Social Science & Medicine
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Social Science & Medicine 191 (2017) 109e116
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Social Science & Medicine
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A good abortion experience: A qualitative exploration of women’s needs and preferences in clinical care
Anna L. Altshuler a, *, Alison Ojanen-Goldsmith b, Paul D. Blumenthal a, Lori R. Freedman c
a Stanford University School of Medicine, Dept. Ob/Gyn, 300 Pasteur Dr. HG332, Stanford, CA 94305, USA b Full Spectrum Doulas, Seattle, WA, USA c Advancing New Standards in Reproductive Health/University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA
a r t i c l e i n f o
Article history: Received 20 January 2017 Received in revised form 2 September 2017 Accepted 7 September 2017 Available online 8 September 2017
Keywords: United States Abortion experience Abortion stigma Abortion services Reproductive justice Abortion access Patient-centered care Abortion normalization
* Corresponding author. Present address: Californ 475 Brannan St #220, San Francisco, CA 94107, USA.
E-mail addresses: aaltshuler@post.harvard.edu (A. com (A. Ojanen-Goldsmith), pblumen@stanford.ed Freedman@ucsf.edu (L.R. Freedman).
http://dx.doi.org/10.1016/j.socscimed.2017.09.010 0277-9536/© 2017 The Authors. Published by Elsevier
a b s t r a c t
What do women ending their pregnancies want and need to have a good clinical abortion experience? Since birth experiences are better studied, birth stories are more readily shared and many women who have had an abortion have also given birth, we sought to compare women’s needs and preferences in abortion to those in birth. We conducted semi-structured intensive interviews with women who had both experiences in the United States and analyzed their intrapartum and abortion care narratives using grounded theory, identifying needs and preferences in abortion that were distinct from birth. Based on interviews with twenty women, three themes emerged: to be affirmed as moral decision-makers, to be able to determine their degree of awareness during the abortion, and to have care provided in a discreet manner to avoid being judged by others for having an abortion. These findings suggest that some women have distinctive emotional needs and preferences during abortion care, likely due to different circum- stances and sociopolitical context of abortion. Tailoring services and responding to individual needs may contribute to a good abortion experience. © 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Many women experience both abortion and birth over the course of their reproductive lives. In the United States, an estimated 30% of women have an induced abortion by age 45 (Jones and Kavanaugh, 2011) and of those women who have had an abor- tion, 59% have previously given birth (Jerman et al., 2016). Abortion represents a transition for pregnant women, moving from the possibility of bearing that child to proceeding with one’s life as is. As with birth, how abortion happens matters to women, their families and communities (Lie et al., 2008; Lyerly, 2013; Simkin, 1991). However, unlike with birth, researchers and policy makers have given less attention to what constitutes a good abortion experience. This reality may be due to a greater focus on defending access to abortion by creating a body of evidence demonstrating that it does not harmwomen physically or mentally and improving
ia Pacific Research Institute,
L. Altshuler), alisonog@gmail. u (P.D. Blumenthal), Lori.
Ltd. This is an open access article u
its technical aspects. Fortunately, undergoing an abortion in the U.S. is extremely safe (Biggs et al., 2017; Jatlaoui et al., 2016) and the process is effective (Ireland et al., 2015), permitting a shift in focus to improving other aspects of care quality, namely patient- centeredness, which encompasses care guided by a patient’s values (Institute of Medicine, 2001). Prior studies suggest that most women tend to be satisfied with their care (Taylor et al., 2013; Tilles et al., 2016) but some women have challenging experiences (Kimport et al., 2012; Weitz and Cockrill, 2010), implying that there is room for improvement. Accordingly, we must learn fromwomen who have sought abortion services about their experiences and how they would like their care to be.
A qualitative investigation of women’s needs and preferences to improve care has been performed for maternity services and it offers a preliminary framework for studying abortion due to their commonalitiesdboth birth and abortion affect pregnant women and are two among other reproductive health services that women’s health clinicians provide. Bioethicist and obstetrician Anne Lyerly examined what constitutes a good birth experience by learning from childbearing women about what they valued, amounting to one of the most comprehensive efforts to date on this subject (Lyerly, 2013). She found that the five core domains for a
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mailto:aaltshuler@post.harvard.edu
mailto:alisonog@gmail.com
mailto:alisonog@gmail.com
mailto:pblumen@stanford.edu
mailto:Lori.Freedman@ucsf.edu
mailto:Lori.Freedman@ucsf.edu
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A.L. Altshuler et al. / Social Science & Medicine 191 (2017) 109e116110
good birth entail being the principal decider and actively wit- nessing the birth process (agency); trusting the health provider and feeling safe from physical harm in the face of risk, being free from unwanted intrusions and feeling at ease (personal security); having the birth experience respected as a significant event, being treated with dignity and possessing self-respect (respect); maintaining clear communication and access to information throughout the birthing process (knowledge); and feeling emotionally connected to the baby, loved ones, health professionals and other women (connectedness) (Lyerly, 2013).
Lyerly found that these domains for a good birth generally correspond to dimensions needed for individual wellbeing theo- rized by Powers et al. in their framework for social justice in health policy (Powers and Faden, 2006), implying that they are potentially broad enough to apply to other areas of healthcare. Moreover, previous studies on abortion suggest that there are parallels be- tweenwomen’s needs in maternity and abortion care. With respect to Lyerly’s domain “agency,” researchers have found that women value being able to decide to have an abortion to plan their lives (Andrews and Boyle, 2003; Fielding et al., 2002) and to determine how the abortion happens (Elul et al., 2000; Fielding et al., 2002; Kerns et al., 2012; Simonds et al., 1998). Elements of “personal se- curity” emerged in women’s narratives in Kimport et al., in which women described a need to feel physically safewhile obtaining care in abortion clinics that operated in hostile anti-abortion environ- ments (Kimport et al., 2012). Findings from Castle et al. under- scored the importance that women ascribe to having information to prepare for an abortion (Castle et al., 1995), consistent with the domain “knowledge.” “Connectedness” and “respect” were also important to women, demonstrated as an appreciation for compassionate behavior from providers (Kimport et al., 2012; McLemore et al., 2014; Taylor et al., 2013) and having a sense of dignity upheld during abortion care (McLemore et al., 2014; Weitz and Cockrill, 2010).
Despite these commonalities in childbirth and abortion, there are also notable differences, such as women’s circumstances at the time of pregnancy and the sociopolitical context within which these reproductive experiences occur. Birth tends to be viewed as joyous and physiological (Gaskin, 2011; Lyerly, 2013) and intra- partum services arewell-integrated into healthcare: they are linked to antepartum and postpartum services, have private and public insurance coverage, and are accessible to most women (Kaiser Family Foundation, 2013; Rayburn et al., 2012). By contrast, abor- tion is politicized and stigmatized (Joffe, 2013; Norris et al., 2011). Services tend to be provided separately from other medical care in limited supply at specialized abortion facilities, requiring amajority of women to travel far and to pay out of pocket for care (Jerman et al., 2016; Jones and Jerman, 2014). Given these different con- texts for birth and abortion, we sought to examine ways in which women’s needs and preferences in abortion care differ from intrapartum care.
2. Methods
The study was conducted in Northern California through semi- structured intensive interviews from April to December 2014 with women who had individually experienced both birth and abortion. Participants were recruited through advertisements on Craigslist, at community colleges and at public libraries that tar- geted women residing in a geographical area with multiple birth and abortion facilities to choose from. We recruited women from the community rather than specific medical facilities to solicit variation in women’s clinical experiences and to identify underly- ing patterns that were not influenced by a particular medical setting. We predicted this recruitment strategy would
underrepresent women who had abortions for fetal or maternal indications given they account for less than 5% of all abortions (Jatlaoui et al., 2016). We did not view it as a limitation as those experiences have been studied (Lafarge et al., 2014). Inclusion criteria were age 18e49 years, had an abortion in the…
