Denial of abortion care due to gestational age limits

"It Was So Easy in a Situation That's So Hard": Structural Stigma and Telehealth Abortion

For decades, sociological research has examined the role of stigma in contributing to health disparities, yet such research seldom grapples with the interplay between individuals and structures. There is a particular paucity of research on abortion that concurrently examines individual experiences with stigma and structural barriers. In this article, we use telehealth abortion as a case, which now accounts for one in five abortions in the United States. We conducted 30 interviews and approach the data using a structural stigma framework in tandem with conceptualizations of felt, internalized, and enacted stigma. Findings advance a sociological theory of structural abortion stigma: a combination of structural barriers, internalized beliefs, and interpersonal shame. Telehealth reduces structural barriers to abortion and mitigates internal and interpersonal experiences of stigma. The latter is achieved by the ability to avoid the traditional abortion clinic, which many interviewees view as the site where stigma is produced and experienced.

Abortion access barriers shared in "r/abortion" after Roe: a qualitative analysis of a Reddit community post-Dobbs decision leak in 2022

With drastic changes to abortion policy, the months following the Dobbs leak and subsequent decision in 2022 were a uniquely uncertain and difficult time for abortion access in the United States. To understand experiences of challenges to abortion access during that time, we used a hybrid inductive and deductive thematic coding approach to analyse descriptions of barriers and their impacts shared in an abortion subreddit (r/abortion). A simple random sample of 10% of posts was obtained from those shared from 02 May 2022 through 23 December 2022; comments were purposively sampled during the coding process. In this sample of submissions (n = 523 posts, 88 comments), people described structural barriers identified in past research, including state abortion bans and gestational limits, high costs, limited appointment availability, and long travel required. Posters also commonly described known social barriers, including limited social support and abortion stigma. Several impactful barriers not well-described in past research emerged inductively, including wait time for receiving mail-ordered abortion medication, low credibility of online ordering platforms, and concerns about legal risks of accessing abortion or related medical care. The most common consequences of experiencing barriers were adverse mental health outcomes, delayed access to care, and being compelled to self-manage their abortion because of access barriers. This analysis provides timely insights into the experiences and impacts of abortion access barriers in a group of people with a range of engagement with clinical abortion care, lived experiences, and points in their abortion processes, with public health implications for mental health and abortion access.

"I was waiting for my period": Understanding pregnancy recognition among adolescents seeking abortions in Ethiopia, Malawi, and Zambia

OBJECTIVES

For a person seeking an abortion, the ability to recognize a pregnancy is a critical first step. Pregnancy recognition is complex and shaped by numerous factors. This paper explores the experiences of pregnancy recognition among adolescents in Ethiopia, Malawi, and Zambia.

STUDY DESIGN

The final sample included 313 adolescents aged 10 to 19 who had sought abortion-related care at urban public facilities in Ethiopia (N = 99), Malawi (N = 104), and Zambia (N = 110). Researchers collected mixed-method data on how adolescents came to recognize that they were pregnant and thematically analyzed qualitative data alongside descriptive statistics from quantitative data.

RESULTS

Most adolescents reported that their main mode of recognizing a pregnancy was medical pregnancy tests or late menstruation. Reasons for not recognizing a pregnancy included irregular menses or recent menarche and attribution of signs and symptoms to other medical conditions. Psychological barriers to pregnancy recognition were important, including the refusal to accept a pregnancy and denial of a pregnancy. Timing of recognition shaped the abortion care available for adolescents and the affordability of care. For some adolescents, their capacity to recognize their pregnancy led to involuntary or voluntary disclosure, which decreased their reproductive autonomy.

CONCLUSIONS

Adolescent experiences of pregnancy recognition complement existing evidence, illustrating critical barriers across age and context. Interrogating pregnancy recognition among adolescents exposed the critical implications for the availability, accessibility, affordability, and autonomy of their abortion trajectory.

IMPLICATIONS

Pregnancy recognition is complex and can influence adolescents' ability to exercise their reproductive rights and access abortion care of their choosing. Programmes to improve awareness of the signs of a pregnancy, increasing the provision of affordable and accessible pregnancy testing and further research on pregnancy recognition are necessary to support adolescents' reproductive autonomy.

Access to Abortion in Central Appalachian States: Examining County of Residence and County-Level Attributes

CONTEXT

Studies of how women's individual characteristics and place of residence are related to variability in gestational age at the time of abortion have not examined county of residence and county-level characteristics. The county level is potentially meaningful, given that county is the smallest geographic unit with policy implications.

METHODS

Data on 38,611 abortions that took place in North Carolina, Virginia and West Virginia in 2012 were used to study the relationship between gestational age and county-level attributes (e.g., metropolitan status and poverty). Three-level hierarchical linear models captured individuals nested in county of residence, clustered by state of residence, and adjusted for individual characteristics and distance traveled to care.

RESULTS

Eight percent of the variation in gestational age at abortion was attributable to county-level characteristics. Residents of counties characterized by persistent poverty obtained abortions 2.3 days later in gestation than those from counties not characterized by that level of economic hardship. Women living in nonmetropolitan counties obtained abortions 1.7 days later than those living in metropolitan counties, even after distance traveled and county-level poverty were controlled for.

CONCLUSION

County of residence is relevant to gestational age at the time of abortion for women in these three states. Evidence that county-level attributes are related to access adds insight to the consequences for women when the landscape of abortion service delivery shifts. Integrating county of residence into research on access to abortion services may be critical to capturing disparities in access.

Barriers to Abortion Care and Their Consequences For Patients Traveling for Services: Qualitative Findings from Two States

CONTEXT

Abortion availability and accessibility vary by state. Especially in areas where services are restricted or limited, some women travel to obtain abortion services in other states. Little is known about the experience of travel to obtain abortion.

METHODS

In January and February 2015, in-depth interviews were conducted with 29 patients seeking abortion services at six facilities in Michigan and New Mexico. Eligible women were 18 or older, spoke English, and had traveled either across state lines or more than 100 miles within the state. Respondents were asked to describe their experience from pregnancy discovery to the day of the abortion procedure. Barriers to accessing abortion care and consequences of these barriers were identified through inductive and deductive analysis.

RESULTS

Respondents described 15 barriers to abortion care while traveling to obtain services, and three major consequences of experiencing those barriers. Barriers were grouped into five categories: travel-related logistical issues, system navigation issues, limited clinic options, financial issues, and state or clinic restrictions. Consequences were delays in care, negative mental health impacts and considering self-induction. The experience of barriers complicated the process of obtaining an abortion, but the effect of any individual barrier was unclear. Instead, the experience of multiple barriers appeared to have a compounding effect, resulting in negative consequences for women traveling for abortion.

CONCLUSION

The amalgamation of barriers to abortion care experienced simultaneously can have significant consequences for patients.

Pregnancy options counseling for adolescents: overcoming barriers to care and preserving preference

Current clinical guidelines for counseling adolescent patients about their pregnancy options fail to give concrete suggestions for how to begin and hold conversations that support patient autonomy, provide accurate and unbiased information, and address barriers to care. Recent research suggests that relative to adult women, adolescents are at increased risk of being denied abortion because they present beyond facilities' gestational age limits. Counseling that neglects to address the structural and developmental challenges that adolescents face when seeking care may contribute to the risk of abortion denial as well as subsequent delays in prenatal care. The task of providing non-directive, patient-centered, evidence-based pregnancy options counseling to an adolescent while ensuring that she receives her chosen course of care in a timely manner is challenging. This article presents a shared decision-making framework and specific suggestions for healthcare providers to support adolescent patients in coming to their decision about whether to continue or terminate an unplanned pregnancy and access follow-up care within the current sociopolitical environment.