Stigma, abortion, and disclosure--findings from a qualitative study

Tanzanian adolescents' attitudes toward abortion: innovating video vignettes in survey research on health topics

BACKGROUND

The purpose of this study was to pilot an innovative cartoon video vignette survey methodology to learn about young people's perspectives on abortion and sexual relationships in Tanzania. The Animating Children's Views methodology used videos shown on tablets to engage young people in conversations. Such conversations are complicated because abortion is highly stigmatized, inaccessible, and illegal in Tanzania.

METHODS

The cartoon video vignette methodology was conducted as a part of a quantitative survey using tablet computers. Hypothetical situations and euphemistic expressions were tested in order to engage adolescents on sensitive topics in low-risk ways. Qualitative interviews and focus groups validated and further explored the perspectives of the young respondents.

RESULTS

Results indicate that 12-17 year-olds usually understand euphemistic expressions for abortion and are aware of social stigma and contradictory norms surrounding abortion from as young as age twelve. Despite the risks involved with abortion, this study finds adolescents sometimes view abortion as a reasonable solution to allow a girl to remain in school. Additional findings show that as adolescents wrestle with how to respond to a schoolgirl's pregnancy, they are considering both the (un)affordability of healthcare services and also expectations for gender roles.

CONCLUSIONS

Digital data collection, such as the Animating Children's Views cartoon video vignettes used in this study, allows researchers to better understand girls' and boys' own perspectives on their experiences and reproductive health.

The risk of opioid use disorder among women undergoing obstetric-related procedures: Results from the Cerner Real-World Database

Introduction

While the relationship between various obstetric procedures and the onset of opioid use disorder (OUD) remains ambiguous, this study aims to elucidate the immediate and prolonged risks of OUD in women who have undergone procedures such as vaginal and cesarean deliveries, induced abortions, and treatments related to miscarriages and ectopic pregnancies.

Methods

Retrospective data (n = 632,872) from the Cerner Real-World Data™ for pregnant females (age 15-44) between January 2010 and March 2020 were used. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were used to compare odds of OUD for each obstetric outcome to normal vaginal delivery using multivariable logistic regression. New opioid prescriptions and persistent opioid prescriptions were secondary outcomes for which modified Poisson regression models were used.

Results

Compared to patients with a vaginal delivery, those with an ectopic pregnancy, a cesarean delivery, miscarriage, and an induced abortion had 84%, 46%, 119%, and 131% significantly higher odds of OUD (aOR [95% CI]: 1.84 [1.36, 2.48], 1.46 [1.29, 1.65], 2.19 [1.94, 2.47], and 2.31 [1.80, 2.96]) respectively. Among opioid naïve patients, all other obstetric procedure groups (besides miscarriage) had significantly higher risk of being prescribed new opioids than those with a vaginal delivery. Among those newly prescribed opioids, patients from all other obstetric procedure groups demonstrated a significantly higher risk of persistent opioid prescription compared to those who had a vaginal delivery.

Conclusion

The association between specific obstetric outcomes, notably miscarriage and induced abortions, and opioid use patterns should inform safer and more effective pain management in a maternal population.

Unwanted abortion disclosure and social support in the abortion decision and mental health symptoms: A cross-sectional survey

OBJECTIVES

To assess the extent of unwanted abortion disclosure and levels of social support in the abortion decision and their association with depression, anxiety, and stress.

STUDY DESIGN

From January to June 2019, we surveyed people presenting for abortion at four clinics in California, New Mexico, and Illinois regarding their experiences accessing abortion. We used multivariable regression to examine associations between unwanted abortion disclosure and social support in the abortion decision, and symptoms of depression, anxiety and stress.

RESULTS

Among 1092 people approached, 784 (72% response rate) eligible individuals initiated the survey, and 746 responded to the unwanted abortion disclosure item and were included in analyses. Over one-quarter (27%) told someone they would have preferred not to tell about their decision, mostly due to obstacles getting to the appointment-time to appointment (46%), travel distance (33%), and costs (32%). Three-quarters (74%, n=546) had at least one person in their life who supported the abortion decision "very much"; 20% had someone who supported the decision "not at all." In adjusted analyses, unwanted abortion disclosure was associated with more symptoms of depression (B = 0.62, 95% confidence interval: 0.28, 0.95), anxiety (B = 1.79; 95% CI: 0.76, 2.82) and stress (B = 1.80, 95% CI: 0.64, 1.72). People also had more symptoms of depression and stress when one or more person (B = 0.64; 95% CI: 0.27, 1.02 and B = 0.75, 95% CI: 0.15, 1.35, respectively) or the man involved in the pregnancy (B = 0.67, 95% CI: 0.16, 1.18 and B = 0.96, 95% CI: 0.13, 1.78, respectively) supported their decision "not at all" (vs "very much" support).

CONCLUSION

Being forced to disclose the abortion decision due to logistical and cost constraints may be harmful to people's mental health.

IMPLICATIONS

Logistical burdens such as travel, time to access care, and costs needed to access abortion may force people seeking abortion to involve others who are unsupportive in the abortion decision having negative implications for their mental health.

The Dobbs Decision and the Future of Occupational Health in the US

Access to abortion care has a profound impact on women's ability to participate in the workforce. In the US, restrictions on abortion care have waxed and waned over the years, including periods when abortion was broadly permitted across the nation for most pregnant people for a substantial proportion of pregnancy and times when restrictions varied across states, including states where abortion is banned for nearly all reasons. Additionally, access to abortion care has always been a reproductive justice issue, with some people more able to access this care than others even when it is structurally available. In June 2022, the US Supreme Court handed down the Dobbs v. Jackson Women's Health Organization, returning to states the ability to determine restrictions on abortion, including near-total bans on abortion. In this anthology, ten experts share their perspectives on what the Dobbs decision means for the future, how it will exacerbate existing, well-researched issues, and likely also create new challenges needing investigation. Some contributions are focused on research directions, some focus on implications for organizations, and most include both. All contributions share relevant occupational health literature and describe the effects of the Dobbs decision in context.

Design and study of psychometric properties of the Community Attitude to Abortion Scale (CAAS) with the Chilean population: Autonomy and Stigma

Introduction

Attitudes toward abortion are related to structural, cultural, and direct gender-based violence. This violence can affect women's mental, physical and reproductive health. Therefore, it is essential to know the nature of community attitudes toward abortion. Since we currently do not have an instrument that measures attitudes towards abortion in Chile, we set the objective of this study to design the Community Attitude to Abortion Scale (CAAS) and analyze its psychometric properties in a Chilean community population.

Methods

This work is an instrumental design study. Using a sampling of panelists by sociodemographic quotas, we obtained a sample of 1,223 participants with a mean age of 36.7 years (SD = 13.56).

Results

As a result, we obtained a scale of 18 items and two correlated factors, Autonomy and Stigma. This structure fits better as an Exploratory Structural Equations Model (ESEM). Both factors have excellent internal consistency. In addition, we obtained evidence of concurrent and discriminant validity: The scores on the factors of the Universal Religious Involvement Scale (I-E12) correlated negatively with Autonomy and positively with Stigma; participants with low levels of identification with a right-wing political orientation, with high levels of identification with a leftwing, pro-feminist, pro-LGBTQ +, and pro-euthanasia political orientation, obtained higher mean scores on Autonomy and lower on Stigma.

Discussion

The CAAS is an adequate tool for use with the Chilean community population, with evidence of consistency and validity. La CAAS is the first tool to measure attitudes to abortion in this country.

Randomized experimental testing of new survey approaches to improve abortion reporting in the United States

CONTEXT

Abortions are substantially underreported in surveys due to social stigma, compromising the study of abortion, pregnancy, fertility, and related demographic and health outcomes.

METHODS

In this study, we evaluated six methodological approaches identified through formative mixed-methods research to improve the measurement of abortion in surveys. These approaches included altering the placement of abortion items in the survey, the order of pregnancy outcome questions, the level of detail, the introduction to the abortion question, and the context of the abortion question, and using graduated sensitivity. We embedded a preregistered randomized experiment in a newly designed online survey about sexual and reproductive health behaviors (N = 6536). We randomized respondents to experimental arms in a fully crossed factorial design; we estimated an average treatment effect using standardized estimators from logistic regression models, adjusted for demographic covariates associated with reporting.

RESULTS

None of the experimental arms significantly improved abortion reporting compared to the control condition.

CONCLUSION

More work is needed to improve reporting of abortion in future surveys, particularly as abortion access becomes increasingly restricted in the United States. Despite this study's null results, it provides a promising path for future efforts to improve abortion measurement. It is proof of concept for testing new approaches in a less expensive, faster, and more flexible format than embedding changes in existing national fertility surveys.

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.

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.

Achieving universal reproductive health coverage for deaf women in Ghana: an explanatory study of knowledge of contraceptive methods, pregnancy and safe abortion practices

Background

The first world conference on sexual and reproductive health (SRH) in 1994 helped create the awareness that reproductive health is a human right. Over the years, attempts have been made to extend services to all persons; however, lapses persist in service provision for all in need. Recently, countries have been encouraged to target minority groups in their reproductive health service provision. However, studies have rarely attempted to develop deeper insights into the experiences of deaf men and women regarding their knowledge of SRH. The purpose of this study was to develop an in-depth understanding of the knowledge of deaf persons regarding services such as knowledge of contraceptive methods, pregnancy and safe abortion practices.

Methods

A sequential explanatory mixed-methods approach was adopted for this study. In the first quantitative phase, 288 deaf persons recruited from three out of the 16 regions in Ghana participated in this study. They completed a 31-item questionnaire on the main issues (knowledge of contraceptive methods, pregnancy and safe abortion practices) addressed in this study. In the second phase, a semi-structured interview guide was used to collect data from 60 participants who took part in the first phase. The key trend emerging in the first phase underpinned the interview guide used for the data collection. While the quantitative data were subjected to the computation of means, t-tests, analyses of variance, correlations and linear regressions to understand the predictors, the in-depth interviews were analysed using the thematic method of analysis.

Results

The results showed a convergence between the quantitative and qualitative data. For instance, the interview material supported the initial findings that deaf women had little knowledge of contraceptive methods. The participants offered reasons explaining their inability to access services and the role of religion in their understanding of SRH.

Conclusion

The study concludes by calling on policymakers to consider the needs of deaf persons in future SRH policies. The study limitations and other implications for future policymaking are discussed.

Fighting for abortion rights: Strategies aimed at managing stigma in a group of Italian pro-choice activists

Despite societal changes in Western countries, abortion continues to be morally stigmatized. While research on abortion stigma targeted both at people who seek or voluntarily terminate their pregnancy and abortion providers has been conducted, stigma directed at those who advocate abortion rights has remained under-researched. The purpose of this study was to deepen understandings of abortion stigma in relation to Italian cisgender female pro-choice activists. Accordingly, a qualitative study was conducted to examine how participants experienced, perceived, and internalized stigma, as well as the strategies they employed to manage it. The sample included 34 Italian cisgender female pro-choice activists who were actively engaged in movements at the time of the study, including organizations or unions that publicly defend the right to abort. The findings revealed that participants perceive they are targets of negative stereotyping and behaviors. Nevertheless, they do not internalize the stigma and use different strategies to manage it, such as speaking openly about their activism.

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.

Permeability of abortion care in the Netherlands: a qualitative analysis of women's experiences, health professional perspectives, and the internet resource of Women on Web

Despite a relatively permissive abortion law, women in the Netherlands encounter difficulties in accessing abortion care. Little is known about their experiences. This study explores women's experiences with (online) abortion services and relevant health professionals' experiences delivering care, with the goal of identifying key barriers encountered by abortion-seekers in the Netherlands. An exploratory qualitative research design with a constructivist approach and an abbreviated grounded theory method was used. Interviews with 20 women who had had an abortion and 14 health professionals who provide abortion care, and 200 emails of women seeking abortion care through the non-governmental organisation Women on Web, were coded inductively and deductively (using the Candidacy Framework) thereby generating themes. Abortion-seekers faced barriers including: (i) burden of taboo, (ii) vulnerability (emotional, financial, and social), (iii) health professional evaluation and (iv) disempowerment and distress. The overarching theme was women's lack of autonomy in access to abortion care. The key barriers to abortion access in the Netherlands are the institutionalisation of taboo in abortion law and care, complex candidacy regulations, lack of permeability for certain marginalised groups, and women's inability to speak openly about abortion. To increase the permeability of abortion care, and thereby women's autonomy, legislators and policy-makers must trust women to make their own reproductive decisions and avoid actions that stigmatise abortion and hinder access to care, while actively developing systemic support for vulnerable groups.

Disclosure to social network members among abortion-seeking women in low- and middle-income countries with restrictive access: a systematic review

Background

Health care for stigmatized reproductive practices in low- and middle-income countries (LMICs) often remains illegal; when legal, it is often inadequate, difficult to find and / or stigmatizing, which results in women deferring care or turning to informal information sources and providers. Women seeking an induced abortion in LMICs often face obstacles of this kind, leading to unsafe abortions. A growing number of studies have shown that abortion seekers confide in social network members when searching for formal or informal care. However, results have been inconsistent; in some LMICs with restricted access to abortion services (restrictive LMICs), disclosure appears to be limited.

Main body

This systematic review aims to identify the degree of disclosure to social networks members in restrictive LMICs, and to explore the differences between women obtaining an informal medical abortion and other abortion seekers. This knowledge is potentially useful for designing interventions to improve information on safe abortion or for developing network-based data collection strategies. We searched Pubmed, POPLINE, AIMS, LILACS, IMSEAR, and WPRIM databases for peer-reviewed articles, published in any language from 2000 to 2018, concerning abortion information seeking, communication, networking and access to services in LMICs with restricted access to abortion services. We categorized settings into four types by possibility of anonymous access to abortion services and local abortion stigma: (1) anonymous access possible, hyper stigma (2) anonymous access possible, high stigma (3) non-anonymous access, high stigma (4) non-anonymous access, hyper stigma. We screened 4101 references, yielding 79 articles with data from 33 countries for data extraction. We found a few countries (or groups within countries) exemplifying the first and second types of setting, while most studies corresponded to the third type. The share of abortion seekers disclosing to network members increased across setting types, with no women disclosing to network members beyond their intimate circle in Type 1 sites, a minority in Type 2 and a majority in Type 3. The informal use of medical abortion did not consistently modify disclosure to others.

Conclusion

Abortion-seeking women exhibit widely different levels of disclosure to their larger social network members across settings/social groups in restrictive LMICs depending on the availability of anonymous access to abortion information and services, and the level of stigma.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01165-0.

Women seeking an induced abortion in LMICs often face inexistent or inadequate, difficult to find and/ or stigmatizing legal services, leading to the use of informal methods and providers, and unsafe abortions. A growing number of studies have shown that abortion seekers contact social network members beyond their intimate circle when seeking care. However, results have been inconsistent. We searched Pubmed, POPLINE, AIMS, LILACS, IMSEAR, and WPRIM databases for peer-reviewed articles published in any language from 2000 to 2018, concerning abortion information seeking, communication, networking and access to services in restrictive LMICs. We screened 4101 references, yielding 79 articles with data from 33 countries for extraction. We grouped countries (or social groups within countries) into four types of settings: (1) anonymous access possible, hyper stigma; (2) anonymous access possible, high stigma; (3) non-anonymous access, high stigma; (4) non-anonymous access, hyper stigma. Most studies fitted Type 3. Disclosing to network members increased across setting types: no women confided in network members in Type 1 settings, a minority in Type 2 and a majority in Type 3. No setting fitted Type 4. The informal use of medical abortion did not modify disclosure to others. Abortion seekers in restrictive LMICs frequently contact their social network in some settings/groups but less frequently in others, depending on the availability of anonymous access to abortion care and the level of stigma. This knowledge is useful for designing interventions to improve information on safe abortion and for developing network-based data collection strategies.

Abortion stigma, class and embodiment in neoliberal England

Research on abortion stigma has given insight into how women experience abortion, tell stories about abortion, and make decisions about abortion. Stigma encompasses a range of feelings, experiences and discourses that can make having an abortion a negative experience or one that women might wish to conceal. This paper explores how abortion stigma is both classed and embodied, using the life stories of 15 middle-class women who have had abortions in England in 'neoliberal times'. It argues that the women's class position gave them access to various discursive resources with which to articulate their abortion stories, shaping their experiences and narration of stigma. It also draws attention to the ways in which both class and stigma are 'made through marking' on the body, and thus to the under-theorised embodied aspects of abortion stigma. In doing so, it argues that abortion stigma acts as a regulatory 'technology of the self' that is enabled by middle-class practices of self-control.

The economics of abortion and its links with stigma: A secondary analysis from a scoping review on the economics of abortion

BACKGROUND

Although abortions are a common aspect of people's reproductive lives, the economic implications of abortion and the stigmas that surround abortion are poorly understood. This article provides an analysis of secondary data from a scoping review on the economic impact of abortion to understand the intersections between stigma and economics outcomes at the microeconomic (i.e., abortion seekers and their households), mesoeconomic (i.e., communities and health systems), and macroeconomic (i.e., societies and nation states) levels.

METHODS AND FINDINGS

We conducted a scoping review using the PRISMA extension for Scoping Reviews. Studies reporting on qualitative and/or quantitative data from any world region were considered. For inclusion, studies must have examined one of the following microeconomic, mesoeconomic, or macroeconomic outcomes: costs, benefits, impacts, and/or value of abortion-related care or abortion policies. Our searches yielded 19,653 items, of which 365 items were included in our final inventory. As a secondary outcome, every article in the final inventory was screened for abortion-related stigma, discrimination, and exclusion. One quarter (89/365) of the included studies contained information on stigma, though only 32 studies included stigma findings directly tied to economic outcomes. Studies most frequently reported stigma's links with costs (n = 24), followed by economic impact (n = 11) and economic benefit (n = 1). Abortion stigma can prevent women from obtaining correct information about abortion services and laws, which can lead to unnecessary increases in costs of care and sizeable delays in care. Women who are unable to confide in and rely on their social support network are less likely to have adequate financial resources to access abortion.

CONCLUSIONS

Abortion stigma has a clear impact on women seeking abortion or post-abortion care at each level. Programmatic interventions and policies should consider how stigma affects delays to care, access to accurate information, and available social and financial support, all of which have economic and health implications.

Resisting abortion stigma in situ: South African womxn's and healthcare providers' accounts of the pre-abortion counselling healthcare encounter

Abortion providers and pregnant people who undergo abortion potentially face significant stigma. Researchers have started to explore how womxn respond to abortion stigma, usually focusing on individual strategies in managing or reducing stigma effects. Drawing on narrative data from research conducted on womxn's and healthcare providers' experiences of the pre-abortion healthcare encounter in the South African public health sector, we highlight how stigma may be resisted in social ways within this context. Everyday chatter and informal social support amongst womxn in the waiting room provided a counterpoint for health service providers' ascription of shame to the womxn, and a sense of solidarity amongst the womxn. Health service providers narrated their decision to do abortion work through the socially affirming hero canonical narrative, and womxn described their counselling as helpful. These social and discursive practices resist the awfulisation of abortion and provide relief for the womxn and the healthcare providers in particular contexts.

Abortion Reporting in the United States: An Assessment of Three National Fertility Surveys

Despite its frequency, abortion remains a highly sensitive, stigmatized, and difficult-to-measure behavior. We present estimates of abortion underreporting for three of the most commonly used national fertility surveys in the United States: the National Survey of Family Growth, the National Longitudinal Survey of Youth 1997, and the National Longitudinal Study of Adolescent to Adult Health. Numbers of abortions reported in each survey were compared with external abortion counts obtained from a census of all U.S. abortion providers, with adjustments for comparable respondent ages and periods of each data source. We examined the influence of survey design factors, including survey mode, sampling frame, and length of recall, on abortion underreporting. We used Monte Carlo simulations to estimate potential measurement biases in relationships between abortion and other variables. Underreporting of abortion in the United States compromises the ability to study abortion-and, consequently, almost any pregnancy-related experience-using national fertility surveys.

[Women's emotional accounts of induced abortion]

OBJECTIVE

To explore women's emotional accounts of induced abortion, analyzing qualitative scientific publications.

METHOD

Qualitative systematic review of 19 studies published in PubMed, Science Direct and Scopus from 2010 onwards. The articles based on qualitative research design were revised using inductive content analysis.

RESULTS

The analysis identified three main themes regarding women's emotional experiences: access to abortion, emotional impact during medical assistance, and individual, relational and sociocultural determinants. The studies showed the variability in women's emotional accounts, mainly determined by the following factors: Access and waiting times, health system, type of intervention, degree of awareness and participation regarding the use of technical and medical technologies, interaction with health professionals, and specificity of individual, relational and sociocultural context. The main emotional difficulties were related to the ethical conflict, the decision-making, the relation with the social and health system and stigma. As main facilitating aspects, women highlighted autonomy in decision-making and emotional support, while barriers referred to social rejection and negative messages perceived from the political, social and health system.

CONCLUSIONS

The emotional accounts around induced abortion depend on individual and relational factors, as well as on health assistance, all mediated by gender inequalities and bias. Improvements in health assistance refer to an integral and individualized attention, adapted to women's needs.

Perceived abortion stigma and psychological well-being over five years after receiving or being denied an abortion

OBJECTIVE

To prospectively assess perceptions of abortion stigma after receiving or being denied an abortion over 5 years, the factors associated with perceived abortion stigma, and the effects of perceived abortion stigma on psychological well-being.

METHODS

We recruited people seeking abortion from 30 facilities across the US, and interviewed them by phone one week post-abortion seeking, then semiannually for 5 years. We used adjusted mixed effects regression analyses to examine the abortion stigma trajectories of those who obtained an abortion near a facility's gestational age limit (Near-limits) compared to those denied an abortion because they were just over the limit and carried their pregnancies to term (Turnaway-births).

RESULTS

Of the 956 people recruited, we removed 28 due to ineligibility or missing data, leaving a final sample of 928. In unadjusted analyses, at one-week post-abortion seeking, over half of those seeking abortion perceived that if others knew they had sought an abortion, they would be looked down upon at least "a little bit" by people close to them (60%) or by people in their community (56%). In longitudinal adjusted analyses, people denied an abortion and who carried their pregnancies to term (Turnaway-birth group) reported significantly lower baseline perceived abortion stigma from people close to them (-0.38; 95% CI, -0.59, -0.16) and from people in their community (0.30; 95% CI, -0.52, -0.08), than Near-limits, differences that remained statistically significant for 1.5 years. Overall perceived abortion stigma declined significantly (p < .001) for both study groups. High perceived abortion stigma at baseline was associated with higher odds of experiencing psychological distress years later (adjusted Odds Ratio, 3.98; 95% CI, 1.39, 11.37).

CONCLUSIONS

Most people considering abortion perceive some abortion stigma, which is associated with psychological distress years later.

Story Circles and abortion stigma in Mexico: a mixed-methods evaluation of a new intervention for reducing individual level abortion stigma

This study presents the results of an evaluation of a Story Circles intervention to reduce individual level abortion stigma among women who have experienced abortion in Mexico. Using a mixed-methods approach, the study explored whether participation in the intervention reduced 18 women's experience of stigma one month after having participated. The study used the Individual Level Abortion Stigma Scale (ILAS Scale), qualitative interviews and focus groups to gain an understanding of women's experiences of the intervention and any changes in stigmatising feelings. Findings suggest that the Story Circles offered women a place to talk about their abortion in an affirmative and supportive environment, unlike the context of their daily lives where stigma generated silence and affected their well-being. Participants were able to build trust, share their experiences, create connections and transform their perception of their abortion from a negative experience to one that was empowering and life-affirming. This also led to other significant positive changes in their lives. The paper offers recommendations about programme and intervention design and implementation for practitioners working to reduce individual level stigma among women who have experienced abortion.

Estimating abortion prevalence and understanding perspectives of community leaders and providers: Results from a mixed-method study in Istanbul, Turkey

OBJECTIVES

Abortions are difficult to measure; yet, accurate estimates are critical in developing health programs. We implemented and tested the validity of a list experiment of lifetime abortion prevalence in Istanbul, Turkey. We complemented our findings by understanding community perspectives using in-depth interviews with key informants.

METHODS

We conducted a household survey between March and June 2018. In a random sample of 4040 married women aged 16-44 years, we implemented a double list experiment. We averaged difference in mean values calculations between the average counts for each list to provide an estimated lifetime abortion prevalence. We conducted in-depth interviews with 16 key informants to provide insights into possible explanations for the quantitative results.

RESULTS

The abortion prevalence estimate from the list experiment was close to that of the direct question (3.25% vs 2.97%). Key informant narratives suggest that differing definitions of abortion, inaccessibility, provider bias, lack of knowledge of abortion laws and safety, and religious norms could contribute to under-reporting. Results from the qualitative study suggest that abortion is largely inaccessible and highly stigmatized.

CONCLUSION

Measuring experiences of abortion is critical to understanding women's needs and informing harm-reduction strategies; however, in highly stigmatized settings, researchers may face unique challenges in obtaining accurate reports.

Increasing misreporting levels of induced abortion in Turkey: is this due to social desirability bias?

Women tend to under-report or misreport their abortion experiences, mainly because abortion is considered a sensitive issue for cultural, religious, political or other reasons in many countries across the world. Turkey, where induced abortion is an increasingly sensitive issue due to intense statements against induced abortion on religious grounds by influential politicians, and a hidden agenda to prohibit the practice, especially in public health facilities, in recent years, is no exception. This study focused on the increase in level of misreporting of induced abortion in Turkey and its link to social desirability bias using pooled data from 1993 and 2013 Turkish Demographic and Health Surveys. A probabilistic classification model was used to classify women's reported abortions. The findings confirmed that the level of misreporting of induced abortions has increased from 18% to 53% among all terminated pregnancies over the period 1993-2013 in Turkey. This marked increase, especially among women in the lower socioeconomic sections of society, may be largely associated with the prevailing political environment, and increase in social stigmatization against induced abortion in Turkey over recent decades.

Written narratives from immigrants following a prenatal diagnosis: qualitative exploratory study

Background

Expectant parents often have optimistic expectations of the obstetric ultrasound examination and are unprepared for a diagnosis of foetal anomaly. Research that gives voice to the experiences of immigrants faced with a prenatal diagnosis is scarce, and there is a need for more exploratory research that provides insights into the experiences of these persons. The aim of this study was to explore narratives of experiences of immigrants with Arabic or Sorani interpreter needs when presented with a prenatal diagnosis of foetal anomaly.

Methods

A web-based tool with open-ended questions was distributed via Arabic and Kurdish non-profit associations and general women’s associations in Sweden. Responses were received from six women and analysed with qualitative content analysis.

Results

The analysis resulted in three themes: (1) an unexpected hurricane of emotions, (2) trying to understand the situation though information in an unfamiliar language, and (3) being cared for in a country with accessible obstetric care and where induced abortion is legal.

Conclusions

Immigrant women described an unexpected personal tragedy when faced with a prenatal diagnosis of foetal anomaly, and emphasised the importance of respectful and empathic psychological support. Their experiences of insufficient and incomprehensible information call attention to the importance of tailored approaches and the use of adequate medical interpreting services. There is a need for more descriptive studies that investigate decision-making and preparedness for induced abortion among immigrants faced with a prenatal diagnosis.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2292-9) contains supplementary material, which is available to authorized users.

Beyond autonomy and care: Experiences of ambivalent abortion seekers

BACKGROUND

While being prepared for abortions, some women experience decisional ambivalence during their encounters with health personnel at the hospital. Women's experiences with these encounters have rarely been examined.

OBJECTIVE

The objective of this study was to explore ambivalent abortion-seeking women's experiences of their encounters with health personnel.

RESEARCH DESIGN

The data were collected in individual interviews and analysed with dialogical narrative analyses.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 13 women (aged 18-36 years), who were uncertain of whether to terminate their pregnancies during the first trimester, were interviewed before and after they made their decisions. The participants were recruited at six Norwegian outpatient clinics.

ETHICAL CONSIDERATIONS

Approval was granted by the Regional Committee for Medical and Health Research Ethics.

FINDINGS

The ambivalent pregnant women sought to make autonomous decisions while simultaneously involving their closest confidants and health personnel in the process. The following three types of narratives of women's experiences with encounters with health personnel were identified: the respected women; the identified women; and the abandoned women.

DISCUSSION

The findings are discussed in terms of the ambivalent pregnant woman's autonomous responsibility in considering an abortion and how her autonomy can be enabled or impaired during encounters with health personnel.

CONCLUSION AND IMPLICATION

Although the women considered themselves autonomous and responsible for their final decisions, they wished health personnel were involved in their situations. The health personnel contributed by enabling or disabling the possibility of decision-making in accordance with the women's values. The findings indicate that health personnel who care for women considering abortions must be trained in dialogical competence.

Contraception and abortion knowledge, attitudes and practices among adolescents from low and middle-income countries: a systematic review

Background

Adolescents face significant barriers to contraception access and utilization that result in adverse health effects of early pregnancy and childbirth. Unsafe abortions continue to occur partly due to failure to prevent pregnancies, with Sub-Saharan Africa contributing the most significant burden of all unsafe abortions among young people globally, of which a quarter occurs in those aged 15–19 years. We aimed to conduct a systematic review of the contraceptive and abortion knowledge, attitudes and practices of adolescents in low and middle-income countries to increase the understanding of the sexual and reproductive health dynamics that they face.

Methods

Literature searches from 6 databases; PubMed, Science Direct, Google Scholar, BioMed Central, CINAHL, MEDLINE, were conducted, covering the period from 1970 to 2016 and concerning the adolescents aged 15–19 years and 21 studies were read and analyzed using thematic analysis.

Results

Limited knowledge about sexual and reproductive health among adolescents was a significant cause of reduced access to contraception and safe abortion services, especially among unmarried adolescents. Reduced access to reproductive health services for some resulted in extreme methods of contraception and abortion such as the use of battery acid and crushed bottles. Despite all adolescents having limited access to information and services, girls faced more consequences such as being blamed for pregnancy or dealing with the effects of unsafe abortions. Parents, health workers, and teachers were cited as trusted sources of information but often received the most information from peers and other family members instead, and the girls mostly confided in their aunties, cousins and peers while the boys resorted to peers, media and even pornography.

Conclusion

The reported observations suggest severe limitations in the access to safe and effective methods of contraception and safe abortion services. There is a need for an urgent response in reducing the “unmet needs” for contraception and to improve access to contraception, abortion information, and services in this group. Interventions which target the involvement of parents and teachers should be considered, to carry one wholesome message to the adolescents.

Medical termination of pregnancy service delivery in the context of decentralization: social and structural influences

Background

Medical termination of pregnancy (MToP) is a safe and acceptable abortion option. Depending on country context, MToP can be administered by general practitioners and mid-level healthcare providers in the first and second trimesters of pregnancy. Like other high-income countries, a range of social and structural barriers to MToP service provision exist in Australia. To counter some of these barriers, geographic decentralization of MToP was undertaken in rural Victoria, Australia, through training service providers about MToP to increase service delivery opportunities. The aim of this study was to investigate the factors that enabled and challenged the decentralization process.

Methods

Face-to-face and telephone interviews were undertaken between April and June 2016 with a purposeful sample of six training providers and 13 general practitioners (GP) and nurse training participants. Study participants were asked about their perceptions of motivations, enablers and challenges to MToP provision. A published conceptual framework of synergies between decentralization and service delivery was used to analyse the study findings.

Results

Three key themes emerged from the study findings. First, the effort to decentralize MToP was primarily supported by motivations related to making service access more equitable as well as the willingness of training providers to devolve their informal power, in the form of MToP medical expertise, to training participants. Next, the enablers for MToP decentralization included changes in the regulatory environment relating to decriminalization of abortion and availability of required medication, formation of partnerships to deliver training, provision of MToP clinical resources and local collegial support. Finally, challenges to MToP decentralization were few but significant. These included a lack of a state-wide strategy for service provision, provider concerns about coping with service demand, and provider stigma in the form of perceived negative community or collegial attitudes. These were significant enough to create caution for GPs and nurses considering service provision.

Conclusions

Decentralization concepts offer an innovative way for reframing and tackling issues associated with improving MToP service delivery. There is scope for more research about MToP decentralization in other country contexts. These findings are important for informing future rural MToP service expansion efforts that improve equity in service access.

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.

Effect of ACASI on Reporting of Abortion and Other Pregnancy Outcomes in the US National Survey of Family Growth

Abortion is a behavior that is stigmatized and difficult to measure. To improve reporting of abortion and other sensitive behaviors in the United States, the National Survey of Family Growth (NSFG) supplements the interviewer administered face-to-face (FTF) interview with audio computer-assisted self-interviewing (ACASI). This paper estimates differential reporting of abortion and other pregnancy outcomes (miscarriage, live birth) in the NSFG (2002, 2006-2010, 2011-2015) between women's ACASI and FTF interviews. Examining reporting of less stigmatized pregnancy outcomes can help understand the relative contributions of stigma and survey-level factors in reporting of abortions. More women reported abortions, miscarriages and births in the ACASI than the FTF interview. Differences in reporting were moderated by the length of recall. The ACASI elicited relatively more reporting of abortions and miscarriages among non-white and low-income women. Reporting ratios increased over time. ACASI is a tool that may work differently across time, for different measures, and with varying survey contexts.

Correlates of individual-level abortion stigma among women seeking elective abortion in Nigeria

Objective

This study aimed to measure individual-level abortion stigma (ILAS) and determine its correlates among women receiving safe elective abortion services.

Patients and methods

Data were collected from a cross-section of women who received safe elective abortion services in select intervention health facilities. Respondents were recruited through a self-selection sampling. ILAS was assessed using a 16-item scale (Cronbach’s alpha =0.9122). Respondents were categorized as high (summed score >40) or low ILAS (summed score ≤40) on a spectrum of a summed minimum score of 16 to a maximum score of 64. A log-binomial regression model was constructed to determine the ILAS correlates.

Results

Among 382 respondents, 43% expressed high ILAS. Women’s age and education, provider’s cadre and type of abortion procedure were significant correlates in the model. Older women (age 25–34 and age ≥35) were less likely (prevalence ratio [PR]=0.60 and 0.39, p<0.001) to express high ILAS than the younger women (age ≤24); those with higher educational status were more likely to express (PR=1.64, p<0.05) high ILAS than those with None/Primary education; those who had medical abortion were less likely (PR=0.54, p<0.01) to express high ILAS than those who had surgical abortion; and lastly, those who received care from midlevel providers were more likely (PR=1.31, p<0.05) to express high ILAS than those who received care from physicians.

Conclusion

High ILAS still exists among women accessing safe elective abortion care in Nigeria. Therefore, interventions at all levels of the socioecological model of abortion stigma need to be considered to address this societal problem that affects and impacts women.

Eliminating the high abortion related complications and deaths in Cameroon: the restrictive legal atmosphere on abortions is no acceptable excuse

BACKGROUND

The abortion law in Cameroon is highly restrictive. The law permits induced abortions only when the woman's life is at risk, to preserve her physical and mental health, and on grounds of rape or incest. Unsafe abortions remain rampant with however rare reported cases of persecution, even when these abortions are proven to have been carried out illegally.

DISCUSSION

Available public health interventions are cheap and feasible (Misoprostol and Manual Vacuum Aspiration in post abortion care, modern contraception, post-abortion counseling), and must be implemented to reduce unacceptably high maternal mortality rates in the country which still stand at as high as 596/100.000. Changes in the legal status of abortions might take a long time to come by. Albeit, advocacy efforts must be reinforced to render the law more liberal to permit women to seek safe abortion services. The frequency of abortions, generally clandestine, in this restrictive legal atmosphere has adverse economic, health and social justice implications.

CONCLUSION

We argue that a non-optimal or restrictive legal atmosphere is not an acceptable excuse to justify these high maternal deaths resulting from unsafe abortions, especially in Cameroon where unsafe abortions remain rampant. Implementing currently available, cheap and effective evidence based practice guidelines are possible in the country. Expansion and use of Manual Vacuum Aspiration kits in health care facilities, post-abortion misoprostol and carefully considering the content of post abortion counseling packages deserve keen attention. More large scale qualitative and quantitative studies nationwide to identify and act on context specific barriers to contraception use and abortion related stigma are urgently needed.

Internalized Stigma and Stigma-Related Isolation Predict Women’s Psychological Distress and Physical Health Symptoms Post-Abortion

Researchers have provided evidence that accessing abortion relates to anticipated, experienced, and internalized stigma. These aspects of stigma have previously been associated with increased psychological distress and physical health symptoms. However, there has been no research on how anticipation, perception, internalization, and stigma-related isolation are related to psychological distress and somatic (physical) symptoms. We examined this question in an online volunteer sample of women in Ireland ( N = 155) who have had an abortion. Internalized stigma and stigma-related isolation significantly predicted higher levels of psychological distress, and internalized stigma also significantly predicted somatic symptoms. The direct effect of each type of stigma on somatic symptoms was mediated by psychological distress. Thus, to the extent that women had internalized greater stigma and isolated themselves, they also reported increased psychological distress, and this psychological distress predicted increased somatic symptoms. The relation between internalized stigma and somatic symptoms was also moderated by stigma-related isolation. Our findings complement and extend the existing literature on the relations between stigmatized identities, psychological distress, and physical health problems, particularly regarding women who have accessed abortion. They also indicate that those involved in policy-making and activism around reproductive rights should avoid inadvertently increasing the stigma surrounding abortion.

"I Just Don't Know": An Exploration of Women's Ambivalence about a New Pregnancy

PURPOSE

We sought to examine how ambivalence manifests in women's lives after confirmation of a new pregnancy by exploring women's feelings, attitudes, and experiences regarding pregnancy intentions, the news itself, and related pregnancy decision making.

STUDY DESIGN

We recruited women aged 15 to 44 and at less than 24 completed weeks of gestational age from urban, walk-in pregnancy testing clinics in New Haven, Connecticut, from June 2014 to June 2015. We obtained quantitative and qualitative data via an enrollment survey and face-to-face, semistructured interviews, respectively. Transcripts were analyzed using framework analysis.

RESULTS

The sample included 84 women. Participants had a mean age of 26 years and were on average 7 weeks estimated gestational age at enrollment. Most identified as Black (54%) or Hispanic (20%), were unmarried (92%), and had at least one other child (67%). More than one-half (55%) described feelings of ambivalence regarding their current pregnancy. We identified ambivalence as a frequent and complex thread that represented distinct but overlapping perspectives about pregnancy: ambivalent pregnancy intentions, ambivalent response to new diagnosis of pregnancy, and ambivalence as uncertainty or conflict over pregnancy decision-making. Sources of ambivalence included relationship status, pregnancy timing, and maternal or fetal health problems.

CONCLUSIONS

This study improves on previous findings that focus only on ambivalence related to pregnancy intention or to decision making, and explores women's mixed, fluctuating, or unresolved feelings and attitudes about pregnancy before many participants had completed pregnancy decision making. Acknowledging and exploring sources of ambivalence regarding pregnancy may help health providers and policymakers to comprehensively support women with respect to both their experiences and reproductive goals.

If, when, and how to discuss available abortion services in the primary care setting

Many women prefer to receive abortion care with their primary care provider; yet, prior studies have suggested that women do not know or assume that their provider does not offer abortion care. Our objective was to explore if, when, and how women wish to be informed of available abortion services at their primary care clinics. We conducted interviews with 21 women at their primary care site during June-July 2014. Vignettes were used to identify clinic visit types in which information regarding abortion services would be welcome and appropriate and inappropriate ways for providers to inform patients of these services. All participants were open to provider-initiated discussion of available abortion services, particularly during women's wellness exams or contraception visits. Themes associated with appropriate communication of abortion services included: 1) using sensitive language, 2) respect for and assessment of patient beliefs, and 3) contextualizing abortion services within reproductive health. Advantages to discussing available abortion services included strengthening the patient-provider relationship and improved awareness of the spectrum of services offered. Routine inclusion of abortion services counseling may help educate patients about available services, strengthen the patient-provider relationship, and reduce the stigma surrounding abortion care.

Mixed-methods investigation of women's experiences with second-trimester abortion care in the Midwest and Northeast United States

OBJECTIVE(S)

We studied women's experiences seeking and receiving second-trimester abortion care in two geographically and legislatively different settings to inform ways to improve abortion care access and services.

STUDY DESIGN

We conducted in-depth interviews with women who obtained second-trimester abortion care. Themes from the interviews were then used to inform a self-administered survey, which was completed by 108 women who received second-trimester abortion care in the Northeast and Midwest. We calculated descriptive statistics and used chi-squared and t-tests to compare responses.

RESULTS

We interviewed eight women and surveyed 108 women. Most interviewees and 65.2% of survey respondents reported difficulties accessing care. Although most interview and survey respondents had insurance, a slight majority reported difficulty funding care. All interviewees and 57.9% of survey respondents reported positive experiences with providers, with many interviewees and 62.0% of survey respondents saying their abortion care was better than their usual health care. Most interviewees and 75.8% of survey respondents reported pain as low to moderate, and the majority of participants reported it was the same or less than expected. Knowledge about abortion restrictions was low. Most interviewees and 68.4% survey respondents disagreed with restrictions on insurance coverage of abortion. Common recommendations to improve experiences were to ensure travel and financial support and to decrease wait times at clinics. There were few regional differences among outcomes.

CONCLUSION(S)

Women seeking second-trimester abortion in these locations reported positive abortion experiences. However, they had to overcome significant obstacles to obtain care.

IMPLICATIONS

This is the first study to systematically research women's second-trimester care experiences in two different regions of the United States. Regardless of location, women experienced barriers due to policies that impose gestational age restrictions, limit provider availability (consequently increasing wait times), and increase costs. Policy change to reduce these barriers is critical to improve access to and experiences with second trimester abortion care.

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.

Articulating reproductive justice through reparative justice: case studies of abortion in Great Britain and South Africa

Public health and rights-based approaches to abortion advocacy are well established. Feminists are, however, increasingly using a broader framework of 'reproductive justice', which considers the intersecting conditions that serve to enhance or hinder women's reproductive freedoms, including their capacities to decide about the outcome of their pregnancies. Nonetheless, reproductive justice approaches to abortion are, conceptually, relatively under-developed. We introduce a reparative justice approach as a method of further articulating the concept of reproductive justice. We first explain how this approach can be used to conceptualise safe, accessible and supportive abortion as a key element of reproductive justice in relation to the injustice of unwanted or unsupportable pregnancies. Using Ernesto Verdeja's critical theory of reparative justice and case studies of two countries (South Africa and Great Britain) where abortion is legal, we show how such an approach enables an analysis of reproductive justice within the specificities of particular contexts. We argue that both the rights-based legal framework adopted in South Africa and the medicalised approach of British law have, in practice, limited reparative justice in these contexts. We discuss the implications of reparative justice for abortion advocacy.

Internalised abortion stigma: Young women’s strategies of resistance and rejection

This paper examines the ways in which young women articulated strategies of resistance to internalised abortion stigma. It does so through secondary analysis of young women’s narratives from two qualitative studies in England and Wales. Whilst participants felt stigmatised by their abortion[s] in different ways, many also resisted stigmatisation. They did this through different stigma resistance strategies that were shaped by a number of different interactions: their socio-economic situations, family and relationships contexts, the circumstances in which they became pregnant, and their beliefs and values with respect to abortion and motherhood. Being able to construct their abortion decision as morally sound was an important element of stigma resistance. Although socio-cultural norms and values on abortion, reproduction, and motherhood were shown to constrain women’s reproductive choices, these norms were all open to challenge. The women were more likely to struggle with their abortion decision-making when they had internalised negativity around abortion.

Untroubling abortion: A discourse analysis of women's accounts

In this paper, I highlight key differences between a discourse analytic approach to women's accounts of abortion and that taken by the growing body of research that seeks to explore and measure women's experiences of abortion stigma. Drawing on critical analyses of the conceptualisation of stigma in other fields of healthcare, I suggest that research on abortion stigma often risks reifying it by failing to consider how identities are continually re-negotiated through language-use. In contrast, by attending to language as a form of social action, discursive psychology makes it possible to emphasise speakers' capacity to construct "untroubled" (i.e. non-stigmatised) identities, while acknowledging that this process is constrained by the contexts in which talk takes place. My analysis applies these insights to interviews with women concerning their experiences of having an abortion in England. I highlight three forms of discursive work through which women navigate "trouble" in their accounts of abortion, and critically consider the resources available for meaning-making within this particular context of talk. In doing so, I aim to provoke reflection about the discursive frameworks through which women's accounts of abortion are solicited and explored.

Abortion Stigma Among Low-Income Women Obtaining Abortions in Western Pennsylvania: A Qualitative Assessment

CONTEXT

Abortion stigma may cause psychological distress in women who are considering having an abortion or have had one. This phenomenon has been relatively underexplored in low-income women, who may already be at an increased risk for poor abortion-related outcomes because of difficulties accessing timely and safe abortion services.

METHODS

A qualitative study conducted between 2010 and 2013 used semistructured interviews to explore pregnancy intentions among low-income women recruited from six reproductive health clinics in Western Pennsylvania. Transcripts from interviews with 19 participants who were planning to terminate a pregnancy or had had an abortion in the last two weeks were examined through content analysis to identify the range of attitudes they encountered that could contribute to or reflect abortion stigma, the sources of these attitudes and women's responses to them.

RESULTS

Women commonly reported that partners, family members and they themselves held antiabortion attitudes. Such attitudes communicated that abortion is morally reprehensible, a rejection of motherhood, rare and thus potentially deviant, detrimental to future fertility and an irresponsible choice. Women reacted to external and internal negative attitudes by distinguishing themselves from other women who obtain abortions, experiencing negative emotions, and concealing or delaying their abortions.

CONCLUSIONS

Women's reactions to antiabortion attitudes may perpetuate abortion stigma. Further research is needed to inform interventions to address abortion stigma and improve women's abortion experiences.

Abortion Stigma: A Systematic Review

CONTEXT

Although stigma has been identified as a potential risk factor for the well-being of women who have had abortions, little attention has been paid to the study of abortion-related stigma.

METHODS

A systematic search of the databases Medline, PsycArticles, PsycInfo, PubMed and Web of Science was conducted; the search terms were "(abortion OR pregnancy termination) AND stigma^* ." Articles were eligible for inclusion if the main research question addressed experiences of individuals subjected to abortion stigma, public attitudes that stigmatize women who have had abortions or interventions aimed at managing abortion stigma. To provide a comprehensive overview of this issue, any study published by February 2015 was considered. The search was restricted to English- and German-language studies.

RESULTS

Seven quantitative and seven qualitative studies were eligible for inclusion. All but two dated from 2009 or later; the earliest was from 1984. Studies were based mainly on U.S. samples; some included participants from Ghana, Great Britain, Mexico, Nigeria, Pakistan, Peru and Zambia. The majority of studies showed that women who have had abortions experience fear of social judgment, self-judgment and a need for secrecy. Secrecy was associated with increased psychological distress and social isolation. Some studies found stigmatizing attitudes in the public. Stigma appeared to be salient in abortion providers' lives. Evidence of interventions to reduce abortion stigma was scarce. Most studies had limitations regarding generalizability and validity.

CONCLUSION

More research, using validated measures, is needed to enhance understanding of abortion stigma and thereby reduce its impact on affected individuals.

Aborto e estigma: uma análise da produção científica sobre a temática

Resumo O artigo objetiva analisar a produção científica sobre aborto e estigma social e o potencial da categoria estigma para estudos sobre a assistência ao abortamento no Brasil. Utilizou-se o método de revisão integrativa de publicações das bases científicas, optando por não estabelecer limite temporal. Analisou-se 65 publicações com as representações sociais de mulheres que abortam e de profissionais que as atendem; exploram os obstáculos para a implementação das leis do aborto e dos protocolos e normas que facilitariam o acesso a serviços de qualidade. À relevância conceitual de Erving Goffman somou-se a compreensão sobre a transgressão dos estereótipos de gênero, o imperativo da maternidade, a pureza sexual, que marca as mulheres que abortam como seres inferiores, deteriorados: promíscuas, pecadoras, assassinas. Identificaram-se grupos mais afetados pela estigmatização: mulheres em abortamento, profissionais de saúde. O conflito feminino pela dualidade ocultar/revelar seus abortamentos, a objeção de consciência de profissionais e os obstáculos na implementação de políticas públicas emergiram dos trabalhos. A reflexão sobre o papel do estigma pode interferir no ciclo do aborto clandestino e contribuir para o (re) desenho de intervenções que apoiem a redução de danos à saúde sexual e reprodutiva das mulheres.

Experiences of termination of pregnancy for a fetal anomaly: A qualitative study of virtual community messages

OBJECTIVE

to explore experiences described by posters in Swedish virtual communities before, during and after termination of pregnancy due to a fetal anomaly.

DESIGN

cross-sectional qualitative study of messages in virtual communities. The messages were purposefully selected in 2014 and analyzed with inductive qualitative manifest content analysis.

SETTING

two large and active Swedish virtual communities.

SAMPLE

1623 messages from 122 posters (112 females, 1 male, and 9 did not disclose their sex), written between 2008 and 2014. The majority of the posters were females (91%) with recent experience of termination of pregnancy following different prenatal diagnoses (63% less than one year since the termination).

MEASUREMENTS AND FINDINGS

before the termination, posters experienced an emotional shock and a difficult decision. During the termination, they needed compassionate care from present caregivers, experienced intense emotional and physical pain, lacked an understanding about the abortion, and expressed varied feelings about the option to view the fetus. After the termination, posters used different strategies to come to terms with and accept the decision, experienced a perinatal loss, expressed fears of recurrence, and longed for a new child.

KEY CONCLUSIONS

spanning across the time before, during and after the abortion, women who terminate a pregnancy due to a fetal anomaly express considerable physical and emotional pain, with psychosocial and reproductive consequences.

IMPLICATIONS FOR PRACTICE

information and preparation, including the decision whether or not to view the fetus, are important aspects to consider when caring for individuals who have decided to terminate a pregnancy for a fetal anomaly. The findings indicate a need for structures that offer support to women who suffer from fears of recurrence in future pregnancies.