Abortion and anxiety: What's the relationship?

Using data from the United States National Survey of Family Growth (NSFG) and the National Comorbidity Survey (NCS), we conducted secondary data analyses to examine the relationship of abortion, including multiple abortions, to anxiety after first pregnancy outcome in two studies. First, when analyzing the NSFG, we found that pre-pregnancy anxiety symptoms, rape history, age at first pregnancy outcome (abortion vs. delivery), race, marital status, income, education, subsequent abortions, and subsequent deliveries accounted for a significant association initially found between first pregnancy outcome and experiencing subsequent anxiety symptoms. We then tested the relationship of abortion to clinically diagnosed generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), and social anxiety disorder, using NCS data. Contrary to findings from our analyses of the NSFG, in the NCS analyses we did not find a significant relationship between first pregnancy outcome and subsequent rates of GAD, social anxiety, or PTSD. However, multiple abortions were found to be associated with much higher rates of PTSD and social anxiety; this relationship was largely explained by pre-pregnancy mental health disorders and their association with higher rates of violence. Researchers and clinicians need to learn more about the relations of violence exposure, mental health, and pregnancy outcome to avoid attributing poor mental health solely to pregnancy outcomes.     

Abortion utilization: does travel distance matter?

The further a woman must travel in order to obtain an abortion, the less likely she is to get one. Distance is especially disadvantageous to blacks, and most so to black teenagers. Distance discourages use among rural as well as urban women. Opening new clinics increases abortion use in nearby communities.     

Abortion and politics in Nicaragua: The women's movement in the debate on the Abortion Law Reform 1999–20021

This paper analyses discussion on a proposed reform to the abortion law in Nicaragua between 1999 and 2002, as a struggle between different actors—politicians, religious leaders, doctors and feminists—over the meaning of abortion, motherhood and sexuality, and ultimately the value of women's lives. It shows how the interplay of gender discourses and political practices shaped the process of discussion: on one hand by making a broad alliance against abortion possible, on the other by highlighting the contradictory role of the women's movement in this discussion, between a dominant leadership and a low mobilizing capacity. The paper argues for the need of an inwards oriented process within the women's movement, that departs from the recognition of the personal issues at stake for women in order to break the silence surrounding abortion, such as prevailing feelings of fear and guilt. This entails recognition of the limits of the liberal feminist claim to ‘abortion as a free choice’, as a discourse of rights that is disconnected from the everyday life conditions and constraints under which women make choices and develop their notions of rights.     

Is Induced Abortion Really Declining in Armenia?

As in other post‐Soviet settings, induced abortion has been widely used in Armenia. However, recent national survey data point to a substantial drop in abortion rates with no commensurate increase in modern contraceptive prevalence and no change in fertility levels. We use data from in‐depth interviews with women of reproductive age and health providers in rural Armenia to explore possible underreporting of both contraceptive use and abortion. While we find no evidence that women understate their use of modern contraception, the analysis suggests that induced abortion might indeed be underreported. The potential for underreporting is particularly high for sex‐selective abortions, for which there is growing public backlash, and medical abortion, a practice that is typically self‐administered outside any professional supervision. Possible underreporting of induced abortion calls for refinement of both abortion registration and relevant survey instruments. Better measurement of abortion dynamics is necessary for successful promotion of effective modern contraceptive methods and reduction of unsafe abortion practices.     

The World Health Organization’s Safe Abortion Guidance Document

We discuss the history of the World Health Organization’s (WHO’s) development of guidelines for governments on providing safe abortion services, which WHO published as Safe Abortion: Technical and Policy Guidance for Health Systems in 2003 and updated in 2012.We show how the recognition of the devastating impact of unsafe abortion on women’s health and survival, the impetus of the International Conference on Population and Development and its five-year follow-up, and WHO’s progressive leadership at the end of the century enabled the organization to elaborate guidance on providing safe abortion services.Guideline formulation involved extensive review of published evidence, an international technical expert meeting to review the draft document, and a protracted in-house review by senior WHO management.Forty-five years ago, in 1967, the World Health Assembly identified unsafe abortion as a serious public health problem for women in many countries.1 Nevertheless, it was not until the Safe Motherhood Conference in Nairobi, Kenya in February 1987 and the publication of the first estimate of abortion-related deaths in 1989 that the extent of this public health problem was understood. Derived from fragmentary information on incidence and from studies on the proportion of maternal deaths that unsafe abortion caused, the estimate suggested that there were at least 115 000 abortion-related deaths annually.2 However, even at the time this figure was published, reservations were expressed about its accuracy. Following the World Health Organization’s (WHO’s) establishment of a formal database, country estimates of unsafe abortion (“frequency and mortality of abortion not provided through approved facilities and/or persons”3^[p13]) and the associated mortality were published in 1990. Data in this first publication were presented by country, and no attempt was made to derive regional or global summary statistics. In 1993, WHO revised the earlier estimate of 115 000 abortion-related deaths downward to 70 000 deaths annually and produced regional and global estimates.4 Deaths owing to unsafe abortions were calculated to represent about 13% of all maternal deaths, a proportion that has remained unchanged.5At the time of the Nairobi conference, Halfdan Mahler, then Director-General of WHO, highlighted the importance of access to family planning services and essential obstetric care for avoiding maternal deaths because of illegal abortion from unwanted pregnancy.6 Yet, for the most part, WHO ignored his call to action on unsafe abortion for some time and generally shied away from advocating intervention to prevent the unnecessary deaths and suffering associated with clandestine abortion through the provision of safe legal abortion.     

Women’s Private Conversations about Abortion: A Qualitative Study

Abortion is a relatively frequent experience, yet public discourse about abortion is contentious and stigmatizing. Little literature is available on private conversations about abortion, which may be distinct from public discourse. We explored private discourse by documenting the nature of women’s discussions about abortion with peers in a book club. We recruited thirteen women’s book clubs in nine states. Participants (n = 119) read the book Choice: True Stories of Birth, Contraception, Infertility, Adoption, Single Parenthood, & Abortion, and participated in a book club meeting, which we audio-recorded and transcribed. Data collection occurred between April 2012 and April 2013. In contrast to public discourse of abortion, private discourse was nuanced and included disclosures of multiple kinds of experiences with abortion. Participants disclosed having abortions, considering abortion as an option for past or future pregnancies, and supporting others through an abortion. Distinguishing between public and private discourse enabled us to identify that an “abortion experience” could include personal decisions, hypothetical decisions, or connection with someone having an abortion. The book club atmosphere provided a rare opportunity for participants to explore their relationship to abortion. More research is needed to understand the role of private discourse in reducing abortion stigma.     

Is “Abortion Culture” Fading in the Former Soviet Union? Views about Abortion and Contraception in Kazakhstan

The Soviet legacy of widespread reliance on induced abortion is of critical importance to reproductive trends and policies in post-Soviet nations, especially as they strive to substitute contraception for abortion. Using data from two Demographic and Health Surveys conducted in 1995 and 1999, this study analyzes and compares trends in abortion and contraception, women's attitudes toward abortion, and their perceptions of problems associated with abortion and contraception in Kazakhstan. Despite an overall decline in abortion and an increase in contraceptive use since Kazakhstan's independence in 1991, abortion has remained a prominent part of the country's reproductive culture and practices. This study shows how abortion-related views reflect the long-standing ethnocultural differences between the indigenous Kazakhs and Kazakhstan's residents of European roots, as the latter continue to have significantly higher levels of abortion. The study, however, also reveals the internal diversity among Kazakhs with respect to abortion experiences and views, stemming from decades of the Soviet sociocultural influence in Kazakhstan. In addition, the analysis points to some generational differences in views concerning abortion and contraception. Finally, the study demonstrates parallels in attitudes toward abortion and toward contraception, thereby questioning straightforward assumptions about the replacement of abortion with contraception.     

Letter to the Editor: Response to “What Women Want From Abortion Counseling in the United States: A Qualitative Study of Abortion Patients in 2008”

Abstract

Diabetes is aggravated by a sedentary lifestyle, obesity and smoking. Based on a theoretical model relating attitudes and behavior, this study examined the association between physicians' self efficacy in counseling diabetic patients on life style behaviors and their counseling practices. Data were gathered from a representative sample of 743 primary care physicians in Israel's two largest health plans. The main findings were that only a small percentage of physicians felt capable of influencing their patients' life-style behaviors. Self-efficacy had an independent effect on the likelihood of counseling diabetic patients on life style behaviors, controlling for other background variables. We conclude that there is a need for enhancing physicians' life-style counseling skills, and that social workers could expand their role by training physicians to counsel effectively. This could both improve the care of diabetic patients, and strengthen the status of the social work profession in the healthcare system.     

At What Cost? Payment for Abortion Care by U.S. Women

BackgroundMost U.S. abortion patients are poor or low-income, yet most pay several hundred dollars out of pocket for these services. This study explores how women procure these funds.MethodsiPad-administered surveys were implemented among 639 women obtaining abortions at six geographically diverse healthcare facilities. Women provided information about insurance coverage, payment for service, acquisition of funds, and ancillary costs incurred.FindingsOnly 36% of the sample lacked health insurance, but at least 69% were paying out of pocket for abortion care. Women were twice as likely to pay using Medicaid (16% of abortions) than private health insurance (7%). The most common reason women were not using private insurance was because it did not cover the procedure (46%), or they were unsure if it was covered (29%). Among women who did not use insurance for their abortion, 52% found it difficult to pay for the procedure. One half of patients relied on someone else to help cover costs, most commonly the man involved in the pregnancy. Most women incurred ancillary expenses in the form of transportation (mean, $44), and a minority also reported lost wages (mean, $198), childcare expenses (mean, $57) and other travel-related costs (mean, $140). Substantial minorities also delayed or did not pay bills such as rent (14%), food (16%), or utilities and other bills (30%) to pay for the abortion.ConclusionsPublic and private health insurance plan coverage of abortion care services could ease the financial strain experienced by abortion patients, many of whom are low income.     

“One Problem Became Another”: Disclosure of Rape-Related Pregnancy in the Abortion Care Setting

ObjectiveWe sought to explore the experiences of women who disclosed that their pregnancies resulted from rape in the abortion care setting, as well as the experiences of professionals involved in care of women with rape-related pregnancy.MethodsIn-depth interviews were conducted with 9 patients who had terminated rape-related pregnancies and 12 professionals working in abortion care or rape crisis advocacy (5 abortion providers, 4 rape crisis center advocates, 2 social workers, and 1 clinic administrator). Transcribed interviews were coded and analyzed for themes related to the experiences of disclosing rape and the consequences of disclosure in the abortion care setting.ResultsPatients and professionals involved in care of women with rape-related pregnancy described opportunities arising from disclosure, including interpersonal (explaining abortion decision making in the context of assault, belief, and caring by providers), as well as structural opportunities (funding assistance, legal options, and mental health options). Whereas most patients did not choose to pursue all three structural opportunities, both patients and professionals emphasized the importance of offering them. The most important consequence of disclosure for patients was being believed and feeling that providers cared about them.ConclusionRape-related pregnancy disclosure in the abortion care setting can lead to opportunities for interpersonal support and open options for funding, legal recourse, and mental health care. Those working in abortion care should create environments conducive to disclosure and opportunities for rape survivors to access these additional options if they desire.     

Decriminalization of Abortion in Mexico City: The Effects on Women’s Reproductive Rights

In April 2007, the Mexico City, Mexico, legislature passed landmark legislation decriminalizing elective abortion in the first 12 weeks of pregnancy.In Mexico City, safe abortion services are now available to women through the Mexico City Ministry of Health’s free public sector legal abortion program and in the private sector, and more than 89 000 legal abortions have been performed. By contrast, abortion has continued to be restricted across the Mexican states (each state makes its own abortion laws), and there has been an antichoice backlash against the legislation in 16 states.Mexico City’s abortion legislation is an important first step in improving reproductive rights, but unsafe abortions will only be eliminated if similar abortion legislation is adopted across the entire country.In April 2007, the Mexico City, Mexico, legislature passed landmark legislation decriminalizing elective abortion in the first 12 weeks of pregnancy. The law included a provision that abortion services be available to women at Mexico City (Distrito Federal) Ministry of Health (MOH-DF) facilities in the city, free of charge for Mexico City residents and on a sliding fee scale for those outside Mexico City. In addition, the law strengthened sexual education curricula in schools and called for widespread access to contraceptive methods. Shortly after being passed, the law was challenged in the Mexican Supreme Court by groups opposed to the legislation, but in August 2008, the Supreme Court voted to uphold the law.1,2In Mexico, abortion laws are made at the state level, and before this reform, across all of Mexico’s states and in the Federal District (or Mexico City, the capital), abortion was permitted under very limited circumstances such as in cases of rape, fetal malformation, or when the survival or health of a woman was in danger. Even when abortions were legally permitted, however, numerous barriers made accessing a legal abortion extremely difficult.3,4 Despite these barriers, abortion was commonly practiced. One study estimated the induced abortion rate in Mexico in 2006 to be 33 abortions per 1000 women aged 15 to 44 years, a comparatively high rate by global standards.5 However, because of the legal restrictions, the vast majority of abortions in Mexico took place clandestinely, often in unsafe circumstances, sometimes causing severe health consequences for women. From 1990 to 2008, 7.2% of all maternal deaths in Mexico were abortion-related.6 Another study estimated that in 2006, 149 700 women were hospitalized from complications following induced abortions nationally.5Inequity was an important dimension of unsafe abortion in Mexico. A study that used data from the 2006 Mexican National Demographic Survey found the risk of having an unsafe abortion was highest for poor women, those with low levels of education, and those who belonged to indigenous groups.7 The abortion reform in Mexico City responded to the gravity of this public health problem, delivering a major victory for women’s reproductive rights by departing from the restrictive abortion laws in the rest of the country.The Mexico City abortion law reform is significant not only for Mexico, but also for the entire Latin American and Caribbean region, which continues to have some of the most restrictive abortion laws globally. Virtually all abortions (95%) in the Latin American and Caribbean region are unsafe, and unsafe abortions cause an estimated 12% of all maternal deaths.8,9 Only a few countries and territories in this region have progressive abortion legislation, including Cuba, Guyana, Puerto Rico, and Uruguay, where first-trimester abortion was decriminalized in 2012.10,11We describe developments since this landmark reform was passed, both in Mexico City and in the states of Mexico. We highlight the development of the public sector legal abortion program by the MOH-DF, including important trends in this program. We also discuss the backlash that has occurred since abortion decriminalization.     

Abortion restrictions and the drive for mental health parity: a conflict in values?

Mental health issues will be in the spotlight in the coming months as a result of a White House conference on mental health in June, the expected release of a report by the surgeon general on mental health in the fall, and the introduction of high-profile legislation in Congress designed to secure complete parity between insurance coverage of mental and physical health benefits. However, this heightened attention may seem somewhat ironic to women's rights and prochoice advocates, given the negative treatment of women's mental health concerns in the context of current abortion politics. Measures have been introduced in recent years, mainly by prochoice legislators, which treat women seeking abortions for mental health reasons differently from those with physical health concerns. These initiatives have significant implications within the larger abortion-rights context, and beyond. The author discusses the rise in public and political support for measures designed to overcome the differential treatment of physical and mental illness in the health insurance context. Parity between physical and mental health has been a central feature of abortion jurisprudence for almost 30 years. As such, prochoice and mental health advocates need to join together to teach policy-makers about the importance of maintaining parity in the abortion context.     

Women Know Best—Findings from a Thematic Analysis of 5,214 Surveys of Abortion Care Experience

ObjectivePatient experience is an essential component of quality care. Few studies have comprehensively evaluated patient experiences of abortion care. The objectives of this study were to describe women's experiences of abortion care in their own words, and to determine themes across patient experiences.Study DesignData for this thematic analysis, a qualitative method that allows for the identification, analysis, and report of patterns or themes within data, come from a larger study of safety and quality of aspiration abortion care across 22 clinical sites. Participants completed an abortion experience survey including fixed choice questions and an open-ended question: “Is there anything you would like to tell us about your experience?” The data were then categorized by responses to another survey question: “Overall, was your experience about, better, or worse than you expected?”ResultsA total of 5,214 responses were analyzed. Women reported positive abortion care experiences with the majority of women rating their experience as better than expected (n = 3,600). Two major themes that emerged from the data include clinic- and patient-level factors that impact how patients rate their experiences. Analysis of the responses categorized in the worse than expected group (n = 136) found that women primarily faulted clinic-level factors for their negative experiences, such as pain control and management, and wait time for appointments and in clinic.ConclusionThis analysis highlights specific areas of abortion care that influence patients' experience. The few women who were disappointed by care in the clinic tended to fault readily modifiable clinical factors, and provided suggested areas of improvement to enhance positive experiences related to their abortion care.