“Am I the Only One Who Feels Like This?”: Needs Expressed Online by Abortion Seekers

Abstract

In the United States, abortion is safe and common, but highly stigmatized and frequently targeted by legislation that aims to restrict access. Numerous obstacles impede access to abortion care, including logistical barriers like cost and transportation, limited clinic availability, and state-mandated waiting periods. Accurate abortion information can also be hard to access. To overcome these barriers, many people seeking abortion turn to anonymous online forums, including Reddit, for information and support. Examining this community provides a unique perspective on the questions, thoughts, and needs of people considering or undergoing an abortion, then web scraped 250 posts from subreddits that contain abortion-related posts, then coded deidentified posts using a combined deductive/inductive approach. The authors identified a subset of these codes in which users were giving/seeking information and advice on Reddit, then engaged in a targeted analysis of the needs expressed in these posts. Three interconnected needs emerged: (1) need for information, (2) need for emotional support, and (3) need for community around the abortion experience. In this study map the authors reflected these needs onto key social work practice areas and competencies; taken alongside support from social work’s governing bodies, this research suggests that social workers would be beneficial additions to the abortion care workforce.

Introduction

Abortion is a common medical event—an estimated one in four people who can become pregnant will have at least one abortion before age 45 (Jones & Jerman, 2017). Because of its politicized nature, abortion is increasingly hard to access, so the process of seeking an abortion can generate a litany of social and emotional needs. Yet social workers rarely address or intervene with these needs; partially due to stigma, abortion is rarely discussed in social work settings or research, though social workers interact with clients who have had or will have an abortion (Witt et al., 2021; Begun et al., 2017). This lack of information and training prevents social workers from fully serving their clients. To help fill this gap, this paper presents results from a qualitative analysis of a large, anonymous dataset documenting and centering people’s needs and emotions about their abortion experience. Amplifying these experiences allows us to center patients and improve their experiences in abortion care work and activism.

This research is timely given current threats to abortion access across the US. The Supreme Court will announce a decision on Dobbs v. Jackson Women’s Health Organization by June 2022, which may overturn the Roe v. Wade precedent that has been interpreted to protect the right to an abortion in the United States. However, from January through March 2022 alone, state legislatures introduced 529 laws to limit access to abortion (Nash et al., 2022). New state-level restrictions mean people across the country increasingly will struggle to access abortion.

Literature Review

From 2010 to 2019, the abortion rate in the United States decreased by 21 percent, to 11.4 abortions per 1,000 people aged 15-44 who can get pregnant (Kortsmit et al., 2021). More than half of people who have abortions are in their 20s (56.7 percent), and the abortion rate for adolescents is decreasing more rapidly than the rate for other age cohorts. About 60 percent of people who have an abortion are parents. In 2019, 92 percent of abortions occurred before 13 weeks’ gestation, with the largest share of abortions occurring before six weeks’ gestation (Kortsmit et al., 2021).

Abortion access differs drastically based on where someone lives. One predominant focus of abortion research is the barriers patients encounter when seeking an abortion. As of this writing, abortion is a constitutional right, but many state legislatures restrict access to abortion. State-based restrictions can make it extremely difficult to get an abortion based on where one lives and their access to resources. Policy barriers include gestational limits, parental consent for minors, and waiting periods between an intake appointment and an abortion (Jerman et al., 2017). Patients further encounter practical barriers. Cost can be prohibitive: abortions generally cost over $500 in the first trimester and most states restrict Medicaid funds from paying for most abortions (Higgins et al., 2021). Many cannot access clinics; one in three people who can get pregnant live in a county without an abortion clinic (Jones et al., 2019). Travel incurs additional logistical and financial costs. Finally, patients report information barriers. Many do not know where to find medically accurate information or struggle to receive care referrals. Others encounter crisis pregnancy centers that aim to dissuade patients from seeking abortion and are known to give patients false information (Swartzendruber et al., 2018). These barriers all delay or prevent abortion. Repeatedly, researchers emphasize that people with multiple marginalized identities, such as people of color, those with low income or a disability, and those under 18, experience compounding, multiplicative effects of barriers to abortion (Ross & Solinger, 2017). Anti-abortion laws disproportionately impact already marginalized people by amplifying the effects of these barriers. (Gomez et al., 2020; Hyatt et al., 2022).

In the context of these barriers, other studies seek to understand patients’ emotions throughout their abortion experiences. In storytelling projects, patients describe techniques for processing their abortion experiences, including introspection about their decision along with their personal values and contextualization of their decision within their life course narrative (Swan et al., 2021). Patients report needing support and affirmation from others during their abortion experience (Altshuler et al., 2017). Stigma and fear of judgement are obstacles inhibit that support (Norris et al., 2011). While scholarship establishes that abortion does not cause long-term mental health effects (Biggs et al., 2020), seeking and obtaining an abortion can be stressful. People need space to process the experience. Some researchers suggest using a trauma-informed lens here (Ely et al., 2017). When asked about their experience with pre- and post-abortion helplines, users stated they needed a space to talk about abortion that was person-centered, non-judgmental, and apolitical (Baum et al., 2020; Kimport et al., 2012; LaRoche & Foster, 2015). Pre-abortion patients found helplines useful in giving prompt, clear information dispelling abortion myths (Baum et al., 2020). Post-abortion, people also found helpline support useful, while not all patients need or want these services (Kimport et al., 2012; LaRoche & Foster, 2015).

Gaps in the Literature: The Need for Integration of Social Work Principles

Due to a relative lack of social workers in the abortion research community, abortion literature rarely adheres to the frameworks and relational dynamics of social work practice. Per the NASW, social workers should have a “particular focus on those who are vulnerable, oppressed, and living in poverty” (2021). While research indicates that people from all backgrounds and life stages have abortions, relevant overlap exists between social work clients and abortion patients. Both include an overrepresentation of people living at or below the federal poverty level (Jones & Jerman, 2017). Social work practice also intersects with abortion care because unwanted pregnancy more frequently occurs in the context of social inequities and poverty (Finer & Zolna, 2016). This correlation is not causal; the structures that produce poverty also produce the circumstances of undesired pregnancies (Dehlendorf et al., 2013). Social work’s scope and mandate to work primarily with oppressed populations allow for intervention and support for abortion patients. This observation is not novel; multiple social work researchers have noted the relative dearth of social work abortion research and thus called for more work in this area (Hyatt et al., 2022; Wright et al., 2015). This paper responds to those calls.

A second gap in the literature pertains to methodologies used in abortion research. Researchers often sample post-abortion, clinical populations, missing those who do not go to an abortion clinic. Missed populations include those who consider but may not have an abortion, cannot navigate barriers, or have an abortion outside of a clinical setting. Social media platforms attract people before they seek an abortion and allow users to communicate with one another. These social interactions are more organic than researcher-subject dynamics, providing new understandings of patient needs. Online anonymity may allow patients to be more honest in expressing their needs. This novel data source provides a new look into the abortion experience.

Methods

Data for this study derive from Reddit, a website that aggregates topical message boards called subreddits, where users write and respond to posts. Nearly 40 percent of people between 18-29 years old in the US use Reddit (Pew Research Center, 2019), one of the top 10 most used websites in the US (Alexa Internet Inc., 2022). Prior researchers have found value in analyzing Reddit data on sensitive topics given its candid, anonymous, discussion-based format (Sowles et al., 2018).

Data Collection

In January and February 2020, we used Python to scrape the 250 most recent posts from abortion-related subreddits. We selected this sample size based on prior Reddit research documenting robust findings with similar Ns (Brett et al., 2019; Sowles et al., 2018). The research team removed all identifying information from posts, including usernames and IP addresses. To answer our research question about experiences of seeking an abortion in the US, we excluded posts containing information suggesting that the user lived elsewhere (e.g., use of metric system) or exclusively asked medical questions. The research team used NVivo (QSR International, 2019) for analysis. The University Institutional Review Board approved this study protocol.

Analysis

We used a combined inductive and deductive qualitative approach, analyzing data in response to our original hypotheses, with additional codes and themes generated in response to the data themselves. We used an analytic design called qualitative description, through which we aimed to describe and summarize posters’ experience, rather than attempting to build theory from the dataset. Qualitative description aims to minimize the amount of interpretation on the part of researchers. In using this methodology, we did not aim to explain posts through an existing conceptual framework, but rather to describe what users were experiencing in plain language. (Sandelowski, 2000).

Four researchers trained in qualitative data analysis generated and reviewed an initial codebook using a random subset of posts, generated a list of themes, and reached consensus on the ultimate codes. The team then developed the final codebook, creating code names, definitions, information on when to use each code, and example quotations. Three team members co-coded 25 posts, discussed discrepancies, and reached consensus on code application. Each of the remaining posts was coded by one team member. As additional themes emerged, the team revised previously coded posts. The final codebook contained 26 codes. We reached theoretical saturation within 200 posts (n=194).

The team examined coding reports about giving or receiving advice, practical support, and community building. The first and second authors independently read these coding reports and collaborated to generate salient themes, then identified posts that supported these concepts.

Results

Analyses revealed three main needs, for 1) information, 2) emotional support, and 3) community.

Theme One: Informational Needs

In terms of informational support needs, posters asked questions about: abortion-seeking experiences, physical experiences of abortion, and self-managing their abortions. Users sought information to help them make choices about, or access, might make obtaining an abortion.

The Abortion Seeking Process

Reddit users in our analysis sought resources and help with planning abortion logistics. People made broad requests for advice and highly specific inquiries, from planning stages through recovery. These questions reflected a general lack of information about what to expect at all stages of the abortion process. Many posters sought help with navigating abortion access, often related to their lack of resources. For example, one user wrote:

I've already had to reschedule my appointment once now, and the current date is for Thursday. Im 2 days off of 19 weeks and very quickly running out of time to reach the20 week limit[…]. The appointment is a2 hour drive away and I can't drive myself. Considering ive only lived here a few weeks, I don't have anyone to take me at, much less someone who can sit with me both days of the procedure. I have no idea what to do at all and I'm actively terrified. Does anyone know what I should do?

Alongside navigation questions, many users wanted to learn about the experience of having an abortion, such as:

Can people tell me about their surgical abortions and the process WITH details?? […] just need some reassurance or advice from women who have had this surgery.

These broad questions seek the experience of others as an idea of what the posters’ own abortion experiences may be like.

Physical Experience

Many posters asked about what to physically expect during their abortion, seeking reassurance that their experiences were normal. Often users posted stories and questions in real time. For example:

I took the 2nd pills around 9:10 this morning and started bleeding by an hour later. I’ve passed 7 clots and had pouring blood but its only when I go to the toilet and squat down. Other than that it’s like there’s no blood coming out with me just sitting normal. Is this normal?

One poster expressed similar questions in the weeks following their abortion:

Does this [bleeding] sound normal to you? Does it sound like it failed (I'm fine with left over tissue, just don't want a continued pregnancy)? My symptoms are gone and I think my boobs are starting to go back to their normal size, I'm just worried about the lack of heavy bleeding, and I keep reading nausea and boob tenderness tend to start going away around 10 weeks/into your second trimester anyways, and now I'm paranoid.

In addition to wanting to know if their experience was normal, many posters wanted to know if they needed to be medically concerned or seek health care. They also had questions about when to take the pills for a medication abortion, or what kind of pads or tampons to use post-abortion.

Self-Management

Finally, people also sought information on self-managing their abortion (e.g., ordering medication online to induce abortion). Self-managing abortion is an effective means of ending a pregnancy at home and can be an option for those who experience other barriers to abortion (Aiken et al., 2018). Users sought a trustworthy information about this option, asking questions such as:

I'm a fifteen year old girl [and] I'm pregnant. My parents are extremely strict so theres no way i can walk/bus/get a ride to a clinic […] Is there anyway i can get an abortion. Do you know of any home remedies or maybe a service with pills that come in a disguised package?

Some users asked about off-label or animal medications or non-medication techniques that might induce an abortion.

Theme Two: Emotional Support Needs

Many posters came to Reddit looking for emotional support or advice. Posters had a range of abortion experiences, so the needs they expressed varied. Many sought emotional validation and a space to process or discuss their feelings.

Wide-Ranging Emotions

Posters expressed emotions such as guilt, fear of the abortion process, fear of future emotional struggles, sadness, emptiness, nervousness, and worry. Posters also expressed gratitude, certainty, and relief. In particular, posters sought advice on ways to process these difficult emotions and heal from their experience.

I'm still feeling a lot of shame and regret about the situation. I am thankful that I had access to resources to allow me to terminate the pregnancy but I guess I regret that I was in that position in the first place. I am a 20 year old college student and feel that if I was a different place in life I would have kept my baby. I felt very emotionally attached to my baby even though I was only pregnant for a short time. I have a lot of shame about abortion and sex in general and dont even know how to start healing from this.

And

I don’t know how to address this and move past it. I expected to feel relieved but instead it like my life has been put on hold. I wondered if feeling like this is common because I feel ridiculous for feeling this way. I am struggling to sleep and cry all the time and fell apart when I saw the [post-abortion] negative test even though I’m sure this was what I wanted and realistically had to do.

Complex and Contradictory Emotions

Some posters discussed their own decision certainty and their process of reaching certainty amidst difficult or contradictory emotions and sought an outlet for these emotions.

I am so eager and desperate to get back to life. I have been physically exhausted, depressed, emotional, nauseated and puking several times a day […] This has been one of the hardest decisions of my entire life. I learned I was pregnant immediately at 4 weeks, and spent two weeks attending therapy (solo and along with my SO), reading books and doing some deep soul searching. I have no doubt that I'm making the right decision - now is NOT the right time. So now, I'm nervous and anxious to be done with this.

Several posters asked for reassurance that they could be “pro-choice” and have negative emotions after their abortion, an incongruity that led some to question their decisions.

I feel like I have so many emotions bottled up from the time I found out I was pregnant to the end of healing post abortion that I’ve stored away and ignored. I have flashbacks to my abortion sometimes. I’ve been thinking a lot about talking to a counselor about my abortion because I’ve definitely been repressing it and pretending it didn’t happen. But this is all confusing to me because I am a HUGE pro-choice advocate and do not regret my decision in anyway.

Such posts illustrate users’ experiences of cognitive dissonance, as they consider the values they hold and the emotional experiences of their abortion.

Isolation

Many posts discussed loneliness. Often, posters experienced abortions alone, faced stigma in their offline lives, and sought comfort from this online forum.

I have no emotional support as I have to hide all my symptoms at work and in school […] Ive only told one friend and she doesnt know how to act and doesnt know how to be caring when I need it and I cant tell my family because we are Mexican and at this age out of wedlock I would be disowned and I just feel alone in all of this. I have no one to confide in.

Some posters noted that receiving advice, support, and reassurance from others in similar situations helped mitigate negative emotions.

Just reaching out for any support and encouragement. Thank you to this entire sub[reddit], without it I would feel utterly alone.

Theme Three: Need for Community

A final theme pertained to posters looking for supportive community where they could share their abortion stories and questions. The forum functioned as a community in several ways, with people reporting benefit from receiving and contributing advice and support.

Benefits of Community

Many posters indicated that they found comfort, support, or reassurance in the space:

Even post-abortion, [this subreddit] has still been helpful. I posted recently when I had a pregnancy scare and I was so scared of having to go through all that again, and the responses were so kind, and actually helped me calm down a lot, and think rationally, and not to worry until I was able to take a test to know for sure (which was negative- yay)

Several posters returned to the forum after their own experience to support others, often by sharing their own story, with detailed descriptions and advice.

i hope this helps someone. i read a thousand horror stories and some good painless stories online before i took my pills. i was prepared for the worst and hoping for the best. i look at it this way. a night of immense pain is worth feeling like yourself again. its worth NOT having a child. its worth so much. this is the first time ive felt like myself in about a month and im so happy.

Some also offered specific advice intended to improve the physical abortion experience, such as recommendations to drink water during a medication abortion or to choose the intravenous painkiller during a procedure. Others shared their general experience and offered support, comfort, and love to the other posters:

Just sharing my story of abortion. For weeks leading up to my abortion I was looking for stories that would make me more comfortable with my decision and also less scared in regards to the procedure itself, so hopefully this brings some comfort to someone else.

Stigma Busting

Posters also contributed to, and benefited from, this online community’s normalization and destigmatization of abortion. Posters explicitly discussed how conversations in this community could reduce stigma and shame around abortion.

I believe we are doing a great thing by supporting, and providing resources to women in need of an abortion. Maybe one day society as a whole will be able to do the same for women. If that day comes, the world will be a better place.

And

I hope this post brings a sense of ease to those going through it, I know it can be a hard decision to make as most of us feel obligated to continue a pregnancy out of shame and fear of the backlash we could receive.

Discussion

Social work research rarely engages with abortion, despite alignment between people’s needs around abortion and social work frameworks. This study finds that people seeking or considering abortions often have questions at all stages in the process, and that they seek answers in a community of like-minded, supportive people rather than (or in addition to) through the health system. Abortion seekers in this study express common emotional threads; hearing about others’ abortion stories, and sharing one’s own, can provide comfort. Posters’ needs are in line with social work’s core competencies, and map easily onto various domains of social work practice, reinforcing that social workers should see abortion care as a work domain. This study adds to the social work literature by highlighting the ways in which social workers can use their existing skillsets to engage with people who have had abortions. It also adds to the social work literature by including perspectives and experiences of patients who wanted an abortion but who were unable to access one. Finally, it provides an unfettered look into the way that users express their needs and how others seek to meet those needs.

Implications for Social Work Practice and Education

The three primary findings in this research (informational needs, emotional needs, and need for community) map well onto primary areas of micro social work practice, and can be spaces for engagement in this work. An estimated 29 percent of social workers work in healthcare, often providing clients information and referrals (Salsbert et al., 2017). Healthcare social workers need to be able to refer clients to abortion services, including local and interstate clinics, abortion funds, and emotional support organizations, yet around 40 percent of social worker students would not feel confident in their ability to provide referrals to abortion care (Ramseyer Winter et al., 2016). This information will be especially crucial as the increasing number and severity of legal restrictions makes it harder to obtain an abortion in many states, and clients need help navigating barriers. Many questions posted by Reddit users in this study were not so medically complex as to require consult from a healthcare provider and could be adequately answered by a trained social worker. Integrating basic medical information about abortion and referral processes into social work training would prepare social workers for a likely job duty.

Abortion seekers in this sample mentioned a desire to or experience with speaking with a mental health professional during their abortion experience, including as a post-abortion emotional coping strategy. A 2019 study on the behavioral health workforce found that about 25 percent of social workers worked in direct practice mental healthcare, with jobs focused on mental health the second most common focus for recent social work graduates (Mullan Institute, 2021; Salsbert et al., 2017). While most abortion patients do not see long-term mental health impacts of their decision, many in abortion care recognize the importance of providing opportunities for patients to discuss and process emotions (Joffe, 2013). While being conscientious to not reinforce misinformation that attributes lasting mental illness to abortion, social workers can make space for a nuanced conversation that acknowledges that some people who have abortions need emotional support before, during, and after their abortions. Further, abortion stigma often mediates negative long-term effects (Biggs et al., 2020); interventions to counter abortion stigma could thus improve mental health outcomes. As abortion becomes a more politically controversial topic while also becoming harder to access, it is reasonable to believe that clients and patients will experience an ever higher burden from stigma. Thus, support could be particularly helpful for patients who, like some Reddit posters, discussed misalignment between personal pro-choice values and negative emotions they experienced after abortions. Researchers also document long-term mental health consequences for people who seek, but are not able to access, abortion care (Biggs et al., 2020). Preparing social workers to hold space for emotional support and processing with abortion patients should be a key component of social work training.

Social workers can uniquely address the third theme, community building, using disciplinary training in group facilitation. Group facilitation is a core competency in social work practice (CSWE, 2015). Social workers could lead online or in-person discussions on abortion. Much like with emotional processing, social workers are trained to facilitate and navigate community-building conversations and spaces. Being trained to lead discussions on abortion will better prepare them for their careers. Again, as abortion legality changes, people will need space to process and discuss abortion experiences.

Future Directions for Social Work Engagement in Abortion Care

While the primary findings of this paper relate to micro social workers, these findings can be a call to the field as a whole to engage in abortion work. NASW clarifies that abortion access is in line with the principles of social and economic justice for all, and explicitly endorses the adoption of reproductive justice principles, including safe access to abortion, into social work (NASW, 2018). Feminist social work scholars have elaborated on concrete policy and practice decisions that the profession could take to answer NASW’s call to reproductive justice, including abortion care (Beddoe, 2021; Gomez et al., 2020; Hyatt et al., 2022). Social work as a field could advocate for relevant policy activity like overturning the Hyde Amendment; provide financial support to abortion funds; integrate reproductive justice into social work scholarship; educate on histories of reproductive coercion, inequity, and racism; and advance these ethics in social work practice. The pending overturn of Roe v. Wade would worsen gaps in care delivery capacity and community needs. It may benefit social work as a field to prepare for those needs. The field also needs research into interventions in abortion care, particularly in healthcare coordination and mental health. Because social workers work in diverse positions across many sectors, this group can engage in abortion care and advocacy in a variety of ways. From clinical providers preparing to emotionally support abortion patients, to program officers devising new systems of care coordination, to policy advisors crafting legislation informed by reproductive justice, the diversity of social work roles means that the field has the capacity for meaningful engagement about abortion.

Limitations

Social media data entail limitations. Reddit posts can be short, lacking information that we might have sought through interviews or other data collection methods. Particularly, while we aimed to only include posts from users in the US, we cannot confirm with perfect certainty that all posters were in the US. However, this project benefited from the open-response nature of Reddit, difficult to achieve with other methodologies. Additionally, though Reddit is popular, its users are not a perfect cross-section of people who seek abortions, limiting the generalizability of these findings. Still, themes elucidated here shine needed light on how social work can improve abortion care. Finally, the steps taken to anonymize the data (e.g., removing all identifiers) mean that one person could technically posts more than once. The large number of posts and their range of style and language suggest a range of users, helping manage this limitation.

Conclusions

Many people have abortions, and social workers work directly with abortion seekers. Social work focuses on centering and valuing the needs of our clients, with our primary responsibility to provide competent care to patients. Striving toward reproductive justice in our work allows us to center our clients, for abortion-specific questions and in other areas of their lives. By being well informed about abortion and abortion-seekers’ needs, social workers can provide essential care to their clients. As the right to abortion is threatened in the United States, the need for social worker engagement in this care is increasingly urgent.