Gestational age limits for abortion and cross-border reproductive care in Europe: a mixed-methods study

Objectives

Little is known about the experiences of women who travel within Europe for abortion care from countries with relatively liberal laws. This paper aims to assess the primary reasons for travel among a sample of women who travelled from European countries with relatively liberal abortion laws to obtain abortion care mainly in the UK and the Netherlands.

Design

Multi‐country, 5‐year mixed methods study on barriers to legal abortion and travel for abortion.

Setting

UK, the Netherlands and Spain.

Population or Sample

We present quantitative data from 204 surveys, and qualitative data from 30 in‐depth interviews with pregnant people who travelled to the UK, the Netherlands and Spain from countries where abortion is legal on broad grounds within specific gestational age (GA) limits.

Methods

Mixed‐methods.

Main outcome measures

GA when presenting at abortion clinic, primary reason for abortion‐related travel.

Results

Study participants overwhelmingly reported travelling for abortion because they had exceeded GA limits in their country of residence. Participants also reported numerous delays and barriers to receiving care.

Conclusions

Our findings highlight the need for policies that support access to abortion throughout pregnancy and illustrate that early access to it is necessary but not sufficient to meet people’s reproductive health needs.

Funding

This study is funded by the European Research Council (ERC).

Tweetable abstract

This study shows that GA limits drive women from EU countries where abortion is legal to seek abortions abroad.

This study shows that GA limits drive women from EU countries where abortion is legal to seek abortions abroad.

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.

Women's health centers and minority women: addressing barriers to care. The National Centers of Excellence in Women's Health

New models of care delivery have been developed to better coordinate and integrate healthcare for women. In the United States, one of the challenges is to incorporate the needs of racial and ethnic minority populations into these newer care paradigms. This paper begins with a brief historical review of the experience of racial and ethnic minorities in the American healthcare system to provide a context for discussing barriers and limitations of more traditional models of women's healthcare. Specific approaches used by National Centers of Excellence in Women's Health are presented as examples of strategies that may be implemented by other communities to address these barriers.

Estimates of pregnancies and pregnancy rates for the United States, 1976-85

After increasing by 9 per cent in the period 1976-80 in the United States, pregnancy rates declined by 4 per cent between 1980 and 1984 (from 111.9 to 107.3 pregnancies per 1,000 women aged 15-44 years). Between 1984 and 1985, the rate rose by less than 1 per cent to 108.2. More detailed data by age and race, available only through 1983, indicate that the decline in the 1980-83 period was not shared by all age groups. For example, pregnancy rates continued to increase for women in their thirties, and teenage pregnancy remained substantially the same. In 1983, 61 per cent of all pregnancies ended in live birth, 26 per cent in induced abortion, and 13 per cent in fetal loss. Pregnancy rates in that year were two-thirds higher for women of races other than White than for White women, and pregnancies of other-than-White women were more likely to terminate as an induced abortion or fetal loss. However, White teenagers and teenagers of other races were about equally likely to have their pregnancy end in induced abortion or fetal loss.

Race-specific patterns of abortion use by American teenagers

Between 1972 and 1978, as legal abortion became more widely available nationally, abortion rates (abortions per 1,000 women) and ratios (abortions per 1,000 live births) increased for all American teenagers; from 1972 to 1975, the rates and ratios for teenagers for Black and other races increased faster than those for White teenagers. For all seven years, abortion rates were higher for teenagers of Black and other races than for white teenagers. This reflected both higher proportions of sexually active teenagers of Black and other races and a greater risk of pregnancy in these teenagers compared with White teenagers. Race-specific differences in legal abortion ratios narrowed during the seven-year interval, as did differences in alternative outcomes of teenage premarital pregnancies (term births, illegal abortions).

Adolescent sexual behavior

Human sexuality is a lifelong process with biologic, psychosocial, and moral consequences. During adolescence, coping with sexual feelings and controlling sexual drive become urgent tasks that are made more difficult by today's society. Recent studies document a dramatic increase in the frequency of sexual activity among teenagers as well as a decrease in the age at which sexual activity begins. The pregnancy rate has increased dramatically in this age-group because of the general lack of willpower and moral strength of young people; lack of adult role models; sexual exploitation of the young, particularly by mass media and industries; and aversion of teenagers to contraception. Births to teenagers have actually decreased slightly, however, because of the accessibility of abortion.

Social, spatial and political determinants of U.S. abortion rates

Abortion rates in the United States have risen annually since the 1973 Supreme Court decision. The regions with the greatest rate increases are the Southern and Plains states; the lowest rate increases were in regions which had high abortion rates soon after abortion was legalized. While spatial contiguity appears to influence abortion rates, that is, states with high rates of abortion are clustered spatially, social and political influence are also evident. Ratification of the equal rights amendment, the seeking of abortion outside the state of residence, and the degree of urbanization within a state are variables which influenced U.S. abortion rates between 1973 and 1977.

Comparative risk of death from induced abortion at less than or equal to 12 weeks' gestation performed with local versus general anesthesia

Although complications of anesthesia are now the leading cause of death from abortion at less than or equal to 12 weeks' gestation, the comparative risk of death from abortions performed with local versus general anesthesia is unknown. To estimate this risk for both anesthesia-related and nonanesthesia-related legal abortion deaths at less than or equal to 12 weeks' gestation, we used 1972-1977 data from the Center for Disease Control and the Alan Guttmacher Institute. When adjusted for preexisting disease and concurrent sterilization, the death-to-case rate for abortions at less than or equal to 12 weeks' gestation associated with general anesthesia was 0.37/100,000 abortions, and the rate with local anesthesia was 0.15/100,000. For nonanesthesia-related deaths, the comparable adjusted rates were 0.49 and 0.28, respectively. Use of general anesthesia is associated with a twofold to fourfold increased risk of death from abortion at less than or equal to 12 weeks' gestation.

Effects of restricted public funding for legal abortions: a second look

At hospitals in three cities where public funding for legal abortions had been restricted, we reviewed the records of women with complications of all types of abortions. We compared the number of complications in the year before funding restriction with the number in the following year, during restriction. For complications of illegal and spontaneous abortions, we found no significant change in either the number or proportion of publicly funded hospitalizations. For complications of legal abortions, we found a decrease in both the number and proportion of publicly funded hospitalizations. For poor women, it appears that restriction of public funding for legal abortions has not markedly increased the number of illegal abortions, but has reduced the number of legal abortions, especially those at later gestational ages, which would have cost more and been at greater risk of complications.