Abortion-related worries, fears and preparedness: a Swedish Web-based exploratory and retrospective qualitative study

The road to equity: A scoping review of the evidence and practices on abortion policies and services in Sweden

OBJECTIVE

The aims of this study are to i) map and synthesize scientific evidence on abortion policies and service provision and delivery developments in Sweden and ii) identify potential facilitators and barriers to equitable abortion services nationally.

METHODS

A scoping review of peer-reviewed papers (n = 51) and grey literature (n = 23) published 1975-2024 was conducted. The PRISMA-ScR protocol for scoping reviews was followed. Seventy-four (n = 74) documents were included, and a qualitative synthesis was used to summarize, analyze, and assess the body of evidence identified.

RESULTS

Divergence in clinical guidelines was found and indicates inconsistencies in service delivery. Although there is strong evidence supporting midwife's role in delivering medication abortion, it has not been fully implemented and differs between and within regions. The Swedish abortion legislation prevents the implementation of midwives being key providers of medication abortion and self-managed home abortions in whole, thereby hampering access. The gap analysis show that although abortion services have been well researched, the experiences of migrants are scarcely addressed, and those of LGBTQI + people and persons with disabilities are absent.

CONCLUSION

Significant progress has been made in advancing access to equitable abortion services through legislative developments, medical innovations and the expansion of midwifery-led medication abortion services. However, some barriers remain including variability in service delivery and there is a research gap from an intersectional perspective. To better inform policy and practice, future research could apply a reproductive justice lens to explore how ethnicity, gender, disability and sexuality intersect and shape access to and experience of abortion services.

Patients' experiences with pain and bleeding in first-trimester abortion care

BACKGROUND

Abortion care is safe and commonly needed. While pain and bleeding are expected, patients' experience of pain and bleeding at the time of abortion can affect patient satisfaction and the abortion experience. There is limited research characterizing factors associated with patient-reported severe pain and heavy bleeding with contemporary abortion methods.

OBJECTIVE

To assess clinical predictors of patient-reported heavy bleeding and pain among first-trimester abortion patients.

STUDY DESIGN

We conducted a secondary analysis of a multicenter prospective cohort study of 644 participants undergoing medication or procedural abortion up to 11w6d. The primary outcome was participant-reported severe postabortion pain; secondary outcomes included bleeding severity and discordance between expected and experienced pain and bleeding. We developed logistic regression models assessing clinical factors associated with severe pain, heavy bleeding, more than expected pain, and heavier than expected bleeding.

RESULTS

Of 644 eligible participants, 516 (80%) responded, 347 (67%) of whom had medication abortion and 169 (33%) of whom had procedural abortion. One-fourth reported severe pain, 35.0% heavy bleeding, 31.6% more than expected pain, and 33.5% heavier than expected bleeding. Factors most strongly associated with participant-reported severe pain included medication abortion (odds ratio=4.69 [95% confidence interval: 2.56-8.58]), history of severe menstrual pain (odds ratio=2.60 [95% confidence interval: 1.38-4.89]), and screening positive for depression at baseline (odds ratio=2.13 [95% confidence interval: 1.18-3.85]). Independent risk factors for pain discordance included first abortion experience (adjusted odds ratio=2.03 [95% confidence interval: 1.18-3.48]), nulliparity (adjusted odds ratio=2.21 [95% confidence interval: 1.26-3.85]), history of a prior cesarean delivery (adjusted odds ratio=2.06 [95% confidence interval: 1.14-3.72]), and baseline depression (adjusted odds ratio=1.72 [95% confidence interval: 1.05-2.82), adjusted for gravidity, abortion method, and location of care. Self-reported heavy bleeding was most strongly associated with medication abortion regimen (adjusted odds ratio=9.19 [95% confidence interval: 5.09-16.61]) and screening positive for depression at baseline (adjusted odds ratio=2.15 [95% confidence interval: 1.28-3.61]). Abortion method and gestational length were the only significant predictors of discordance between bleeding expectations and experience.

CONCLUSION

While most patients were prepared for the pain and bleeding experienced after abortion, the patient experience may be improved by anticipatory guidance that incorporates risk factors for severe pain and heavy bleeding.

Fear of procedure and pain in individuals considering abortion: A qualitative study

OBJECTIVES

To explore concerns about procedural abortion and abortion-related pain in a cohort searching for abortion online.

METHODS

The Google Ads Abortion Access Study was a national longitudinal cohort study that recruited people searching for abortion online. Participants completed a baseline demographic survey and a follow-up survey four weeks later evaluating barriers and facilitators to abortion. This qualitative study utilized thematic analysis to produce a descriptive narrative based on overarching themes about procedural abortion and abortion-related pain.

RESULTS

There were 57 separate mentions from 45 participants regarding procedural abortion or abortion-related pain. We identified two main themes: 1) concerns about the procedure (with subthemes, fear of procedural abortion, comparison to medication abortion, lack of sedation) and 2) abortion-related pain (with subthemes fear of abortion-related pain, experiences of pain, fear of complications and cost-barriers to pain control).

CONCLUSIONS

This study highlights the need for improved anticipatory guidance and accessible resources to assuage potential fears and misconceptions regarding abortion.

PRACTICE IMPLIACTIONS

Abortion resources, particularly online, should provide accurate and unbiased information about abortion methods and pain to help patients feel more prepared. Providers should be aware of potential concerns surrounding procedural abortion and pain when counseling patients presenting for care.

Assessing psychosocial costs: Ohio patients' experiences seeking abortion care

OBJECTIVES

Existing research has not thoroughly characterized the psychosocial costs associated with seeking abortion care in restrictive states. Our study seeks to fill this gap by analyzing the accounts of Ohio abortion patients from 2018 to 2019.

STUDY DESIGN

Using inductive and deductive approaches, we analyzed semi-structured in-depth qualitative interviews with 41 Ohio residents who obtained abortion care from one of three clinics in Ohio or Pennsylvania.

RESULTS

Ohioans seeking abortion care often experienced fear of judgment, interpersonal strain, and stress as a result of efforts to overcome pre-Dobbs financial, geographic, and timing challenges. Those who needed financial assistance or traveled more than an hour generally reported greater exposure to psychosocial costs.

CONCLUSIONS

Participants in this study incurred a complex set of psychosocial costs. Psychosocial costs often resulted from, or were exacerbated by, the financial, geographic, and time-sensitive burdens that patients experienced seeking care.

IMPLICATIONS

The psychosocial costs incurred by patients seeking abortion care may be exacerbated in restrictive contexts, especially those who do not have access to insurance coverage for care. Psychosocial costs associated with care seeking are likely to increase as states implement more severe restrictions post-Dobbs. To fully understand abortion costs, researchers must examine costs comprehensively, including both financial and psychosocial costs.

Higher readability of institutional websites drives the correct fruition of the abortion pathway: A cross-sectional study

Background

In Italy, abortion services are public: therefore, health Institutions should provide clear and easily readable web-based information. We aimed to 1) assess variation in abortion services utilisation; 2) analyse the readability of institutional websites informing on induced abortion; 3) explore whether easier-to-read institutional websites influenced the correct fruition of abortion services.

Methods

We identified from the 2021 administrative databases of Tuscany all women having an abortion, and–among them–women having an abortion with the certification provided by family counselling centres, following the pathway established by law. We assessed variation in total and certified abortion rates by computing the Systematic Component of Variation. We analysed the readability of the Tuscan health authorities’ websites using the readability assessment tool READ-IT. We explored how institutional website readability influenced the odds of having certified abortions by running multilevel logistic models, considering health authorities as the highest-level variables.

Results

We observed high variation in the correct utilization of the abortion pathway in terms of certified abortion rates. The READ-IT scores showed that the most readable text was from the Florence Teaching Hospital website. Multilevel models revealed that higher READ-IT scores, corresponding to more difficult texts, resulted in lower odds of certified abortions.

Conclusions

Large variation in the proper fruition of abortion pathways occurs in Tuscany, and such variation may depend on readability of institutional websites informing on induced abortion. Therefore, health Institutions should monitor and improve the readability of their websites to ensure proper and more equitable access to abortion.

Why does abortion stigma matter? A scoping review and hybrid analysis of qualitative evidence illustrating the role of stigma in the quality of abortion care

Abortion stigma shapes the environment in which abortion is delivered and received and can have important implications for quality in abortion care. However, this has not previously been clearly articulated and evidenced. We conducted a scoping review of existing qualitative evidence to characterize the relationship between abortion stigma and quality in abortion care. Using a systematic process, we located 50 qualitative studies to include in our analysis. We applied the interface of the WHO quality of care and abortion stigma frameworks to the qualitative evidence to capture manifestations of the interaction between abortion stigma and quality in abortion care in the existing literature. Four overarching themes linked to abortion stigma emerged: A) abortion as a sin and other religious views; B) regulation of abortion; C) judgement, labelling and marking; and D) shame, denial, and secrecy. We further characterized the emerging ways in which abortion stigma operates to inhibit quality in abortion care into seven manifestations of the relationship between abortion stigma and quality in abortion care: 1) poor treatment and the repercussions, 2) gatekeeping and obstruction of access, 3) avoiding disclosure, 4) arduous and unnecessary requirements, 5) poor infrastructure and lack of resources, 6) punishment and threats and 7) lack of a designated place for abortion services. This evidence complements the abortion stigma-adapted WHO quality of care framework suggested by the International Network for the Reduction of Abortion Discrimination and Stigma (inroads) by illustrating specifically how the postulated stigma-related barriers to quality abortion care occur in practice. Further research should assess these manifestations in the quantitative literature and contribute to the development of quality in abortion care indicators that include measures of abortion stigma, and the development of abortion stigma reduction interventions to improve quality in abortion care.

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.

Preparing nurses and midwives to provide perinatal bereavement care: A systematic scoping review

OBJECTIVES

To provide a comprehensive cross-sectional overview of published studies on perinatal bereavement care education programmes developed and tested with nurses and midwives.

DESIGN

A scoping review following the Arksey and Malley's framework.

DATA SOURCES

Eight electronic databases were searched in December 2020 without restriction on language and publication date: PubMed, EMBASE, Cochrane Library, CINAHL, PsycINFO, Web of Science, Scopus and ProQuest.

REVIEW METHODS

All identified studies were reviewed by two reviewers based on the article title and abstract screening. Full-text articles were assessed according to the inclusion criteria. Original studies that reported on perinatal bereavement care education for nursing and midwifery students or clinical nurses and midwives were included.

RESULTS

Eighteen studies out of 817 articles were included. Perinatal bereavement care knowledge and skills, improvement in clinical skills in abortion care and psychological support for nurses and midwives are three core elements of the education content. Workshops and debriefing are the most frequently used formats. The duration mostly ranges from a half day to 3 days. Knowledge, confidence, satisfaction and relevant psychological variables such as posttraumatic stress symptoms are frequently used to evaluate the education programme's effectiveness. Most studies chose to use self-designed questionnaires as measurement tools. Nurses and midwives reported both positive experiences and improvement suggestions for perinatal bereavement care education programmes.

CONCLUSIONS

This scoping review highlights the benefits of implementing education programmes for preparing nurses and midwives for perinatal bereavement care in the context of universities and hospitals. Longitudinal randomized controlled trials or quasi-experiments could further investigate the effectiveness of a more enhanced perinatal bereavement care education programme with a longer intervention time using valid and reliable evaluation tools.

Readability of web-based sources about induced abortion: a cross-sectional study

Background

High-quality information is essential if clients who request an abortion are to reach informed decisions and feel prepared for the procedure, but little is known concerning the readability of web-based sources containing such material. The aim was to investigate the readability of web-based information about induced abortion.

Methods

The search engine Google was used to identify web pages about induced abortion, written in the English language. A total of 240 hits were screened and 236 web pages fulfilled the inclusion criteria. After correcting for duplicate hits, 185 web pages were included. The readability of the text-based content of each web page was determined with Flesch Kincaid Grade Level, Gunning Fog Index, Coleman-Liau Index, Simple Measure of Gobbledygook, and Flesch Reading Ease. Data were analyzed with descriptive statistics, Pearson’s correlation coefficient and Kruskal-Wallis with Dunn’s test as post hoc analysis.

Results

Across all grade level measures, a small minority of the web pages had a readability corresponding to elementary school (n < 3, 1%), while the majority had readability corresponding to senior high school or above (n > 153, 65%). The means of the grade level measures ranged between 10.5 and 13.1, and the mean Flesch Reading Ease score was 45.3 (SD 13.6). Only weak correlations (rho < 0.2) were found between the readability measures and search rank in the hit lists. Consistently, web pages affiliated with health care had the least difficult readability and those affiliated with scientific sources had the most difficult readability.

Conclusions

Overall, web-based information about induced abortions has difficult readability. Incentives are needed to improve the readability of these texts and ensure that clients encounter understandable information so that they may reach informed decisions and feel adequately prepared when requesting an abortion.