Barriers and delays in access to abortion care: a cross-sectional study of people traveling to obtain care in England and the Netherlands from European countries where abortion is legal on broad grounds.

INTRODUCTION: This study characterized the extent to which (1) financial barriers and (2) abortion care-seeking within a person's country of residence were associated with delays in abortion access among those travelling to England and the Netherlands for abortion care from European countries where abortion is legal on broad grounds in the first trimester but where access past the first trimester is limited to specific circumstances. METHODOLOGY: We drew on cross-sectional survey data collected at five abortion clinics in England and the Netherlands from 2017 to 2019 (n = 164). We assessed the relationship between difficulty paying for the abortion/travel, acute financial insecurity, and in-country care seeking on delays to abortion using multivariable discrete-time hazards models. RESULTS: Participants who reported facing both difficulty paying for the abortion procedure and/or travel and difficulty covering basic living costs in the last month reported longer delays in accessing care than those who had no financial difficulty (adjusted hazard odds ratio: 0.39 95% CI 0.21-0.74). This group delayed paying other expenses (39%) or sold something of value (13%) to fund their abortion, resulting in ~ 60% of those with financial difficulty reporting it took them over a week to raise the funds needed for their abortion. Having contacted or visited an abortion provider in the country of residence was associated with delays in presenting abroad for an abortion. DISCUSSION: These findings point to inequities in access to timely abortion care based on socioeconomic status. Legal time limits on abortion may intersect with individuals' interactions with the health care system to delay care.

This paper explores delays in accessing abortion care associated with financial and medical system barriers. We focus on residents of countries in Europe where abortion is available on broad grounds in the first trimester seeking abortion care outside of their country of residence. This study demonstrates an association between difficulty covering abortion costs for people facing financial insecurity and in-country care seeking and delays in accessing abortion abroad. Policy barriers, medical system barriers, as well as financial barriers may interact to delay access to care for people in European countries with broad grounds for abortion access in the first trimester but restrictions thereafter, especially for people later in pregnancy.

"The first difficulty is time": The impact of gestational age limits on reproductive health and justice in the context of cross-border travel for abortion care in Europe.

Drawing on qualitative and quantitative data collected during a 5-year multi-disciplinary European research project, in this article we show how restrictions on access to legal abortion, and particularly gestational age (GA) limits at the end of the first trimester of pregnancy, negatively affect women and pregnant people living in European countries where abortion is legal on request or on broad grounds. First, we examine why most European legislations establish GA limits, and illustrate how abortion is framed in national laws and in the current national and international legal and political debates on abortion rights. We then show, based on research data we collected during our 5-year project and contextualized with existing data and statistics, how these restrictions force thousands of people to travel across borders from European countries where abortion is legal, delaying access to care, and increasing pregnant people's health risks. Finally, we explore, from an anthropological perspective, how pregnant people who travel across borders for abortion care conceptualize abortion access, and the relationship between the right to abortion care and the GA restrictions that limit this right. Our study participants criticize the time restrictions established by the laws in their countries of residence as failing to meet pregnant people's needs, highlight the crucial importance of easy, timely access to abortion care even beyond the first trimester of pregnancy, and suggest a more relational approach to the right to access safe, legal abortion. Abortion travel is also a matter of reproductive justice because access to care depends on specific resources including finances, information, support, citizenship status, and social networks. Our work contributes to scholarly and public debates about reproductive governance and justice, by shifting the locus of attention to GA limits and its impact on women and pregnant people, particularly in geopolotical settings where abortion laws are deemed liberal.

French women's experiences and opinions with in-country versus cross-border abortion travel: a mixed-methods paper.

OBJECTIVES: This is the first study contrasting the experience of women residing in France and travelling for abortion services inside and outside their country of residence. We compare travel reasons and costs as well as our study participants' opinions of abortion legislation. The article documents legal and procedural barriers related to accessing local and timely abortions and provides policy recommendations to broaden care options. METHODS: The study is based on a mixed-methods research design. Quantitative data were descriptively analysed using Stata and drawn from 100 surveys with in-country abortion seekers collected from 3 Parisian hospitals, and 57 surveys with French residents seeking abortion care in the Netherlands (42), Spain (10) and the UK (5). Qualitative data were thematically analysed using ATLAS.ti and drawn from 36 interviews with French residents (23 in-country abortion seekers and 13 cross-border abortion travellers). FINDINGS: Gestational age (GA) limits were the key reason for cross-border travel, while lack of close-by, timely and good quality abortion care was the main driver for in-country abortion travel. Unlike in-country travellers, cross-border abortion seekers faced significant financial costs and burdens related to such travel. Partners, family members and service providers offered important support structures to both cross-border and in-country travellers. CONCLUSIONS: Legal time limits appeared to be the key driver for abortion-related travel of French residents. Having passed or being at risk of exceeding the GA limit caused women to travel outside their country or department of residence for abortion care.

'To be vigilant to leave no trace': secrecy, invisibility and abortion travel from the Republic of Ireland.

Until 2018, abortion in the Republic of Ireland was banned in almost all circumstances under one of the most restrictive legal regimes in Europe. The main solution for Irish women and pregnant people seeking abortion services had been to pursue care abroad, typically in clinics in England. In this paper we focus on the hardships of waiting for abortion care experienced by Irish residents leading up to their travel for appointments in England in 2017 and 2018. Based on in-depth interviews with 53 Irish women collected at three British Pregnancy Advisory Services (BPAS) clinics in England we analyse women's experiences as they navigated an 'environment of secrecy' in Ireland. This included making specific secrecy efforts when navigating travel arrangements, conversations, movement, health records, and the travel itself. Despite the expansion of abortion access in Ireland in 2018, the need to travel abroad continues for many women. We argue that the continued need for secrecy when women have to travel abroad for care perpetuates this important phenomenon's invisibility. This argument also applies to other countries where abortion access is restricted, and women are forced to travel for care. We also caution against the presumption that all Irish residents are able to travel internationally for healthcare.

Inter-departmental abortion travels in metropolitan France: A mixed-methods analysis of women's experiences, access, and barriers to abortion care.

In Europe, there is a dearth of studies on abortion-related mobilities within countries where abortion is legal. In France, 18% of women seek abortion care outside their department of residence care. Most of these flows take place within Île-de-France region. This paper aims at providing novel insights into the motives and experiences of women traveling within France and particularly within the Île-de-France region for abortion care. It draws upon official abortion statistics as well as quantitative and qualitative data collected in three Parisian hospitals during a five-year European research project on barriers to legal abortion and abortion travel. Despite governmental efforts to facilitate access to abortions over the past decades, our findings show that various barriers exist for why women do not find services in their department of residence (lack of services or access to preferred methods, quality of care, long waiting times). However, most of our study participants report coming to Paris as a convenience and use commuting as a strategy to overcome obstacles in receiving abortion care.

Demographic Anxiety and Abortion: Italian Pro-Life Volunteers' and Gynecologists' Perspectives.

In this article, we analyze the public debate on fertility decline and abortion in Italy, focusing on demographic anxieties, fueled by conservative demographers and politicians, about the different reproductive behavior of native Italians and migrants. We argue that vitapolitics, a moral regime that defends "life" and condemns abortion, is one of the main mechanisms of reproductive governance in Italy. Drawing on two studies 1) on pro-life volunteers' activism and 2) gynecologists' attitudes to abortion and conscientious objection, we illustrate how vitapolitics shapes the demographic anxieties of these two social actors, who contribute to discipline reproduction on the ground.

Cross-country abortion travel to England and Wales: results from a cross-sectional survey exploring people's experiences crossing borders to obtain care.

BACKGROUND: The laws governing abortion access vary across Europe. Even in countries with relatively liberal laws, numerous barriers to abortion access exist. In response to these barriers, evidence suggests that people living in countries with both restrictive and liberal laws travel outside of their home country for abortion care. England and Wales are common destinations for those who travel to seek abortions, but little is known about the motivations and experiences of those who undertake cross-country travel to England or Wales to obtain care. This paper aims to describe the abortion seeking and travel experiences of women and pregnant people who traveled to England and Wales for an abortion between 2017 and 2019. METHODS: We recruited 97 participants who had traveled cross-country from both liberal and restrictive contexts to seek abortion care at three participating BPAS clinics in England and Wales. Participants completed an electronic survey about their reproductive histories, abortion decision-making, experiences seeking abortion care, and traveling. We conducted a descriptive analysis, and include comparisons between participants who traveled from liberal and restrictive contexts. RESULTS: Over a third of participants considered abortion four weeks or more before presenting for care at BPAS, and around two-thirds sought abortion services in their home country before traveling. The majority of participants indicated that they would have preferred to have obtained an abortion earlier and cited reasons including scheduling issues, a dearth of local services, delayed pregnancy recognition, and financial difficulties as causing their delay. About seventy percent of participants reported travel costs between €101-1000 and 75% of participants reported that the cost of the abortion procedure exceeded €500. About half of participants indicated that, overall, their travel was very or somewhat difficult. CONCLUSIONS: This analysis documents the burdens associated with cross-country travel for abortion and provides insight into the factors that compel people to travel. Our findings highlight the need for expanded access to abortion care throughout Europe via the removal of legal impediments and other social or procedural barriers. Removing barriers would eliminate the need for cumbersome abortion travel, and ensure that all people can obtain necessary, high-quality healthcare in their own communities.

In Europe, people who live in countries where abortion is severely restricted or illegal altogether lack access to abortion care entirely, but even people who live in countries with more liberal laws face barriers due to gestational age limits, waiting periods, and a lack of trained and willing providers. Existing evidence suggests that restrictions and barriers compel people from both countries with restrictive laws as well as those from countries with more liberal laws to travel outside of their home country for abortion services. England and Wales are common destinations for people traveling within Europe to obtain abortion services, but little is known about the experiences of these travelers. We surveyed individuals who had traveled from another country to seek abortion services in England or Wales. Our analysis documents that many participants contemplated getting an abortion and sought care in their home countries before traveling. Likewise, many participants indicated that they would have preferred to have obtained an abortion earlier in their pregnancy, and referenced scheduling issues, a dearth of local services, delayed pregnancy recognition, and financial difficulties as causing their delay. A majority of participants indicated that covering the costs of their abortion, and the costs of travel was difficult, and that the travel experience in its entirety was difficult. Our findings document the reasons for, and burdens associated with abortion travel and highlight the need to expand access to abortion across Europe via the elimination of all legal restrictions and impediments.

Re-situating abortion: Bio-politics, global health and rights in neo-liberal times.

New modes of neoliberal and rights-based reproductive governance are emerging across the world which either paradoxically foreclose access to universal health services or promote legislative reform without providing a continuum of services on the ground. These shifts present new opportunities for the expansion but also the limitation of abortion provision conceptually and 'on-the-ground', both in the Global North and South. The collection of papers in this special issue examine current abortion governance discourse and practice in historical, socio-political contexts to analyse the threat posed to women's sexual and reproductive health and rights globally. Focusing on abortion politics in the context of key intersectional themes of morality, law, religion and technology, the papers conceptually 're-situate' the analysis of abortion with reference to a changing global landscape where new modes of consumption, rapid flows of knowledge and information, increasingly routinised recourse to reproductive technologies and related forms of bio-sociality and solidarity amongst recipients and practitioners coalesce.

From women's 'irresponsibility' to foetal 'patienthood': Obstetricians-gynaecologists' perspectives on abortion and its stigmatisation in Italy and Cataluña.

This article explores obstetricians-gynaecologists' experiences and attitudes towards abortion, based on two mixed-methods studies respectively undertaken in Italy in 2011-2012, and in Spain (Cataluña) in 2013-2015. Short questionnaires and in-depth interviews were conducted with 54 obstetricians-gynaecologists at 4 hospitals providing abortion care in Rome and Milan, and with 23 obstetricians-gynaecologists at 2 hospitals and one clinic providing abortion care in Barcelona. A medical/moral classification of abortions, from those considered 'more acceptable', both medically and morally - for severe foetal malformations - to the 'least acceptable' ones - repeated 'voluntary abortions', emerged in the discourse of most obstetricians-gynaecologists working in public hospitals, regardless of their religiosity. I argue that this is the result of the increasing medicalisation of contraception as well as of reproduction, which has reinforced the stigmatisation of 'voluntary abortion' (in case of unintended pregnancy) in a context of declining fertility rates. This contributes to explain why obstetricians-gynaecologists working in Catalan hospitals, which provide terminations only for medical reasons, unlike Italian hospitals, do not experience abortion stigma and do not object to abortion care as much as their Italian colleagues do.

[[Abortion, Stigma and Conscientious Objection: Experiences and Opinions of Gynecologists in Italy and Catalonia].] / Lo Stigma Dell'Aborto E l'Obiezione di Coscienza: L'Esperienza e le Opinioni dei Ginecologi in Italia e in Catalogna (Spagna).

This article discusses the issue of abortion stigma and conscientious objection based on the main results of a qualitative study carried out in hospitals providing abortion care in Italy and Spain (Catalunya). This study was aimed at examining obstetricians-gynaecologists' experiences and attitudes to abortion, or voluntary interruption of pregnancy. The abortion law is relatively liberal in these two Catholic countries (much more liberal in Spain than in Italy). However, abortion still is strongly stigmatized in the public debate on human and reproductive rights, whose focus has shifted, over the last decade, from women's rights to the "rights of the conceived". Based on a study carried out in Italy in 2011-2012 and in Spain in 2013- 2015, this article discusses the impact of the stigmatization of abortion on the quality of obstetricians-gynaecologists' training and on their professional choices concerning conscientious objection and shows how physicians contribute to reproduce abortion stigma in the two countries.

[Representations and experiences of obstetrician/gynecologists with legal and illegal abortion in two maternity-hospitals in Salvador da Bahia]. / Representações e experiências sobre aborto legal e ilegal dos ginecologistas-obstetras trabalhando em dois hospitais maternidade de Salvador da Bahia.

The objective of this qualitative study, carried out in two maternity-hospitals in Salvador da Bahia, was to investigate the experience and representations of health professionals, and particularly obstetricians-gynecologists, regarding legal abortion in comparison with their representations and experience with illegal abortion. A questionnaire was distributed and semi-structured interviews were conducted with 25 health professionals (13 obstetricians-gynecologists) in a hospital providing legal abortion (P) and with 20 health professionals (9 obstetricians-gynecologists) in another hospital that does not provide this service (F). The factors that influence the representations and experience of abortion of most obstetricians-gynecologists and explain the high rate of conscientious objection at Hospital P were: 1- the criminalization of abortion and the fear of being denounced; 2- the stigmatization of abortion by certain religious groups and by the physicians themselves; 3- training in obstetrics and the lack of good training in the epidemiology of maternal morbidity-mortality and abortion; 4- representations on gender relations. The main factors associated with liberal attitudes were: age - under 30 and over 45 years of age - experience with high maternal mortality rates due to abortion and experience with legal abortion.

Programming the body, planning reproduction, governing life: the '(ir-) rationality' of family planning and the embodiment of social inequalities in Salvador da Bahia (Brazil).

This paper examines family planning in Brazil as biopolitics and explores how the democratization of the State and of reproductive health services after two decades of military dictatorship (1964-1984) has influenced health professionals' and family planning users' discourses and practices. Do health professionals envisage family planning as a 'right' or do they conceive it, following the old neo-Malthusian rationale, as a 'moral duty' of poor people, whose 'irrational' reproduction jeopardizes the family's and the nation's well being? And how do their patients conceptualize and embody family planning? To answer these questions, this paper draws on 13 months of multi-sited ethnographic research undertaken between 2003 and 2005 in two public family planning services in Salvador da Bahia, where participant observation was undertaken and unstructured interviews were conducted with 11 health professionals and 70 family planning users, mostly low income black women. The paper examines how different bio-political rationalities operate in these services and argues that the old neo-Malthusian rationale and the current, dominant discourse on reproductive rights, gender equality and citizenship coexist. The coalescence of different biopolitical rationalities leads to the double stigmatization of family planning users as 'victims' of social and gender inequalities and as 'irrational' patients, 'irresponsible' mothers and 'bad' citizens if they do not embody the neo-Malthusian and biomedical rationales shaping medical practice. However, these women do not behave as 'docile bodies': they tactically use medical and non-medical contraceptives not only to be good mothers and citizens, but also to enhance themselves and to attain their own goals.

Representações e experiências sobre aborto legal e ilegal dos ginecologistas-obstetras trabalhando em dois hospitais maternidade de Salvador da Bahia / Representations and experiences of obstetrician/gynecologists with legal and illegal abortion in two maternity-hospitals in Salvador da Bahia

O objetivo deste estudo qualitativo, realizado em dois hospitais-maternidade de Salvador da Bahia, foi investigar a experiência e as representações do aborto legal, analisadas em contraste com as representações do aborto ilegal, dos profissionais de saúde, em particular dos ginecologistas-obstetras.Usou-se como instrumentos um questionário e entrevistas semi-estruturadas com 25 profissionais de saúde (dos quais 13 ginecologistas-obstetras) num hospital que oferece um serviço de aborto legal (P), e 20 profissionais de saúde (dos quais 9 ginecologistas-obstetras) em outro hospital, que não oferece este serviço (F). Os fatores que mais influenciam as representações dos ginecologistas-obstetras entrevistados acerca do aborto e que explicam a alta taxa de objeção de consciencia no hospital P foram: 1- a criminalização do aborto e o medo de serem denunciados; 2- a estigmatização do aborto por certos grupos religiosos e pelos proprios médicos; 3- o treinamento em obstetrícia e a falta de uma formação boa no campo da epidemiologia da morbi-mortalidade materna e do aborto; 4- as representações acerca das relações de gênero. Os fatores principais associados à atitudes liberais foram: a idade - abaixo de 30/acima de 45 anos - a experiência com altas taxas de mortalidade materna devidas ao aborto e a experiência com o aborto legal.

The objective of this qualitative study, carried out in two maternity-hospitals in Salvador da Bahia, was to investigate the experience and representations of health professionals, and particularly obstetricians-gynecologists, regarding legal abortion in comparison with their representations and experience with illegal abortion. A questionnaire was distributed and semi-structured interviews were conducted with 25 health professionals (13 obstetricians-gynecologists) in a hospital providing legal abortion (P) and with 20 health professionals (9 obstetricians-gynecologists) in another hospital that does not provide this service (F). The factors that influence the representations and experience of abortion of most obstetricians-gynecologists and explain the high rate of conscientious objection at Hospital P were: 1- the criminalization of abortion and the fear of being denounced; 2- the stigmatization of abortion by certain religious groups and by the physicians themselves; 3- training in obstetrics and the lack of good training in the epidemiology of maternal morbidity-mortality and abortion; 4- representations on gender relations. The main factors associated with liberal attitudes were: age - under 30 and over 45 years of age - experience with high maternal mortality rates due to abortion and experience with legal abortion.

Programming the body, planning reproduction, governing life: the ‘(ir-) rationality’ of family planning and the embodiment of social inequalities in Salvador da Bahia (Brazil)

This paper examines family planning in Brazil as biopolitics and explores how the democratization of the State and of reproductive health services after two decades of military dictatorship (1964–1984) has influenced health professionals’ and family planning users’ discourses and practices. Do health professionals envisage family planning as a ‘right’ or do they conceive it, following the old neo-Malthusian rationale, as a ‘moral duty’ of poor people, whose ‘irrational’ reproduction jeopardizes the family's and the nation's well being? And how do their patients conceptualize and embody family planning? To answer these questions, this paper draws on 13 months of multi-sited ethnographic research undertaken between 2003 and 2005 in two public family planning services in Salvador da Bahia, where participant observation was undertaken and unstructured interviews were conducted with 11 health professionals and 70 family planning users, mostly low income black women. The paper examines how different bio-political rationalities operate in these services and argues that the old neo-Malthusian rationale and the current, dominant discourse on reproductive rights, gender equality and citizenship coexist. The coalescence of different biopolitical rationalities leads to the double stigmatization of family planning users as ‘victims’ of social and gender inequalities and as ‘irrational’ patients, ‘irresponsible’ mothers and ‘bad’ citizens if they do not embody the neo-Malthusian and biomedical rationales shaping medical practice. However, these women do not behave as ‘docile bodies’: they tactically use medical and non-medical contraceptives not only to be good mothers and citizens, but also to enhance themselves and to attain their own goals. (AU)

Physicians and abortion: provision, political participation and conflicts on the ground--the cases of Brazil and Poland.

BACKGROUND: Two qualitative studies have been conducted between 2002 and 2009 in Poland and Brazil, two different geopolitical settings in which the Catholic Church has had a significant political influence and where abortion is highly restricted. In both countries, struggles for abortion rights have played an important role in challenging the current restrictive policies and bringing attention to the plight of women unable to obtain abortions. This article examines the political role that physicians play in these contestations, drawing on some findings of two larger qualitative studies. METHODS: In Poland semi-structured interviews were conducted with 26 physicians in Warsaw and Krakow and with 55 women aged 18 to 45 in Gdansk. In Brazil questionnaires were administered and semi-structured interviews conducted with 22 obstetrician-gynecologists and 23 health professionals in two public maternity hospitals in Salvador da Bahia. FINDINGS: This article argues that gynecologists' perspectives and practices not only reflect or heed religious precepts on reproductive rights, but are also deeply influenced by inadequate medical training and by the fear of being prosecuted or stigmatized, especially in Brazil. The political non-engagement of physicians in Poland is driven by the lack of abortion rights discourse in the public arena, poor links with women's rights groups, and the lack of political unity within the medical community. CONCLUSIONS: Comparisons between Brazil and Poland ultimately suggest that strong liaisons between physicians and the feminist movement influence physicians' attitudes and political engagement and are most promising in abortion rights advocacy efforts.

Abortion stigma: a reconceptualization of constituents, causes, and consequences.

Stigmatization is a deeply contextual, dynamic social process; stigma from abortion is the discrediting of individuals as a result of their association with abortion. Abortion stigma is under-researched and under-theorized, and the few existing studies focus only on women who have had abortions. We build on this work, drawing from the social science literature to describe three groups whom we posit are affected by abortion stigma: Women who have had abortions, individuals who work in facilities that provide abortion, and supporters of women who have had abortions, including partners, family, and friends, as well as abortion researchers and advocates. Although these groups are not homogeneous, some common experiences within the groups--and differences between the groups--help to illuminate how people manage abortion stigma and begin to reveal the roots of this stigma itself. We discuss five reasons why abortion is stigmatized, beginning with the rationale identified by Kumar, Hessini, and Mitchell: The violation of female ideals of sexuality and motherhood. We then suggest additional causes of abortion stigma, including attributing personhood to the fetus, legal restrictions, the idea that abortion is dirty or unhealthy, and the use of stigma as a tool for anti-abortion efforts. Although not exhaustive, these causes of abortion stigma illustrate how it is made manifest for affected groups. Understanding abortion stigma will inform strategies to reduce it, which has direct implications for improving access to care and better health for those whom stigma affects.