Understanding the role of race in abortion stigma in the United States: a systematic scoping review

Abstract

The impact of abortion stigma is broad. Stigma impacts abortion providers, abortion patients and the broader community. Understanding how race and culture affect aspects of abortion stigma may be an important piece of expanding access to and support of abortion. We conducted a systematic search for studies involving abortion stigma and race in PubMed, PubMed Central, Embase, PsycINFO, Sociological Abstracts, Social Services Abstracts, GenderWatch and Ethnic NewsWatch on 7 January 2020. Articles were eligible for inclusion if they explored stigma and included participant race and/or ethnicity, were in English, and included original research. Thirty studies were included in the final review, including 11 quantitative studies, 9 qualitative studies, 4 mixed methods studies and 6 dissertations. Most studies provided basic racial and demographic data but did not provide racial differences in experiences of abortion stigma. Three quantitative studies found that women of colour had different experiences of abortion stigma compared to White women. Non-peer-reviewed studies of qualitative PhD-level dissertation research found that race, culture, religion and immigration had unique and complex effects on abortion stigma experienced by Latinx women. While abortion stigma is common, we found that there is a lack of research contextualising the racialisation of the United States. Quantitative studies found that women of colour experience abortion stigma at lower levels compared to White women. However, qualitative analyses of experiences suggest that quantitative measures of abortion stigma may not capture unique aspects of abortion stigma as experienced by women of colour.

Introduction

Abortion is one of the most common procedures in the USA, yet accessing abortion is limited by an increasingly hostile anti-choice landscape. Nearly 40% of reproductive-aged women live in 90% of US counties without an abortion provider.¹ State-level anti-abortion regulations also serve to decrease access to abortion. Restrictions on abortion care and the limited number of providers are reflective of the fact that abortion is highly stigmatised, and they can act to perpetuate stigma. Abortion stigma, defined as “the shared understanding that abortion is morally wrong and/or socially unacceptable,”² also serves to limit women’s access to abortion care and services. Cockrill and Nack’s 2013 framework of abortion stigma further describes abortion stigma as internalised stigma, felt stigma and enacted abortion stigma. Internalised stigma encompasses stigma that is internalised by women, including their attitudes about abortion and feelings toward themselves after their abortion experience. Felt stigma reflects one’s understandings of others’ valuation of abortion, including concerns about poor treatment or damage to reputation if an abortion experience became known to others. Enacted stigma is defined as one’s experience of judgment of their abortion(s) and can include actual experiences that demonstrate this judgment such as discrimination, gossip and physical abuse.² Abortion stigma can affect abortion providers, people who have abortions, people who support others who have abortions, and people who have the capacity for pregnancy and may consider abortion in the future. Abortion stigma leads to the social, medical and legal marginalisation of abortion care around the world and is a barrier to accessing high quality, safe abortion care. The impact of abortion stigma is broad and it ultimately serves as a barrier to reproductive rights and healthcare.

Several abortion stigma scales have been developed to quantitatively measure stigma, with the most recent scale in 2015.^3,4 Because cultures, laws and societal constructs of how abortion fits into people’s reproduction differ greatly, the definition and impacts of stigma vary greatly depending on the person. In a US-based context, race, religion and region are just some of the social constructs that affect the experience of abortion stigma. Within the United States, people of colour have a deeply complex and painful history of controlled reproduction. This history extends from slavery to the eugenics movement to today.⁵ The reproductive justice framework was brought to life by twelve Black women who defined reproductive justice as the right to bodily autonomy, to have children, not have children, and parent children in safe and sustainable communities. This framework^6,7 allows for understanding reproduction and reproductive opportunities in the context of several injustices. For example, multiple states have recently held policies that require the use of long-acting reversible contraception to qualify for welfare.⁸ From 2005 to 2013, more than a quarter of women who underwent tubal ligation procedures were unlawfully sterilised without consent in California State Prisons,⁹ a policy that disproportionately affected women of colour. Multiple factors disproportionately impact women of colour’s right and ability to parent. Criminalisation in pregnancy, disproportionate referrals to child protective services, forced deportation and separation of families, environmental injustice and policing of Black communities are just a few examples. Current measures of abortion stigma may not capture the important racialised context in which stigma is embedded; for example, the fact that abortion experiences may vary by patient’s racialised identities. Additionally, we know little about how intersecting identities and oppressions influence the experience of abortion stigma.

Anti-abortion messaging has targeted Black women by using racially stigmatising messages claiming that abortion targets communities of colour as a form of genocide. This messaging extends beyond billboards into pop culture.¹⁰ In a qualitative analysis of abortion in Hip Hop, Premkumar et al. found that abortion was discussed as sinful, likened to Black genocide, and socially and morally devious.¹¹ Understanding how abortion stigma is experienced by providers and patients of different races has implications for protecting reproductive rights and for supporting and improving abortion care for people of colour and those who provide this care. This article reviews how race is studied, discussed and contextualised in the abortion stigma literature in a US context.

Methods

Search strategy

We used a three-step search process for identifying studies for this review. First, term harvesting was conducted by identifying keywords and controlled vocabulary, including MeSH and Emtree terms, from key articles on our topic. Next, we developed a search strategy in collaboration with a clinical librarian (JBW) using an iterative process that involved testing search terms and examining the relevance of corresponding search results. Our search combined the concepts of abortion, stigma and race. Boolean logic was applied by combining similar keywords and controlled vocabulary with OR and using AND between each concept: for example (abortion) AND (stigma) AND (race OR ethnicity).

We conducted a systematic search for studies involving abortion stigma and race in PubMed, PubMed Central, Embase, PsycINFO, Sociological Abstracts, Social Services Abstracts, GenderWatch and Ethnic NewsWatch on 7 January 2020. No date or language limits were used. Additionally, we searched the reference lists of included articles to identify additional studies, and the reviewers contacted experts to ensure that relevant studies were not missed. Detailed search strategies and a PRISMA-S checklist¹² can be found in Appendices 1 and 2.

Study selection

One reviewer (KB) screened all articles based on title and abstract, and two reviewers independently double-screened all articles for full-text review (KB & RL). Discrepancies were discussed and resolved through group consensus. Studies were excluded if they were not in English, were not original research, were not conducted in a US setting, did not mention race or ethnicity, or did not include some form of abortion stigma. We did not require the use of an official abortion stigma measurement for inclusion; studies were included if they discussed the concept of abortion stigma or its effects (e.g. abortion attitudes or cultural norms that led to abortion stigma).

Data extraction

A standardised form was created to extract data in the following areas: study type and methodology, study question, study population, characteristics of the intervention (e.g. intervention type, duration and outcome measures used) and study findings. Data extraction was completed by two reviewers (KB, RL).

Results

The literature search yielded 1075 articles. After excluding duplicates and identifying articles from additional sources, 841 articles were screened for inclusion based on title and abstract and 812 were eliminated because of their irrelevance to the topic. Two publications (one journal article and one published abstract) represented the same study population and question, and the abstract was thus excluded. An additional article was identified. Thirty studies were included in the final review, as indicated in the PRISMA chart (Figure 1).

Figure 1.

PRISMA flowchart of included studies in the review.

Included studies

Of the 30 included publications (Table 1), 10 reported participant race but did not provide information on how stigma varied by race. Eight reported stigma and race but provided no further context for their findings. Twelve publications reported race and levels of abortion stigma and offered some context of the findings.

Table 1.

Included studies.

Study	Year	Study population	Methods	Primary findings	Race and abortion stigma findings	Context of racial findings
Qualitative
Gelman13	2016	Low-income women 18–45, recent abortion	Content analysis	• Women experience negative messaging on social media around abortion • Women held anti-abortion attitudes • Women’s reactions may perpetuate abortion stigma	• 11/17 Black, 6/17 White • No report of experience by race	None
Gelman14	2017	Low-income women Pittsburg, Pennsylvania Currently pregnant or recent abortion	Content Analysis	• Sources of anti-abortion attitudes: partners, family members, social networks, self • Anti-abortion attitudes: immoral, murder, belief that abortion uncommon and thus deviant, view of women who have abortions as selfish • Managing anti-abortion views: keeping it a secret, negative emotions, regret and guilt	• 60% Black, 40% White • No report of experience by race	None
Brandi15	2017	English-speaking women >18yo	Modified Grounded Theory	• Pressure from providers to choose contraceptive method at time of abortion • Pressure to use LARC • Counselling motivated by goal to prevent future abortions	• 52% Black, 19% White, 23% Latinx, 3% Asian • No report of experience by race	None
Deeb-Sossa16	2014	Mexican immigrant women, midwives, community providers, folk healers, Mexican-American women who have experiences with abortion	Ethnography	• Navigating judicial system • Navigating healthcare systems • Looking for folk healer	• Focus on experience of Mexican-American women	Navigating judicial systems, healthcare systems, interactions with providers, and family expectations are interconnected with experiences of race and experiences of immigrants
Turan17	2014	Low-income women Birmingham, Alabama	Thematic analysis	• Mixture of attitudes towards abortion. Stigmatising attitudes include: poor upbringing, immorality, lack of contraception use. Keeping the baby is common and seen as the right thing to do • Abortion and adoption seen as selfish and weak decision	• Race reported • No report of experience by race	None
Littman18	2009	English-speaking women > 18 yo, termination in past 2 months in New York City	Exploratory qualitative study	• Sources of stigma: family, societal views, religious groups, media, friends, self • Abortion diaries intervention well-received, made women feel less alone	• No report of experience by race	None
Frohwirth19	2018	Women at abortion clinics in Connecticut, Texas, Michigan, New Mexico	Qualitative	• Religiously informed stigma is common • Felt stigma – fears of religious community finding out and facing consequences • Strategies for managing religious based abortion stigma: rejection of religion, personal exceptionalism, revising beliefs, challenge stigmatised status	• No report of experience by race	None
Keys20	2010	Women who have had abortions	Constant comparative method and grounded theory	• Stigma salient in participants abortion experiences • Stigma seen in word choice – both trying to hide word abortion and in choice of words such as “murder”	• No report of experience by race	None
Smith21	2016	English-speaking 19–24 yo in Birmingham, Alabama	Thematic Analysis	• Abortion seen as acceptable only in very difficult circumstances • Negative perceptions of what community members would think • People who have abortion keep it secret	• All participants Black or White • Abortion as common experience described more among the Black participants • Similar experiences of stigma by race	Describe similar experiences of stigma
Mixed Methods
Cockrill3	2013	English and Spanish speaking women who had 1 prior abortion	Content Analysis/cross-sectional survey	• Four factors related to abortion stigma: worries about judgment, isolation, self-judgment and community condemnation	• 39% white, 30% Black 20% Latinx, 5% Asian • Black women had less abortion stigma related to worrying about judgment compared to White women • Black women had higher levels of abortion stigma related to isolation compared to White women • Overall scale no racial differences	Hypothesise Black women more pro-choice and thus perceive less judgment
Woodruff22	2018	English and Spanish speaking women, > 15yo, seeking abortion	Prospective Longitudinal study	• 80% supported abortion legality • 20% believed abortion is morally wrong • Women denied an abortion less likely to support the legal right to abortion at six months (62%) and 4.5 years (77%)	• Women of color more likely to believe that abortion is morally wrong • Women of color less likely to be in favour of legal right to abortion	None
Ellison23	2003	White women age 22–72	Mixed Methods	• Abortion to avoid social stigma of pregnancy/single motherhood • Social stigma of abortion and secrecy	• Study of White women	Contextualises reproductive experiences through multiple eras. “Cult of maternity as civic duty” for White middle-class women
Rice24	2017	Women age 18–24 Birmingham, Alabama	Mixed Methods	• Stigma around parenting: higher among White women, University students • Stigma of adoption higher among minority women • Stigma around abortion higher among White women, religious women	• 45.5% Black, 39.5% White, 15.0% other • White women higher parenting and abortion stigma • Women of color higher adoption stigma	None
Quantitative
Cockrill25	2018	English speaking women, > 18yo, already in a book club	Longitudinal cohort study	• Abortion disclosure in 10/13 book groups • Book club intervention led participants to have more positive feelings toward women who have abortions and abortion providers	• 4 Black participants • No report of experience by race	None
Shellenberg26	2012	English and Spanish speaking abortion patients	Cross-sectional study	• 66% felt others would look down on them for abortion • 58% needed to keep abortion secret	• Black women less likely to perceive stigma • White women most likely to perceive stigma in general • Latinx women most likely to perceive stigma from friends/family and most likely to need to keep abortion a secret	None
Mosley27	2019	Representative population English and Spanish speaking (in US and South Africa)	Cross-sectional study	• US Sample, 49.3% felt abortion is always wrong if indication is poverty • 23.3% felt abortion is always wrong if fetal indication • Abortion attitudes not correlated with attitudes about social welfare programs	• No differences in abortion acceptability by race	None
Rocca28	2015	English and Spanish speaking women who have had an abortion	Longitudinal cohort study	• 60% perceived some abortion stigma • Abortion stigma not correlated with whether abortion is the right decision	• Latinx women less likely to think abortion was the right decision than White women	None
Lindberg29	2018	US women 15-44yo, National survey of Family Growth	Cross-sectional study	• More women report prior abortion using computer-based interview	• Latinx had greater difference in reporting prior abortion in computer-based interview compared to face-to-face interview	Less threat of social stigma for privileged groups
Cowan30	2017	US adults, American Miscarriage and Abortion Communication Survey	Cross-sectional study	• Reactions to abortion: 32.6% supportive, 40.6% sympathetic, 26.8% negative	• Latinx more likely to perceive negative reactions to abortion • Black individuals more likely to perceive mixed positive/negative reactions	Religiosity and attitudes towards unintended pregnancy in Latinx community
Martin31	2014	Abortion providers and anyone who assisted with (i.e. administrators, etc.) at the providers share workshop	Longitudinal cohort study	• Stigma was frequent • 62% felt unappreciated, 71% felt media rarely takes balanced view, 54% marginalisation within healthcare, • 66% worried about consequences of disclosure	• 56% White, 15% Black, 19% Hispanic, 4% Asian, 4% multi-racial, 2% other • No baseline difference in stigma scores by race/ethnicity • No change in scores overall	None
Steinberg32	2016	Women 18 or older seeking abortion	Cross-sectional study	• 37.4% perceived abortion stigma • Childhood adversity and abortion stigma associated with negative mental health symptoms	• 25.6% White, 20.7% Black, 27.9% Hispanic, 25.9% other • No report of experience by race	None
Bos33	2014	Women who had undergone abortion	Retrospective study	• 29.1% reported feelings of shame or guilt • Correlates of shame/guilt: religious beliefs, difficulty making decision	• Race not correlated with shame/guilt	None
Bommaraju34	2016	English and Spanish speaking women, > 18yo, recently delivered baby	Cross-sectional study	• Among all women White women perceived abortion to be more stigmatising than Black and Latina women • Among those who had had an abortion, Black women perceived miscarriage stigma to be higher than white women.	• See primary findings	Stratified reproduction: Women exposed to differential valuation of pregnancy by race
Biggs35	2020	English and Spanish speaking women seeking abortion across the US	Longitudinal cohort study	• Higher perceived stigma among those who had an abortion near gestational age limit of clinic compared to those who were turned away and had a birth • Higher baseline stigma associated with higher psychological distress	• Black women had lower baseline abortion stigma compared to White, Latinx, and other race individuals • Among participants with no abortion stigma, Black patients had lower psychological distress compared to White patients	Stratified reproduction: Women exposed to differential valuation of pregnancy by race
Non peer-reviewed Dissertation
Margo36	2016	Women undergoing abortion in South Carolina	Thematic analysis, processing mapping	• Stigma perceived when trying to organise life to access abortion • Judgment perceived from providers • Anticipation of stigma from providers prevented patients from stating intention for abortion with providers	• 70% Black, 25% White • No report of experience by race	None
Hunt37	2019	Sample of general population Arkansas	Randomised controlled trial	• Video-based intervention • Watching videos increased support for abortion	• No difference in empathy scores by race (of person in video intervention)	Relatively liberal sample, not representative of state population
Simmons38	2018	People seeking abortion	Mixed methods	• Internalised and felt stigma challenges in decision-making process	• Black and Latinx participants had more challenges accessing abortion compared to White individuals	Not available
Hernandez39	2014	English-speaking US born Latinx women	Thematic analysis	• Stigmatisation of unintended pregnancy is common	• Religiosity • Negative stereotypes around Latinx women regarding sexuality and pregnancy	Contextualised in results
Stack40	2013	Women 18–25 who have had an abortion within last 10 years	Qualitative analysis	• How women experience abortion stigma: stereotypes, pro-life rhetoric, politics, religion, silence. • Stigma very common • Stigma directly related to disclosure.	• Stigma related to stereotypes around race and class, sexuality and motherhood	Contextualised in results
Welter41	2016	English and Spanish speaking Mexican-American women 18–35 yo, abortion last 1–10 years	Phenomenology	• Primary findings on race and abortion stigma see next column	• Tension between religion and culture • Abortion experience and decision more complex for Mexican-American and Latina women • Cultural values around sexual and reproductive health • Cultural values around unplanned pregnancy • Having an abortion seen as not taking responsibility • Cultural norms of keeping things private, secret • Practical considerations drove decision to have an abortion, but cultural values drove interpretation of meaning of abortion	Contextualised in results

Of the included studies, there were 11 quantitative studies, 9 qualitative studies and 4 mixed methods studies published in peer-reviewed journals. We additionally included 1 quantitative study and 5 qualitative studies that were described in dissertations. Quantitative study methods included 7 cross-sectional studies, 3 longitudinal studies and 1 controlled trial.

Abortion stigma among abortion providers

Only one of the included studies focused on abortion stigma among abortion providers. Martin et al.³¹ conducted a 2014 study of the impacts of the Providers Share Workshop on abortion stigma by creating and assessing the Abortion Provider Stigma Survey. Abortion providers included anyone who helped provide abortion, including healthcare practitioners, clinic administrators and counselors. They found that abortion stigma was common, 62% of providers felt unappreciated in their work and 54% felt that abortion care was marginalised in healthcare. Black providers had lower baseline abortion stigma scales (indicating less stigma), but this difference was not statistically significant. The authors did not discuss the role of race in their findings.³¹

Abortion stigma among abortion patients

Included studies of patients’ abortion stigma used surveys and interviews to understand several types of stigma: internalised stigma through exploring their personal beliefs about abortion; enacted stigma through exploring others’ reactions to their abortion disclosure; felt stigma through exploring their perceptions of providers’ stigma and willingness to report the history of abortion as a proxy, and the association between stigma and access barriers, decision rightness, and psychological distress. In general, findings by race were mixed with some studies reporting lower rates of stigma among Black and Latinx individuals³⁵ and others indicating higher levels of stigma compared to White individuals.^29,30

Most of the included studies assessed abortion stigma among abortion patients or those seeking abortion and found that abortion stigma is common. Simmons et al. found that abortion stigma was a common barrier in the decision-making process for women seeking abortion.³⁸ Black and Latinx individuals had more barriers to accessing abortion, but this study did not report any racial differences in abortion stigma.³⁸

One study included the experiences of abortion stigma among abortion patients and partners of abortion patients.³⁰ Cowan et al. assessed enacted abortion stigma by conducting an analysis of women and men with personal experience with abortion using data from the American Miscarriage and Abortion Communication Survey. Latinx-identified individuals were more likely than any other group to perceive negative reactions to their abortion disclosures. The authors contextualised these findings in a body of literature around differences in norms around unintended pregnancy and religiosity.³⁰

Brandi et al. explored contraceptive coercion at the time of abortion by conducting in-depth interviews with 31 abortion patients several weeks after their abortions; interview guides were informed by the Integrated Behavioural Model and the Reproductive Autonomy Scale.¹⁵ Participants described pressure from providers to start contraceptive methods, specifically long-acting reversible methods, at the time of their abortion care. Contraceptive coercion was perceived as an attempt for providers to prevent future abortions and revealed abortion provider-enacted stigma. Within this theme, participants shared perceptions of their providers’ beliefs around abortion, including the perceptions that providers are not supportive of abortion, participants “should” prevent unintended pregnancy, and that pressure to choose a contraceptive method was a form of judgment against their decision to have an abortion. This study population was 52% Black individuals, but the authors did not report their findings by race or discuss the role of race.¹⁵

Although not directly focused on the experience of abortion stigma, one study compared reporting an abortion history via the National Survey of Family Growth (NSFG) in face-to-face interviews compared with audio computer-assisted self-interviewing (ACASI), a tool designed to increase privacy and reduce stigma.²⁹ They found that all women were more likely to report a prior abortion when using the self-interview. Latinx women had a higher differential in the report of abortion compared to White women. Black and Latinx women had higher differentials of reporting prior miscarriages compared to White women, with a higher likelihood of reporting a prior miscarriage in the computer-assisted self-report interview. This may indicate higher levels of abortion stigma for Latinx women and higher levels of miscarriage stigma for Black and Latinx women. This study also reported differentials in reporting prior births and found that Black women had a higher differential in reporting prior births favouring more reporting with the computer interview. This difference was significantly higher for Black women compared to White women.²⁹

Rocca et al. analysed several factors correlated with decision rightness and emotional responses to abortion among a cohort of women who had received abortion care in the Turnaway Study, a longitudinal study whose overall sample included women that had received or been denied an abortion,²⁸ In this study, 60% perceived some level of abortion stigma (measured by a direct question indicating how much participants would be looked down upon by people in their communities if their abortion was known), but perceived abortion stigma was not positively or negatively associated with feeling that abortion was the right decision. At three years post-abortion, Latinx women had lower odds of reporting that abortion was the right decision compared to White women. Abortion stigma was not the focus of this study, and the authors did not report differences in abortion stigma by race.²⁸

Woodruff et al. also used data from the Turnaway Study to assess abortion attitudes among women who had received or been denied an abortion.²² This paper did not specifically address abortion stigma but did touch on abortion attitudes that led to forms of abortion stigma. Overall, 20% of participants thought abortion was morally wrong. Participants who were denied an abortion were significantly more likely to think that abortion was morally wrong after six months than those able to receive an abortion. They found that women who identified as Black, Latinx or mixed race were more likely than White women to feel that abortion was morally wrong. Additionally, women of colour were less likely to support that abortion should be legal.²²

Biggs et al. also used Turnaway Study data to assess abortion stigma and psychological distress among women who sought abortion, by asking two questions that measured perceived stigma.³⁵ They found that abortion stigma was more common in people who had an abortion near the gestational age limit of the clinic compared to individuals who had sought abortion but were turned away and went on to have a birth. Black women had lower baseline abortion stigma.³⁵

Interventions to reduce abortion stigma

Two studies of interventions to reduce abortion stigma showed some positive benefits. In one study, after participating in a book club in which they read and discussed a non-fiction book that included abortion stories, participants had more accepting attitudes toward abortion and providers.²⁵ Another showed videos of women sharing their abortion stories with women at their post-abortion visit and found watching the video made them feel less isolated.¹⁸ While both studies described the race of participants, neither compared findings by race.

Hunt’s dissertation work evaluated the role of an empathy-based media intervention in shifting attitudes and knowledge around abortion among Arkansas residents.³⁷ The author conducted a randomised controlled study of video interventions and assessed pre- and post-test knowledge, attitudes and empathy. The video interventions told the stories of people seeking abortion care and varied the storytellers’ race and the context of the reason they sought an abortion. The participants were mostly White. There was no difference in empathy scores by the race of the person in the intervention video although overall there were the highest empathy scores for Black women who were seeking abortion because they had been raped. Hunt discussed whether these findings may exist because the study population over-sampled very liberal, well-educated people. The author also theorised that higher total empathy scores for Black woman who were raped may be reflective of the liberal-well-educated sample that understood marginalisation of women of colour. Hunt also posed the theory that this may have been a form of authority and paternalism – believing that being a poor Black woman who is raped is an “acceptable” reason for seeking an abortion.³⁷

The broader community and abortion stigma

Several studies assessed abortion stigma among the broader community, including people who have and have not had abortions in the past and people who have and do not have the capacity for pregnancy.

Mosley et al. conducted a survey in the USA and South Africa and assessed if support for abortion correlated with support for social welfare programs.²⁷ This study utilised two national datasets from each country (the General Social Survey for the USA and the South African Social Attitudes Survey) and assessed broadly if individuals supported abortion for a pregnancy indication or economic reasons. They did not find racial differences in abortion acceptability.²⁷

Contextualising race and abortion stigma: differences by race

Several studies reported their findings by race and discussed the role of race in abortion stigma.

Bommeraju et al. conducted a cross-sectional survey to assess the role of race and abortion history in abortion and miscarriage among 306 new parents in Boston, MA, and Cincinnati, OH.³⁴ They also assessed differences in abortion and miscarriage stigma by race. The study sample included English and Spanish speakers and was racially diverse with 50.7% Black, 38.6% White, 10.8% Latinx. White women perceived abortion to be more stigmatising than Black and Latinx participants. Among participants who had previously had an abortion, Black women perceived miscarriage stigma to be higher than White women. Comparing the stigma of abortion to the stigma of a miscarriage, White women perceived higher stigma from abortion, where Black and Latinx women perceived higher stigma from miscarriage. The authors described these findings by understanding the role of stratified reproduction. They discussed that White women’s pregnancies are given higher values in US society. When facing abortion, a White woman may face higher levels of stigma as they are defying traditional roles of motherhood and expectations of patriarchy. Women of colour’s pregnancies, on the other hand, are assigned a lower societal value. When facing a miscarriage, Black and Latinx women may perceive more stigma as they may be seen as having fault in the miscarriage. Higher miscarriage stigma was only found in Black and Latinx women who had previously undergone abortion.³⁴

Cockrill et al. also found that Black people compared to White perceived less judgment around abortion.³ They reported their development, validation and use of an abortion stigma scale among a diverse population across the United States. They identified four elements of stigma: worries about judgment, isolation, self-judgment and community condemnation. On the combined score that included all elements of stigma, the study found no racial differences in stigma scores. They found that Black women scored lower (indicating lower stigma) than White women on worries about judgment, but higher (indicating higher stigma) than White women on the isolation subscale. The authors posited that this may be because Black people are more pro-choice but discussed that further research on understanding the intersectional roles of gender and racism is important to finding these answers.³

Shellenberg et al. also found similar trends with Black women experiencing less abortion stigma compared to White and Latinx individuals.²⁶ Using a survey that included five questions focused on stigma, the authors assessed correlates of perceived and internalised abortion stigma by race and ethnicity among 3293 abortion patients at the time of their abortion. Among the total sample, 66% perceived stigma from others and 58% felt the need to keep the abortion a secret. Black participants reported lower levels of perceived and internalised stigma compared to White participants. White women were most likely to perceive stigma in general (75% among White women vs. 52% Black and 67% Latinx). Latinx women were most likely to perceive stigma from friends and family (50% Latinx vs. 27% Black and 44% White). Latinx women were also the most likely to need to keep their abortion secret (69% Latinx vs. 47% Black and 58% White). This study also assessed perceived and internalised stigma by race, allowing for some nuanced understanding of intersectional identities including race, nationality, religion, age and socioeconomic status. All participants reported more stigma from others if the man involved in the pregnancy did not know about the abortion. Black and Latinx participants from the West and South compared to those in the Northeast reported more stigma. Protestant religion was associated with more stigma for White participants; however, among Black and Latinx participants there was no significant association between religion and abortion stigma from others. The authors noted these racial differences in stigma and call for further research to explore the basis for these differences.²⁶

Contextualising race and abortion stigma: racialised lived experience, culture and stigma

As a part of their published dissertation research, Welter conducted a phenomenological study of Mexican-American women’s experiences of abortion.⁴¹ Welter found that women’s understandings of culture and religion were deeply intertwined, and that multiple aspects may contribute to how women view their abortion experiences, including cultural and religious views of unplanned pregnancy and cultural norms of being secretive and private with personal affairs. Participants in this study found that sharing abortion stories did help with healing. While participants made abortion decisions for themselves, their cultural values drove the interpretation of the meaning of their abortion experiences which resulted in negative emotions around abortion, including shame and guilt, for many.⁴¹

Hernandez, also as part of dissertation work, conducted an in-depth analysis exploring the meaning of unintended pregnancy among 18–25-year-old English-speaking American-born Latinx participants in South Florida.³⁹ Hernandez found that stigma was tied to the social consequences of unintended pregnancy and connected to societal stereotypes of young Latinx women who have babies. Specifically, participants shared the stereotypes that Latinx women are hypersexual, frequently pregnant, and do not receive the same dignity and respect when seeking care for unintended pregnancy. The study found that participants made abortion decisions in the setting of stigma around unintended pregnancy.³⁹

Stack’s dissertation explored the role of abortion stigma and disclosure. In this study, the author conducted in-depth interviews with 18–25-year-old women who had undergone non-medically-indicated abortions within the past 10 years in the Midwest.⁴⁰ Stigma was related to stereotypes around race, class, sexuality and motherhood. The author specifically noted that White women commented on being the only White women when accessing abortion care. Stack contextualised her findings in a feminist history. The author described societal norms around motherhood and against abortion as an expectation that was placed on White women in the early 1900s to help expand the reproduction of White people in the face of a nation that was becomingly increasingly diverse.⁴⁰

Smith et al. did not find substantial differences in social norms and stigma around pregnancy between Black and White women who were aged 19–24 in Birmingham, Alabama.²¹ The authors conducted a qualitative study using six focus groups and 12 in-depth interviews to explore social norms and stigma around unintended pregnancy and pregnancy decisions. While the study found that abortion was seen as a more common experience among Black participants, abortion was seen as acceptable only in particularly difficult circumstances among all participants. Participants of all races agreed that if they did have an abortion, community members would have negative perceptions of them.²¹

Deeb-Sossa and Billings report on barriers to abortion access among Mexican immigrant women in North Carolina.¹⁶ This ethnographic study collected data from midwives, health project coordinators, women seeking abortion, and several community healers. This study did not specifically study abortion stigma as a construct but provided an in-depth analysis of the barriers to abortion and the ways in which stigma, race, and culture intersect with those barriers. In states requiring a parental permission or judicial bypass for minors seeking abortion, immigrant women faced unique challenges navigating parents who lived outside the country and the judicial system, while also considering concerns of their parents and their immigration statuses. Accessing abortion required simultaneously navigating stigma related to abortion in society and close communities, and stigma while accessing medical care in a system that was not built for non-English-speaking immigrant Latinx women. The stigmatising beliefs of providers further marginalised immigrant women seeking abortion care.¹⁶

Discussion

Abortion stigma is a common phenomenon that affects how women experience, access and share experiences of abortion. This review provides an overview of the literature on abortion stigma and understanding the context of race in the United States. We identified 30 studies, which included 24 peer-reviewed studies of abortion stigma that included racial data. Eight peer-reviewed studies reported racial differences in stigma and provided a hypothesis or framework for understanding those racial differences indicating a need for further research in this area.

Multiple studies document abortion stigma as common – as an important element that impacts the ways in which patients view their pregnancies, access abortion care, disclose their abortion to others, and reflect on their abortions. The studies that included race without a deeper context of race had mixed findings on racial differences in abortion stigma. One study that found lower stigma among Black individuals compared to White individuals used a validated abortion stigma measure.³⁵ The two studies that suggest higher stigma among Black and Latinx individuals compared to White individuals used proxy measures of stigma (perceived negative reaction to abortion³⁰ and less self-report of abortion²⁹), as opposed to validated direct measures of stigma. Only eight studies offer insights into the racialised context of abortion stigma. All of these studies suggest that elements of racialised lived experiences impact how abortion stigma is experienced. These studies found racial differences in abortion stigma, with White women experiencing higher levels of overall abortion stigma compared to Black and Latinx women.^{3, 26, 34} However, Shellenberg and Tsui found that Latinx women were more likely than Black or White women to perceive stigma from close loved ones and feel that they need to keep their abortions secret.²⁶ These three studies are concordant in their findings of stigma overall. There are however variations in racial differences with certain elements of abortion stigma. For example, Cockrill et al.³ found that Black individuals had higher levels of isolation compared to White people and Bommaraju et al. found higher levels of miscarriage stigma among Black and Latinx individuals.³⁴ These differences are not contradictions in findings, but nuances in specific elements of abortion stigma. By conducting a stratified analysis, Shellenberg and Tsui’s analysis gives some insight into how abortion stigma varies by intersecting identities.²⁶ Several qualitative in-depth analyses of abortion experiences and abortion stigma among Latinx women document complex levels of abortion stigma that encompass community and cultural expectations, religion, stigma of unintended pregnancy, and pervasive racial stereotypes against Latinx people.^16,39,41 We did not find any studies evaluating the role of race and culture among other racial groups. The quantitative ^3,26,34 and qualitative^16,39,41 studies ask different questions about abortion stigma but may point to an important discrepancy in findings. When comparing people of colour to White people, in aggregate the data supports that White individuals experience more abortion stigma. However, the in-depth qualitative analyses of Latinx people suggest that abortion stigma is very real for some Latinx people and that it is closely tied to their experiences as Latinx individuals in a racialised society. This suggests that quantitative measures of abortion stigma may not be capturing aspects of race, ethnicity and culture that impact the way individuals experience abortion stigma. Future research should expand the definition and understanding of what abortion stigma is, how it is experienced, and how it impacts care to better understand the experiences of diverse populations, and should use a reproductive justice framework to understand abortion stigma in a larger context. Until the concept of abortion stigma and its definitions are revisited and reframed in these contexts, the experiences of people of colour around abortion will continue to be ignored, misunderstood and marginalised.

Interestingly, there was only one published study on abortion stigma with race data among abortion providers.³¹ Similar to quantitative studies of abortion stigma among abortion patients, Black-identified abortion providers had lower levels of baseline stigma. There were no in-depth qualitative studies of experiences of abortion stigma and the role of race among abortion providers. Understanding abortion stigma and race among providers may be an important part of supporting a diverse workforce while navigating working in a highly stigmatised part of healthcare. Further research on the racialisation of felt abortion stigma among abortion providers is needed.

This review has several strengths and limitations. To our knowledge, this is the first article that reviews racial differences in abortion stigma. This study includes peer-reviewed literature and a body of dissertation research that has not been previously summarised. Given the diverse mixture of included studies, we were not able to provide any summary statistics of abortion stigma. Additionally, our review focuses on papers studying abortion stigma and attitudes in the United States. The role of race as it relates to reproductive opportunities and abortion is complex and unique in the United States; therefore, the summary of these findings may not apply to abortion stigma in other countries, particularly those that were not built on the presumption of racial inequality and White supremacy. This review focuses on the role of race on abortion stigma, but there are many other intersecting identities including gender, ability, and immigration status, that are also important to centre to better understand abortion stigma and centre marginalised communities in abortion care provision. Finally, our search was conducted in January 2020: abortion has become more restricted in the United States since then, and our review does not capture the impact of these restrictions or any articles published since 2020.

Understanding the stigma around abortion provides an important understanding of how abortion can be accessed, is experienced and provided. Understanding the racial context of abortion stigma will help provide a framework to providing better access to and support around abortion. Specifically, using a reproductive justice framework and placing abortion stigma and abortion in the context of broader reproductive opportunities, restrictions, and injustices may allow for a better understanding of abortion stigma in traditionally marginalised communities. Breaking down the elements of stigma is an important piece of providing high quality, respectful and accessible abortion care.

Appendices.

Appendix 1.

Search strategy details. All searches were run on 7 January 2020. No date or language limits were used.

Database	Search strategy	Number of results
PubMed (1966 – )	(abortion[tw] OR abortions[tw] OR (pregnan* AND terminat*))AND(stigma[tw] OR stigmatisation[tw] OR stigmatised[tw] OR stigmatise[tw] OR stigmatises[tw])AND(race[tiab] OR racial[tiab] OR ethnicity[tiab] OR ethnicities [tiab] OR ethnic[tiab] OR cultural[tiab] OR culture[tiab] OR white[tiab] OR black[tiab] OR "african american"[tiab] OR latina[tiab] OR latino[tiab] OR latinx[tiab] OR hispanic[tiab] OR mexican[tiab] OR asian[tiab] OR minority[tiab] OR minorities[tiab] OR "of color"[tiab])	74
PubMed Central	(abortion[Title] OR abortions[Title] OR ((pregnancy[Title] OR pregnancies[Title] OR pregnant[Title]) AND (termination[Title] OR terminate[Title] OR terminated[Title])))AND(stigma OR stigmatise OR stigmatised OR stigmatises OR stigmatisation)AND(race OR racial OR ethnicity OR ethnicities OR ethnic OR cultural OR culture OR white OR black OR "african american" OR latina OR latino OR latinx OR hispanic OR mexican OR asian OR minority OR minorities OR "of color")	303
Embase (1947 – )	('abortion'/exp OR abortion OR abortions OR (('pregnancy'/exp OR pregnancy OR pregnancies OR pregnant) AND ('termination'/exp OR termination OR terminate OR terminated))) AND ('stigma'/exp OR stigma OR stigmatise OR stigmatised OR stigmatises OR 'stigmatisation'/exp OR stigmatisation) AND and AND ('race'/exp OR race OR racial OR 'ethnicity'/exp OR ethnicity OR ethnicities OR ethnic OR cultural OR 'culture'/exp OR culture OR 'white'/exp OR white OR 'black'/exp OR black OR 'african american'/exp OR 'african american' OR 'latina'/exp OR latina OR 'latino'/exp OR latino OR latinx OR 'hispanic'/exp OR hispanic OR 'mexican'/exp OR mexican OR 'asian'/exp OR asian OR minority OR minorities OR 'of color')	161
PsycINFO (ProQuest, 1887 – )	(abortion OR abortions OR ((pregnancy OR pregnancies OR pregnant) AND (termination OR terminate OR terminated)))AND(stigma OR stigmatise OR stigmatised OR stigmatises OR stigmatisation)AND(race OR racial OR ethnicity OR ethnicities OR ethnic OR cultural OR culture OR white OR black OR "african american" OR latina OR latino OR latinx OR hispanic OR mexican OR asian OR minority OR minorities OR "of color")	73
Sociological Abstracts & Social Services Abstracts (searched together via ProQuest, 1963 – )	ab(abortion OR abortions OR ((pregnancy OR pregnancies OR pregnant) AND (termination OR terminate OR terminated)))AND(stigma OR stigmatise OR stigmatised OR stigmatises OR stigmatisation)AND(race OR racial OR ethnicity OR ethnicities OR ethnic OR cultural OR culture OR white OR black OR "african american" OR latina OR latino OR latinx OR hispanic OR mexican OR asian OR minority OR minorities OR "of color")	198
GenderWatch (1970 – ) & Ethnic NewsWatch (1959 – ) (searched together via ProQuest)	ab(abortion OR abortions OR ((pregnancy OR pregnancies OR pregnant) AND (termination OR terminate OR terminated))) AND (stigma OR stigmatise OR stigmatised OR stigmatises OR stigmatisation) AND (race OR racial OR ethnicity OR ethnicities OR ethnic OR cultural OR culture OR white OR black OR "african american" OR latina OR latino OR latinx OR hispanic OR mexican OR asian OR minority OR minorities OR "of color")Exclude newspapers and magazines	266
Total number of results		1075
Total number of duplicates identified via EndNote X9		234
Total number of results after de-duplication		841

Appendix 2.

PRISMA-S Checklist.

Section/topic	#	Checklist item	Location(s) Reported
INFORMATION SOURCES AND METHODS
Database name	1	Name each individual database searched, stating the platform for each	p 4, Appendix 1
Multi-database searching	2	If databases were searched simultaneously on a single platform, state the name of the platform, listing all of the databases searched	Appendix 1
Study registries	3	List any study registries searched	n/a
Online resources and browsing	4	Describe any online or print source purposefully searched or browsed (e.g. tables of contents, print conference proceedings, web sites), and how this was done	n/a
Citation searching	5	Indicate whether cited references or citing references were examined, and describe any methods used for locating cited/citing references (e.g. browsing reference lists, using a citation index, setting up email alerts for references citing included studies)	5
Contacts	6	Indicate whether additional studies or data were sought by contacting authors, experts, manufacturers, or others	5
Other methods	7	Describe any additional information sources or search methods used	n/a
SEARCH STRATEGIES
Full search strategies	8	Include the search strategies for each database and information source, copied and pasted exactly as run	Appendix 1
Limits and restrictions	9	Specify that no limits were used, or describe any limits or restrictions applied to a search (e.g. date or time period, language, study design) and provide justification for their use	p 4, Appendix 1
Search filters	10	Indicate whether published search filters were used (as originally designed or modified), and if so, cite the filter(s) used	n/a
Prior work	11	Indicate when search strategies from other literature reviews were adapted or reused for a substantive part or all of the search, citing the previous review(s)	n/a
Updates	12	Report the methods used to update the search(es) (e.g. rerunning searches, email alerts)	n/a
Dates of searches	13	For each search strategy, provide the date when the last search occurred	p 4, Appendix 1
PEER REVIEW
Peer review	14	Describe any search peer review process	n/a
MANAGING RECORDS
Total Records	15	Document the total number of records identified from each database and other information sources	Appendix 1, Fig 1
Deduplication	16	Describe the processes and any software used to deduplicate records from multiple database searches and other information sources	Appendix 1

Funding Statement

No funding was provided for this systematic scoping review project.

Disclosure statement

No potential conflict of interest was reported by the author(s).