Exploring provider preference and provision of abortion methods and stigma: Secondary analysis of a United Kingdom provider survey.

INTRODUCTION: Method choice is an important component of quality abortion care and qualitative research suggests that abortion stigma can influence provider preference and provision of abortion methods. This study is the first to explore the relationships between abortion providers' method preferences, their provision of medication or instrumentation abortion or both methods, and abortion stigma. METHODS: We conducted secondary analysis of a survey of United Kingdom (UK) abortion providers (N = 172) to describe and compare providers' self-reported method preferences and provision. We used multinomial logistic regression to assess the association between method preference and provider experiences of abortion stigma (measured using a revised Abortion Provider Stigma Scale (APSS)), adjusting for relevant provider and facility characteristics. RESULTS: Almost half (52%) of providers reported that they only provided medication abortion care, while 5% only provided instrumentation abortion care and 43% provided both methods. Most (62%) preferred to provide both methods while 32% preferred to provide only medication abortion and 6% only instrumentation abortion. There was no significant difference in revised APSS scores by provider method preference or provision. DISCUSSION: Most surveyed UK abortion providers prefer to offer both methods, but over half only provide medication abortion. This may reflect patients' preferences for medication abortion, and health system and legal constraints on instrumentation abortion. Addressing these systemic constraints on method provision could expand patient choice. Providers' method preference was not significantly associated with provider stigma but future research should consider the influence of structural stigma on method provision at the health system level.

Foregrounding pain in self-managed early medication abortion: a qualitative study.

OBJECTIVE: To explore experiences of pain in the context of early medical abortion (EMA) in the UK and to guide best practice around anticipatory guidance on pain. METHODS: From late 2020 to early 2021, we recruited individuals from across the UK who had undergone abortion during the COVID-19 pandemic to participate in in-depth, semi-structured telephone interviews. A storytelling approach was used and data were analysed thematically using NVivo 12 software. RESULTS: Focused coding and thematic analysis addressed accounts of pain, which were prominent in many interviews. We constructed the following subthemes: expected pain is manageable for some; the problem with unexpected pain; pain (co)produces fear; and problematising 'period-like pain'. The key issue which our analysis draws out is that while EMA pain experience might vary, for some it may be much worse than anticipated. Moreover, the common trope of likening it to 'period pain' can be misleading and a source of additional uncertainty at a potentially already challenging time. CONCLUSIONS: For some individuals, pain experienced in EMA will be severe and/or worse than expected. Insufficient preparation for pain can result in extremely negative experiences of EMA. Alongside development of improved analgesia, improvements should be made to anticipatory guidance on pain, particularly for those self-manging EMA at home. Framings of 'period-like pain' do not clarify expectations and should be avoided.

Patient experiences of undergoing abortion with and without an ultrasound scan in Britain.

BACKGROUND: Routine ultrasound scanning to determine gestational age and pregnancy location has long been part of pre-abortion assessment in Britain, despite not being legally required or recommended in national clinical guidelines. To support implementation of fully telemedical abortion care (implemented in Britain in April 2020), the Royal College of Obstetricians and Gynaecologists (RCOG) issued clinical guidance for an 'as-indicated' approach to pre-abortion ultrasound, removing the need for a clinic visit. We aimed to understand patient experiences of ultrasound in abortion care by conducting a qualitative study with individuals who had abortions with and without an ultrasound scan. METHODS: Between November 2021 and July 2022, we recruited patients who had a medical abortion at home without a pre-procedure ultrasound at 69 days' gestation or less at British Pregnancy Advisory Service (BPAS), and also had at least one other abortion with an ultrasound from any provider in Britain. We conducted interviews using a semi-structured interview guide to explore our participants' experiences and conducted reflexive thematic analysis. RESULTS: We recruited 24 participants and included 19 interviews in our analysis. We developed three themes from our data. These were 'Ultrasound scans and their relationship with autonomy and decision-making', 'Intrusive and out of place: the ultrasound as an inappropriate technology' and 'Towards preference-centred, quality care'. CONCLUSIONS: Further research and user-testing of strategies to improve the scan experience should be undertaken. Patient testimonies on the negative impact of ultrasound scans in abortion care should reassure providers that omitting them according to patient preference is a positive step towards providing patient-centred care.

'I have to pretend that I don't care': Stigma management among unmarried young mothers in South-Western Nigeria.

Young mothers often encounter stigma and discrimination, affecting their lives and that of their children. This paper explores stigma management strategies and their effectiveness for young mothers in rural Nigeria. Ten key informants and 24 young mothers were recruited from Ife-East in South-Western Nigeria. Data from semi-structured interviews showed that societal disapproval of pregnant teenagers and young mothers were common experiences. Women used a range of strategies to actively cope with stigma including: belief in predestination, avoidance, concealment, and cohabitation. These strategies could be seen as tools to mitigate negative stereotypes and discrimination. However, they also had the unintended consequences of compounding many young women's difficult circumstances and exposing them to adverse outcomes, including gender-based violence, repeat pregnancies, poor mental health, and low uptake of services. The results show the need for policy frameworks to actively combat stigma by addressing the negative framing of early pregnancy and motherhood and promoting supportive environments for young mothers. Health professionals need to be trained to offer de-stigmatising services to encourage young mothers to seek help and reduce pre-existing inequities in access to services, and policies need to include measures that address the rights of young mothers and protect them from violence and abuse.

Social connectedness and supported self-management of early medication abortion in the UK: experiences from the COVID-19 pandemic and learning for the future.

Medication abortion has been established globally as safe and effective. This modality has increased accessibility and the opportunity to centre individual autonomy at the heart of abortion care, by facilitating self-managed abortion. Previous research has shown how self-managed abortion is beneficial in myriad settings ranging from problematic to (relatively) unproblematic contexts of access. In this paper we explore the relationship between self-management and sources of support (including health professionals, family, and friends); as well as considering issues of reproductive control and autonomy. Drawing on qualitative, experience-centred interviews, we utilise the concept of social connectedness to examine how supported self-managed abortion was experienced in the United Kingdom during the COVID-19 pandemic. Overall, self-management was welcomed, with participants speaking positively about managing their own abortion at home. However, a sense of connectedness was crucial in helping participants deal with difficult experiences; and functioned to support individual autonomy in self-care. This paper is the first to examine factors of connection, support, and isolation, as experienced by those undergoing self-managed abortion in the UK in detail. Our research suggests a continued need to advocate for high quality support for self-managed abortion, as well as for choice of abortion method, to support patient-centered care.

A qualitative analysis of medical students' attitudes to abortion education in UK medical schools.

BACKGROUND: Despite abortion being a common part of reproductive healthcare, UK undergraduate medical school abortion education varies widely. We therefore aimed to explore medical students' views on their undergraduate abortion education, including whether it prepared them to be a competent practitioner. METHODS: We conducted in-depth semi-structured interviews with 19 students from five UK medical schools, all of whom had received abortion teaching. The qualitative research followed a quantitative survey of UK undergraduate abortion education; the five medical schools were purposively sampled to encompass a wide variety of teaching approaches. Interviews were transcribed and data were analysed using an inductive thematic approach. RESULTS: Dedicated abortion teaching was highlighted as necessary and valuable, as abortion care is so commonly accessed. Participants felt that abortion education should prepare students to be competent practitioners, with inclusion of clinical placements and an emphasis on non-stigmatising care. Most interviewees felt that the perceived sensitive nature of abortion should act as an incentive to comprehensive teaching. It was suggested that teaching should be inclusive for all, including those with a conscientious objection to abortion. CONCLUSION: The medical students interviewed viewed comprehensive abortion education as an important aspect of their undergraduate curriculum. Conversely to the accompanying quantitative survey of educators, participants believed that the perceived sensitivity of abortion increases the importance of effective teaching that prepares them to provide competent respectful care when they qualify. It is incumbent on medical schools to provide the comprehensive education that students need and the Royal College of Obstetricians and Gynaecologists recommends.

'I really wanted to abort' Desire for abortion, failed abortion and forced motherhood in South-Western Nigeria.

Continued pregnancy after an abortion attempt is a likely outcome in countries where unsafe abortions prevail. Yet there is a paucity of literature on the consequences and implications of failed abortions. This study explored young women's abortion decision-making, their experiences of failed abortion and its consequences in South-Western Nigeria. It presents findings from semi-structured interviews conducted with 14 women who had become unintentionally pregnant as unmarried teenagers, desired abortions, yet became mothers. Whilst the fear of the stigma associated with young unmarried motherhood gave rise to participants' desire for abortion, restrictive abortion laws influenced their experiences and abortion decision-making. Participants who attempted an abortion failed and were forced to carry their unwanted pregnancies to term. They then experienced continued discrimination, forced motherhood, and a rejection of maternalism. Their experiences are analysed as responses to the complex interplay between social norms, abortion restrictions, stigma and forced motherhood. The paper makes a case for improving women's reproductive autonomy in decision-making, - highlighting the social and mental health consequences of restricted access to abortion, and reinforce the importance of taking a holistic approach to addressing the sexual health of young women, by focusing not only on physical health but also on ensuring wellbeing.

Normalising abortion: what role can health professionals play?

BACKGROUND: Despite being a common gynaecological procedure, abortion continues to be widely stigmatised. The research and medical communities are increasingly considering ways of reducing stigma, and health professionals have a role to play in normalising abortion as part of routine sexual and reproductive healthcare (SRH). We sought to investigate how health professionals may normalise abortion and challenge prevailing negative sociocultural narratives. METHODS: As part of the Sexuality and Abortion Stigma Study (SASS), qualitative secondary analysis was conducted on two datasets containing health professionals' accounts of providing abortion in Scotland and England. A subsample of 20 interviews were subjected to in-depth, thematic analysis. RESULTS: Four key themes were identified in heath professionals' accounts: (1) encountering resistance to abortion from others working in SRH; (2) contending with prevailing negative sociocultural narratives of abortion; (3) enacting overt positivity towards abortion provision; and (4) presenting abortion as part of normal, routine healthcare. CONCLUSIONS: It is clear that negative attitudes toward abortion persist both inside and outside of healthcare systems, and need to be challenged in order to destigmatise those accessing and providing services. Health professionals can play a key role in normalising abortion, through the ways in which they frame their work and present abortion to women they treat, and others more widely. Our analysis suggests a key way to achieve this is by presenting abortion as part of normal, routine SRH, but that appropriate support and structural change are essential for normalisation to become embedded.

Toward normalising abortion: findings from a qualitative secondary analysis study.

In most settings worldwide, abortion continues to be highly stigmatised. Whilst a considerable body of literature has addressed abortion stigma, what is less commonly examined are the ways in which those with experience of abortion describe it in non-negative terms which may resist or reject stigma. Drawing on qualitative secondary analysis of five UK datasets using a narrative inquiry approach, we explore: the use of non-negative language around abortion, potential components of a normalising narrative, and constraints on non-negativity. As such, we present the first empirical UK study to critically examine how a dominant negative abortion narrative might be disrupted.

Young women's fertility knowledge: partial knowledge and implications for contraceptive risk-taking.

BACKGROUND: There is a lack of research on young women's fertility knowledge and awareness. This has implications for contraceptive risk-taking, including the use of emergency hormonal contraception (EHC). By drawing on two research studies, this article shows how greater fertility knowledge could benefit young women in terms of pregnancy prevention. METHODS: We draw on two qualitative research studies ('fertility study' and 'abortion study') resulting in a composite sample of 46 interviews with women aged 16-24 years. Focused secondary analysis was undertaken looking specifically at fertility knowledge in relation to contraceptive behaviour. FINDINGS: A lack of accurate knowledge about the menstrual cycle was evident in two ways. Young women drew conclusions about their invulnerability to pregnancy if previous unprotected sexual intercourse (UPSI) had not resulted in pregnancy. Additionally, although participants were aware of EHC, there was no awareness of when it might fail other than after a certain time limit. CONCLUSIONS: Young women would benefit from a more nuanced understanding of fertility. Episodes of UPSI that do not result in pregnancy can encourage a belief that 'it won't happen to me', and this has implications for taking chances with contraception. Partial knowledge about the effectiveness of EHC may also lead to unintended pregnancy. Calculating the number of hours following UPSI generates overreliance on what is only one of the factors determining the effectiveness of EHC. Information regarding the link between EHC and failure rates near the day of ovulation needs to be more widely publicised.

Moral dilemmas and abortion decision-making: Lessons learnt from abortion research in England and Wales.

This paper scrutinises the concepts of moral reasoning and personal reasoning, problematising the binary model by looking at young women's pregnancy decision-making. Data from two UK empirical studies are subjected to theoretically driven qualitative secondary analysis, and illustrative cases show how complex decision-making is characterised by an intertwining of the personal and the moral, and is thus best understood by drawing on moral relativism.

Provider-based barriers to provision of intrauterine contraception in general practice.

OBJECTIVES: Intrauterine contraception (IUC) is highly effective, safe and long-lasting, but is not a popular method of contraception among British women. This study examined barriers to the uptake of IUC in general practice in England. METHOD: A sequential mixed-method approach to explore the views of practitioners regarding the provision of IUC. We e-surveyed 208 practitioners from 69 practices in a region of England and subsequently interviewed 14 practitioners from eight practices. RESULTS: Just under half of general practitioners (GPs) (46.8%; 58/124), and only 8.2% (4/49) of nurses reported being trained to fit IUC. Lack of knowledge of IUC was a barrier to fitting, and also to recommending IUC, especially by practitioners who were not trained to fit. There was discordance between reported knowledge of eligibility for IUC and the likelihood of recommending IUC. Respondents were less likely to recommend IUC to young, nulliparous women, women who had experienced a previous ectopic pregnancy, a recent sexually transmitted infection (STI), or an abnormal cervical smear. The qualitative data indicate that risk aversion and limited training, together with practitioners' assessments that women are uninterested, may lead to IUC being precluded as a suitable method. CONCLUSIONS: Increased practitioner education, for those not trained to fit IUC, may remove a barrier to the uptake of IUC in general practice. More research is required on the discordance between the practitioners' views on the characteristics of women considered suitable for IUC, and the criteria set out in the UK Medical Eligibility Criteria (UKMEC) guidelines.

"I think maybe 10 years seems a bit long." Beliefs and attitudes of women who had never used intrauterine contraception.

AIM: To explore, in a general practice setting, the concerns, beliefs and attitudes about intrauterine contraception (IUC) reported by women, who had never used the methods. METHODS: We used a sequential mixed-method (QUAL/quant) approach. A pragmatic, self-selecting sample of 30 women, aged 18-46 years, who had never used IUC), was recruited through seven general practices in South East England. Themes arising from qualitative interviews were used to construct a quantitative survey, completed by a pragmatic sample of 1195 women, aged 18-49 years, attending 32 general practices in the same region, between February and August 2015. RESULTS: Qualitative themes were concerns about the long-acting nature of IUC, concerns about body boundaries, and informal knowledge of IUC, especially 'friend of a friend' stories. Women were not sure if the devices can be removed before their full 5- or 10-year duration of use, and felt that these timeframes did not fit with their reproductive intentions. Quantitative survey data showed that the most commonly endorsed concerns among never-users were painful fitting (55.8%), unpleasant removal of the device (60.1%), and concern about having a device 'inside me' (60.2%). CONCLUSIONS: To facilitate fully informed contraceptive choice, information provided to women considering IUC should be tailored to more fully address the concerns expressed by never-users, particularly around the details of insertion and removal, and concerns about the adverse, long-term effects of the device. Women need to be reassured that IUC can be removed and fertility restored at any time following insertion. TRIAL REGISTRATION: Trial registration NIHR CRN portfolio; 15912.

The need to improve fertility awareness.

Women and men globally are delaying the birth of their first child. In the UK, the average age of first conception in women is 29 years. Women experience age-related fertility decline so it is important that men and women are well-informed about this, and other aspects of fertility. A group of UK stakeholders have established the Fertility Education Initiative to develop tools and information for children, adults, teachers, parents and healthcare professionals dedicated to improving knowledge of fertility and reproductive health.

'Repeat abortion', a phrase to be avoided? Qualitative insights into labelling and stigma.

BACKGROUND: In recent years there has been growing international interest in identifying risk factors associated with 'repeat abortion', and developing public health initiatives that might reduce the rate. This article draws on a research study looking at young women's abortion experience in England and Wales. The study was commissioned with a specific focus on women who had undergone more than one abortion. We examine what may influence women's post-abortion reproductive behaviour, in addition to exploring abortion-related stigma, in the light of participants' own narratives. STUDY DESIGN: Mixed-methods research study: a quantitative survey of 430 women aged 16-24 years, and in-depth qualitative interviews with 36 women who had undergone one or more abortions. This article focuses on the qualitative data from two subsets of young women: those we interviewed twice (n=17) and those who had experienced more than one unintended/unwanted pregnancy (n=15). RESULTS: The qualitative research findings demonstrate the complexity of women's contraceptive histories and reproductive lives, and thus the inherent difficulty of establishing causal patterns for more than one abortion, beyond the obvious observation that contraception was not used, or not used effectively. Women who had experienced more than one abortion did, however, express intensified abortion shame. CONCLUSIONS: This article argues that categorising women who have an abortion in different ways depending on previous episodes is not helpful. It may also be damaging, and generate increased stigma, for women who have more than one abortion.