceived stress between women traveling 50 or fewer miles and more than 50 miles for abortion care. Secondary objectives were to compare individual-level stigma and hardship scores in patients by distance traveled to the clinic.

METHODS

We performed a cross-sectional study of patients presenting for care at an independent abortion clinic in southern Illinois. Participants completed a self-administered, tablet computer-based survey asking about their experiences seeking abortion, including the Perceived Stress Scale (PSS) and Individual Level Abortion Stigma (ILAS) scale. We created a composite score to characterize patient hardship regarding abortion care (range, 0-4). We examined responses stratified by the patients' self-reported one-way distance traveled to the clinic (group 1, ≤50 miles; group 2, >50 miles).

RESULTS

A total of 308 women completed the survey. There was no significant difference in mean PSS scores (p = .71) or median ILAS scores (p = .40) between groups. A majority of the cohort reported moderate or high stress (68.2%). The median hardship score was significantly higher in the greater than 50 mile group (median, 1 [interquartile range, 0-2] vs. 2 [interquartile range 1-3]; p < .001). Patients who traveled more than 50 miles reported difficulties related to missing work (58.3%), delays in obtaining an abortion owing to financial costs (35.7%), lodging (13.9%), and transportation (11.3%).

CONCLUSIONS

There was no difference in PSS or ILAS scores by distance traveled among patients seeking an abortion; however, patients who traveled more than 50 miles had a higher hardship score, suggesting greater difficulty accessing abortion. The most common difficulties encountered included missing time from work and financial costs associated with the abortion.

Psychosocial Experiences of Adolescent Girls and Young Women Subsequent to an Abortion in Sub-saharan Africa and Globally: A Systematic Review

Introduction: Unmet need for contraception, unintended pregnancy, and access to safe abortion remain global challenges preventing adolescent girls and young women (AGYW) from achieving optimal reproductive health. Furthermore, AGYW face difficulties navigating sexual autonomy, lack of agency or experience negotiating sexual acts, and challenges accessing sexual health information and services. The aim of this systematic review is to assess the psychosocial outcomes of AGYW who have experienced an abortion with particular focus on sub-Saharan Africa, which bears the global burden of unintended pregnancy and risk of death due to unsafe abortion. Materials and Methods: The systematic review was registered and used search terms to identify peer-reviewed articles relevant to "post-abortion," "psychosocial," "adolescent girls," and "young women" from PubMed, Embase, PsycInfo, and Cumulative Index to Nursing and Allied Health Literature. Examples of psychosocial experiences include quality of life, stigma, and mental health outcomes. Rayyan software (Qatar, 2020) was used by two reviewers to assess the relevance of each article to psychosocial outcomes of AGYW any time after an abortion or accessing post-abortion services. Analysis was conducted with a focus on data from Africa and comparisons are made to non-African settings. Results: A total of 2,406 articles were identified and 38 articles fit the criteria. Six selected articles were from Africa, including Ghana, Kenya, Uganda, and Zambia, and the remaining articles were from other regions. Themes around stigma, shame, and abandonment associated with the experience of abortion were prevalent in all regions. Studies of psychosocial outcomes of AGYW in sub-Saharan Africa highlight social isolation as well as learned resilience among young women who abort. Discussion: Navigating abortion as an AGYW involves managing internalized and perceived stigma, fear of violence, secrecy, and growing resilient in order to overcome the significant barriers that society and culture place on access to an essential service in sexual and reproductive health. Post-abortion psychosocial outcomes highlight the need for support services and investigation of contexts that perpetuate and necessitate unsafe abortion. Empowerment of AGYW may present an important opportunity to build self-agency and positive coping mechanisms to withstand social pressures during stigmatizing circumstances associated with abortion.

Mental health of adolescents associated with sexual and reproductive outcomes: a systematic review

Objective

To systematically review the literature on the mental health of adolescents associated with sexual and reproductive outcomes, and compare the mental health outcomes with that of other age groups.

Methods

We searched seven databases for relevant peer-reviewed articles published between 1 January 2010 and 25 April 2019. Our inclusion criteria required that the study included age-disaggregated data on adolescents, and focused and assessed mental health outcomes associated with pregnancy or sexually transmitted infections. We extracted data on the specific health event, the mental health outcome and the method of measuring this, and comparisons with other age groups.

Findings

After initially screening 10 818 articles by title and abstract, we included 96 articles in our review. We observed that a wide-ranging prevalence of mental ill-health has been reported for adolescents. However, most studies of mental health during pregnancy did not identify an increased risk of depression or other mental disorders among adolescents compared with other age groups. In contrast, the majority of studies conducted during the postpartum period identified an increased risk of depression in adolescents compared with other age groups. Three studies reported on mental health outcomes following abortion, with varying results. We found no studies of the effect of sexually transmitted infections on mental health among adolescents.

Conclusion

We recommend that sexual and reproductive health services should be accessible to adolescents to address their needs and help to prevent any adverse mental health outcomes.

Developing and validating the Psychosocial Burden among people Seeking Abortion Scale (PB-SAS)

While there is a large body of research demonstrating that having an abortion is not associated with adverse mental health outcomes, less research has examined which factors may contribute to elevated levels of mental health symptoms at the time of abortion seeking. This study aims to develop and validate a new tool to measure dimensions of psychosocial burden experienced by people seeking abortion in the United States. To develop scale items, we reviewed the literature including existing measures of stress and anxiety and conducted interviews with experts in abortion care and with patients seeking abortion. Thirty-five items were administered to 784 people seeking abortion at four facilities located in three U.S. states. We used exploratory factor analysis (EFA) to reduce items and identify key domains of psychosocial burden. We assessed the predictive validity of the overall scale and each sub-scale, by assessing their associations with validated measures of perceived stress, anxiety, and depression using multivariable linear regression models. Factor analyses revealed a 12-item factor solution measuring psychosocial burden seeking abortion, with four subdomains: structural challenges, pregnancy decision-making, lack of autonomy, and others' reactions to the pregnancy. The alpha reliability coefficients were acceptable for the overall scale (α = 0.83) and each subscale (ranging from α = 0.82-0.85). In adjusted analyses, the overall scale was significantly associated with stress, anxiety and depression; each subscale was also significantly associated with each mental health outcome. This new scale offers a practical tool for providers and researchers to empirically document the factors associated with people's psychological well-being at the time of seeking an abortion. Findings suggest that the same restrictions that claim to protect people from mental health harm may be increasing people's psychosocial burden and contributing to adverse psychological outcomes at the time of seeking abortion.

Emotions over five years after denial of abortion in the United States: Contextualizing the effects of abortion denial on women's health and lives

BACKGROUND

The Turnaway Study was the first to follow women denied abortions because of state law or facility policy over five years. The study has found negative effects on women's socioeconomic status, physical health, and on their children's wellbeing. However, women did not suffer lasting mental health consequences, prompting questions about the effects of denial on women's emotions.

METHODS

In this mixed methods study, we used quantitative and qualitative interview data from the Turnaway Study to offer insight into these findings. We surveyed 161 women who were denied abortions at 30 facilities across the United States between 2008 and 2010 one week after the abortion denial and semiannually over five years. Mixed-effects regression analyses examined emotions about having been denied the abortion over time. To contextualize the quantitative findings, we draw on in-depth qualitative interviews with 15 participants, conducted in 2014-2015, for their accounts of their emotions and feelings over time.

RESULTS

Survey participants reported both negative and positive emotions about the abortion denial one week after. Emotions became significantly less negative and more positive over their pregnancy and after childbirth. In multivariable models, lower social support, more difficulty deciding to seek abortion, and placing the baby for adoption were associated with reporting more negative emotions. Interviews revealed how, for some, belief in antiabortion narratives contributed to initial positive emotions. Subsequent positive life events and bonding with the child also led to positive retrospective evaluations of the denial.

CONCLUSIONS

Findings of emergent positive emotions about having been denied an abortion suggest that individuals are able to cope emotionally with an abortion denial, although evidence that policies leading to abortion denial cause significant health and socioeconomic harms remains.

Mandatory Waiting Periods Before Abortion and Sterilization: Theory and Practice

Some laws insist on a fixed, compulsory waiting period between the time of obtaining consent and when abortions or sterilizations are carried out. Waiting periods are designed to allow for reflection on the decision and to minimize regret. In fact, the cognitive processing needed for these important decisions takes place relatively rapidly. Clinicians are used to handling cases individually and tailoring care appropriately, including giving more time for decision-making. Psychological considerations in relation to the role of emotion in decision-making, eg, regret, raise the possibility that waiting periods could have a detrimental impact on the emotional wellbeing of those concerned which might interfere with decision-making. Having an extended period of time to consider how much regret one might feel as a consequence of the decision one is faced with may make a person revisit a stable decision. In abortion care, waiting periods often result in an extra appointment being needed, delays in securing a procedure and personal distress for the applicant. Some women end up being beyond the gestational limit for abortion. Those requesting sterilization in a situation of active conflict in their relationship will do well to postpone a decision on sterilization. Otherwise, applicants for sterilization should not be forced to wait. Forced waiting undermines people's agency and autonomous decision-making ability. Low-income groups are particularly disadvantaged. It may be discriminatory when applied to marginalized groups. Concern about the validity of consent is best addressed by protective clinical guidelines rather than through rigid legislation. Waiting periods breach reproductive rights. Policymakers and politicians in countries that have waiting periods in sexual and reproductive health regulation should review relevant laws and policies and bring them into line with scientific and ethical evidence and international human rights law.