Factors Shaping Women’s Pre-abortion Communication with Members of Their Social Network

Abstract

We sought to understand women's pre-abortion conversations with members of their social network about their abortion decision. Semi-structured interviews were conducted with women presenting for first-trimester surgical abortion at a high volume, hospital-based abortion clinic. Women were asked their reasons for discussing or not discussing abortion and responses received after disclosing their abortion decision. Interviews were transcribed and computer-assisted content analysis was performed. Salient themes are presented. Thirty women who obtained an abortion were interviewed. All but three spoke to at least one member of their social network about their abortion decision making. However, women were very selective about whom they spoke to regarding this decision. Reasons not to discuss their abortion decision included: concerns about judgment, desiring to maintain privacy, and certainty about their decision. Reasons to discuss their abortion decision included: seeking information about the procedure, needing guidance about their decision, wanting support for their decision to proceed with abortion. While many were concerned about being judged, most women who spoke about their decision experienced a positive response. Though most women in this study had at least one person to turn to for assistance with abortion decision making, many participants avoided confiding in some or all members of their social network about their abortion decision due to concerns of judgment and stigma.

Introduction

Little is known about the private conversations women choose to have with members of their social network prior to seeking an abortion. Previous research indicates that women often fall into two categories when making an abortion decision: 1) women know their decision once a pregnancy is confirmed or 2) women want more time to think about and discuss a decision (1–3). Women who do seek emotional support prior to the abortion largely turn to partners, family, a regular gynecologic care provider, and clinics (2,4–6).

Some women who would like to discuss abortion are deterred, often because of abortion stigma. Abortion stigma has been defined as, “a negative attribute ascribed to women who seek to terminate a pregnancy that marks them, internally or externally, as inferior to ideals of womanhood” (2,4,5,7,8). As Kumar writes, “Abortion stigma is generated through popular and medical discourses, government and political structures, institutions, communities and via personal interactions” (7). While abortion is a safe procedure, generally without adverse mental health outcomes, mental health outcomes are improved when women perceive support pre- and post-abortion (6,9).

Prior studies that have looked at whether women seek support prior to obtaining an abortion have been largely quantitative (2,4–6). Quantitative studies have limited ability to elucidate how women experience and internalize pre-abortion conversations. The current study examines the nature of the conversations that women have prior to obtaining an abortion, in order to understand who women turn to within their social network as sources of support, whom they regard as sources of stigma in abortion decision-making, and how these conversations influence women’s feelings about their abortion decision. Having a fuller understanding of the nature of these pre-abortion conversations is essential to optimizing women’s experience with abortion. Information regarding these conversations might inform the content of abortion counseling, which presents an important opportunity to reduce stigma and bolster women’s perception of social support.

MATERIALS AND METHODS

The findings described in this paper are from a sub analysis of a qualitative study exploring how women’s experiences with first trimester surgical abortion are influenced by the presence of a lay health worker, a doula. This study was conducted between May and July 2014 in a high-volume, hospital-based first trimester surgical abortion clinic that cares for a predominantly low-income population. The Institutional Review Boards at at the John H. Stroger Jr. Hospital and the University of Chicago approved this study. All participants provided verbal consent prior to participating in phone interviews.

A trained research assistant recruited women for study participation upon completion of routine clinic abortion counseling. Inclusion criteria included: (1) Age ≥ 18 years; (2) gestational age ≤ 13 6/7 weeks gestation; (3) ability to understand the study and provide informed consent; and (4) English speaking. The research assistant assessed for study eligibility and obtained consent to contact women by phone to participate in an interview within two weeks of the abortion. Study personnel invited women to participate in semi-structured phone interviews using purposive sampling to obtain variation in the following factors: age, gestational age, presence or absence of a doula during the abortion, and history of prior abortion. Women received a $25 gift card for study participation. We presumed an a priori sample size of thirty participants. The final sample size was determined based on thematic saturation – the point at which conducting additional interviews was not expected to result in additional themes.

After completing the verbal consent process and completing a brief survey assessing demographic and reproductive health data, women completed a 30–40 minute phone interview that explored abortion decision-making, sources of emotional support and stigma, and experiences with doula support in abortion care. This paper presents analyses of women’s responses to the questions: “What things have you heard about having an abortion? Who told you those things? Did it make it harder or easier to decide to have an abortion?” and “Before coming to the clinic today, who did you talk to about your decision to have an abortion? Why? What were your concerns about speaking to different people?” Interviews were digitally recorded, professionally transcribed, verified for accuracy, and de-identified prior to analysis.

Analysis was conducted using a modified template approach (10). Using the interview guide as a framework, the principal investigator developed a preliminary code directory. The research team subsequently revised the code directory in an iterative process based on emerging themes from continued readings of the transcripts. Atlas.ti® Version 7 (Berlin) qualitative analysis software was used to code all transcripts. Two research team members independently coded five transcripts and achieved 84.5% interrater reliability. One member of the team coded the remainder of the interviews based on the agreed upon code directory. The same team members conducted queries to identify salient themes and subsequently met to review key findings and resolve disagreements regarding data analysis and interpretation through discussion. This paper presents salient themes regarding: (1) reasons for not discussing abortion; (2) reasons for discussing abortion; and (3) responses received after disclosing abortion decision.

RESULTS

A total of 191 women were invited to participate in the parent study and 144 women provided consent to be contacted. Thirty interviews were conducted. Participant recruitment concluded upon reaching thematic saturation. Table 1 presents demographic data for both study participants and clinic patients during the study period. We did not collect direct measures of socioeconomic status for this study. However, women who obtain care at this public-safety net hospital are predominantly low income.

Table 1.

Socio-demographic, obstetric history, and abortion disclosure decision factors for interview participants

	Interview participants n=30	Surgical abortion patients >18 years of age May-July 2014 n=1144
Age (years)
18–25	18 (60)	668 (58.4)
26–35	10 (33.3)	406 (35.5)
≥36	2 (6.7)	70 (6.1)
Education
≤ High school	15 (50)	644 (59.3)
≥ Some college	15 (50)	500 (43.7)
Gestational age
≤ 9 0/7 weeks	17 (56.7)	626 (54.7)
9 1/7 weeks to 13 6/7 weeks	13 (43.3)	518 (45.3)
Prior surgical abortion
Yes	20 (66.7)	556 (49.3)
No	10 (33.2)	572 (50.7)
Race/ethnicity
African American	29 (96.7)	994 (86.9)
Hispanic/Latina	1 (3.3)	118 (10.3)
White	0 (0)	19 (1.7)
Other*	0 (0)	13 (1.1)
Gravidity (median, range)	2 (1–10)	3 (1–13)
Parity (median, range)	1 (0–7)	1 (0–12)
Number of prior induced abortion (median, range)	2 (0–5)	1 (0–9)
Number of women who discussed abortion decision with ≥1 person***	27(90)	–
Who spoke to***
Partner	12(40%)	–
Family	18 (60%)
Friends	10 (33%)
Other**	1 (3.3%)
Outcome of pre-abortion discussions***
Supportive	15 (55)	–
Not supportive	2 (7)
Mixed	6 (22)
Unknown	4 (15)

Data are n (column%) unless otherwise specified.

^*Other includes Asian, Native Hawaiian/Pacific Islander, American Indian/Alaskan Native, and Other.

^**Religious counselor

^***Data not routinely collected for clinic patients.

Upon being asked whom they had spoken to about their abortion decision prior to presenting to the clinic, many women initially stated that they had not spoken to anyone. However, upon further discussion and with additional probes, the majority of women (90%) indicated they had spoken with someone about their abortion decision; three participants had not spoken to anyone about their abortion. Many women were selective with whom they spoke and deliberate with whom they did not speak. Most commonly, women spoke to their partner, friends, sisters, and mothers.

Reasons for not discussing the abortion decision

Among the three women who did not discuss their abortion decision with anyone and among women who deliberately avoided telling certain people about their decision, the most salient themes regarding not discussing abortion decision-making were: (1) having concerns about being judged, (2) desiring to maintain privacy, and (3) being certain of their decision.

Nearly half of all participants (13/30) expressed concerns about encountering judgment when talking to others about having an abortion. Though many of these women did ultimately discuss their decision with at least one person, some avoided telling certain individuals due to fears of judgment or of that person having negative opinions about the procedure. Some women perceived that people writ large would judge them negatively about their choice to have an abortion. One of the three women who did not tell anyone about her decision stated, “Some people would like be cruel, and like bring it up in the past, I mean bring it up in the future, and they’ll throw it at you and say, oh you know I thought you did it too. . . They might throw it in your face.” Another woman described her skepticism about sharing this decision with other people, “Like people that knows you or think they have the right opinion of you, they want to judge you. . . So I don’t need no one there to be judging me, or acting like they there to help when really they looking at something from a whole different point of view.”

Other women had concerns about being judged by a specific person or persons, frequently based on prior experiences or conversations. One such participant felt that she would have disappointed her family if they knew she was having an abortion. This participant had had abortions in the past anticipated that her family would judge her for having repeated abortions, “Uh, yeah my family, like my grandfather, and some, people that know I had abortions before, I didn’t want to find out because I didn’t want them to like judge me and stuff.”

Some women had concerns about being judged because of their religious upbringing or other people’s religious convictions. One woman who strongly defined herself according to her religion was concerned about the opinions of others in her community. “Just the whole abortion thing is - it’s a touchy subject. It’s embarrassing… First being a Christian, I’m still battling some things like is God mad at me? Like is people gonna be mad at me if they found out? I keep a lot of things to myself anyway, so I knew I wasn’t going to share this.” Another woman avoided discussing her difficult decision with her counselor due to concerns about her counselor’s religious convictions, “Like my counselor that I had over the past two years like, been there for me through a lot of stuff, I didn’t even tell her what was going on… She wouldn’t have thought nothing bad of me, she just would have saw her religion in the situation and [inaudible], I just didn’t want to hear nothing about that.”

In addition to expressing overt concerns about being judged, women also expressed a desire to maintain privacy. As one woman explained, “I mean, there’s too much talking outside of my family. Like, no friends I could trust. At the end of the day, everyone talks, you know. So I just kept it in the family. I wouldn’t go outside my family and tell a friend, because when you tell a friend and your friend tells a friend and another friend tell a friend, tell a friend, tell a friend, and then the whole world knows.” Another woman who wanted to maintain her privacy about this decision expressed, “No, I didn’t feel comfortable telling anybody about it, so I was just like I’m just gonna keep this all to myself. I don’t want anybody to know at all.”

Several women felt no need to discuss their decision, as they were confident in their decision to proceed with their abortion. As another of the three women who did not tell anyone about her decision to have an abortion stated, “I felt like it was my decision, so I just felt like I don’t have to speak to anyone about it.” Another woman confided in her husband, but had already made up her mind and did not see the need to discuss the decision further with others, “No one knew that I was pregnant. The only one knew that I was pregnant was him, my husband. . . I didn’t really want to have a conversation about it because I didn’t feel it needed to be a topic of discussion, because I was going to get rid of it.”

Similarly, some women chose not to disclose because they did not want others to try to dissuade them from having the abortion. One woman explained, “[As] far as family, I didn’t tell them because I didn’t want nobody to try and change my mind.” One woman’s experiences with prior pregnancies lead her not to disclose her decision to have an abortion out of fear that others would try to steer her decision-making away from having an abortion. “I didn’t want anybody to try to influence me, like with my first two pregnancies. I didn’t want nobody to tell me, like, you should keep it, or you should not, I just want to make my own decision.” Another woman expressed similar sentiments about wanting to avoid other people’s opinions, “Some people don’t like to talk about it. Some people are like, ‘You better not get an abortion.’ You know what I’m sayin, therefore, I don’t want to talk about it cuz if you talk to that person, they try to talk you out of it. You know, things like that.”

Reasons for discussing the abortion decision

The majority of women spoke to at least one person about their decision to have an abortion. Reasons for doing so included: (1) seeking information about the procedure, (2) obtaining guidance in their decision, (3) desiring support for their decision to proceed with abortion.

Some women sought counsel from a friend or family member who had previously had the procedure to help address their concerns about the actual procedure or to answer questions. One woman reported,

I had like two different friends that have went to the [HOSPITAL NAME] and they were the two that I did confide in because I was so scared … but I’m like I gotta get this… I asked them a couple times you know, how they felt, did they feel comfortable, was it clean or whatever. And uh, I just asked them how the procedure went and they went, still every woman’s body is different and you will never know what anybody else goes through, and it might be different from you, so I did get two different reviews from two different people.

Other women spoke to someone to receive counsel in their decision to undergo the abortion. One women sought affirmation from her niece when determining whether her partner was the right person to have a child with, “I talked to my niece and just letting her know that the guy I had been seeing, he’s not right, he’s a liar and he wasn’t the right person for me to have a child by and that’s why I’m going on to the make the decision I had made.” Another woman valued her aunt’s opinion regarding the decision to have an abortion, “I had told my aunt that I was pregnant and she said, ‘You don’t want [to be bothered] with another kid.’ And that I need to go get it done. And I listened to what she had to say, she took me over.”

Finally, other women whose decision was already made sought support and affirmation from loved ones and friends for their decision to have an abortion. One such woman who was concerned about telling those whom she thought would not support her decision, deliberately told one friend about her decision. “She’s [a friend] not a judgmental person and I felt like I really couldn’t talk to nobody else I trusted that I knew that wouldn’t judge me or like put it out there for everybody else to talk about.” Another woman explained, “I was comfortable, they [mom and sister] were really on my side as to what I want to do and then just more so, just telling me it was my choice and they would stand by me.”

Responses to initiating discussion about abortion

Many participants feared receiving negative responses when bringing up their decision to have an abortion. However, people’s reactions to hearing about a woman’s decision to have an abortion ranged from positive/supportive to negative/judgmental. Of the 27 women who discussed their abortion with at least one other person, 15 (55%) reported positive outcomes, 2 (7%) reported negative outcomes, and 6 (22%) reported mixed outcomes. One woman who had a positive conversation with her friend described, “. . . I thought she [a friend] will probably understand like my situation so you know, I dunno, she made me feel better about it. Even though you know it’s not something to be happy about, she made me feel a little better.” Another woman explained that her generally supportive family extended their support to her decision to have an abortion.

Yeah, I talked to, um, my mom. You know my mom and dad are a great support system in my life, so… with them like growing old right now they want some grandkids. So I had to tell them, like, “Yea, you want grandkids, but I’m going to be stuck with the baby the majority of the time, you know, not you guys.” . . . I told them, “I’m just not ready right now. It’s not a good time.” . . . Yeah, my mom came with me. You know, my dad came to pick me up, my brothers was in the car. Like I say, my family, they’re behind me 100%, you know, they have my back. So they don’t make me feel like, oh I made a bad decision or nothing, they just want me to be happy, and OK with what I did.

Some who disclosed their decision to family or friends, however, received upsetting, negative responses. While these reactions did not deter them from obtaining the abortion, women expressed hurt and frustration with such interactions. One such woman who disclosed her decision to have an abortion to several people in her life received negative feedback from many sources. ““…I mean I had some people say like I’m going to go to hell, and all this, but like, why you judge me?” Another woman described her experience telling her mother about the abortion,

After I paid I was sitting there waiting for them to come get me, I talked to my mom on the phone, and that’s the first thing that came out of her mouth. She was like, “You can die like that” and “You messing your body up.” And it was just stuff that- negative stuff- and bad luck [inaudible]. After her conversation I really didn’t want to hear no more… I: And how did you feel about having to tell her and feel about her reaction? R: I just, I was angry, it made me want to, me at the time I didn’t care no more, just wanted to get it over with, that’s how I felt, and then she’s shouting at me and doubting me, and [inaudible] going through my head. Like I was just ready to get it over with.

Lastly, it was common for women who faced negative responses to be confronted with false information. One participant noted of her abortion conversation with her grandmother, “Yes, my grandma told me, that you know, that’s not good. I think those things are cancerous. You know, you get different opinions about it but it’s something you gotta do.”

DISCUSSION

While one in four women will have an abortion during her reproductive years, a woman’s decision to have an abortion remains hushed and stigmatized (11). This study sought to understand women’s pre-abortion conversations with members of their social network. Specifically, this study evaluated women’s decisions whether to communicate with family or friends about their abortion decision and the content and outcomes of these discussions. Despite a culture of secrecy and shame around abortion, the vast majority of participants spoke to at least one person about her abortion decision. This finding is consistent with a large study by Foster and colleagues of over 5000 women presenting for abortion that found that only 2% had not discussed their abortion with another person (4). While some women who had already decided to have the procedure sought out individuals they knew would support the decision, other women who were less resolute in their decision sought information or counsel to ultimately help come to a decision about whether to have an abortion. These conversations speak to the value that women place on family and friends as sources of information and support around abortion decision-making.

Many women either selectively or entirely avoided speaking to members of their social network about their decision to have an abortion. While some of these women did not feel a need or desire to discuss this issue with anyone else, most women chose not to disclose to specific individuals or all individuals out of a fear of judgment or a desire for privacy. Some of these fears proved to be true, as one third of women reported negative or mixed responses when disclosing their abortion decision to a friend or family member. However, some concerns about being judged may have been unfounded, as the majority of women who did discuss their decision with another person encountered a positive, supportive response.

This study underscores the pervasiveness of abortion stigma, and its impact on the communication women choose to have as well as the information that some women receive about abortion. Specifically, these findings illustrate three facets of abortion stigma: perceived stigma (the perception that others will judge a woman for her abortion), enacted stigma (the experience of encountering judgment or negative treatment due to having had an abortion), and internalized stigma (the incorporation of negative attitudes and beliefs about one’s own decision to have an abortion) (12). Despite the fact that many of these women demonstrated perceived stigma through their concerns that some or all members of their social network would judge them for their decision to have an abortion, few actually encountered enacted stigma upon disclosing their decision. Those women who did experience enacted stigma were not deterred from having the procedure by these interactions.

That so few women in our study encountered enacted stigma may reflect a disconnect between the degree to which women anticipated receiving negative responses for their decision and the actual rarity of such negative responses within this sample. A recent systematic review of abortion stigma found no quantitative data on rates of enacted stigma (12). Foster and colleague’s study of over 5000 women presenting for abortion, however, found that 87% of partners, 92% of mothers, and 94% of friends were supportive after being told of a woman’s decision to have an abortion (4). In contrast, a qualitative study examining sources of abortion stigma among low-income women in Pennsylvania found that many participants had encountered negative attitudes regarding their decision to have an abortion (13). However, the findings in the current study may also reflect that women in our study very intentionally sought to engage with those whose reactions they could anticipate, and avoided individuals whom they thought would provide judgment.

Limitations of this study must be acknowledged. This study was conducted in Illinois, a state that has only one abortion restriction: parental notification. Women’s concerns about being judged for their abortion decision may have differed had this study been conducted in states with more restrictive anti-abortion policies. Additionally, our study population consisted only of women who had actually presented for and obtained an abortion. The private conversations of women who had considered but chose not to have an abortion are not represented in this study. Furthermore, few of our participants had not spoken to anyone about their decision. These women in particular are an important voice to reach out to, as they may have unique needs that could be addressed through abortion counseling. Finally, our study population consisted of largely lowincome, African-American women. The concerns of and issues encountered by these women may not be generalizable to all women presenting for abortion. However, this is an important population to hear from, as low-income and minority women are disproportionately represented among abortion patients (14).

While most women in this study felt that they had at least one person to turn to as a source of information or support around their abortion decision, participants experienced perceived or enacted stigma around their abortion decision-making. Addressing women’s experiences with abortion stigma is essential, as stigma may lead to delays in care, isolation, and adverse emotional sequelae after abortion (7,15). Social support plays an important role in helping to counter stigma (15,16). Efforts to foster private discussion about abortion experiences, for example though book clubs, have been demonstrated to improve feelings about women who have abortions and abortion providers (17).

Though women tend not to turn to their regular gynecologic care providers as a potential source of support in their abortion decision-making, the abortion visit presents an opportunity to provide social support to women presenting for abortion (2). Through individually tailored patient-centered care and the provision of supportive resources, clinics may have the potential to help mitigate some effects of negative encounters or feelings of isolation (19). One study of 27 abortion clinics found that over 80% felt that it was their duty to provide counseling for emotional issues stemming from abortion and most clinics rely on trained non-clinician staff to provide informational and emotional support to patients (20).

Potential avenues for providing social support in abortion care are manifold. One such source of social support in the abortion setting are abortion doulas, or lay health workers trained to provide verbal and physical support and to address women’s psychosocial needs at the time of abortion (18). Women who receive this care overwhelmingly recommend that it should be routinely offered, and many endorse the idea of continuing the relationship with their abortion doula after the abortion to address further informational and emotional needs (2,18). Linking women to abortion talklines is another approach to help women address their potential emotional needs after the abortion (16). Further studies are needed to examine the impact of these sources of social support on abortion stigma.