Misperceptions About the Risks of Abortion in Women Presenting for Abortion

Experiences of abortion care in Australia: a qualitative study examining multiple dimensions of access

BACKGROUND

The United Nations' Sustainable Development Goals identify universal access to sexual and reproductive health services as a global priority. Yet barriers to abortion access remain, including legal restrictions, cost, stigma, and limited services and information. The aim was to identify barriers to and facilitators of abortion care access experienced in Australia.

METHODS

This qualitative phenomenological study examined abortion access in Australia, where abortion is decriminalised, from March 2020 to December 2022. We used social media and flyers in clinics to recruit adults who had sought abortion care, then interviewed them in-depth. We mapped participant experiences to five dimensions of access identified by Levesque et al.'s patient-centred access to healthcare framework: approachability, acceptability, availability and accommodation, affordability, and appropriateness.

RESULTS

The 24 participants lived across Australia and sought abortion during the COVID-19 pandemic. Approachability: Before seeking abortion, most did not know where to access information about the service and where to obtain it. Acceptability: Many were uncomfortable disclosing their abortion to family or friends; they reported that healthcare providers demonstrated varying levels of support. Availability and accommodation: Regional participants travelled far and faced long wait-times, exacerbated by pandemic restrictions. Affordability: Participants described financial stress paying for the service, travel, and related expenses. Appropriateness: Most participants expected judgemental care. Experiences varied widely: many participants experienced unempathetic, rushed, or judgemental interactions with healthcare staff, and many also reported at least one non-judgmental and supportive interaction on the same pathway to care.

DISCUSSION

Abortion seekers experienced varying obstacles when seeking care. The findings illustrate the need for population- and system-level initiatives such as: providing accurate information about and normalising abortion; implementing system-level strategies to reduce wait times, travel, and costs, especially for rural populations; and developing regulatory and quality improvement initiatives to increase the workforce and its readiness to provide high-quality, non-judgemental abortion care. Challenges seeking care during pandemic restrictions illustrate the importance of social support during care and choice between abortion modalities and service types. Consumer voices can help understand the diverse pathways to abortion care and inform solutions to overcome the multidimensional barriers to access.

Separating Procedure-related Fears From Future Fertility Concerns Among a Cohort Seeking Abortion Information Online

INTRODUCTION

The general public and abortion patients in the United States have misinformation about the risks of infertility associated with abortion, which may influence abortion care-seeking.

METHODS

The Google Ads Abortion Access Study was a national study of people considering abortion and searching online for information. Participants completed baseline and follow-up surveys, providing free text responses to questions about barriers and facilitators to abortion. We conducted an exploratory analysis of the free text responses related to fertility and used thematic analysis to identify concerns raised about links between abortion and future fertility.

RESULTS

Of 864 participants who provided free text responses in the follow-up survey, 32 specifically mentioned fertility. Few expressed fear that complications from the abortion procedure would somehow lead to infertility; rather, most discussed complex and overlapping thoughts about how abortion factored into their reproductive life plans. These included age-related concerns, missing out on their "chance" to have a child, fear of being punished by God with infertility for having an abortion, and conflicting emotions if they had previously been told they were subfecund or infertile.

CONCLUSION

Although previous research has focused on misinformation about the link between abortion and infertility, participants in this study rarely mentioned it as a concern. Researchers and practitioners should be attuned to the distinctions people make between infertility occurring as a result of abortion and other fears they might have about not achieving their future reproductive aspirations, ask questions, and provide counseling accordingly.

Public perceptions of abortion complications

BACKGROUND

Misinformation contributes to the perception that abortion has substantial health risks, despite the known safety of medication and aspiration abortion. We lack detailed information about which health risks the public believes are most likely.

OBJECTIVE

This study aimed to describe public perception of short- and long-term risks of abortion.

STUDY DESIGN

We conducted a cross-sectional survey of US residents aged ≥18 years using Amazon Mechanical Turk (MTurk). We collected information regarding participant demographics, reproductive history, political views, and position on abortion restrictions. We provided participants with a list of 9 short-term and 15 long-term possible complications and asked them to indicate whether they occurred never (0%), very rarely (<1%), rarely (1%-5%), occasionally (5%-20%), or frequently (>20%) following abortion. We used descriptive statistics to understand our population demographics and to capture the perceived incidence of all complications. We created a binary indicator of answering all risk estimates incorrectly vs at least 1 estimate correctly, separately for all long-term possible complications, and the 2 short-term risks of infection and bleeding. We determined the proportion of individuals who responded incorrectly to all questions in each category and used multivariable logistic regression to identify factors associated with incorrect perceptions about the risks of abortion.

RESULTS

For all listed complications, participant (N=1057) estimates of risk were higher than the known incidence. For both short-term risks of bleeding and infection, over 40% of participants reported that these outcomes occur occasionally or frequently. Similarly, for both long-term risks of depression and anxiety, over 60% of respondents reported that these outcomes occur occasionally or frequently after abortion. Participants reported that possible complications known to not be associated with abortion, including hair loss, future pregnancy complications, breast cancer, and cosmetic disfigurement, occurred at least rarely. Nearly one-quarter of participants responded that death occurs occasionally or frequently (in over 5% of abortions), and 79% of participants responded that breast cancer can result from abortion. One-quarter (24.9%) of participants incorrectly overestimated both short-term outcomes of infection and bleeding, whereas 19.5% answered all long-term complication questions incorrectly, including outcomes that never occur. On multivariable analyses, we identified that the participants most likely to incorrectly identify risks of abortion identified as Asian or Black race/ethnicity, were from rural communities, or believed that abortion should have more legal restrictions.

CONCLUSION

The public perceives abortion to be much riskier than it actually is. This information can be used to develop targeted clinical and public health efforts to disseminate the true risks of abortion.

Sexual and reproductive health teaching in undergraduate medical education: A narrative review

OBJECTIVE

Contraception use, undesired pregnancy, and abortion care are common medical experiences that most physicians will encounter for their patients. Future physicians should therefore have some formal education on these topics. In this narrative review, we focused on how medical education approaches these sometimes polarizing yet fundamental topics.

METHODS

We assessed the published literature on sexual and reproductive health education in undergraduate medical education from 2000 to 2021, screening 868 articles and including 52 articles. We included articles that discussed contraception, emergency contraception, pregnancy options counseling, abortion, and ethics related to sexual and reproductive health.

RESULTS

Included studies came from 14 countries and described both preclinical and clinical education. Studies assessed medical student knowledge, the effectiveness of educational interventions and medical school faculty perspectives on sexual and reproductive health curricula. Medical educators have employed a variety of approaches to teach sexual and reproductive health including simulation, objective structured clinical examinations, team-based learning, narrative medicine, online modules, and flipped classrooms.

CONCLUSION

Students generally received sexual and reproductive health education favorably, demonstrating increased knowledge and comfort with these topics after an education session. Studies also identified curricular gaps and deficiencies in student knowledge, which may indicate a need for improved and consistent medical school education on contraception and abortion.

Abortion Knowledge and Attitudes Among Psychologists and Graduate Students

Abortion is often misunderstood and steeped in misinformation. Laypeople and medical professionals tend to have limited abortion knowledge. Among the public, individuals who hold accurate information about abortion are more likely to endorse pro-choice attitudes than individuals who are misinformed. We explored knowledge of, and attitudes toward, abortion among 142 psychologists and graduate students. Participants responded accurately, on average, to 68% of the items on a true–false measure of abortion knowledge. In addition, participants with higher levels of accurate knowledge were more likely to endorse pro-choice attitudes. Participants were especially likely to incorrectly answer items related to the prevalence, availability, and current legality of abortion in the United States. Analyzing qualitative interviews with a subset of 13 participants, we generated four themes related to knowledge and attitudes about abortion: Assuming Proficiency Despite Minimal Training, Pursuing Outside Knowledge and Training, Framing Abortion Around Identities, and Perceiving and Experiencing Consequences from Abortion Attitudes. Implications for training are delineated.

State-Mandated (Mis)Information and Women's Endorsement of Common Abortion Myths

PURPOSE

The extent that state-mandated informed consent scripts affect women's knowledge about abortion is unknown. We examine women's endorsement of common abortion myths before and after receiving state-mandated information that included accurate and inaccurate statements about abortion.

METHODS

In Utah, women presenting for an abortion information visit completed baseline surveys (n = 494) and follow-up interviews 3 weeks later (n = 309). Women answered five items about abortion risks, indicating which of two statements was closer to the truth (as established by prior research) or responding "don't know." We developed a continuous myth endorsement scale (range, 0-1) and, using multivariable regression models, examined predictors of myth endorsement at baseline and change in myth endorsement from baseline to follow-up.

RESULTS

At baseline, many women reported not knowing about abortion risks (range, 36%-70% across myths). Women who were younger, non-White, and had previously given birth but not had a prior abortion reported higher myth endorsement at baseline. Overall, myth endorsement decreased after the information visit (0.37-0.31; p < .001). However, endorsement of the myth that was included in the state script-describing inaccurate risks of depression and anxiety-increased at follow-up (0.47-0.52; p < .05).

CONCLUSIONS

Lack of knowledge about the effects of abortion is common. Knowledge of information that was accurately presented or not referenced in state-mandated scripts increased. In contrast, inaccurate information was associated with decreases in women's knowledge about abortion, violating accepted principles of informed consent. State policies that require or result in the provision of inaccurate information should be reconsidered.

Measuring decisional certainty among women seeking abortion

OBJECTIVE

Evaluating decisional certainty is an important component of medical care, including preabortion care. However, minimal research has examined how to measure certainty with reliability and validity among women seeking abortion. We examine whether the Decisional Conflict Scale (DCS), a measure widely used in other health specialties and considered the gold standard for measuring this construct, and the Taft-Baker Scale (TBS), a measure developed by abortion counselors, are valid and reliable for use with women seeking abortion and predict the decision to continue the pregnancy.

METHODS

Eligible women at four family planning facilities in Utah completed baseline demographic surveys and scales before their abortion information visit and follow-up interviews 3 weeks later. For each scale, we calculated mean scores and explored factors associated with high uncertainty. We evaluated internal reliability using Cronbach's alpha and assessed predictive validity by examining whether higher scale scores, indicative of decisional uncertainty or conflict, were associated with still being pregnant at follow-up.

RESULTS

Five hundred women completed baseline surveys; two-thirds (63%) completed follow-up, at which time 11% were still pregnant. Mean scores on the DCS (15.5/100) and TBS (12.4/100) indicated low uncertainty, with acceptable reliability (α=.93 and .72, respectively). Higher scores on each scale were significantly and positively associated with still being pregnant at follow-up in both unadjusted and adjusted analyses.

CONCLUSION

The DCS and TBS demonstrate acceptable reliability and validity among women seeking abortion care. Comparing scores on the DCS in this population to other studies of decision making suggests that the level of uncertainty in abortion decision making is comparable to or lower than other health decisions.

IMPLICATIONS

The high levels of decisional certainty found in this study challenge the narrative that abortion decision making is exceptional compared to other healthcare decisions and requires additional protection such as laws mandating waiting periods, counseling and ultrasound viewing.

Does state-level context matter for individuals' knowledge about abortion, legality and health? Challenging the 'red states v. blue states' hypothesis

Recently, the hypothesis that state-level political context influences individuals' cultural values--the 'red states v. blue states' hypothesis--has been invoked to explain the hyper-polarisation of politics in the USA. To test this hypothesis, we examined individuals' knowledge about abortion in relation to the political context of their current state of residence. Drawing from an internet-survey of 586 reproductive-age individuals in the USA, we assessed two types of abortion knowledge: health-related and legality. We found that state-level conservatism does not modify the existing relationships between individual predictors and each of the two types of abortion knowledge. Hence, our findings do not support the 'red states' versus 'blue states' hypothesis. Additionally, we find that knowledge about abortion's health effects in the USA is low: 7% of our sample thought abortion before 12 weeks gestation was illegal.