The experiences and perspectives of abortion seekers who travel for care: a qualitative evidence synthesis

Objectives

This is a protocol for a Cochrane Review (qualitative). The objectives are as follows:

This QES aims to address the following question:

What are the lived experiences and perceptions of abortion seekers (i.e. pregnant women, transgender men, and non‐binary people of any gender) traveling to obtain care?

The review objectives are to:

• synthesize the qualitative evidence to address the review question;

• identify factors that influence abortion travel experiences and perspectives, which may include the specific abortion regulatory and care delivery context (e.g. legal restrictions, unavailability) and abortion seekers’ personal circumstances (e.g. age, race/ethnicity, gender, partnership status, gestational duration, social/family support, income/wealth).

Background

Description of the topic

Abortion care is sought by people throughout the world for diverse health, family, and personal reasons (Chae 2017). This care involves the use of medications and procedures to terminate a pregnancy. In recent years, telemedicine and the rise of online vendors has enabled medications to be sent to patients directly for medication abortion. However, using just these pills at home for an abortion is not always possible and may not meet an individual's goals or incorporate their preferences related to the experience. To receive the care they need and want, some individuals may undergo a multi‐day process, for instance when a certain type of procedure is required. Sometimes, in order to safely obtain abortion services, individuals will need an obstetric ultrasound, will need to provide blood samples for lab work, or get medical clearance from a healthcare provider, all prior to the abortion. In terms of medical and technical complexity, abortion care can be simple or complicated. More often than not, though, it is simply inaccessible to individuals (i.e. due to lack of trained providers or a lack of ultrasound resources), and often it is just illegal. As a result, those seeking abortion often need to travel to obtain this important care.

How this topic might affect people

Traveling significant distances for abortion is common globally because of legal restrictions that limit where abortion can be obtained within a country (e.g. United States, Mexico) or whether it can be legally obtained at all in the country (e.g. Ireland until recently and Northern Ireland) (Barr‐Walker 2019). Travel poses financial and logistical challenges for abortion seekers (Barr‐Walker 2019). In addition to these practical and often more quantifiable aspects of traveling to obtain abortion, the experiences and perspectives of women, transgender men, and non‐binary individuals of any gender (for simplicity thereafter referred to collectively as abortion seekers) traveling for abortion (or unable to obtain abortion due to the need for travel) are important when it comes to deepening our understanding of the impact that abortion restrictions can have (Kimport 2023).

The World Health Organization (WHO) presents a conceptual framework for abortion care in the most recent guidelines for service provision. The model has at its center the values and preferences of individuals seeking care and highlights the many elements that can create an enabling environment for quality abortion care, from the types of abortion methods available to the support provided by community outreach programs (WHO 2022). When we understand the experience of people seeking abortions in the context of this framework, we can identify areas of disconnect between their ideal experience, influenced by their individual values and preferences, and the reality of seeking abortion care. By understanding the experiences of people obtaining care in contexts where travel is required or desired, a more comprehensive analysis of the impact of abortion policy and care delivery systems can be obtained. Ultimately, through this understanding of the experiences of those seeking and traveling to obtain abortion, care can be improved and the needs of those seeking abortion care under different circumstances better attended to. Greater understanding of the client perspective can inform improvements in clinical care and assist those supporting and providing abortion care. It can also provide policymakers and legal teams with information needed to better characterize the effects of policies aimed at either restricting or expanding the availability of safe, legal, accessible abortion care.

Why is it important to do this review?

Abortion‐related policy restrictions have been enacted in countries throughout the world, limiting the availability of services and reducing access to care. Although the types of barriers to care that abortion seekers face may differ depending on the setting, access can be difficult in low‐ and middle‐income countries as well as high‐income countries when clinical and abortion care is sparsely distributed due to resource limitations and when legal limits impact on care provision or access (Chakravarty 2023; Jones 2013; Rahm 2022).

Characterizing the experiences of abortion seekers when access is limited can help policymakers understand the effects of policy changes from the perspectives of those affected. In addition, clinicians providing abortion care in the setting of legal restrictions can better understand the lived experience of the patients they serve, helping them to provide support and resources targeted to specific challenges. One example of a rapidly changing policy context is in the United States (Ranji 2023). In recent years, states have enacted various bans and restrictions to abortion access following the loss of federal legal protections. Even before the US Supreme Court’s decision in Dobbs versus Jackson Women’s Health Organization (Dobbs), a decision that reversed nearly 50 years of precedent, the proportion of people traveling to another state to obtain abortion services rose from 6% in 2011 to 9% in 2020 (Maddow‐Zimet 2022; Smith 2017). People in rural counties in the United States are disproportionally more likely to be adversely affected by increasing restrictions to abortion access (Bearak 2017). Global data have shown that restricting abortion access does not affect how often it is needed, but instead restrictions increase the number of unsafe abortions performed (Bankole 2020). Those who have experienced traveling for abortions emphasize being motivated to do so because of the legal and medical risks associated with self‐managing an abortion at home (Broussard 2020). It should be noted that self‐managed abortion has in fact been very helpful for many abortion seekers (Aiken 2017); however, this review will focus primarily on travel for healthcare‐associated abortion services.

Legal disparities seen across Europe have led to unequal reproductive health opportunities that have necessitated travel for services, deepening inequalities, delaying access to care, and increasing health risks (De Zordo 2023; Gerdts 2016; Mishtal 2022). Even in countries where abortion is legal, access is not evenly geographically distributed (Ranji 2019). A study completed in the United States before the 2022 Dobbs decision showed that a greater distance to travel to abortion services was associated with delays in access to care (Rader 2022). Reduced service availability in rural areas, especially for more complex procedures, can also make travel necessary or reduce access to care in the context of legal abortion.

Traveling for abortion care represents a multifaceted and unique challenge for individuals who are pregnant. Key challenges related to abortion care logistics have been identified in a previous mixed‐methods review that described financial and logistical burdens and the effects these had on abortion care decisions, for instance whether a medication versus a procedural abortion should be pursued (Barr‐Walker 2019). A separate qualitative study examined why and how women sought out at‐home medication abortion online and identified barriers, comfort and support of available options, and trust of options as key decision points (Aiken 2018). While access to healthcare‐associated medication abortion or self‐managed/at‐home medication abortion may in some cases reduce the need to travel for abortion care, not all abortion seekers will be eligible due to gestational limits or have access to the medication(s). As abortion restrictions increase, more people will likely have to consider traveling for care. It is critical for those providing and facilitating care to understand what the reality is for abortion seekers so appropriate support and assistance can be provided.

How this review might inform or supplement what is already known in this area

The qualitative evidence synthesis (QES) described in this protocol will be complementary to an ongoing review on the effects of different abortion policy environments on women’s health being conducted by a separate study team (MacLeod 2023). That review examines quantitative evidence comparing the economic and social well‐being of women experiencing different abortion policy contexts.

We identified relatively few QESs or protocols published on the topic of traveling to obtain abortion and none published as Cochrane reviews.

One mixed‐methods systematic review of women’s experiences with travel for abortion included studies published through March 2017 (Barr‐Walker 2019). The review included 12 qualitative studies, most of which were conducted in the United States. That review identified themes related to the characteristics and burdens of travel and how travel affected the abortion care received, such as abortion method and number of clinical visits. The authors called for further research on the abortion seeker’s experience in non‐US contexts and for studies that focus on the experiences of individuals unable to obtain care due to travel constraints. The review authors also noted the increasing amount of research on this topic. Our QES will contribute to the literature by updating the evidence and applying newer Cochrane methods for QES that include GRADE‐CERQual (Confidence in the Evidence from Reviews of Qualitative research) assessments of confidence in the findings.

Another non‐Cochrane QES examining the experiences of women with self‐managed abortion touched on the topic of logistics, but focused on the experience of the self‐administration process and does not substantively overlap with the aims of our review protocol (Wainwright 2016).

One Cochrane QES included abortion services in their examination of clients’ experiences with mobile phone‐based health interventions, but the themes identified did not address the topic of travel for abortion (Ames 2019).

QESs on abortion have tended to focus on abortion decision‐making and experiences for specific groups of abortion seekers, for instance those seeking abortion for different reasons (e.g. fetal anomalies or maternal conditions) or those with specific demographic characteristics (e.g. specific race or age). We intend to look beyond just the decision‐making process and ideally explore the experiences of all types of abortion seekers.

Objectives

This QES aims to address the following question:

What are the lived experiences and perceptions of abortion seekers (i.e. pregnant women, transgender men, and non‐binary people of any gender) traveling to obtain care?

The review objectives are to:

• synthesize the qualitative evidence to address the review question;

• identify factors that influence abortion travel experiences and perspectives, which may include the specific abortion regulatory and care delivery context (e.g. legal restrictions, unavailability) and abortion seekers’ personal circumstances (e.g. age, race/ethnicity, gender, partnership status, gestational duration, social/family support, income/wealth).

Methods

When preparing this protocol/review, we used the Cochrane Protocol and Review Template for Qualitative Evidence Synthesis and guidance from the Cochrane Qualitative and Implementation Methods Group on specifying and describing the topic of interest in a qualitative evidence synthesis (Glenton 2020).

In developing our protocol and conducting the review, we referred to the PROGRESS+ acronym to focus attention on a broad set of factors and their myriad intersections that can influence health opportunities and outcomes (methods.cochrane.org/equity/projects/evidence-equity/progress-plus). In establishing our research aims and conducting the review, we will build on this organizing principle and literature on health equity, including Chapter 16 of the Cochrane Handbook for Systematic Reviews of Interventions (Welch 2023), to ensure consideration of the perspectives of abortion seekers affected by these intersecting identities and circumstances when available. We will highlight any areas where data were not available on the experiences and perceptions of groups that have unique and less commonly understood needs or challenges in obtaining abortion care.

PROGRESS+

Place of residence Race/ethnicity/culture/language Occupation Gender/sex Religion Education Socioeconomic status Social capital

+ plus refers to: 
1) personal characteristics associated with discrimination (e.g. age, disability)
2) features of relationships (e.g. marital status, exclusion from school)
3) time‐dependent relationships (e.g. instances where a person may be temporarily at a disadvantage)

Criteria for considering studies for this review

We used the PerSPE(C)TiF framework to formalize the question and to characterize the features of studies eligible for inclusion in the review (Table 1).

Table 1. Review Scope Using the PerSPE(C)TiF Framework

Per	S	P	E	(C)	Ti	F
Perspective	Setting	Phenomenon of interest or Problem	Environment	Comparison	Time/timing	Findings
From the perspective of abortion‐seeking women, transmen, or non‐binary individuals	In any community, institutional, or healthcare setting	The phenomenon or process of accessing abortion‐related travel including financial, logistical, and emotional resources required and associated equity considerations	In any country	Compared across all types of legal, regulatory, or health system conditions, individual and personal characteristics, abortion circumstances (e.g. gestation, reason)	During any time in the past 20 years, from the time pregnancy was known through its resolution, including follow‐up care	In relation to the abortion seeker’s perceptions and experiences

Types of studies

We will include primary studies that use qualitative study designs and methods, such as ethnography, phenomenology, case studies, grounded theory studies, and qualitative process evaluations. We will include studies that use diverse qualitative methods for data collection (e.g. focus group discussions, individual interviews, observation, diaries, document analysis) and qualitative methods for data analysis (e.g. thematic analysis, framework analysis, grounded theory). Depending on the volume and comprehensiveness of the available literature, we may employ further limits on the study designs included. We will exclude studies that collect data using qualitative methods but do not analyze the data using qualitative analysis methods (e.g. open‐ended survey questions where the response data are analyzed using descriptive statistics only). We will include mixed‐methods studies only if it is possible to extract and analyze the data collected using qualitative methods. We will not exclude studies based on our assessment of methodological limitations. We will use this information about methodological limitations to assess our confidence in the review findings.

We expect studies conducted more than 20 years ago to have less relevance to the current population and policy context, due primarily to changes to the abortion technology and abortion access landscape related to the development and widespread dissemination of medication abortion products and protocols. For example, mifepristone was approved for abortion use in the United States in the year 2000. Our review aims to identify themes relevant to the current global abortion policy context and will therefore focus on the qualitative literature from 2003 to the present.

We will assess published and unpublished studies in any language for potential inclusion in the review (see also 'Language translation' section below).

Topic of interest

We will include qualitative studies of individuals sharing their experiences and perspectives related to the need for travel to obtain an abortion. We expect that data for this QES may be found in qualitative studies examining a range of topics including access to abortion and abortion decision‐making. Studies focused explicitly on experiences of traveling to obtain an abortion will be especially important for addressing the review question. We have not established an a priori definition of ‘travel’ at the outset of this review so as not to exclude relevant studies that may not define travel in terms of distance or other quantitative metrics. We will provide definitions and descriptions of travel from the included studies, recognizing that what constitutes travel may vary considerably depending on the abortion legal context as well as the social and personal circumstances of abortion seekers. For example, even if it does not involve traveling a great distance, a border crossing could impact an abortion seeker’s experiences and perceptions. These experiences may take place in any global context, regardless of the legal status and policies governing access to abortion care. Abortion sought in any setting—including clinics, hospitals, or the community—are of interest, so long as the effort to obtain care involves travel beyond a familiar or local setting where routine care is obtained.

Types of participants

We will include studies focused on participants who experienced a pregnancy and sought to obtain or obtained an abortion that required travel. We will include studies regardless of the pregnancy outcome. We will exclude studies focused on information about travel for abortion obtained from healthcare providers or caregivers and partners about the process of obtaining care, as we are focused on the first‐hand reports of those who have experienced a pregnancy. Depending on the volume of the evidence available for this review, we may impose further limits, for example specifying a recall period (e.g. within three years of travel for abortion) as an inclusion criterion.

Search methods for identification of studies

The search will be developed and conducted by the Fertility Regulation Review Group’s Information Specialist in consultation with the review authors (Appendix 1). The search will be limited to publications from the past 20 years (January 2003 to present). We will not apply any limits on language. The search will employ an iterative search process, adapted as the review progresses, with the aim of ensuring that all available themes or concepts related to the review question are identified. We will develop search strategies for each database, using guidelines developed by the Cochrane Qualitative and Implementation Research Methods Group for searching for qualitative evidence (Booth 2016). Books and book chapters are important publication vehicles for social science research on our topic, so we will also search WorldCat.org.

Electronic searches

We will search the following databases (2003 to present).

• MEDLINE ALL (Ovid)

• APA PsycINFO (Ovid)

• CINAHL (EBSCOhost) (Cumulative Index to Nursing and Allied Health Literature)

• Anthropology Plus (EBSCOhost)

• Dissertations and Theses Global (ProQuest)

• Gender Studies Database (EBSCOhost)

• SocINDEX (EBSCOhost)

• African Journals Online (www.ajol.info)

• Sinomed (www.sinomed.ac.cn/index.jsp)

• WHO Global Index Medicus (www.globalindexmedicus.net/)

• WorldCat.org (www.worldcat.org/)

Grey literature

We will search the following sources for grey literature.

• Center for Reproductive Rights (reproductiverights.org/)

• Eldis (www.eldis.org)

• Guttmacher Institute (www.guttmacher.org/)

• Ipas (www.ipas.org)

• MedRxiv (www.medrxiv.org/)

Searching other resources

We will review the reference lists of all included studies and key references (i.e. relevant systematic reviews). We will contact the authors of included studies to clarify published information and to seek unpublished data as needed.

The Cochrane review process has not been developed to evaluate books, but academic press publications that include sufficient methodologic reporting will be considered for potential inclusion, particularly if the included studies published as articles are lacking in depth or richness for the topic of interest. We will consider piloting processes for their inclusion. For this pilot, we will conduct searches of academic publications in university presses, possibly considering both monographs and edited volumes for inclusion. This pilot effort will employ a flexible approach to the inclusion of books and monographs and make consensus decisions based on available resources and time available to complete the QES. We are aware that coding and data extracting from books and monographs may take too long and produce too much data to conduct a meaningful synthesis, so a balanced approach will be required. On the other hand, the proposed pilot may provide evidence on the value of this additional source of data for Cochrane QESs.

Selection of studies

At least two review authors (JH, SR, RS) will independently assess the titles and abstracts of the identified records for potential relevance. We will retrieve the full text of all the papers identified as potentially relevant by one or both review authors. Two review authors will then assess these papers independently. We will resolve disagreements by discussion or by involving a third review author (AF, KK, JN) when required. We will contact the study authors for further information as needed.

We will review the titles and abstracts in chronological order, beginning with the most recent evidence.

We will include a table listing studies excluded at the full‐text stage along with the main reasons for their exclusion. A separate Appendix table will list the eligible studies that were not included in our review if a sampling approach is used to select the included studies.

Where the same study using the same sample and methods is presented in different reports, we will collate these reports so that each study, rather than each report, is the unit of interest in the review.

We recognize that potentially rich and rigorous studies, particularly from the fields of sociology and anthropology, may only appear in the literature as books or academic theses; we will therefore consider their inclusion and identify relevant sections of the publications for our review question and any peer‐review publications also available from the study. Books and theses identified as eligible but not included will be listed in the Appendix, and we will note potential limitations of our review related to their exclusion.

We will include a PRISMA flow diagram illustrating the process of screening and selecting studies for inclusion.

Language translation

Because this review has global relevance, we will include studies published in any language spoken fluently by someone on our multilingual study team (i.e. Arabic, English, French, Spanish), emulating methods developed by World Health Organization methodologists (Downe 2019). For titles and abstracts published in a language in which none of our review team members are proficient, we will carry out an initial translation through open‐source software (Google Translate). If translation suggests a paper could be eligible for inclusion, we will retrieve the full text of the paper and will seek additional resources within the Cochrane or our professional networks. Evidence synthesis requires shared understandings and interpretations of meaning and context, and the ability of review authors to translate relevant studies needs to be considered. If this cannot be done for a paper in a particular language, the paper will be listed as 'awaiting classification' to ensure transparency in the review process. The role of language in the primary study (participants' first language, data collection, synthesis, publication) will be described in data extraction and methodological assessment.

Sampling of studies

We will aim to achieve a maximum variation sample rather than an exhaustive/comprehensive sample, since large amounts of study data can impair the quality of the analysis and synthesis (Sandelowski 1995). Once we have identified all eligible studies, we will assess whether their number, coverage of the phenomenon of interest, and aspects of context specified in the protocol or data richness are likely to represent a problem for the analysis and will consider selecting a sample of studies.

QESs do not generally seek to obtain the greatest number of studies possible, but instead to optimize the diversity of concepts and contexts found in the studies synthesized. Including a large number of studies with repetition of the same concept or context can limit the quality of analysis. We will therefore select a sample of studies if the number of studies eligible for inclusion is large. (The determination of what constitutes large depends on the type, richness, and thickness of data obtained, since different types of publications include different amounts and density of information.) Similar to primary qualitative studies, we will aim for concept saturation. Allowing for the broadest possible variation across the included studies, we will use maximum variation purposive sampling to select from the eligible studies (Noyes 2017). We will produce a knowledge map to assist in the selection of studies. This knowledge map will be created by categorizing the studies according to features that vary in the eligible studies and that have conceptual importance (Ames 2024). These features will be informed by our developing familiarity with the literature, including variables such as the type of setting (e.g. Human Development Index, rurality, policy context), participant characteristics (e.g. race and ethnicity, gender, age), abortion care (type of abortion obtained, gestation when aware of pregnancy and at the time of abortion). This process will be important for identifying which studies are important to include because they represent uncommon concepts and perspectives and should be included to optimize variation. The knowledge map will also help us to understand where we lack evidence (to identify needs for future research). We will also evaluate the thickness and richness of the eligible studies using 3‐point instruments developed by Ames and colleagues (manuscript in progress shared by author). These tools use sliding scales for assessing the conceptual thickness and contextual thickness of the data reported in primary qualitative studies. We will select studies with the aim of optimizing the thickness and richness of included studies when there are multiple studies addressing a particular context or population. Our first priority will be to ensure that we have included studies that span the range of perspectives, experiences, and settings identified through the knowledge mapping process. In other words, if there is only one study focused on experiences of individuals or a context rarely addressed in the qualitative literature, we would include the study regardless of the richness/thickness or assessment of methodological limitations (see below). In our QES we will provide information about the studies eligible for inclusion but not purposively sampled for the review.

Data extraction

We will use Covidence software to screen articles and record descriptive data about the included studies. We will extract descriptive data into a table from each included study that describes the study context and participants as well as the study design and methods used, including the following.

• Study objectives, participants, settings

• Study design, sample selection, interview procedures

• Analytic approach, theoretical models or frameworks used

• Author reflexivity

• Timing of data collection, type of qualitative data

• Abortion policy context at the time of the setting (e.g. legal and clinical restrictions)

We will extract qualitative data from primary studies, with the approach used dependent on the method of synthesis. ‘Findings’ can generally be found in all parts of a qualitative study report but primarily in the findings, tables, and discussion sections, and increasingly in additional online files, infographics, logic models, theories, and other types of illustrations. Tags will be used to track first‐order data (quotations) and second‐order data (author interpretations, conclusions) abstracted. Data extraction will be conducted by one review author and checked by a second review author to ensure the key information from each study has been selected. We will likely conduct thematic synthesis (see below), so data will be identified first through line‐by‐line coding. We plan to use the cloud version of ATLAS.ti for coding, extracting, analyzing, and synthesizing textual and other types of data such as images, theories, tables and diagrams, etc.

If a book meets the review inclusion criteria and is included, an indexing approach will be used to identify the sections or chapters relevant to the review, and excerpts will be coded from the selected material. Again, this aspect of the review will be approached as a pilot that aims to contribute to QES methodological development. For journal articles described in greater detail in a book or other long‐format publication, additional findings, context, and methodological information will be extracted from the underlying source for our synthesis. Generally, when academic theses are identified that have corresponding peer‐reviewed journal publications, we will prioritize the article, as these often are the culminating work, providing fully synthesized findings.

Assessing the methodological limitations of included studies

At least two review authors (JH, SR) will independently assess the methodological limitations for each included qualitative study using the Cochrane qualitative Methodological LImitations Tool (CAMELOT) (Munthe‐Kaas 2024), regardless of the type of publication (e.g. book/chapter, monograph, journal article). If review authors are also authors of primary studies eligible for the review, they will not be involved in the assessment of that study’s methods. We will resolve any disagreements by discussion or by involving a third review author (JN, KK, AF) when needed. We will assess methodological limitations using the guidance in the CAMELOT tool, which outlines a process for judging the fit between four Meta domains (research aim and questions, stakeholders, researchers, context) and two Method domains (research design, research conduct). The two Method domains comprise the following.

• Research design: research strategy, ethical considerations, equity/diversity/inclusion considerations, theory

• Research conduct: participant recruitment and selection, data collection, analysis and interpretation, presentation of findings

Relevant features of the included studies will be extracted to support assessment of methodological limitations, and additional forms will be used to organize notes and evaluate the congruence between domains (four Meta domains across eight Method subdomains) that underlies the CAMELOT approach. Review authors will independently assign ratings for the fit between domains (excellent, good, fair, poor, unclear) and develop an overall assessment of limitations based on their notes and ratings. Limitations will be assessed as 'no or minimal,' 'minor,' 'moderate,' or 'serious.' An explanation of the assessment will be provided. Review authors will develop their consensus assessment through discussion, involving other authors as needed.

We will report our assessments in a Methodological Limitations table (Noyes 2017) and identify whether there are no/minor concerns, moderate, or serious concerns about methodological limitations to feed into the GRADE‐CERQual assessment. We will not exclude studies on the basis of methodological limitations, but will take the assessments into account if study sampling is conducted due to a high volume of eligible studies.

Data management, analysis, and synthesis

Our synthesis aims to develop an in‐depth understanding of the experiences and perspectives of individuals traveling to obtain an abortion outside a local or familiar setting. The process for identifying the appropriate synthesis method will follow the RETREAT approach (Booth 2018). We plan to conduct our QES using thematic synthesis, but will consider other synthesis methods if upon familiarizing ourselves with the study data, it becomes evident that another method would offer greater insight (Thomas 2008). For example, we may consider a best‐fit framework synthesis if our synthesis would be strengthened by relying on an existing framework from the literature and adapting it to our review topic (Carroll 2013). If we find particularly rich, thick data, we will consider a synthesis approach that could support further theory development (e.g. best‐fit framework synthesis or meta‐ethnography).

We will consider the Levesque framework on healthcare access as a starting point for a framework or best‐fit framework synthesis (Cu 2021; Levesque 2013). This conceptual model describes multidimensional and interacting factors that contribute to the process of obtaining health care. The healthcare system and environment are important context surrounding accessibility in terms of care approachability, acceptability, availability and accommodation, affordability, and appropriateness. Additionally, the framework identifies social determinants of health and personal characteristics as contributors to the steps in seeking and obtaining health care in terms of the ability to perceive needs and desire care, seek care, reach care, pay for care, and engage in healthcare use. A further adaptation of this framework adds the legality of services to the context of care seeking, which may be particularly relevant to our research objectives (Tschirhart 2016). We anticipate that the domains included in this conceptual model would apply to abortion‐seeking experiences and perceptions in the qualitative literature included in this review. In keeping with the best‐fit framework method, we could potentially adapt this model if needed to better describe the relationships among the themes identified in our review.

Individuals’ perceptions and experiences could also potentially be organized according to factors identified in the review that seem to shape their stories about travel for abortion care, such as personal characteristics, pregnancy duration, available support, and material resources. A framework defining different stages in the process of traveling for abortion care could also be considered, to organize the data in terms of abortion seekers' perspectives and experiences in the initial planning process, during the effort to organize care, seeking resources (funds and transportation), attending the clinic visit, and when after care is recommended.

As outlined above, our review will also draw upon the PROGRESS+ framework as a theoretical lens by identifying stratifying factors that can contribute to health inequities and noting when they are represented or not in the literature included in our review and the data extracted. Synthesis by subgroup may consider the role of the legal and policy context as factors influencing travel and shaping experience (e.g. presence or absence of legal restrictions such as required wait periods and parental involvement for adolescents, criminalized versus legal). We may conduct additional subgroup synthesis according to the Human Development Index (HDI) of the setting (e.g. very high/high HDI versus medium/low HDI) if data allow, because these factors are likely to be highly influential on the experiences and perspectives of the individuals included in the primary studies.

Assessing our confidence in the review findings

At least two review authors (JH, SR, RS) will use the GRADE‐CERQual approach to assess our confidence in each finding (www.cerqual.org) (Lewin 2018). GRADE‐CERQual assesses confidence in the evidence, based on the following four key components.

• Methodological limitations of the included studies: the extent to which there are concerns about the design or conduct of the primary studies that contributed evidence to an individual review finding.

• Coherence of the review finding: an assessment of how clear and cogent the fit is between the data from the primary studies and a review finding that synthesizes those data. By cogent, we mean well‐supported or compelling.

• Adequacy of the data contributing to a review finding: an overall determination of the degree of richness and quantity of data supporting a review finding.

• Relevance of the included studies to the review question: the extent to which the body of evidence from the primary studies supporting a review finding is applicable to the context (perspective or population, phenomenon of interest, setting) specified in the review question.

After assessing each of the four components, we will make a judgment about the overall confidence in the evidence supporting the review finding as high, moderate, low, or very low. The final assessment will be based on consensus among the review authors. All findings start as high confidence and are then downgraded if there are important concerns regarding any of the GRADE‐CERQual components.

Development of the 'Implications for practice' section of the review

Once we have finished preparing the review findings including the GRADE‐CERQual confidence ratings, we will examine each finding to identify connections to the practical concerns of different stakeholders (see 'Stakeholder involvement' section below). We expect that our synthesis will provide valuable insight for several stakeholders working in the following areas.

• Policymakers and legal scholars can consider the perspectives of individuals who are impacted by legal and resource limitations on abortion care.

• Clinical guidance and institutional protocols can be developed to improve the well‐being and health of individuals who traveled for abortion care to medical care including psychological services.

• Funders of health care (private payors and insurance companies, foundations, governments) may come to recognize cost implications and population health implications of the necessity of travel for abortion care.

• Advocacy organizations can use the review findings to identify and highlight financial and logistical support that those traveling from abortion may need.

• Those individuals who have experienced the need to travel for abortion care will have their perspectives shared and potentially impact others who may need to travel for abortion care in the future.

We will develop an 'Implications for practice' section of the review that describes whether each finding has relevance to each of these areas, and how they might be used to develop specific policy, clinical, or advocacy interventions. The implications draft will be shared with a selection of stakeholders from different settings to gather their feedback and further insights into the potential value and utility of the results. The input from stakeholders will be used to further refine and specify the implications of our review.

Summary of qualitative findings tables and evidence profiles

We will present summaries of the findings and our assessments of confidence in these findings in the summary of qualitative findings tables. We will present detailed descriptions of our confidence assessment in evidence profiles.

Review author reflexivity

The authors of this review hold perspectives and have had life experiences that inherently influence how we conceptualize this QES, make decisions about the scope, and conduct all stages of the synthesis. The review authors will aim to consider how their professional and personal positions influence their thinking during the QES conduct and reporting, and these will be discussed in further detail when the QES is complete. Considering prospective reflexivity, or perspectives of the authors as we commence this review, we all view abortion as essential to ensure the continued health and well‐being of women and other pregnancy‐capable people. Some of us have been or are currently involved in the provision of abortion care or abortion research. We all have backgrounds and current life and professional situations shaped by educational, socioeconomic, and/or racial privilege. We also engage with communities and have families that bring us into contact with a range of experiences and perspectives. We have collectively lived and worked in a number of countries and in settings where laws and policies surrounding abortion vary considerably. As we conduct this qualitative synthesis, we will aim to have conversations that consider perspectives that may be missing and to make space to hear and understand ideas and interpretations from all team members.

Stakeholder involvement and engagement

This protocol and the review findings will be circulated to key stakeholders from public health organizations and institutions that advise policymakers, guideline groups, and non‐governmental organizations. These will include representatives from the World Health Organization and the Centers for Disease Control and Prevention.

Appendices

Appendix 1. Search strategies

MEDLINE ALL (Ovid) 1 January 2003 ‐ 10 October 2023
Date searched: 11 October 2023
1 Abortion, Induced/ or Abortion, Eugenic/ or Abortion, Legal/ or Abortion, Therapeutic/ or Abortion, Incomplete/ or Abortion, Septic/ or Abortion Applicants/ or Abortion, Criminal/
2 (abortion* or feticid* or foeticid* or ((interrupt* or terminat*) adj3 pregnan*) or preabortion).ti.
3 or/1‐2
4 Travel/ or Medical Tourism/
5 (((across or cross* or inter* or intra* or near* or "out of") adj (border* or city or cities or county or counties or country or countries or department$3 or provinc$3 or state$1 or town$1)) or bus or buses or car or cars or closest or crossborder$1 or crosscountry or distance or distant or drive or driving or far or fly or flying or geographic* or interstate$1 or intrastate or intercity or intracity or intercountr* or intracountry or interprovinc* or intraprovinc* or kilometers or kilometres or locally or locat*or logistical$2 or logistics or miles or near or nearest or "out of state" or rural or spatial or transport* or tourism or travel* or trip$1).ti,ab.
6 or/4‐5
7 Focus Groups/ or Grounded Theory/ or Qualitative Research/
8 ("critical interpretive" or "critical race" or "critical realism" or "critical realist" or ethnograph* or "grounded theory" or phenomenolog*).ti,ab,kf,kw.
9 (((content or document) adj2 analys*) or diary or diaries or "focus group" or "focus groups" or interview* or "mixed design" or "mixed methods" or observation$1 or qualitative).ti,ab,kf,kw.
10 (barrier$1 or deciding or decision$1 or experien*).ti,ab.
11 or/7‐10
12 and/3,6,11
13 12 not ((animal or animals or bovine or breeds or cancer or canine or capra or case‐control or case‐report or case‐series or cat or cats or cattle or climacteric or clinician$1 or cohort or cohorts or commentary or contracept* or cow or cows or doctor$1 or dog or dogs or ectopic or equine or ewe or ewes or feline or fibroids or goat or goats or habitual‐abortion or hamster or hamsters or "health worker$1" or "healthcare worker$1" or hepatitis or horse or horses or infertil* or invertebrate or invertebrates or IVF or livestock or macaque or macaques or mare or mares or miscarriage or menopaus* or mice or missed‐abortion or missed‐abortions or monkey or monkeys or mouse or murine or nonhuman or non‐human or mosquito* or ovine or pastoral or pharmacist$1 or pharmacy or physician$1 or pig or pigs or polycystic or porcine or preeclampsia or pre‐eclampsia or primate or primates or questionnaire or rabbit or rabbits or rat or rats or rattus or recurrent‐abortion or randomized or rhesus or rice or rodent* or ruminant* or sheep* or simian or sow or sows or "spontaneous abortion" or stillbirth or stillbirths or survey or tsetse or vertebrate or vertebrates or zebrafish).ti. or (case reports or clinical trial or controlled clinical trial or comment or editorial or letter or meta‐analysis or practice guideline or randomized controlled trial or review).pt.)
14 limit 13 to yr="2003 ‐Current"

APA PsycInfo (Ovid) 1 January 2003 to Week 1 October 2023
Date searched: 11 October 2023
1 Induced Abortion/ or Abortion Laws/
2 (abortion* or feticid* or foeticid* or ((interrupt* or terminat*) adj3 pregnan*) or preabortion).ti.
3 or/1‐2
4 Traveling/
5 (((across or cross* or inter* or intra* or near* or "out of") adj (border* or city or cities or county or counties or country or countries or department$3 or provinc$3 or state$1 or town$1)) or bus or buses or car or cars or closest or crossborder$1 or crosscountry or distance or distant or drive or driving or far or fly or flying or geographic* or interstate$1 or intrastate or intercity or intracity or intercountr* or intracountry or interprovinc* or intraprovinc* or kilometers or kilometres or locally or locat*or logistical$2 or logistics or miles or near or nearest or "out of state" or rural or spatial or transport* or tourism or travel* or trip$1).ti,ab. 
6 or/4‐5
7 Content Analysis/ or Focus Group/ or Focus Group Interview/ or Grounded Theory/ or Interpretative Phenomenological Analysis/ or Journal Writing/ or Qualitative Methods/ or Narrative Analysis/ or Semi‐Structured Interview/ or Thematic Analysis/
8 ("critical interpretive" or "critical race" or "critical realism" or "critical realist" or ethnograph* or "grounded theory" or phenomenolog*).ti,ab.
9 (((content or document) adj2 analys*) or diary or diaries or "focus group" or "focus groups" or interview* or "mixed design" or "mixed methods" or observation$1 or qualitative).ti,ab.
10 (barrier$1 or deciding or decision$1 or experien*).ti,ab.
11 or/7‐10
12 and/3,6,11
13 12 not (animal or animals or bovine or breeds or cancer or canine or capra or case‐control or case‐report or case‐series or cat or cats or cattle or climacteric or clinician$1 or cohort or cohorts or commentary or contracept* or cow or cows or doctor$1 or dog or dogs or ectopic or equine or ewe or ewes or feline or fibroids or goat or goats or habitual‐abortion or hamster or hamsters or "health worker$1" or "healthcare worker$1" or hepatitis or horse or horses or infertil* or invertebrate or invertebrates or IVF or livestock or macaque or macaques or mare or mares or miscarriage or menopaus* or mice or missed‐abortion or missed‐abortions or monkey or monkeys or mouse or murine or nonhuman or non‐human or mosquito* or ovine or pastoral or pharmacist$1 or pharmacy or physician$1 or pig or pigs or polycystic or porcine or preeclampsia or pre‐eclampsia or primate or primates or questionnaire or rabbit or rabbits or rat or rats or rattus or recurrent‐abortion or randomized or rhesus or rice or rodent* or ruminant* or sheep* or simian or sow or sows or "spontaneous abortion" or stillbirth or stillbirths or survey or tsetse or vertebrate or vertebrates or zebrafish).ti.
14 limit 13 to yr="2003 ‐Current"

CINAHL Plus with Full Text (EBSCOhost) 1 January 2003 to 10 October 2023
Date searched: 11 October 2023
S1 (MM "Abortion, Induced") OR (MM "Abortion, Criminal")
S2 TI (abortion* or feticid* or foeticid* or ((interrupt* or terminat*) N3 pregnan*) or preabortion)
S3 S1 OR S2
S4 (MM "Travel") OR (MM "Medical Tourism")
S5 TI ( (((across or cross* or inter* or intra* or near* or "out of") N1 (border* or city or cities or county or counties or country or countries or department* or provinc* or state* or town*)) or bus or buses or car or cars or closest or crossborder* or crosscountry or distance or distant or drive or driving or far or fly or flying or geographic* or interstate* or intrastate or intercity or intracity or intercountr* or intracountry or interprovinc* or intraprovinc* or kilometers or kilometres or locally or locat* or logistical* or logistics or miles or near or nearest or "out of state" or rural or spatial or transport* or tourism or travel* or trip or trips) ) OR AB ( (((across or cross* or inter* or intra* or near* or "out of") N1 (border* or city or cities or county or counties or country or countries or department* or provinc* or state* or town*)) or bus or buses or car or cars or closest or crossborder* or crosscountry or distance or distant or drive or driving or far or fly or flying or geographic* or interstate* or intrastate or intercity or intracity or intercountr* or intracountry or interprovinc* or intraprovinc* or kilometers or kilometres or locally or locat* or logistical* or logistics or miles or near or nearest or "out of state" or rural or spatial or transport* or tourism or travel* or trip or trips) )
S6 S4 OR S5
S7 (MH "Diaries") OR (MH "Document Analysis") OR (MH "Ethnographic Research") OR (MH "Ethnological Research") OR (MH "Ethnonursing Research") OR (MH "Focus Groups") OR (MH "Grounded Theory") OR (MH "Interviews") OR (MH "Naturalistic Inquiry") OR (MH "Observational Methods") OR (MH "Phenomenological Research") OR (MH "Qualitative Studies")
S8 TI ( ("critical interpretive" or "critical race" or "critical realism" or "critical realist" or ethnograph* or "grounded theory" or phenomenolog*) ) OR AB ( ("critical interpretive" or "critical race" or "critical realism" or "critical realist" or ethnograph* or "grounded theory" or phenomenolog*) )
S9 TI ( (((content or document) N2 analys*) or diary or diaries or "focus group" or "focus groups" or interview* or "mixed design" or "mixed methods" or observational or qualitative) ) OR AB ( (((content or document) N2 analys*) or diary or diaries or "focus group" or "focus groups" or interview* or "mixed design" or "mixed methods" or observational or qualitative) )
S10 TI ( (barrier* or deciding or decision* or experien*) ) OR AB ( (barrier* or deciding or decision* or experien*) )
S11 S7 OR S8 OR S9 OR S10
S12 S3 AND S6 AND S11
S13 TI (animal or animals or bovine or breeds or cancer or canine or capra or case‐control or case‐report or case‐series or cat or cats or cattle or climacteric or clinician$1 or cohort or cohorts or commentary or contracept* or cow or cows or doctor$1 or dog or dogs or ectopic or equine or ewe or ewes or feline or fibroids or goat or goats or habitual‐abortion or hamster or hamsters or "health worker$1" or "healthcare worker$1" or hepatitis or horse or horses or infertil* or invertebrate or invertebrates or IVF or livestock or macaque or macaques or mare or mares or miscarriage or menopaus* or mice or missed‐abortion or missed‐abortions or monkey or monkeys or mouse or murine or nonhuman or non‐human or mosquito* or ovine or pastoral or pharmacist$1 or pharmacy or physician$1 or pig or pigs or polycystic or porcine or preeclampsia or pre‐eclampsia or primate or primates or questionnaire or rabbit or rabbits or rat or rats or rattus or recurrent‐abortion or randomized or rhesus or rice or rodent* or ruminant* or sheep* or simian or sow or sows or "spontaneous abortion" or stillbirth or stillbirths or survey or tsetse or vertebrate or vertebrates or zebrafish)
S14 S12 NOT S13 Limiters ‐ Published Date: 20030101‐; Exclude MEDLINE records

Anthropology Plus (EBSCOhost) 2003 ‐ 5 November 2023
Date searched: 6 November 2023
TX ( abortion* or feticid* or foeticid* or ((interrupt* or terminat*) N3 pregnan*) or preabortion ) AND TX ( (((across or cross* or inter* or intra* or near* or "out of") N2 (border* or city or cities or county or counties or country or countries or department* or provinc* or state* or town*)) or bus or buses or car or cars or closest or crossborder* or crosscountry or distance or distant or drive or driving or far or fly or flying or geographic* or interstate or intrastate or intercity or intracity or intercountr* or intracountry or interprovinc* or intraprovinc* or kilometers or kilometres or locally or locat*or logistic* or logistics or miles or near or nearest or "out of state" or rural or spatial or transport* or tourism or travel* or trip*) )

Gender Studies Database (EBSCOhost) 2003 ‐ 5 November 2023
Date searched: 6 November 2023
S1 ZU ("abortion") OR (TI ( abortion* or feticid* or foeticid* or ((interrupt* or terminat*) N3 pregnan*) or preabortion ) ) OR ( AB ( abortion* or feticid* or foeticid* or ((interrupt* or terminat*) N3 pregnan*) or preabortion ) ) 
S2 ZU ("travel") or TI (((across or cross* or inter* or intra* or near* or "out of") N2 (border* or city or cities or county or counties or country or countries or department* or provinc* or state* or town*)) or bus or buses or car or cars or closest or crossborder* or crosscountry or distance or distant or drive or driving or far or fly or flying or geographic* or interstate* or intrastate or intercity or intracity or intercountr* or intracountry or interprovinc* or intraprovinc* or kilometers or kilometres or locally or locat*or logistic* or miles or near or nearest or "out of state" or rural or spatial or transport* or tourism or travel* or trip*) OR AB (((across or cross* or inter* or intra* or near* or "out of") N2 (border* or city or cities or county or counties or country or countries or department* or provinc* or state* or town*)) or bus or buses or car or cars or closest or crossborder* or crosscountry or distance or distant or drive or driving or far or fly or flying or geographic* or interstate* or intrastate or intercity or intracity or intercountr* or intracountry or interprovinc* or intraprovinc* or kilometers or kilometres or locally or locat*or logistic* or miles or near or nearest or "out of state" or rural or spatial or transport* or tourism or travel* or trip*) 
S3 ZU ("content analysis" or "critical realism" or "diaries" or "focus groups" or "grounded theory" or "interviews" or "mixed methods research" or "phenomenology" or "qualitative research" or "thematic analysis") or TI ("critical interpretive" or "critical race" or "critical realism" or "critical realist" or ethnograph* or "grounded theory" or phenomenolog* or ((content or document) N2 analys*) or diary or diaries or "focus group" or "focus groups" or interview* or "mixed design" or "mixed methods" or observation* or qualitative or barrier* or deciding or decision* or experien*) or AB ("critical interpretive" or "critical race" or "critical realism" or "critical realist" or ethnograph* or "grounded theory" or phenomenolog* or ((content or document) N2 analys*) or diary or diaries or "focus group" or "focus groups" or interview* or "mixed design" or "mixed methods" or observation* or qualitative or barrier* or deciding or decision* or experien*) 
S4 (S1 AND S2 AND S3) Limiters ‐ Date Published: 20030101‐20231131

SocINDEX (EBSCOhost) 2003 ‐ 6 November 2023
Date searched: 7 NOvember 2023
S1 DE "ABORTION" OR DE "ABORTION clinics" OR DE "ABORTION clinics ‐‐ Social aspects" OR DE "ABORTION & psychology" OR DE "ABORTION & society" OR DE "ABORTION counseling" OR DE "LATE‐term abortion" OR DE "THERAPEUTIC abortion" 
S2 TI (abortion* or feticid* or foeticid* or ((interrupt* or terminat*) N3 pregnan*) or preabortion) OR AB (abortion* or feticid* or foeticid* or ((interrupt* or terminat*) N3 pregnan*) or preabortion) 
S3 S1 OR S2 
S4 TI ( (((across or cross* or inter* or intra* or near* or "out of") N1 (border* or city or cities or county or counties or country or countries or department* or provinc* or state* or town*)) or bus or buses or car or cars or closest or crossborder* or crosscountry or distance or distant or drive or driving or far or fly or flying or geographic* or interstate* or intrastate or intercity or intracity or intercountr* or intracountry or interprovinc* or intraprovinc* or kilometers or kilometres or locally or locat* or logistical* or logistics or miles or near or nearest or "out of state" or rural or spatial or transport* or tourism or travel* or trip or trips)
S5 DE "DIARY studies" OR DE "CONTENT analysis" OR DE "ETHNOGRAPHIC analysis" OR DE "ETHNOLOGY" OR DE "ETHNOLOGY fieldwork" OR DE "ETHNOLOGY research" OR DE "ETHNOMETHODOLOGY" OR DE "FOCUS groups" OR DE "INTERVIEWING" OR DE "QUALITATIVE research" OR DE "PHENOMENOLOGY" 
S6 TI ( ("critical interpretive" or "critical race" or "critical realism" or "critical realist" or ethnograph* or "grounded theory" or phenomenolog*) ) OR AB ( ("critical interpretive" or "critical race" or "critical realism" or "critical realist" or ethnograph* or "grounded theory" or phenomenolog*) ) 
S7 TI ( (((content or document) N2 analys*) or diary or diaries or "focus group" or "focus groups" or interview* or "mixed design" or "mixed methods" or observational or qualitative) ) OR AB ( (((content or document) N2 analys*) or diary or diaries or "focus group" or "focus groups" or interview* or "mixed design" or "mixed methods" or observational or qualitative) ) 
S8 TI ( (barrier* or deciding or decision* or experien*) ) OR AB ( (barrier* or deciding or decision* or experien*) ) 
S9 S5 OR S6 OR S7 OR S8 
S10 S3 AND S4 AND S9 Limiters ‐ Date of Publication: 20030101‐20241231

WHO Global Index Medicus 2003 ‐ 7 November 2023
Date searched: 8 November 2023
tw:((tw:(abortion* OR feticid* OR foeticid* OR ((interrupt* OR terminat*) AND pregnan*) OR preabortion)) AND (tw:(border* OR city OR cities OR county OR counties OR country OR countries OR department* OR provinc* OR state* OR town* OR bus OR buses OR car OR cars OR closest OR crossborder* OR crosscountry OR distance OR distant OR drive OR driving OR far OR fly OR flying OR geographic* OR interstate* OR intrastate OR intercity OR intracity OR intercountr* OR intracountry OR interprovinc* OR intraprovinc* OR kilometers OR kilometres OR locally OR locat* OR logistical* OR logistics OR miles OR near OR nearest OR "out of state" OR rural OR spatial OR transport* OR tourism OR travel* OR trip OR trips)) AND (tw:(barrier* OR "content analysis" OR "critical realism" OR "critical interpretive" OR "critical race" OR "critical realist" OR deciding OR decision* OR diary OR diaries OR "document analysis" OR ethnograph* OR experien* OR "focus groups" OR "grounded theory" OR interview* OR "mixed methods" OR "mixed design" OR observation* OR phenomenolog* OR qualitative OR "thematic analysis"))) AND ( mj:("Abortion, Induced" OR "Abortion" OR "Abortion, Criminal" OR "Reproductive Rights") AND type_of_study:("qualitative_research")) AND (year_cluster:[2003 TO 2024])

Contributions of authors

JT, SR, RS drafted the protocol.

KK, AF, JN reviewed and edited the protocol.

KK, AF provided conceptual and content expertise.

JN provided methods expertise.

RP drafted the search strategy approach and provided expertise on qualitative search methods.

Sources of support

Internal sources

• No internal sources of support received., Other

  No internal sources of support received.

External sources

• No external sources of support received., Other

  No external sources of support received.

Declarations of interest

JT has declared that they have no conflict of interest.

SR has declared that they have no conflict of interest.

KK has declared that they have no conflict of interest.

AF has declared that they have no conflict of interest.

RP has declared that they have no conflict of interest.

RS has declared that they have no conflict of interest.

JN has declared that they have no conflict of interest.

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