Access to and experience of later abortion: accounts from women in Scotland

Characteristics of patients requesting an abortion beyond 14 weeks of gestation: Retrospective study in Brussels

OBJECTIVES

The debate over extending the legal time limit for abortion in Belgium has intensified in recent years. Health care providers must refer patients seeking abortion beyond the legal deadline to other countries, such as the Netherlands, where the time limits are more permissive. In light of this situation, we analyzed the demographic and social characteristics of patients requesting abortion after 14 weeks of gestation and compared them with those seeking the procedure within the legal limits.

STUDY DESIGN

This retrospective study examines the sociodemographic characteristics of individuals requesting abortion at City Planning Brussels between January 1, 2022, and March 30, 2023. We employed logistic regression to identify predictive factors for late abortion.

RESULTS

We analyzed 627 abortion requests, with 593 occurring before 14 weeks and 34 after 14 weeks. Patients seeking abortion due to precarity or rape had a higher risk of presenting beyond the legal time limit (odds ratio [OR] 3.64, p = 0.001, and OR 3.96, p = 0.009, respectively). Factors that appeared to reduce this risk included requests for abortion based on personal reasons (lack of desire for a child) and being covered by mutual health insurance (OR 0.22, p < 0.001, and OR 0.25, p = 0.001).

CONCLUSIONS

Management of late abortion in Belgium is difficult due to law's restriction. Our data indicate that the circumstances resulting in late abortion requests are often complex, frequently involving factors such as financial difficulties and precarity. A law modification is necessary to provide uniform and effective care for these patients.

IMPLICATIONS

Since late abortion requests predominantly come from vulnerable patients, revising the law is essential to ensure consistent and equitable care for these individuals. These patients often encounter penalties due to their personal and financial challenges, highlighting the need for a legal framework that better addresses their specific circumstances.

The impact of gestational age limits on abortion-related outcomes: a synthesis of legal and health evidence

BACKGROUND

Gestational age limits (GLs) are common in abortion laws and policies. They restrict when lawful abortion may be accessed by reference to the gestational duration of a pregnancy, in some cases specifying that abortion is a criminal offense after, but not before, the GL. This synthesis of legal and health evidence addresses knowledge gaps on the health and non-health outcomes plausibly related to the effects of GLs on abortion-related outcomes.

METHODS

This paper synthesizes the results of a systemic review with the identification and application of relevant international human rights standards. A search strategy was drawn up to capture public health, international human rights law, and policy evidence related to the impacts of GLs. We limited our search to papers published in English since 2010, including quantitative studies (comparative and non-comparative), qualitative and mixed-methods studies, reports, PhD theses, and economic or legal analyses. Only studies that undertook original data collection or analysis were included. Review of treaties, opinions, interpretations, general comments, and special procedures of UN human rights bodies identified relevant human rights standards, which were then synthesized with the extracted data to create a comprehensive evidence synthesis.

RESULTS

GLs do not prevent people from seeking abortion but do operate as a regulatory barrier that can result in people seeking abortion outside of the formal health system or unwillingly continuing pregnancy. In many jurisdictions, they interact with the criminalization of abortion, with significant health and non-health impacts. GLs impact most on people who are least able to access abortion because of later detection of pregnancy, lack of access to abortion provision, and lack of access to the resources required to avail of abortion.

CONCLUSIONS

Although paradigmatic in abortion law, GLs are not based on evidence of either the safety or effectiveness of abortion or the needs and preferences of pregnant people. They produce rights-limiting impacts for pregnant people and, in some cases, result in arbitrary and disproportionate violations of legally protected rights. The persistence of GLs as part of the regulatory framework for abortion provision cannot be said to ensure an enabling environment for quality abortion care.

A global scoping review of the circumstances of care seeking for abortion later in pregnancy

Understanding the circumstances of abortions later in pregnancy provides insight about the barriers and delays to timely care. Limited synthesized information is available on these circumstances, especially from low and middle incomes countries. Reviewing what is reported in the literature about the circumstances of abortion later in pregnancy and the methodological approaches used to study this is needed to reveal evidence gaps. The purpose of this study is to describe what is documented and methodological approaches used in existing literature on the circumstances and characteristics associated with seeking care for abortion later in pregnancy reported in population and facility-based studies. We conducted a scoping review of peer-reviewed research in OVID/PubMed, Embase, Scopus, SocIndex, and LILACs from 2007-2024 that described the circumstance, sociodemographic characteristics, population- or facility-based proportion of abortion later in pregnancy (≥12 weeks of gestation or "second trimester") reported in the literature. We screened 2598 records by title and/or abstract and 668 of those by full text. We included 78 studies that described the circumstances around seeking care for abortion later in pregnancy from qualitative data (12 studies); included information on associated characteristics from quantitative data (15 studies); reported a population- (17 studies) or facility-based (45 studies) proportion of abortion later in pregnancy. Prominent themes included health system challenges, late pregnancy recognition, financial challenges, and delayed decision making. Low economic status and adolescence were commonly associated characteristics. Population and facility-based studies lacked standardization when reporting durations of gestation. Facility studies reported a wide variety of populations and number of facilities. Circumstances surrounding abortions later in pregnancy include health system challenges, late pregnancy recognition, financial issues, and delayed decision-making, which intersect to compound and extend delays. More research guided by clear methods and standard definitions when reporting on population and facility-based proportions of abortions later in pregnancy is needed to reveal evidence gaps and better inform policies and programs.

"It was a foregone conclusion": a qualitative study of women's experiences and meaning-making of later-in-life abortion in Belgium

Abortion is an indispensable healthcare service for women of all reproductive ages. Research on abortion is often focused on younger women, neglecting those who are closer to the end of their reproductive lifespan. This study presents findings from qualitative interviews with Belgian women who had an abortion at the age of 40 or older, conducted between May 2022 and April 2023. Using interpretative phenomenological analysis, we explored the experiences and decision-making processes of women who had abortions later in life. We identified three main themes. First, the women's families were at the centre of their abortion decisions, with some women also presenting advanced age as a significant factor in their decision-making. This emphasis on age was connected to perceived social norms about appropriately timed childbearing. Second, the women experienced their unplanned pregnancies as both physically and emotionally demanding, and desired to terminate them as soon as possible. Some participants felt additional emotional burdens because of delays caused by the mandatory waiting period and/or busy schedules at abortion centres. Third, the women expressed feelings of self-blame for their unplanned pregnancies. This self-blame was closely tied to their expectation of social disapproval, which made them cautious to share their abortion experience with people in their social circle. This study enhances our understanding of the experiences and meaning-making of abortion in women of advanced reproductive age. It highlights the need to destigmatise the topic and the importance for professionals and researchers to consider family preservation and advanced reproductive age as potential factors shaping abortion decision-making.

Magnitude of late presentation for induced abortion care services and the associated factors among reproductive-age women at selected hospitals in the South Gondar district of Northwest Ethiopia in 2023: a multicentred, cross-sectional study

OBJECTIVE

The objective of the study was to determine the magnitude of and the factors associated with late presentation for induced abortion care services at hospitals in the South Gondar district of Ethiopia.

DESIGN

This study employed an institution-based, cross-sectional design.

SETTING

The study was conducted at five hospitals in the South Gondar district of Ethiopia.

PARTICIPANTS

A total of 381 women recruited through systematic random sampling techniques from October 2022 to February 2023 participated in the study. All women presenting for safe abortion care services at selected hospitals during the data collection period were included, whereas induced abortion care service due to the pregnancy being a high risk to maternal health or at high risk for fetal anomaly were excluded from the study. Data were collected at the abortion clinic at the time of presentation through face-to-face interviews using a pretested and structured questionnaire.

OUTCOME MEASURES

The magnitude of and the factors associated with late presentation for induced abortion care service were assessed in the study.

STATISTICAL ANALYSIS

The collected data were entered and coded using EpiData V.4.6, and SPSS V.25 was used for analysis. Binary logistic regression analyses were undertaken to identify the factors associated with the outcome variable. The level of significance was declared at a p value of <0.05.

RESULTS

The magnitude of late presentation for induced abortion care service was 21.5% (95% CI 17.7, 25.7). Being a rural resident (adjusted OR (AOR) = 1.934; 95% CI 1.010, 3.703), history of use of contraceptives (AOR=0.462; 95% CI 0.227, 0.938), having irregular menstrual cycles (AOR=5.132; 95% CI 2.648, 9.944), delayed decision for termination (AOR=8.196; 95% CI 3.996, 16.808) and pregnancy resulting from incest (AOR=2.549; 95% CI 1.286, 5.052) were factors significantly associated with late presentation for induced abortion care.

CONCLUSION

Increased awareness and education in rural communities related to late presentations for induced abortion and the associated complications may facilitate timely decision-making in the context of induced abortion, resulting in reduced morbidity and mortality.

Abortion Trajectory, Timing, and Access Study (ATTAS): study protocol

BACKGROUND

This study protocol outlines the phased construction of a questionnaire, data collection, and a strategy for analysis within the framework of the ATTAS project. This study has two primary objectives. First, it allows us to map the duration of the various phases of the abortion trajectory for women presenting for abortion in Flanders, Belgium. Second, it identifies barriers that cause delays within these phases.

METHODS

The questionnaire was distributed to all women seeking abortion care at one of the five Flemish abortion centers; specifically, the LUNA centers, which are located in Ostend, Ghent, Antwerp, and Hasselt, as is the VUB-Dilemma center in Brussels during the fall and winter of 2023-2024. Ethical clearance for the described research was obtained from the University of Antwerp's Ethics Committee for the Social Sciences and Humanities (reference numbers: SHW_2023_48_1 and SHW_2023_48_2).

DISCUSSION

The collected data provide a dataset on the abortion trajectories of Flanders women who presented for abortion. This study protocol outlines the ATTAS project's rationale, phased development, and implementation of the questionnaire, as well as the upcoming data analyses. To our knowledge, this is the first study within the Flemish context to investigate abortion trajectories, timing, and access. Furthermore, this study protocol provides a phased and systematic approach to adapt validated research instruments to fit within diverse legal and cultural contexts. Building on this protocol, future research will seek to advance reproductive justice for all women in Belgium.

The missing voices in the conscientious objection debate: British service users' experiences of conscientious objection to abortion

BACKGROUND

The fourth section of the 1967 Abortion Act states that individuals (including health care practitioners) do not have to participate in an abortion if they have a conscientious objection. A conscientious objection is a refusal to participate in abortion on the grounds of conscience. This may be informed by religious, moral, philosophical, ethical, or personal beliefs. Currently, there is very little investigation into the impact of conscientious objection on service users in Britain. The perspectives of service users are imperative in understanding the real-world consequences and potential impact of conscientious objection and should be considered when creating and reviewing policies and guidelines. This research provided a platform for women and those who can become pregnant to share their experiences and opinions at a time when these voices are largely excluded in the great tradition of Western political philosophy and law-making processes.

METHOD

Five service users were interviewed using a narrative interview approach to uncover their abortion journeys and experiences of conscientious objection.

FINDINGS

The findings were presented as found poems and uncovered that doctors are not always: informing service users that they have a conscientious objection to abortion, giving service users enough information to access abortion (indirect referral), treating them non-judgmentally, and providing medically correct information. Service users did not experience burdens such as long waiting times and were still able to access legal abortion. However, service users did experience negative emotional effects, as they were often left feeling scared, angry, and hopeless when they were not referred and/or were mistreated.

CONCLUSIONS

Findings indicate that conscientious objection could work in practice. However, it is currently failing some individuals on an emotional level, as not all doctors are adhering to guidelines. Conscientious objection in Britain needs to be addressed, to ensure service users receive fair, impartial, non-judgmental care.

Too big, too young, too risky: How diagnosis of the foetal body determines trajectories of care for the pregnant woman in pre-viability second trimester pregnancy loss

Women in the English National Health Service facing pre-viability second trimester pregnancy loss through foetal death, premature labour or termination of pregnancy for foetal anomaly find themselves in a particular trajectory of care. This usually involves the requirement to labour and birth the foetal body and may involve undergoing feticide in cases of termination. Drawing on ethnographic research investigating women's experiences of second trimester pregnancy loss, I argue that the determining factor affecting care trajectories for the pregnant body is the biomedically diagnosed status of the foetal body. Foetal size, non-viability and the potential for live birth during terminations all structure the healthcare options for the woman facing pregnancy loss in the second trimester. As such, the diagnostic classification of the foetal body in the context of gestational time determines the medical care afforded to the pregnant body. This results in specific consequences for women, whose experiences of, and choices around, second trimester pregnancy loss are constrained by diagnostic and classificatory decisions around the status of the foetal being before legal viability.

It's a small bit of advice, but actually on the day, made such a difference…: perceptions of quality in abortion care in England and Wales

BACKGROUND

Quality of care (QOC) is increasingly identified as an important contributor to healthcare outcomes, however little agreement exists on what constitutes quality in abortion care or the recommended indicators from the service-user perspective. Our study aimed to explore perceptions and experiences of abortion QOC in England and Wales.

METHODS

We performed in-depth interviews (via phone or in-person) with participants who had an abortion at a nationwide independent sector provider in the previous 6 months. We explored their experiences of the abortion service at each point in the care pathway, their perspectives on what contributed to and detracted from the experience meeting their definitions of quality, and their reflections on different aspects of QOC. We used content analysis to generate themes.

RESULTS

From December 2018 to July 2019, we conducted 24 interviews. Ten participants had a surgical and 14 had a medical abortion. Seventeen (71%) were treated in the first 12 weeks of pregnancy and 7 (29%) beyond that, with an average gestational age of 10 weeks + 5 days (range 5-23 + 6). We identified 4 major themes that contributed to participant's perception of high quality care: (1) interpersonal interactions with staff or other patients, (2) being informed and prepared, (3) participation and choices in care and (4) accessibility. Nearly all participants identified interpersonal interactions with staff as an important contributor to quality with positive interactions often cited as the best part of their abortion experience and negative interactions as the worst. For information and preparation, participant described not only the importance of being well prepared, but how incongruencies between information and the actual experience detracted from quality. Participants said that making choices about their care, for example, method of abortion, was a positive contributor. Finally, participants identified access to care, specifically in relation to waiting times and travel, as an important aspect of QOC.

CONCLUSIONS

Participants situated quality in abortion care in 4 domains: interpersonal aspects of care, information and preparation, choices, and accessibility. Indicators identified can be used to develop standard metrics to ensure care meets service-user needs.

Legal and non-legal barriers to abortion in Ireland and the United Kingdom

This article compares abortion laws, regulations and access patterns in the United Kingdom and the Republic of Ireland. We focus in most detail on the Republic of Ireland, Northern Ireland and England with a shorter discussion of Scotland and Wales. We attend to the laws and legal reforms in each region but also consider the non-legal factors that restrict or facilitate abortion services in each place. In this article, we seek to illustrate the complex relationship between abortion law and abortion access, noting especially how non-legal barriers shape the way an abortion law functions for the people who live under it.

Using candidacy theory to explore unemployed over-50s perceptions of suitability of a welfare to work programme: A longitudinal qualitative study

Welfare to work interventions seek to move out-of-work individuals from claiming unemployment benefits towards paid work. However, previous research has highlighted that for over-50s, particularly those with chronic health conditions, participation in such activities are less likely to result in a return to work. Using longitudinal semi-structured interviews, we followed 26 over-50s during their experience of a mandated welfare to work intervention (the Work Programme) in the United Kingdom. Focusing on their perception of suitability, we utilise and adapt Candidacy Theory to explore how previous experiences of work, health, and interaction with staff (both in the intervention, and with healthcare practitioners) influence these perceptions. Despite many participants acknowledging the benefit of work, many described a pessimism regarding their own ability to return to work in the future, and therefore their lack of suitability for this intervention. This was particularly felt by those with chronic health conditions, who reflected on difficulties with managing their conditions (e.g., attending appointments, adhering to treatment regimens). By adapting Candidacy Theory, we highlighted the ways that mandatory intervention was navigated by all the participants, and how some discussed attempts to remove themselves from this intervention. We also discuss the role played by decision makers such as employment-support staff and healthcare practitioners in supporting or contesting these feelings. Findings suggest that greater effort is required by policy makers to understand the lived experience of chronic illness in terms of ability to RTW, and the importance of inter-agency work in shaping perceptions of those involved.

Access to and sustainability of abortion services: a systematic review and meta-analysis for the National Institute of Health and Care Excellence-new clinical guidelines for England

BACKGROUND

Induced abortion is a common procedure. However, there is marked variation in accessibility of services across England. Accessing abortion services may be difficult, particularly for women who live in remote areas, are in the second trimester of pregnancy, have complex pre-existing conditions or have difficult social circumstances.

OBJECTIVE AND RATIONALE

This article presents a two-part review undertaken for a new National Institute of Health and Care Excellence guideline on abortion care, and aiming to determine: the factors that help or hinder accessibility and sustainability of abortion services in England (qualitative review), and strategies that improve these factors, and/or other factors identified by stakeholders (quantitative review). Economic modelling was undertaken to estimate cost savings associated with reducing waiting times.

SEARCH METHODS

Ovid Embase Classic and Embase, Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), PsycINFO, Cochrane Library via Wiley Online, Cinahl Plus and Web of Science Core Collection were searched for articles published up to November 2018. Studies were included if they were published in English after 2001, conducted in Organization for Economic Co-operation and Development (OECD) countries and were: qualitative studies reporting views of patients and/or staff on factors that help or hinder the accessibility and sustainability of a safe abortion service, or randomized or non-randomized studies that compared strategies to improve factors identified by the qualitative review and/or stakeholders. Studies were excluded if they were conducted in OECD countries where abortion is prohibited altogether or only performed to save the woman's life. One author assessed risk of bias of included studies using the following checklists: Critical Appraisal Skills Programme checklist for qualitative studies, Cochrane Collaboration quality checklist for randomized controlled trials, Newcastle-Ottawa scale for cohort studies, and Effective Practice and Organization of Care risk of bias tool for before-and-after studies.Qualitative evidence was combined using thematic analysis and overall quality of the evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Confidence in the Evidence from Reviews of Qualitative Research (CERQual). Quantitative evidence was analysed in Review Manager 5.3 and overall quality of evidence was assessed using GRADE.

OUTCOMES

Eight themes (service level barriers; financial barriers; logistical barriers; personal barriers; legal and policy barriers; privacy and confidentiality concerns; training and education; community prescribing and telemedicine introduce greater flexibility) and 18 subthemes were identified from 23 papers (n = 1016) included in the qualitative review. The quality of evidence ranged from very low to high, with evidence for one theme and seven subthemes rated as high quality. Nine studies (n = 7061) were included in the quantitative review which showed that satisfaction was better (low to high quality evidence) and women were seen sooner (very low quality evidence) when care was led by nurses or midwives compared with physician-led services, women were seen sooner when they could self-refer (very low quality evidence), and clinicians were more likely to provide abortions if training used an opt-out model (very low quality evidence). Economic modelling showed that even small reductions in waiting times could result in large cost savings for services.

WIDER IMPLICATIONS

Self-referral, funding for travel and accommodation, reducing waiting times, remote assessment, community services, maximizing the role of nurses and midwives and including practical experience of performing abortion in core curriculums, unless the trainee opts out, should improve access to and sustainability of abortion services.

Cross-country abortion travel to England and Wales: results from a cross-sectional survey exploring people's experiences crossing borders to obtain care

Background

The laws governing abortion access vary across Europe. Even in countries with relatively liberal laws, numerous barriers to abortion access exist. In response to these barriers, evidence suggests that people living in countries with both restrictive and liberal laws travel outside of their home country for abortion care. England and Wales are common destinations for those who travel to seek abortions, but little is known about the motivations and experiences of those who undertake cross-country travel to England or Wales to obtain care. This paper aims to describe the abortion seeking and travel experiences of women and pregnant people who traveled to England and Wales for an abortion between 2017 and 2019.

Methods

We recruited 97 participants who had traveled cross-country from both liberal and restrictive contexts to seek abortion care at three participating BPAS clinics in England and Wales. Participants completed an electronic survey about their reproductive histories, abortion decision-making, experiences seeking abortion care, and traveling. We conducted a descriptive analysis, and include comparisons between participants who traveled from liberal and restrictive contexts.

Results

Over a third of participants considered abortion four weeks or more before presenting for care at BPAS, and around two-thirds sought abortion services in their home country before traveling. The majority of participants indicated that they would have preferred to have obtained an abortion earlier and cited reasons including scheduling issues, a dearth of local services, delayed pregnancy recognition, and financial difficulties as causing their delay. About seventy percent of participants reported travel costs between €101–1000 and 75% of participants reported that the cost of the abortion procedure exceeded €500. About half of participants indicated that, overall, their travel was very or somewhat difficult.

Conclusions

This analysis documents the burdens associated with cross-country travel for abortion and provides insight into the factors that compel people to travel. Our findings highlight the need for expanded access to abortion care throughout Europe via the removal of legal impediments and other social or procedural barriers. Removing barriers would eliminate the need for cumbersome abortion travel, and ensure that all people can obtain necessary, high-quality healthcare in their own communities.

In Europe, people who live in countries where abortion is severely restricted or illegal altogether lack access to abortion care entirely, but even people who live in countries with more liberal laws face barriers due to gestational age limits, waiting periods, and a lack of trained and willing providers. Existing evidence suggests that restrictions and barriers compel people from both countries with restrictive laws as well as those from countries with more liberal laws to travel outside of their home country for abortion services. England and Wales are common destinations for people traveling within Europe to obtain abortion services, but little is known about the experiences of these travelers. We surveyed individuals who had traveled from another country to seek abortion services in England or Wales. Our analysis documents that many participants contemplated getting an abortion and sought care in their home countries before traveling. Likewise, many participants indicated that they would have preferred to have obtained an abortion earlier in their pregnancy, and referenced scheduling issues, a dearth of local services, delayed pregnancy recognition, and financial difficulties as causing their delay. A majority of participants indicated that covering the costs of their abortion, and the costs of travel was difficult, and that the travel experience in its entirety was difficult. Our findings document the reasons for, and burdens associated with abortion travel and highlight the need to expand access to abortion across Europe via the elimination of all legal restrictions and impediments.

Women's experiences of self-referral to an abortion service: qualitative study

BACKGROUND

Guidelines from the UK recommend that women should be able to self-refer to abortion services. In 2016, a self-referral system was introduced to the abortion service in Edinburgh, Scotland, as an option for women. Women could telephone a dedicated phone line during office hours and speak to an administrative assistant working in the abortion service who provided them the next available appointment to be seen in the service. This study aimed to evaluate a self-referral service to abortion by investigating its impact on women's experiences of the referral process.

METHODOLOGY

21 semistructured interviews of women attending a specialist abortion service in Edinburgh, Scotland, were conducted. Interviews were transcribed verbatim and thematically analysed. The interviews focused on women's experience of the referral process.

RESULTS

Three main themes arose from the interviews, including reasons for choosing self-referral, experience of self-referral and challenges to using self-referral. Reasons for choosing self-referral were related to convenience, privacy and autonomy. Women found the experience of self-referral to be pleasant, non-judgemental and patient-centred, and self-referral prepared them for the appointment at the specialist abortion service. However, some women felt rushed, and self-referral made them anxious to attend the appointment. Challenges were difficulty with getting through on telephone lines, varying levels of support required for different individuals and awareness about the option of self-referral.

CONCLUSION

Women valued the option of self-referral. Women felt that the service should be expanded to increase availability,and promoted to women more widely within the community .

Toward normalising abortion: findings from a qualitative secondary analysis study

In most settings worldwide, abortion continues to be highly stigmatised. Whilst a considerable body of literature has addressed abortion stigma, what is less commonly examined are the ways in which those with experience of abortion describe it in non-negative terms which may resist or reject stigma. Drawing on qualitative secondary analysis of five UK datasets using a narrative inquiry approach, we explore: the use of non-negative language around abortion, potential components of a normalising narrative, and constraints on non-negativity. As such, we present the first empirical UK study to critically examine how a dominant negative abortion narrative might be disrupted.

What are the social correlates of subsequent abortions in Flanders, Belgium?

OBJECTIVE

To study whether the social correlates of subsequent abortions vary depending on the order of the abortion. Methodology: Drawing upon the Flemish abortion centres' anonymized patient records (2010-2019), discrete-time hazard models were used to examine whether individual abortion experiences across women's reproductive life course have different social correlates.

RESULTS

Overall, women who were in their twenties, of foreign origin, single, had non-tertiary education, were not in paid employment, had children, did not (consistently and without errors) use contraception and had a previous abortion through medication, had an elevated probability to experience subsequent abortions. While single women and women with a vulnerable socioeconomic status were more likely to have a second or third abortion, this difference is no longer prevalent when considering higher-order abortions. The hazard for higher-order abortions was more pronounced in women with a migration background, regardless of the order considered. Contraceptive use was unrelated to fourth or higher-order abortions.

CONCLUSION

Using discrete-time hazard models, we unpack individual abortion experiences across women's reproductive life courses. By studying the transitions into different orders of subsequent abortions separately, we provide a more detailed understanding of risk factors compared to other European studies. The social correlates vary by the order considered: A certain profile emerges for women who have a second or third abortion, but disintegrates when considering higher-order abortions. This knowledge enables clinicians and policymakers to better understand women who experience subsequent abortions and to tailor services best suited to their needs.

Characteristics of Women Who Present for Abortion Beyond the Legal Limit in Flanders, Belgium

CONTEXT

Women who seek abortion care beyond the first trimester of gestation are often in a vulnerable socioeconomic position with limited social support, and in Belgium, the details of their circumstances are insufficiently understood. A better understanding of this group is essential to a critical evaluation of Belgian abortion policy, which restricts abortions on request after the first trimester.

METHODS

Anonymized patient records were collected between 2013 and 2016 from LUNA centers, which are non-hospital-based abortion clinics in Flanders. Logistic regression analyses were used to identify associations between women's characteristics and whether they presented within or beyond the legal limit, which was 13 weeks and 1 day at the time of the study.

RESULTS

A total of 28,741 women requested an abortion, and 972 individuals (3.4%) presented beyond the legal limit; 29% of these latter women were unable to receive abortion care as a result of the mandatory six-day waiting period. Characteristics positively associated with presenting beyond the limit, instead of beforehand, were being younger than 20, as opposed to 20-24 (odds ratio, 1.7); receiving a primary, lower secondary, upper secondary or special-needs education, rather than a higher education (1.8-3.1); being unemployed, rather than employed (1.3); and holding Belgian rather than a foreign nationality (0.8). Being accompanied by someone to the LUNA center (0.8), having irregularly (0.6) or regularly used contraceptives (0.7), and having ever had an abortion (0.8) were negatively associated with presenting beyond, rather than before, the limit.

CONCLUSIONS

A fuller consideration of patients' characteristics when evaluating Belgian abortion policy is needed to ensure that the needs and rights of socioeconomically vulnerable women are addressed.

Experiences of women who travel for abortion: A mixed methods systematic review

OBJECTIVE

To systematically review the literature on women's experiences traveling for abortion and assess how this concept has been explored and operationalized, with a focus on travel distance, cost, delays, and other barriers to receiving services.

BACKGROUND

Increasing limitations on abortion providers and access to care have increased the necessity of travel for abortion services around the world. No systematic examination of women's experiences traveling for abortion has been conducted; this mixed-methods review provides a summary of the qualitative and quantitative literature on this topic.

METHODS

A systematic search was conducted using PubMed, Embase, Web of Science, Popline, and Google Scholar in July 2016 and updated in March 2017 (PROSPERO registration # CRD42016046007). We included original research studies that described women's experiences traveling for abortion. Two reviewers independently performed article screening, data extraction and determination of final inclusion for analysis. Critical appraisal was conducted using CASP, STROBE, and MMAT checklists.

RESULTS

We included 59 publications: 46 quantitative studies, 12 qualitative studies, and 1 mixed-methods study. Most studies were published in the last five years, relied on data from the US, and discussed travel as a secondary outcome of interest. In quantitative studies, travel was primarily conceptualized and measured as road or straight-line distance to abortion provider, though some studies also incorporated measures of burdens related to travel, such as financial cost, childcare needs, and unwanted disclosure of their abortion status to others. Qualitative studies explored regional disparities in access to abortion care, with a focus on the burdens related to travel, the impact of travel on abortion method choice, and women's reasons for travel. Studies generally were of high quality, though many studies lacked information on participant recruitment or consideration of potential biases.

CONCLUSIONS

Standardized measurements of travel, including burdens associated with travel and more nuanced considerations of travel costs, should be implemented in order to facilitate comparison across studies. More research is needed to explore and accurately capture different dimensions of the burden of travel for abortion services on women's lives.

Timing of abortion among adolescent and young women presenting for post-abortion care in Kenya: a cross-sectional analysis of nationally-representative data

Background

Complications of unsafe abortion are a leading cause of maternal mortality in sub-Saharan Africa. Adolescents and young women are disproportionately represented among those at risk of these complications. Currently, we know little about the factors associated with young women’s timing of abortion. This study examined the timing of abortion as well as factors influencing it among adolescents and young women aged 12–24 years who sought post-abortion care (PAC) in health facilities in Kenya.

Methods

We draw on data from a cross-sectional study on the magnitude and incidence of induced abortion in Kenya conducted in 2012. The study surveyed women presenting with a diagnosis of incomplete, inevitable, missed, complete, or septic abortion over a one-month data collection period in 328 health facilities (levels 2–6). Survey data, specifically, from adolescents and young women were analyzed to examine their characteristics, the timing of abortion, and the factors associated with the timing of abortion.

Results

One thousand one hundred forty-five adolescents and young women presented for PAC during the data collection period. Eight percent of the women reported a previous induced abortion and 78% were not using a modern method of contraception about the time of conception. Thirty-nine percent of the index abortions occurred after 12 weeks of gestation. A greater proportion of women presenting with late abortions (more than 12 weeks gestational age) (46%) than those presenting with early abortions (33%) presented with severe complications. Controlling for socio-demographic and reproductive history, timing of abortion was significantly associated with place of residence (marginal), education, parity, clinical stage of abortion and level of severity.

Conclusions

Late-term abortions were substantial, and may have contributed substantially to the high proportion of women with post-abortion complications. Efforts to reduce the severity of abortion-related morbidities and mortality must target young women, particularly those living in rural and other remote areas. Interventions to reduce unintended pregnancies in this population are also urgently needed to improve early pregnancy detection and timely care seeking.

Gestating times: women's accounts of the temporalities of pregnancies that end in abortion in England

Tensions between the 'clock time' of medicine and the embodied times of its subjects are central to feminist writing concerning Western obstetric practice. In this article, I expand the focus of this literature by addressing the temporal dynamics of another site of reproductive healthcare: abortion provision. Echoing obstetric accounts of birth, time in legal, healthcare and social scientific discourse on abortion is routinely conceptualised as a finite resource contained within the pregnant/foetal body, which can be measured using clocks and calendars. I argue that women's interview accounts of their experiences of ending their pregnancies offer opportunities for critical reflection on this characterisation of pregnancy as linear 'gestational time'. First, participants in this study re-position the significance of gestational time by articulating its embodied meaning. Second, they provide alternative accounts of the temporality of pregnancy as a process which emerges through, and is disrupted by, the dynamics of socio-material relations. The article considers the broader implications of women's accounts of pregnancy times for legal, healthcare and social scientific accounts of 'later' 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.

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.

Women's embodied experiences of second trimester medical abortion

Abortions in general, and second trimester abortions in particular, are experiences which in many contexts have limited sociocultural visibility. Research on second trimester abortion worldwide has focused on a range of associated factors including risks and acceptability of abortion methods, and characteristics and decision-making of women seeking the procedure. Scholarship to date has not adequately addressed the embodied physicality of second trimester abortion, from the perspective of women's lived experiences, nor how these experiences might inform future framings of abortion. To progress understandings of women's embodied experiences of second trimester abortion, we draw on the accounts of 18 women who had recently sought second trimester abortion in Scotland. We address four aspects of their experiences: later recognition of pregnancy; experiences of a second trimester pregnancy which ended in abortion; the "labour" of second trimester abortion; and the subsequent bodily transition. The paper has two key aims: Firstly, to make visible these experiences, and to consider how they relate to dominant sociocultural narratives of pregnancy; and secondly, to explore the concept of "liminality" as one means for interpreting them. Our findings contribute to informing future research, policy and practice around second trimester abortion. They highlight the need to maintain efforts to reduce silences around abortion and improve equity of access.

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.

Comparison of uptake of long-acting reversible contraception after abortion from a hospital or a community sexual and reproductive healthcare setting: an observational study

BACKGROUND

Uptake of the most effective long-acting reversible methods of contraception (LARC) immediately after abortion has been shown to reduce a woman's risk of further abortion. We aimed to compare the uptake of LARC at abortion services from a hospital department of obstetrics and gynaecology and a specialist contraceptive setting of a community sexual and reproductive health (SRH) service within the same city.

METHODS

Retrospective database review of women (n=2473) requesting abortion who were assessed at either a community SRH service or a hospital department of obstetrics and gynaecology, in the same UK city over a period of 1 year. The main outcome measures were immediate post-abortal uptake of LARC from each site.

RESULTS

A higher proportion of women assessed at the SRH service received LARC after abortion [50.2%; 95% confidence interval (CI) 0.47-0.53%] compared to those attending the hospital site (39.2%; 95% CI 0.36-0.42%; p<0.0001). Amongst women having an outpatient early medical abortion, LARC uptake at the SRH was twice that of the hospital setting (48.4% vs 23.3%; p<0.0001).

CONCLUSIONS

Higher uptake of immediate post-abortal LARC was observed amongst women who were assessed at the specialist contraceptive service in the community SRH setting compared to the hospital setting. Further research is required to determine the reasons for these observations since all abortion services should provide the same high-quality contraceptive service to women undergoing abortion.

Characteristics of women who present for abortion towards the end of the mid-trimester in Scotland: national audit 2013-2014

OBJECTIVES

Women in Scotland who request an abortion (for non-medical reasons) within the legal gestational limit (up to 24 weeks) but beyond the gestational limit of all abortion facilities in Scotland (only up to 20 weeks) must travel to England if they wish to terminate the pregnancy. We wished to determine the number and characteristics of women presenting at ≥16 weeks' gestation for abortion, and compare the characteristics of those proceeding to abortion with those continuing the pregnancy.

METHODS

Over a period of 12 months we conducted a prospective audit of women presenting at ≥16 weeks' gestation to abortion services throughout Scotland. The characteristics of women proceeding to abortion and those continuing the pregnancy were compared.

RESULTS

A total of 267 women presented for abortion at ≥16 weeks' gestation. Their median age was 22 years (range 14 to 47 years); 231 were from deprived areas (86.5%), 128 (47.9%) already had a child and 73 (27.3%) had previously undergone abortion. A total of 175 women (65.5%) proceeded to abortion, locally (n = 125; 46.8%) or in England (50; 18.7%). Those at ≥20 weeks' gestation were statistically more likely to continue the pregnancy than those at earlier gestations (p < 0.001).

CONCLUSIONS

Relatively few women present for abortion in Scotland at ≥16 weeks' gestation. Those who are over 20 weeks' gestation and would need to travel to England for abortion are more likely to continue the pregnancy, suggesting that travel is a barrier to accessing legal abortion for this group of women. Provision of abortion services up to 24 weeks' gestation should be considered within Scotland.

Experiences, feelings and thoughts of women undergoing second trimester medical termination of pregnancy

Main Objective

The objective of this study was to explore women's expectations and experiences of undergoing second trimester abortion.

Methods

This is a cross-sectional study using a screening questionnaire and semi-structured interviews for data collection. Thirty-one women filled out the questionnaire and 23 of them were later interviewed. The questionnaires were analyzed by descriptive statistics. The interviews were recorded, transcribed verbatim and analyzed with qualitative content analysis.

Most Important Findings

Indications for the abortion were fetal malformation or unintended pregnancy. The women expressed similar feelings and these were irrespective for the reason for having an abortion. Both physical and mental pain was experienced during the abortion process and described by the women. Taking the mifepristone-pill was experienced as especially emotionally difficult for many participants. Professional support from the staff together with support from the partner, a friend or relative helped in transforming the worries related to something unknown to feelings of coping with a new and hard experience. Prior to the abortion most women stated that they did not want to view the fetus but women who chose to view the fetus described this as a way of confronting the reality and an opportunity to say farewell to the pregnancy/fetus. The analysis of the interview transcripts revealed five themes mirroring the women's experiences, thoughts and feelings related to the abortion.

Conclusions

The decision to undergo second trimester abortion sometimes exposes women to strong and conflicting emotions which are irrespective for the reason for having an abortion. Despite this women do not regret their decision to terminate the pregnancy. This analysis shows that their rational thinking outweighs their emotionally difficult feelings. It is important for the attending staff to be responsive to the needs of each individual woman whatever the indication is for the abortion.