Variation in Pregnancy Options Counseling and Referrals, And Reported Proximity to Abortion Services, Among Publicly Funded Family Planning Facilities

"At the End of the Day it's Their choice": An Exploratory Qualitative Study of Pregnancy Options Counseling

This study's purpose was to explore the current models and approaches of pregnancy options counseling across three types of agency settings in a Northeastern state. Additionally, this study aimed to determine if individuals who receive pregnancy options counseling obtained medically factual, non-directive, and non-biased information needed to make informed decisions related to their pregnancy decisions. Using qualitative research methodology, semi-structured interviews were conducted with 10 participants across three different agency settings in one state in the Northeastern United States. Results indicated agencies shared a definition of pregnancy options counseling. Outcomes also suggest agency type impacted how pregnancy options counseling was delivered, as variations were found in education provided to patients. Lastly, the interviews imply no standardized model or training for pregnancy options counselors is currently being used.

"I Wasn't Expecting That Question": Responses to Requests for Abortion Referral at College Student Health Centers

BACKGROUND

Women 18-24 years of age have the highest proportion of unintended pregnancies of any age group, and thus represent a significant population in need of abortion services. Prior research indicated that only half of college student health centers provide appropriate abortion referrals. Our objective was to better understand the referral experience and barriers to abortion referral at college student health centers.

PROCEDURES

We conducted a "secret caller" study at all 4-year colleges in Pennsylvania between June 2017 and April 2018, using a structured script requesting abortion referral. Calls were transcribed, coded using an iteratively developed codebook, and analyzed for themes related to barriers and facilitators of abortion referral.

MAIN FINDINGS

A total of 202 completed transcripts were reviewed. Themes that emerged were knowledge, experience, and comfort with abortion referral; support, empathy, and reassurance; coercion; misleading language; questioning the caller's autonomy; and institutional policy against referral. Most staff lacked knowledge and comfort with abortion referral. Although some staff members made supportive statements toward the caller, others used coercive language to try to dissuade the caller from an abortion. Many staff cited religious institutional policies against abortion referral and expressed a range of feelings about such policies.

CONCLUSIONS

Abortion referrals at student health centers lack consistency. Staff members frequently did not have the knowledge needed to provide appropriate abortion referrals, used coercive language in responding to requests for referrals, and perpetuated abortion stigma. Some health staff used coercive or evasive language that further stigmatized the caller's request for an abortion referral. College health centers should improve training and resources around abortion referral to ensure they are delivering appropriate, high-quality care.

The practice of pregnancy options counseling in social service and healthcare settings in the United States: a systematic literature review

INTRODUCTION

The purpose of this systematic literature was to summarize the literature on pregnancy options counseling for women and patients who experience an unintended pregnancy across healthcare and social service settings.

METHODS

We conducted a systematic literature review using the PRISMA Checklist. Following the literature search of 8 electronic databases, we used a three-stage search process to screen articles for inclusion.

RESULTS

A total of 20 peer-reviewed articles met the inclusion criteria for this study. Half (n = 10) of the articles reviewed were empirical studies utilizing quantitative or qualitative methodology while the other half (n = 10) were conceptual or non-empirical. The articles affirmed a shared definition of pregnancy options counseling, but terminology differences were noted over time. Lastly, variations of intervention practices appeared across practice settings, with referral practice variations being the most notable.

CONCLUSION

Pregnancy options counseling practices varied across settings, suggesting patients who received this intervention may not have accessed equitable or ethical care.

Preferences and Experiences Regarding Pregnancy Options Counseling in Adolescence and Young Adulthood: A Qualitative Study

PURPOSE

Perspectives of adolescents and young adults (AYAs) experiencing pregnancy options counseling (POC) are absent from the literature. This study explores AYA experiences and preferences related to POC to inform best practice guidelines.

METHODS

We conducted semistructured phone interviews in 2020-2021 among US-based individuals, 18-35 years old, who experienced a pregnancy less than 20 years of age. We performed qualitative descriptive analysis of positive and negative attributes of AYA's experiences with POC.

RESULTS

Fifty participants reported 59 pregnancies (16 parenting, 19 abortions, 18 adoptions, three miscarriages) between the ages of 13 and 19 years. Positive attributes of POC experienced included: (1) provider communication that was compassionate, respectful, supportive, and attentive to nonverbal cues; (2) provider neutrality; (3) discussion of all pregnancy options; (4) asking about feelings, choice, life plans, and additional supports; (5) provision of informational materials; and (6) warm handoffs/follow-up facilitation. Negative attributes of POC experienced included: (1) judgmental, impersonal, or absent communication; (2) lack of counseling on all options and/or coercive/directive counseling; (3) insufficient time and supportive resources; and (4) confidentiality concerns. We identified no differences in these perspectives across pregnancy outcomes reported. Participants generally desired counseling about all options, with rare exceptions of ambivalence.

DISCUSSION

Individuals who experienced an adolescent pregnancy described similar positive and negative attributes of POC regardless of preferred pregnancy outcome. Their perspectives highlight how crucial interpersonal communication skills are for effective POC for AYA. POC training across health care specialties should emphasize confidential, compassionate, and nonjudgmental care for AYA patients.

Pregnancy options counseling

PURPOSE OF REVIEW

This article reviews key aspects of pregnancy options counseling, and highlights how inappropriate counseling can create barriers to timely and safe abortion care.

RECENT FINDINGS

Access to safe abortion services in the United States is increasingly constrained. One way to combat this hostile environment is to ensure that individuals presenting for care early in pregnancy have access to comprehensive and unbiased pregnancy options counseling. There are unfortunately many barriers to individuals receiving adequate pregnancy options counseling, and marginalized groups experience disproportionate effects of inappropriate counseling. Research shows that individuals desire appropriate pregnancy options counseling when seeking early pregnancy care, and that providers often serve as a barrier to this care. Provider miseducation and opposition to pregnancy options counseling, particularly as it concerns abortion care, creates challenges and delays for people seeking abortion services. Crisis Pregnancy Centers use misinformation to further these barriers to appropriate care.

SUMMARY

Nondirective and patient-centered pregnancy options counseling is standard of care. People seeking pregnancy options counseling desire and deserve comprehensive and accurate information. Providers must not serve as barriers to safe and appropriate care. Increasing nondirective pregnancy options counseling research, education, and training is crucial to ensuring access to safe and appropriate abortion care.

"We have to respect that option": The abortion aversion complex in safety-net healthcare organizations

In July 2019, the Trump administration began implementing its domestic gag rule to ban discussion of abortion in pregnancy options counseling and ensure physical separation of contraceptive and abortion services at clinical sites funded by the federal government's Title X Family Planning program. In this paper, we examine how organizational policy utilization correlated with organization-level protocols for discussing abortion in options counseling interactions while the domestic gag rule policy was under legal contest. From April 2018 to July 2019, we conducted in-depth interviews with 50 administrators in charge of setting clinical protocols regarding options counseling after a positive pregnancy test at 20 Title X-covered and 14 non-Title X-covered safety-net healthcare organizations in Ohio. We found that organizational characteristics and Title X policy utilization did not explain the heterogeneity in approaches to abortion referral that administrators reported. Administrators from 2 of 20 organizations covered by Title X policy requirements pre-emptively restricted discussion of abortion in their facilities in advance of policy enactment. Meanwhile, administrators from 10 of 14 non-Title X-covered organizations did not restrict discussion of abortion. Our analysis demonstrates how safety-net healthcare organizations' response to federal policy is shaped by administrators' institutional entrepreneurship within the abortion aversion complex: a pattern of policy miscomprehension and endorsed abortion stigma that facilitates the structural stigmatization of abortion within safety-net healthcare organizations. We conclude that current efforts to reverse the domestic gag rule will fail unless local abortion aversion complexes are targeted with intervention.

Family medicine provision of online medication abortion in three US states during COVID-19

OBJECTIVE

To examine provision of direct-to-patient medication abortion during COVID-19 by United States family physicians through a clinician-supported, asynchronous online service, Aid Access.

STUDY DESIGN

We analyzed data from United States residents in New Jersey, New York, and Washington who requested medication abortion from 3 family physicians using the online service from Aid Access between April and November 2020. This study seeks to examine individual characteristics, motivations, and geographic locations of patients receiving abortion care through the Aid Access platform.

RESULTS

Over 7 months, three family physicians using the Aid Access platform provided medication abortion care to 534 residents of New Jersey, New York, and Washington. There were no demographic differences between patients seeking care in these states. A high percentage (85%) were less than 7 weeks gestation at the time of their request for care. The reasons patients chose Aid Access for abortion services were similar regardless of state residence. The majority (71%) of Aid Access users lived in urban areas. Each family physician provided care to most counties in their respective states. Among those who received services in the three states, almost one-quarter (24%) lived in high Social Vulnerability Index (SVI) counties, with roughly one-third living in medium-high SVI counties (33%), followed by another quarter (26%) living in medium-low SVI counties.

CONCLUSIONS

Family physicians successfully provided medication abortion in three states using asynchronous online consultations and medications mailed directly to patients.

IMPLICATIONS

Primary care patients are requesting direct-to-patient first trimester abortion services online. By providing abortion care online, a single provider can serve the entire state, thus greatly increasing geographic access to medication abortion.

Abortion Referral Practices among a National Sample of Obstetrician-Gynecologists

BACKGROUND

Obstetrician-gynecologists (ob-gyns) play a critical role in improving access to timely abortion care. This cross-sectional study estimates the proportion of ob-gyns providing abortion referral in the prior year and identifies predictors of direct (facilitated) referral compared with indirect referral (providing contact information).

METHODS

In 2016-2017, we invited a national sample of 2,500 ob-gyns to complete a survey. We restricted the final sample of 1,280 respondents (52% response rate) to participants who had abortion-seeking patients in the last 12 months (n = 868, 68% of the sample). We calculated descriptive statistics by referral type and conducted logistic regression analyses to examine associations between physician and practice setting characteristics and abortion referral type (direct vs. indirect).

RESULTS

Eighty-eight percent of ob-gyns provided abortion referral (479 [55%] indirect referrals; 287 [33%] direct referrals). Abortion provision in the prior year (adjusted odds ratio, 2.82; 95% confidence interval, 1.80-4.42) was a significant predictor of direct referrals. Compared with ob-gyns practicing in the Northeast, ob-gyns in the South had lower odds of direct referrals (adjusted odds ratio, 0.39; 95% confidence interval, 0.24-0.62), whereas those in the West had higher odds (adjusted odds ratio, 1.91; 95% confidence interval, 1.14-3.23). Ob-gyns providing direct referrals were more likely to practice within 25 miles of an abortion facility compared with those who provided indirect referrals (25% vs. 5%, respectively; p < .001).

CONCLUSIONS

Although the majority of ob-gyns refer patients for abortion care, most offer indirect referrals, only providing contact information for an abortion provider. Ob-gyns should facilitate referrals as access becomes more constrained, especially in regions where abortion facilities are limited.

County-Level Clustering and Characteristics of Repeat Versus First Teen Births in the United States, 2015-2017

PURPOSE

Approximately 16% of U.S. births to women aged 15-19 years are repeat (second or higher order) births. Repeat teen mothers are at elevated risk for poor perinatal outcomes. Geographic clustering and correlates of repeat teen birth are unknown.

METHODS

Data from birth certificates on N = 629,939 teen births in N = 3,108 U.S. counties in 2015-2017 were merged with data on county-level demographic, socioeconomic, and health provider characteristics. We identified contiguous clusters of counties with significantly elevated rates of first teen births only, repeat teen births, both, or neither between 2015 and 2017 and compared demographic, socioeconomic, and medical provider characteristics of counties between 2010 and 2016 in each cluster type.

RESULTS

A total of 193 counties (6.21%) had high rates of repeat births only; 504 (16.22%) had high rates of first teen birth only; 991 (31.89%) had high rates of both repeat and first teen births; and 1,420 (45.69%) had neither. Counties with high repeat (vs. first only) birth rates had higher rates of poverty and unemployment, higher levels of income inequality, lower high school graduation rates, a higher share of racial and ethnic minority residents, fewer publicly funded family planning clinics per capita, and more women receiving contraceptive services at publicly funded clinics.

CONCLUSIONS

First and repeat teen births cluster in differentially resourced geographic areas. Counties with high repeat teen birth rates have lower socioeconomic conditions than counties with high rates of first teen births only. These counties are more reliant on publicly funded family planning clinics but have fewer of them per capita.

Quality of Information Available Online for Abortion Self-Referral

OBJECTIVE

To assess the quality of information available online for abortion self-referral and to determine whether quality varies by region or distance to an abortion provider.

METHODS

This was a cross-sectional study. We used a standard protocol to perform internet searches from August 2016 to June 2017 for abortion services in the 25 most populous U.S. cities and the 43 state capitals that were not one of the 25 most populous cities. We classified the first 10 webpage results and the first five map results and advertisements as facilitating abortion referral (local independent abortion provider, local Planned Parenthood facility, national abortion provider or organization, prochoice website, or abortion directory), not facilitating abortion referral (nonproviding physician office, nonmedical website, abortion provider greater than 50 miles from the location, news article, general directory, other), or hindering abortion referral (crisis pregnancy center or antichoice website). We used U.S. Census Bureau subregions to examine geographic differences. We made comparisons using a χ test.

RESULTS

Overall, from 612 searches from 68 cities, 52.9% of webpage results, 67.3% of map results, and 34.4% of advertisements facilitated abortion referral, whereas 12.9%, 21.7%, and 29.9%, respectively, hindered abortion referral. The content of the searches differed significantly based on U.S. Census Bureau subregion (all P≤.001) and distance to an abortion provider (all P≤.02).

CONCLUSION

Two thirds of map results facilitated abortion self-referral, whereas only half of webpage results did so. Advertisements were the least likely to facilitate and the most likely to hinder self-referral. Quality was lowest in areas that were farthest from abortion providers.

"It's not something you talk about really": information barriers encountered by women who travel long distances for abortion care

OBJECTIVE

For individuals traveling significant distances for time-sensitive abortion care, accurate information about service options and locations is critical, but little is known regarding information barriers that individuals may encounter and strategies for circumventing these barriers.

STUDY DESIGN

In early 2015, we conducted in-depth interviews with 29 patients who had traveled for abortion care at six facilities in Michigan and New Mexico. We identified information-related barriers that respondents encountered in understanding their pregnancy options and/or where to obtain an abortion between the time of pregnancy discovery, including any contact with a crisis pregnancy center, to the day of the abortion procedure through inductive and deductive analysis.

RESULTS

We identified two logistical information-related barriers - a general lack of reproductive-related knowledge and unhelpfulness on the part of perceived members of the healthcare community - and one broader barrier of perceived stigma within respondents' narratives. Of the seven respondents who did not encounter a logistical information-related barrier, having previous personal or close experience with abortion and internet savviness were both identified as strategies enabling them to circumvent the barriers.

CONCLUSION

Lack of clear, easy-to-find and accurate information about abortion services and availability represents a key barrier to obtaining an abortion; health care providers play a crucial role in ensuring pregnant patients' right to informed consent within reproductive health care delivery.

IMPLICATIONS

Women's health care providers should provide their patients with the full spectrum of resources and referrals for pregnancy and abortion care; recent federal guidelines proposing to restrict abortion counseling and referral at Title X-funded facilities would only exacerbate the current challenges that pregnant patients encounter when seeking abortion-related information and further decrease linkages to timely, desired abortion care.

Access to Abortion Services in Tennessee: Does Distance Traveled and Geographic Location Influence Return for a Second Appointment as Required by the Mandatory Waiting Period Policy?

The purpose of this article was to examine the average distance traveled to access an abortion procedure, rates of return for the procedure, and whether or not those living in rural zip codes were less likely to return for the abortion compared with residents in urban zip codes, in the context of a 48-hour in-person mandatory waiting period in Tennessee. Findings indicated that over 12 percent of patients who attended the in-person counseling session did not return for the procedure. Moreover, abortion patients in this study traveled an average of 50.53 miles to access abortion care, which is notably higher than the estimated national average of 11.00 miles. Rural residents were significantly more likely than urban residents to have to travel farther to access abortion services. However, neither geographic location nor distance traveled were predictive of returning to the clinic for the second appointment to obtain the abortion, suggesting that patients who did return were able to overcome any geographic disparities. Given the policy mandate that requires a minimum of two in-person clinic visits to obtain the abortion, patients who are traveling farther must still use more resources for two trips, which is a burden to them that is not experienced by more urban residents who are located in closer proximity to abortion providers. The article concludes with a discussion of the implications of the findings for social work practice and policy.

Counseling and referrals for women with unplanned pregnancies at publicly funded family planning organizations in Texas

OBJECTIVES

To compare pregnancy options counseling and referral practices at state- and Title X-funded family planning organizations in Texas after enforcement of a policy restricting abortion referrals for providers participating in state-funded programs, which differed from Title X guidelines to provide referrals for services upon request.

STUDY DESIGN

Between November 2014 and February 2015, we conducted in-depth interviews with administrators at publicly funded family planning organizations in Texas about how they integrated primary care and family planning services, including pregnancy options counseling and referrals for unplanned pregnancies. We conducted a thematic analysis of transcripts related to organizations' pregnancy options counseling and referral practices, and compared themes across organizations that did and did not receive Title X funding.

RESULTS

Of the 37 organizations with transcript segments on options counseling and referrals, 15 received Title X and 22 relied on state funding only. All Title X-funded organizations but only nine state-funded organizations reported offering pregnancy options counseling. Respondents at state-only-funded organizations often described directing pregnant women exclusively to prenatal care. Regardless of funding source, most organizations provided women a list of agencies offering abortion, adoption and prenatal care. However, some respondents expressed concern that providing other information about abortion would threaten their state funding. In contrast, respondents indicated staff would make appointments for prenatal care, assist with Medicaid applications and, in some instances, directly connect women with adoption-related services.

CONCLUSIONS

Pregnancy options counseling varied by organizations' funding guidelines. Additionally, abortion referrals were less common than referrals for other pregnancy-related care.

IMPLICATIONS

Programmatic guidelines restricting information on abortion counseling and referrals may adversely affect care for pregnant women at publicly funded family planning organizations.

Abortion-related care and the role of the midwife: a global perspective

Introduction

The International Confederation of Midwives (ICM) represents 132 midwifery associations in 113 countries. The ICM disseminates the Essential Competencies for Basic Midwifery Practice (EC) that describes the global scope of midwifery practice. The basic (core) and expanded (additional or optional) role of midwives in providing abortion-related care services was first described in 2010. A literature review about three items that are particularly critical to access to abortion services was conducted. Findings that emerged in the recent 2016-2017 update study about these three items are presented.

Methods

A modified Delphi study was administered via the Internet in a series of three rounds. Thirty-seven statements of abortion-related knowledge and skill were presented.

Results

A total of 895 individuals participated. The total of respondents across all three rounds represented 90 of the 105 member countries at the time of the study. The role of midwives in providing comprehensive abortion care, including referral for abortion and provision of postabortion family planning, achieved the necessary 85% agreement to be designated as essential (basic) knowledge or skill for the global scope of midwifery practice. The provision of medication abortion and performance of manual vacuum aspiration abortion were designated as optional for midwives who wished to provide these services. Endorsement of these latter practices was highest in both Francophone and Anglophone regions of Africa, Asian Pacific countries, and countries at a lower state of economic development.

Conclusion

The role of midwives in provision of abortion-related care services was reaffirmed in the recent Delphi study to inform the update to the EC. The role of midwives as direct providers of medical and vacuum aspiration abortions was reaffirmed for those individual midwives who wish to obtain the requisite competency to provide those services, in jurisdictions where these services are legally authorized.

Evaluation of a Training for Health and Social Service Providers on Abortion Referral-Making

Purpose Engaging trusted care providers and empowering them with information and skills about abortion is a critical opportunity to improve coordination of care for women seeking abortion, if and when these services are needed. Description Provide, a nonprofit that works in partnership with health and social service providers to build a health system that is equipped to respond to women's health care needs around abortion, launched a referrals training program in 2013. To assess the effectiveness of this training program, we conducted an evaluation of satisfaction with training and the impact of the intervention on provider knowledge of safety of abortion, self-efficacy to provide abortion referrals, and intention to provide pregnancy options counseling and referrals in the future. Assessment Approximately 90% of participants were "very satisfied" with their training experience. Results show significant increase in intention to provide non-judgmental pregnancy options counseling and referrals for abortion care after participants went through training. Post-training, significantly more reported that they would present all pregnancy options without judgment or bias (94 vs. 82%, p < .0001), provide a referral for abortion care if needed (80 vs. 50%, p < .0001), and follow-up with the client (71 vs. 39%, p < .0001). Further, more also reported they would refer a client for prenatal care if the client requested it (78 vs. 67%, p < .0001). Conclusion Our results suggest that abortion referrals training hold potential to build the capacity of health and social service providers' ability to meet client needs related to pregnancy and could be implemented at a larger scale.

Should prenatal care providers offer pregnancy options counseling?

BACKGROUND

Professional guidelines indicate that pregnancy options counseling should be offered to pregnant women, in particular those experiencing an unintended pregnancy. However, research on whether pregnancy options counseling would benefit women as they enter prenatal care is limited. This study examines which women might benefit from options counseling during early prenatal care and whether women are interested in receiving counseling from their prenatal care provider.

METHODS

At four prenatal care facilities in Louisiana and Maryland, women entering prenatal care completed a self-administered survey and brief structured interview (N = 586). Data were analyzed through descriptive statistics, bivariate analyses, multivariate multinomial logistic regression, and coding of open-ended responses.

RESULTS

At entry into prenatal care, most women reported that they planned to continue their pregnancy and raise the child. A subset (3%) scored as having low certainty about their decision on the validated Decision Conflict Scale, indicating need for counseling. In addition, 9% of women stated that they would be interested in discussing their pregnancy options with their prenatal care provider. Regression analyses indicated some sociodemographic differences among women who are in need of or interested in options counseling. Notably, women who reported food insecurity in the prior year were found to be significantly more likely to be in need of options counseling (RRR = 3.20, p < 0.001) and interested in options counseling (RRR = 5.48, p < 0.001) than those who were food secure. Most women were open to discussing with their provider if their pregnancy was planned (88%) or if they had considered abortion (81%). More than 95% stated they would be honest with their provider if asked about these topics.

CONCLUSIONS

Most women are certain of their decision to continue their pregnancy at the initiation of prenatal care. However, there is a subset of women who, despite entering prenatal care, are uncertain of their decision and wish to discuss their options with their health care provider. Screening tools and/or probing questions are needed to support prenatal care providers in identifying these women and ensuring unbiased, non-directive counseling on all pregnancy options.

What Women Want from Their Health Care Providers about Pregnancy Options Counseling: A Qualitative Study

OBJECTIVES

Unintended pregnancy is common in the United States, yet scant research has evaluated women's preferences on pregnancy options counseling. This study explores pregnant women's preferences for pregnancy options counseling from health care providers.

METHODS

We conducted semistructured interviews with pregnant women at a prenatal clinic and an abortion clinic. We asked women about recent discussions-or lack thereof-about pregnancy options (parenting, adoption, and abortion) with a clinician, and what they would want their provider to discuss about pregnancy options. We analyzed transcripts using modified grounded theory.

FINDINGS

We interviewed 10 women in prenatal care and 18 women seeking abortion. In both settings, most said clinicians should discuss pregnancy options with pregnant women and 1) respect patient autonomy, 2) avoid assumptions about a woman's desired pregnancy outcome, and 3) consider the patient-including her health and fertility intentions-beyond her pregnancy. Participants wanted their doctors to assess a pregnancy's individual circumstances to determine the appropriateness of options counseling. A few participants, including women who did and did not receive options counseling, reported they personally preferred not to receive such counseling. Explaining this preference, they cited preservation of privacy, having already made a decision for the pregnancy, or just not wanting to discuss abortion. Regarding best practices for providing options counseling, participants said it should be done in a routine manner, with discretion, and early in pregnancy.

CONCLUSIONS

Pregnant women seeking both prenatal and abortion care broadly support options counseling.

IMPLICATIONS

Discussion of pregnancy options, including abortion, provides patient-centered care and supports women's preferences.

Adoption Decision Making among Women Seeking Abortion

BACKGROUND

Little is known about how adoption factors into pregnancy decision making, particularly when abortion is unavailable.

METHODS

We used data from the Turnaway Study, a longitudinal study of 956 women seeking abortion, including 231 women denied abortions owing to gestational limits. Through semiannual quantitative interviews, we assessed the frequency with which women denied abortion consider and choose adoption, and, among adoption participants, decision satisfaction. We compared differences in the demographic profiles of parenting and adoption participants using mixed effects regression models. We conducted in-depth interviews with 31 women who received or were denied wanted abortions, including 2 adoption participants, focused on understanding pregnancy decision making and feelings about their choice. Interviews were coded using inductive and deductive methods.

RESULTS

Most women who received abortions were aware of but uninterested in adoption. A minority of women denied abortions (n = 231; 14%) were considering adoption at 1 week after denial. Of participants who gave birth (n = 161), most (91%) chose parenting. Parenting participants (n = 146) did not differ from adoption participants (n = 15) on measures of age, race, or poverty status, although adoption participants were somewhat less likely to be employed (20% vs. 43%; p = .1), and somewhat more likely to have completed high school (87% vs. 74%; p = .08). Although satisfaction with their decision was high among adoption participants, in-depth interviews revealed mixed emotions.

CONCLUSIONS

Among women motivated to avoid parenthood, as evidenced by abortion seeking, adoption is considered or chosen infrequently. Political promotion of adoption as an alternative to abortion is likely not grounded in the reality of women's decision making.

Examining the association between motivations for induced abortion and method safety among women in Ghana

This article draws on data from 552 women interviewed in the 2007 Ghana Maternal Health Survey to examine the association between motivations for women's pregnancy terminations and the safety of methods used. Women's reasons for induced abortions represented their vulnerability types at the critical time of decision making. Different motivations can result in taking various forms of action with the most vulnerable potentially resorting to the most harmful behaviors. Analysis of survey data pointed to spacing/delaying births as the main reason for abortion. Furthermore, women were more likely to terminate pregnancies unsafely if their main motivation for abortion was financial constraints. Especially among rural women, abortions for any reason were more likely associated with safe methods than if for financial reasons. These findings suggest a theme of vulnerability, resulting from poverty, as the motivations for women to resort to harmful abortion methods. Therefore, interventions formulated to reduce instances of unsafe pregnancy terminations should target reducing poverty and capacity building with the aim of economic advancement, in addition to curbing the root of the problem: unintended pregnancy.