Communication and Counseling Preferences of Women Who Chose Abortion During Adolescence: A Qualitative Study

Abstract

Study Objective:

As part of a larger study about pregnancy options counseling with adolescents, we interviewed women in the United States who chose abortion during adolescence about preferences and experiences regarding communication from healthcare professionals during abortion care.

Design, Setting, and Participants:

We conducted individual semi-structured interviews with women ages 18–35 years old who were pregnant before age 20 years old and chose abortion. We recruited participants through social media, a research registry, and flyers in healthcare facilities. We recorded and transcribed interviews. Two investigators coded interview transcripts using thematic analysis.

Results:

We conducted interviews with 17 US women (median age 32 years old, range 20–35 years old) from 11/2020–4/2021. The median age at time of abortion was 18 years old (range 14–19 years). The sample was 58% (n = 10) Caucasian and 65% (n = 11) heterosexual. Themes included: 1) Participants perceived options counseling before abortion as important and necessary but did not always feel they personally needed it. 2) Participants reported that clinicians including nurses, physicians, and other staff sometimes had poor bedside manner, which was not aligned with their perceived need for gentleness due to their adolescence. 3) Participants valued nonjudgmental communication including normalization of abortion care. 4) Participants desired privacy and confidentiality throughout their clinic appointment, but clinic logistics led to concerns about limited privacy. 5) Participants appreciated medically accurate information about abortion in plain language balancing safety and risk information for reducing fear before the procedure.

Conclusion:

Responses suggested specific best practices that healthcare providers can adopt to improve care for youth considering abortion.

Introduction

The United States continues to have a high rate of adolescent pregnancies compared to other high-income countries, with one quarter to one third culminating in abortion. ^1–4 Little research has explored US adolescents’ experiences and preferences regarding communication and counseling about abortion. Existing guidelines and expert reviews on abortion care for adolescents focus on the procedural aspects of care, which are largely similar to those for adults, and/or pertain to opposition to parental consent laws. ^5–9 Guidelines on abortion care for all ages emphasize the importance of counseling and communication, but provide little insight on patient preferences regarding communication, which may be particularly important to serve the unique developmental needs of adolescents. ^{10, 11}

In this study, we interviewed United States adults who experienced abortion before 20 years old about their experiences with abortion care, communication, and counseling. Our goal was to increase understanding of the counseling and communication preferences of adolescents to support healthcare professionals in providing highest-quality, patient-centered abortion care.

Methods

This project was part of a larger US study concerning perspectives on pregnancy options counseling in adolescence. ¹² This analysis is limited to individuals who chose abortion. For the overarching study, we created a semi-structured interview guide informed by previous literature on adolescent pregnancy and options counseling ( Appendix 1 ). Two adolescent medicine clinicians reviewed the guide. The principal investigator (LK) trained 3 team members (NS, MR, EH) on using the guide.

For the overarching study, we used purposive sampling to recruit participants who chose parenting, adoption, and abortion, aiming for thematic saturation for each outcome. We desired heterogeneity across demographics, including age at pregnancy, geography, race and ethnicity, and sexual orientation. Among participants who chose abortion, we achieved thematic saturation after the 12th interview, though performed additional interviews to ensure demographic heterogeneity.

We recruited nationally in the United States from social media such as Craigslist and Facebook. We also recruited through a research registry maintained at our institution and flyers in practices in our region (Western Pennsylvania) in family medicine, internal medicine, obstetrics-gynecology, and family planning, though we limited the number of participants from our region to avoid excessive local sampling. Participants were 18–35 years old and experienced at least one pregnancy before 20 years old. The study team decided on the upper bound of 35 years old to counter-balance clarity of recollection with opportunity for reflection and understanding of salience over time. We excluded individuals who exclusively speak a non-English language due to logistical/budgetary constraints in conducting recruitment, interviews, and analysis in translation.

We performed telephone interviews from November 2020 to April 2021. The interview team consisted of 2 female pediatric neurologists (LK and EH), a female pediatrician (MR), and a male pediatrician (NS). Interviews lasted 30–60 minutes. Interviews were audio-recorded and professionally transcribed. We compensated participants with a gift card. The Institutional Review Board deemed this study exempt.

We created an initial codebook based on the interview guide. Following the thematic analysis approach of Braun and Clarke, ¹³ 2 independent coders (LK, LB) coded all transcripts using Dedoose software. We used deductive and inductive analytic approaches. We used a consensus approach to reconcile coding and create new codes. The final codebook was applied to all transcripts. Senior co-investigators (TMK, TS, CT) resolved any discrepancies. We ascertained themes and selected representative quotations. We did not return results to participants for comment.

Results

Out of 50 individuals interviewed for the overarching project, there were 17 women who chose abortion. These 17 participants ranged in age from 20 to 35 years and their age during pregnancy ranged from 14 to 19 years. We display demographic information in Table 1. We assigned pseudonyms to participants. We did not use a random name generator to assign pseudonyms.

Table 1.

Pseudonyms and Demographic Characteristics.

Pseudonym	Current Age	Age at Abortion	Race/Ethnicity	Gender Identity	Sexual Orientation
Anna	30	19	Hispanic	Female	Bisexual
Martie	34	19	Caucasian	Female	Bisexual
Lindsey	33	19	Caucasian	Female	Straight
Valerie	33	15	African American	Female	Straight
Sammi	35	17	Caucasian	Female	Queer
Hannah	34	18	Caucasian	Female	Gay
Khalilah	30	18	Biracial (African American / Caucasian)	Female	Straight
Nina	27	16	Biracial (African American/Caucasian)	Female	Bisexual
Sarah	30	14	Caucasian	Female	Straight
Alexis	34	18	Hispanic	Female	Straight
Stacy	34	19	Caucasian	Female	Straight
Nadia	20	19	Caucasian	Female	Straight
Katie	31	17	Biracial (African American/Native American)	Female	Straight
Marcela	21	18, 19	Hispanic	Female	Straight
Clara	35	19, 19	Caucasian	Female	Straight
Megan	32	16	Caucasian	Female	Bisexual
Stefanie	31	18	Caucasian	Female	Straight

Participants in our study spoke little about their abortion procedures, with most describing the abortion as brief or having no recollection due to sedation. Participants’ satisfaction with their abortion care pertained most to their perceptions of interpersonal interactions with health professionals. Most participants described feeling afraid or anxious—about abortion itself, confidentiality, protesters, or fear of judgment from healthcare professionals, peers and family. They described how different interactions with healthcare professionals heightened or assuaged these feelings, leading to their level of satisfaction with their abortion experiences. In the themes that follow, we describe participants’ preferences for high-quality abortion care. Themes and representative quotations are also listed in Table 2 .

Table 2.

Themes and Illustrative Quotations.

Theme	Quotation
Participants generally perceived options counseling before abortion as important and necessary but did not always feel they personally needed it.	“It felt weird that everybody makes such a big deal out of it [during counseling], but it was such a quick [procedure], so it’s certainly just a lot of buildup to something that is over with within, like, a half an hour.”—Lindsey (33 years old, 19 at time of abortion)
	“She did the standard of ‘There are these options. Here’s like adoption or taking care of the pregnancy to full-term and parenting.’ Because I was very clear from the start, I was like ‘There is no way.’ Like she didn’t push on that anymore as soon as I made it clear that I was not interested in being pregnant any longer. I was not interested in being a teenaged parent. […] And she was just like ‘Okay, cool’ and said ‘We’ll meet you where you’re at.’ And then just went into explaining the process itself… I do think that options counseling to some degree is important. I just don’t think it needs to be like shoved in their faces. Like, for me, it was a very brief like ‘Are you aware that these are options?’[…] and gauging my interest in that, and if I wasn’t, then not pushing any further. I think that’s the nice happy balance between them.”—Nina (27 years old, 16 at time of abortion)
Participants reported that clinicians including nurses, physicians, and other staff sometimes had poor bedside manner, which was not aligned with their perceived need for gentleness due to their adolescence.	“It felt like something that they had done thousands of times, and I was just a number.”—Alexis (34 years old, 18 at time of abortion)
	“I’ve met doctors who were nice, but they weren’t nice there. They were, like, the worst people you’ve ever met. It was horrible. Like, absolutely horrible.”—Stacy (34 years old, 19 at time of abortion)
	“I just didn’t feel like that connection… it more or less felt like I was just in and out, like, ‘Okay, on to the next.’” - Khalilah (30 years old, 18 at time of abortion)
Participants valued nonjudgmental communication including normalization of abortion care.	“I thought everyone was very nice, and super understanding and not judgmental which I liked which is obviously their job. So they’re used to people coming in and asking and doing that. But I just thought, they were very understanding and very kind. I don’t know what I was really expecting going in. But they were a lot more approachable about it than I was expecting”—Nadia (20 years old, 19 at time of abortion)
	“Just because I was young, I was so nervous and I was worried. They made me feel like, you know, I’m not the only young mother that has ever came through their door. I thought they were gonna be a little judgmental, but they weren’t. At the end of the day, it was a beautiful experience.” - Katie (31 years old, 17 at time of abortion)
	“The clinic was fantastic. I swear that my abortion counselor saved my life… The biggest thing, it’s like the normalization of it. I think it’s really, really significant when it comes to abortion for minors or anyone under the age of 20.”—Nina (27 years old, 16 at time of abortion)
Participants desired privacy and confidentiality throughout their clinic appointment, but clinic logistics led to concerns about limited privacy	“I was still pretty young at the time. I think I was just kind of concerned with the fact that my family wouldn’t find out. And that might have been all that I heard or all that I was listening for [during counseling].”—Alexis (34 years old, 18 at time of abortion)
	“I was alone in a room with other people that were in the same exact situation as me. There was a couple there that clearly wanted to have a baby. For whatever reason, they had to have an abortion and it was highly, highly emotional. I was a wreck. I think that couple should have had their own room. That was really a horrible situation. ‘Cause they clearly didn’t want that to be going on.” – Megan (32 years old, 16 at time of abortion)
Participants appreciated medically accurate information about abortion in plain language balancing safety and risk information for reducing fear before the procedure.	“She gave me a piece of paper. She was reading through it with me, and she just said, “Oh, you know, going through labor and delivery is—” I think she said it was, like, 8 to 10—I can’t remember the exact number, but she said it was like 10 times more dangerous than, like, having the procedure. It was just little stuff that she was saying throughout that put me at ease about the procedure.”—Megan (32 years old, 16 at time of abortion)
	“I know there was the myth out there that it’s gonna be harder to have children when you’re older. That made me feel better, knowing that it doesn’t really affect that and that I still, like, when I was older, could have the option. I guess, like, knowing that it’s not dangerous.”—Clara (35 years old, 19 years old at time of 2 abortions)

Theme 1.

Participants generally perceived options counseling before abortion as important and necessary but did not always feel they personally needed it.

Participants had mixed reactions to options counseling occurring before their abortions, largely seeing it as a needed safeguard for decision-making but not always pertinent to them personally if they had already definitively chosen abortion.

A majority found it acceptable that clinic staff performed pregnancy options counseling prior to their abortions. As Nadia (20 years old, 19 years old at time of abortion) said, “They asked me, like, if I knew all my options and, like, if I knew this was something I really wanted to do. It didn’t really bother me any type of way because I understand, like, it’s important to make sure you know what you’re getting into, and this decision is a permanent decision. And they were really nice about it.”

Some participants, however, felt frustrated by options counseling that they perceived as excessive given their decisiveness. Valerie (33 years old, 15 at time of abortion) explained: “They kept asking me was I sure I wanted to do that. And I’m like, “Yes. More than positive.” I told them I needed to do it more than I wanted to do it. Once I got there and they asked that question, I did recall me saying, “Well, isn’t it obvious? I’m here, and this is my appointment. So can we do it?” It felt like I had to rush the doctors or the nurses. A whole lot of buildup. It felt like I had to go through a class, pass a test, just to get an abortion done.”

Three participants desired more options counseling prior to their abortion, and 2 wondered if they would have made a different pregnancy decision had they received more counseling.

Theme 2.

Participants reported that clinicians sometimes had poor bedside manner, which was not aligned with their perceived need for gentleness due to their adolescence.

Several participants reported negative experiences with healthcare providers related to poor bedside manner. Perceptions of poor bedside manner were often tied to clinic staff seeming insensitive regarding their age.

Sammi (35 years old, 17 years old at time of abortion) described a nurse in an abortion clinic setting who she felt was patronizing: “The nurse who sat with me…-the basic gist of [what she said] was like, ‘Well, now you see what happens when you do what you did.’”

Sarah (30 years old, 14 years old at time of abortion) felt that providers were brusque: “It was like a job that they had to do, and I just didn’t feel like they were very gentle or very sensitive about it with a teenager. [It would have been better] if they’d been a little more emotional about understanding my perspective as a teenager and trying to think of that.” Multiple participants perceived care as detached and mechanical.

Stacy (34 years old, 19 years old at time of abortion) described a provider who was physically rough with her during a transvaginal ultrasound, which was all the more unpleasant because she was not experienced with gynecologic care. She reported dissatisfaction with the bedside manner of physicians as well: “I’ve met doctors who were nice, but they weren’t nice there. They were, like, the worst people you’ve ever met. It was horrible. Like, absolutely horrible.”

Participants with negative interpersonal experiences generally did not express regret or negative attitudes toward abortion. Nearly all participants who reported challenging experiences remained satisfied years later with their abortion decision and supportive of abortion care for others.

Theme 3.

Participants valued nonjudgmental communication including normalization of abortion.

Participants appreciated nonjudgmental care and normalization of abortion during counseling. Marcela (21 years old, 18 and 19 years old at time of abortions) described how clinic staff treated her during her second abortion appointment: “I told them, ‘Unfortunately I did have one [an abortion] here before,’ and she [clinic staff member] said, ‘Please don’t say that.’ She told me, ‘I want you to not worry about that. I want you to make yourself feel worth’ She was like, ‘Don’t feel worthless. Don’t feel bad about yourself.’ She said, ‘Women come in here all the time, multiple times a year.’ She was telling me, just comforting me in that way, telling me that, ‘Don’t think of it like such a stressful situation because it happens every day, and people have to do what they’ve gotta do. We have our own lives to worry about, and people make mistakes’ And she just really just comforted me personally, and she didn’t even have to do that.”

Many participants reported heightened sensitivity to any perception of judgmental attitudes, and were pleasantly surprised in finding clinic staff to be nonjudgmental and supportive.

Theme 4.

Participants desired privacy and confidentiality throughout their clinic appointment, but clinic logistics led to concerns about limited privacy.

Participants appreciated assurances of confidentiality about their abortion care, particularly in relation to parents or other authority figures such as employers. As Martie (34 years old, 19 years old at time of abortion) stated, “I felt like it was all done, in secret, which was kind of cool at the time. I felt like no one was gonna find out about it unless I told them about it.”

Participants appreciated clinic staff respecting their privacy during counseling by counter-balancing interpersonal engagement with respectful distance. Lindsey (33 years old, 19 at time of abortion) appreciated that “[the clinic staff] didn’t pry too much.” Marcela (21 years old, 18 and 19 at time of abortions) similarly expressed, “[The clinic staff] can’t get too personal, and they don’t wanna get too close or make you too emotional, so they really stood the ground, which was comforting. Like, they weren’t too close. They weren’t too far.”

Several participants expressed concerns about lack of privacy in clinic areas. Sammi (35 years old, 17 at time of abortion) said: “I don’t really know how else to describe it other than a cattle farm. So there’s just rows of beds. And there’s no individual rooms. And so, it’s like the doc goes from one to the other—and then she wakes up crying. And then he does the next one and she wakes up crying. It’s like a strange meat warehouse. It was awful. It was truly horrifying.”

Participants described frustrations when legal or financial issues threatened confidentiality. Marcela (21 years old, 18 and 19 at time of abortions) described logistical challenges related to confidentiality with using insurance coverage provided through her parents and was grateful that clinic staff helped her identify alternative financial assistance for her procedure. Nina (27 years old, 16 years old at time of abortion) described how, to her dismay, her mother accompanied her to her appointment due to her state’s parental consent law for minors seeking abortion; at the time, she was not aware of the judicial bypass process. She discussed how her mother’s erratic behavior required significant time and attention from clinic personnel, with her appointment often seeming “more about her mother than her.”

Theme 5.

Participants appreciated medically accurate information about abortion in plain language balancing safety and risk information for reducing fear before the procedure.

Most participants described having anticipatory anxieties or fears about undergoing abortion, and felt that receiving clear, medically accurate information about abortion was reassuring. As Martie (34 years old, 19 years old at time of abortion) stated, “I think that they should try to make it so that it’s not as scary as it sounds. Uh, that word [abortion] can be quite scary sometimes.” She described anxiety that her abortion would affect her sexual function as well as relief when told that would be unlikely.

Nina (27 years old, 16 years old at time of abortion) echoed the need for reassurance about safety, “It’s a terrifying thing to have to go through. And for many, many of us, it is the first gynecological experience we have of any type. So just recognizing that that’s a really scary and vulnerable moment, and being very honest about what can be expected and how safe it is.”

Several participants emphasized the need for comprehensible language during counseling about abortion. Valerie (33 years old, 15 at time of abortion) advised, “Specify it in general. Like instead of using all the big words in the books of it, break it down. Explain exactly what those words mean if you gotta say it. Specify all that has to be done, what will be done.” She reported that the counseling she received was insufficient and confusing due to technical language.

Discussion

In this study, we described experiences and preferences of women who underwent abortion during adolescence. Preferences for care included gentle bedside manner, respect for privacy/confidentiality, nonjudgmental language that normalized having an abortion, and plain language pre-procedure counseling about abortion that balanced information on safety and risk. The importance of assuring adolescents about the confidentiality of their reproductive healthcare is well documented in the literature, although our study findings also raise concerns about adolescent perceptions of privacy of shared spaces such as waiting rooms and recovery rooms. ^14–17 Because participants in our study emphasized interpersonal interactions and counseling in their satisfaction with their abortion experiences, our study supports the pivotal role of clinical staff interactions in shaping adolescents’ experiences of abortion. Existing guidelines on abortion care, either for adolescents specifically or patients in general, provide minimal guidance on communication and counseling beyond indicating its over-all importanc. ^5–11 Understanding our participants’ perspectives may help clinicians support adolescents presenting for abortion.

We are aware of few previous studies concerning interactions between US adolescents and healthcare professionals providing abortion. There is a more extensive body of literature on such interactions in lower-income countries with findings that might not be transferrable to the United States or other higher-income countries. ^18–21 Participants in our study and these prior studies expressed fears about privacy/confidentiality, and fears of judgmental attitudes by healthcare professionals. However, participants also had concerns beyond those identified in our study, including experiences of frank abuse or denial of care. ^18–21 Despite major professional organizations such as the Society for Adolescent Health and Medicine calling for safe and accessible abortion services for adolescents, shifting US state-specific laws regarding abortion may lead to an increase in similar concerns among US adolescents, particularly following the 2022 US Supreme Court decision in Dobbs vs. Jackson Women’s Health Organization. ^{22, 23}

Our findings overlap with those identified by a study of adolescent communication preferences in an outpatient sexual health clinic offering testing for pregnancy and sexually transmitted infections and provision of contraception. ²⁴ However, participants in our study appeared to report greater anticipatory anxiety and fear about abortion care—especially as a first gynecologic or procedural experience, requiring particular gentleness and reassurance from clinic staff—which were not reported as especially needed in the outpatient sexual health clinic.

Our findings also align with literature about general patient preferences for interpersonal communication in abortion care, although with important adolescent-specific divergences. ^25–27 Adolescent-specific concerns include a heightened need for gentleness due to the potentially intimidating experience of obtaining an abortion during youth; additional barriers to privacy and confidentiality, including involvement of parents; concerns about judgment specifically related to their young age; and need for medical information to be presented in a developmentally appropriate manner tailored to health literacy levels that may differ from those of adults.

Future research may explore appropriately balancing the necessity of pre-abortion options counseling with respect for patients’ decisiveness about abortion where present. Although expert opinion recommends options counseling for pregnant adolescents, participants in our study had diverse perspectives on this issue. ^28–30 Clinic personnel may be able to reconcile these conflicting perspectives by assessing patients’ level of interest in options counseling and tailoring counseling accordingly. Our findings complement previous research which found that adult women have mixed feelings about pre-procedure options counseling. ³¹ Of note, some counseling may be mandated by state laws concerning abortion and, in those situations, nonverbal cues, explanation of the need to provide such counseling, and plain language may be helpful for improving the patient experience.

Limitations of this study include that participants’ retrospective narratives may be subject to recall bias. Many participants were over 30 years of age at the time of the study, recollecting experiences that occurred before age 20. Yet, there were no substantive differences in experiences reported by participants in the sample when stratified by years since abortion at time of interview. In addition, the more distanced narratives can demonstrate which experiences with healthcare professionals remain emotionally impactful and significant to patients over time. Furthermore, information about the strengths and shortcomings of past practices may nevertheless be helpful in ascertaining best practices in the present.

We were unable to include US participants who exclusively spoke a non-English language, due to logistical/budgetary limitations in our ability to conduct recruitment, interviews, and analysis in translation. Future research should include US populations who exclusively speak a language other than English. These individuals may face additional challenges related to abortion access and communication and may have different preferences and ideas about best practices potentially related to different cultural norms within their communities. Future studies should also collect information on partner support, family support, and education level.

Conclusion

In conclusion, people who experienced abortion during adolescence report that they desired compassionate, confidential, patient-centered abortion care and counseling, but did not always experience this level of care. Adolescents have unique considerations in the abortion care context related to their developmental status, potential lack of experience with gynecological care, and need and desire for confidentiality and privacy. The narratives expressed in this study might provide insight to abortion providers and healthcare professionals in family planning contexts regarding providing communication and counseling tailored to adolescents’ needs.

Supplementary Material

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jpag.2024.08.007.

Appendix 1. Interview Guide

Topics	Key Questions
Demographics	What is your age? How would you describe your racial or ethnic background? What is the sex on your birth certificate? Is it male, female, or other? What is your gender identity? Do you consider female, male, transgender, nonbinary or something else? Do you identify as straight, gay, bisexual, or something else?
Learning about the pregnancy	How old were you when you first had a positive pregnancy test? Tell me the story of finding out that you had a positive pregnancy test. Prompts : Where/how did you receive this news? Did you suspect that you might be pregnant ? How did you feel at that time? What ideas came up initially about what you might do? Who did you decide to tell or speak with? How? Who was in your support system at the time?
Initial interactions with healthcare providers	Did you go to see a healthcare provider? Tell me what that was like. Prompts: How did you come to a decision to talk to a healthcare provider? How soon after finding out about the pregnancy test, or was the positive pregnancy test at the healthcare visit? What kind of provider were they? Had you ever seen them before? How did you feel about going to see a healthcare provider? How could your healthcare provider have best supported you in making a decision about the pregnancy?
Quality of encounter with health care provider	How did you feel about your conversation with the healthcare provider? What happened? General prompts: What was something that went well? What would you have changed? How could that experience have been better for you? How did you feel during the appointment? Prompts about confidentiality: Who was with you in the room while you were talking to the healthcare provider? Did the healthcare provider ask if you wanted to speak privately? Did the healthcare provider ask if you wanted to have anyone else in the room? How did you feel about that? Was there a discussion about confidentiality? Options-specific prompts: Did the healthcare provider talk to you about your options such as choosing to become a parent, pursuing adoption or having an abortion? If so, what was that like? Did they discuss each of these possibilities and how did that go? How did you feel about your pregnancy decision during this encounter? Prompts about next steps How did you and the healthcare provider decide what would happen next? What follow up was arranged after this visit? What referrals or resources were offered?
Subsequent encounters with healthcare providers	What happened next? When was the next time that you saw a healthcare provider, and how did that go?
Pregnancy decision-making	How did you arrive at a decision regarding your pregnancy test results (such as whether to become a parent, pursue adoption, or have an abortion)? Prompts: What was helpful to you in decision making? At what time did you make this decision? What factored into the decision for you? How did interactions with healthcare providers affect your decision making? How could healthcare providers have best supported you in your decision making?
Support system	Who was helpful to you in thinking about whether to become a parent, have an abortion, or plan for adoption? Who was helpful to you in making a decision (about whether to become a parent, pursue adoption, or have an abortion)? Prompts: What role did parents play? A partner? Friends or other family? Healthcare providers? Online information? Websites? Social media?
Advice	What advice do you have for healthcare providers who are speaking with young people about their pregnancy test results? What advice do you have for healthcare providers who are supporting young women in deciding about their pregnancy test results? What advice do you have for young people who have a positive pregnancy test?
Questions for Participants who chose abortion	Tell me about your experience with abortion care. Prompts: What was most memorable to you? What went well? What could have gone better?