Week 6 Assignment 1 - Paper Answers

Please no plagiarism and make sure you are able to access all resources on your own before you bid. Main references come from Murray, C., Pope, A., & Willis, B. (2017) and/or American Psychological Association (2014). Assignments should adhere to graduate-level writing and be free from writing errors. Please follow the instructions to get full credit. I need this completed by 04/05/2020 at 6pm.

Assignment 1- Week 6

Counseling Clients Considering Abortion

A client facing the decision of whether or not to have an abortion is likely to consider a wide range of factors before making the final decision. This is often the case for clients regardless of whether they view themselves as generally for or against abortion (or somewhere in between), as the decision is different when considering how it applies to one’s own life.

The types of factors that can influence a client’s decisions include (but are not limited to) physical health considerations, educational background, cultural values, and predictions about short- and long-term consequences of abortion. Consider these, and other, factors as you respond to this week’s Assignment.

The Assignment (2- to 3-page paper):

· Explain potential factors that might influence whether or not a client decides to have an abortion. Include short- and long-term considerations that might impact this decision.

· Explain why certain factors might have a stronger impact on a client’s decision regarding abortion depending on the client’s background (age, gender, religion, socioeconomic status, etc.).

Support your Assignment with specific references to all resources used in its preparation. You are to provide a reference list for all resources, including those in the Learning Resources for this course.

Required Resources

· Article: American Counseling Association (ACA). (2014). ACA Code of Ethics. Retrieved from http://www.counseling.org/docs/ethics/2014-aca-code-of-ethics ?sfvrsn=4

· Article: Altshuler, A. L., Ojanen-Goldsmith, A., Blumenthal, P. D., & Freedman, L. R. (2017). A good abortion experience: A qualitative exploration of women’s needs and preferences in clinical care. Social Science & Medicine, 191, 109–116. Retrieved from the Walden Library databases.

· Article: Coast, E., Norris, A. H., Moore, A. M., & Freeman, E. (2018). Review article: Trajectories of women’s abortion-related care: A conceptual framework. Social Science & Medicine, 200, 199–210. Retrieved from the Walden Library databases.

· Article: Edwards, A., & Seck, M. M. (2018). Ethnicity, Values, and Value Conflicts of African American and White Social Service Professionals. Journal of Social Work Values & Ethics, 15(2), 37–47. Retrieved from the Walden Library databases.

· Article: Hoggart, L. (2015). Abortion Counselling in Britain: Understanding the Controversy. Sociology Compass, 9(5), 365–378. Retrieved from the Walden Library databases.

lable at ScienceDirect

Social Science & Medicine 191 (2017) 109e116

Contents lists avai

Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

A good abortion experience: A qualitative exploration of women’s
needs and preferences in clinical care

Anna L. Altshuler a, *, Alison Ojanen-Goldsmith b, Paul D. Blumenthal a, Lori R. Freedman c

a Stanford University School of Medicine, Dept. Ob/Gyn, 300 Pasteur Dr. HG332, Stanford, CA 94305, USA
b Full Spectrum Doulas, Seattle, WA, USA
c Advancing New Standards in Reproductive Health/University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA

a r t i c l e i n f o

Article history:
Received 20 January 2017
Received in revised form
2 September 2017
Accepted 7 September 2017
Available online 8 September 2017

Keywords:
United States
Abortion experience
Abortion stigma
Abortion services
Reproductive justice
Abortion access
Patient-centered care
Abortion normalization

* Corresponding author. Present address: Californ
475 Brannan St #220, San Francisco, CA 94107, USA.

E-mail addresses: aaltshuler@post.harvard.edu (A.
com (A. Ojanen-Goldsmith), pblumen@stanford.ed
Freedman@ucsf.edu (L.R. Freedman).

http://dx.doi.org/10.1016/j.socscimed.2017.09.010
0277-9536/© 2017 The Authors. Published by Elsevier

a b s t r a c t

What do women ending their pregnancies want and need to have a good clinical abortion experience?
Since birth experiences are better studied, birth stories are more readily shared and many women who
have had an abortion have also given birth, we sought to compare women’s needs and preferences in
abortion to those in birth. We conducted semi-structured intensive interviews with women who had
both experiences in the United States and analyzed their intrapartum and abortion care narratives using
grounded theory, identifying needs and preferences in abortion that were distinct from birth. Based on
interviews with twenty women, three themes emerged: to be affirmed as moral decision-makers, to be
able to determine their degree of awareness during the abortion, and to have care provided in a discreet
manner to avoid being judged by others for having an abortion. These findings suggest that some women
have distinctive emotional needs and preferences during abortion care, likely due to different circum-
stances and sociopolitical context of abortion. Tailoring services and responding to individual needs may
contribute to a good abortion experience.
© 2017 The Authors. Published by Elsevier

Ltd. This is an open access article u

nder the CC BY-NC-ND

license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Many women experience both abortion and birth over the
course of their reproductive lives. In the United States, an estimated
30% of women have an induced abortion by age 45 (Jones and
Kavanaugh, 2011) and of those women who have had an abor-
tion, 59% have previously given birth (Jerman et al., 2016). Abortion
represents a transition for pregnant women, moving from the
possibility of bearing that child to proceeding with one’s life as is.
As with birth, how abortion happens matters to women, their
families and communities (Lie et al., 2008; Lyerly, 2013; Simkin,
1991). However, unlike with birth, researchers and policy makers
have given less attention to what constitutes a good abortion
experience. This reality may be due to a greater focus on defending
access to abortion by creating a body of evidence demonstrating
that it does not harm women physically or mentally and improving

ia Pacific Research Institute,

L. Altshuler), alisonog@gmail.
u (P.D. Blumenthal), Lori.

Ltd. This is an open access article u

its technical aspects. Fortunately, undergoing an abortion in the U.S.
is extremely safe (Biggs et al., 2017; Jatlaoui et al., 2016) and the
process is effective (Ireland et al., 2015), permitting a shift in focus
to improving other aspects of care quality, namely patient-
centeredness, which encompasses care guided by a patient’s
values (Institute of Medicine, 2001). Prior studies suggest that most
women tend to be satisfied with their care (Taylor et al., 2013; Tilles
et al., 2016) but some women have challenging experiences
(Kimport et al., 2012; Weitz and Cockrill, 2010), implying that there
is room for improvement. Accordingly, we must learn from women
who have sought abortion services about their experiences and
how they would like their care to be.

A qualitative investigation of women’s needs and preferences to
improve care has been performed for maternity services and it
offers a preliminary framework for studying abortion due to their
commonalitiesdboth birth and abortion affect pregnant women
and are two among other reproductive health services that
women’s health clinicians provide. Bioethicist and obstetrician
Anne Lyerly examined what constitutes a good birth experience by
learning from childbearing women about what they valued,
amounting to one of the most comprehensive efforts to date on this
subject (Lyerly, 2013). She found that the five core domains for a

nder the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

http://creativecommons.org/licenses/by-nc-nd/4.0/

mailto:aaltshuler@post.harvard.edu

mailto:alisonog@gmail.com

mailto:pblumen@stanford.edu

mailto:Lori.Freedman@ucsf.edu

http://crossmark.crossref.org/dialog/?doi=10.1016/j.socscimed.2017.09.010&domain=pdf

www.sciencedirect.com/science/journal/02779536

http://www.elsevier.com/locate/socscimed

http://dx.doi.org/10.1016/j.socscimed.2017.09.010

http://creativecommons.org/licenses/by-nc-nd/4.0/

http://dx.doi.org/10.1016/j.socscimed.2017.09.010

A.L. Altshuler et al. / Social Science & Medicine 191 (2017) 109e116110

good birth entail being the principal decider and actively wit-
nessing the birth process (agency); trusting the health provider and
feeling safe from physical harm in the face of risk, being free from
unwanted intrusions and feeling at ease (personal security); having
the birth experience respected as a significant event, being treated
with dignity and possessing self-respect (respect); maintaining
clear communication and access to information throughout the
birthing process (knowledge); and feeling emotionally connected
to the baby, loved ones, health professionals and other women
(connectedness) (Lyerly, 2013).

Lyerly found that these domains for a good birth generally
correspond to dimensions needed for individual wellbeing theo-
rized by Powers et al. in their framework for social justice in health
policy (Powers and Faden, 2006), implying that they are potentially
broad enough to apply to other areas of healthcare. Moreover,
previous studies on abortion suggest that there are parallels be-
tween women’s needs in maternity and abortion care. With respect
to Lyerly’s domain “agency,” researchers have found that women
value being able to decide to have an abortion to plan their lives
(Andrews and Boyle, 2003; Fielding et al., 2002) and to determine
how the abortion happens (Elul et al., 2000; Fielding et al., 2002;
Kerns et al., 2012; Simonds et al., 1998). Elements of “personal se-
curity” emerged in women’s narratives in Kimport et al., in which
women described a need to feel physically safe while obtaining care
in abortion clinics that operated in hostile anti-abortion environ-
ments (Kimport et al., 2012). Findings from Castle et al. under-
scored the importance that women ascribe to having information
to prepare for an abortion (Castle et al., 1995), consistent with the
domain “knowledge.” “Connectedness” and “respect” were also
important to women, demonstrated as an appreciation for
compassionate behavior from providers (Kimport et al., 2012;
McLemore et al., 2014; Taylor et al., 2013) and having a sense of
dignity upheld during abortion care (McLemore et al., 2014; Weitz
and Cockrill, 2010).

Despite these commonalities in childbirth and abortion, there
are also notable differences, such as women’s circumstances at the
time of pregnancy and the sociopolitical context within which
these reproductive experiences occur. Birth tends to be viewed as
joyous and physiological (Gaskin, 2011; Lyerly, 2013) and intra-
partum services are well-integrated into healthcare: they are linked
to antepartum and postpartum services, have private and public
insurance coverage, and are accessible to most women (Kaiser
Family Foundation, 2013; Rayburn et al., 2012). By contrast, abor-
tion is politicized and stigmatized (Joffe, 2013; Norris et al., 2011).
Services tend to be provided separately from other medical care in
limited supply at specialized abortion facilities, requiring a majority
of women to travel far and to pay out of pocket for care (Jerman
et al., 2016; Jones and Jerman, 2014). Given these different con-
texts for birth and abortion, we sought to examine ways in which
women’s needs and preferences in abortion care differ from
intrapartum care.

2. Methods

The study was conducted in Northern California through semi-
structured intensive interviews from April to December 2014
with women who had individually experienced both birth and
abortion. Participants were recruited through advertisements on
Craigslist, at community colleges and at public libraries that tar-
geted women residing in a geographical area with multiple birth
and abortion facilities to choose from. We recruited women from
the community rather than specific medical facilities to solicit
variation in women’s clinical experiences and to identify underly-
ing patterns that were not influenced by a particular medical
setting. We predicted this recruitment strategy would

underrepresent women who had abortions for fetal or maternal
indications given they account for less than 5% of all abortions
(Jatlaoui et al., 2016). We did not view it as a limitation as those
experiences have been studied (Lafarge et al., 2014). Inclusion
criteria were age 18e49 years, had an abortion in the last 5 years
and a prior birth at any time point in the United States, and not
pregnant at the time of interview. These timeframes were selected
because it has been demonstrated that women remember their
births accurately and vividly as many as 10e20 years later (Simkin,
1992) but this information is unknown for abortion. All women
gave informed consent prior to participating and received a $40 gift
card as compensation for their time.

An obstetrician/gynecologist-researcher (AA) who had prior
interview experience and did not know the participants personally
or professionally conducted interviews in English over the phone
and in-person in a nonmedical setting. Phone interviews allowed
us to expand recruitment and to accommodate women who had
childcare or transportation difficulties. AA did not identify herself
as a physician unless asked as she noticed that participants shared
less comfortably when they viewed her as more authoritative on
the topic (Weiss, 1994). Participants were invited to describe their
pregnancies by answering open-ended questions regarding the
highs and lows of all their intrapartum and abortion experiences;
decision to parent or not; selection of the provider and facility;
interactions with the healthcare staff, support people and other
patients; pain management, spiritual or religious support; and
postabortion/postpartum care. Women who also wanted to discuss
their miscarriages did so. We anticipated that many women would
have had more than one abortion as per national statistics (Jones
et al., 2017) and sought to contextualize their most recent abor-
tion by inquiring about all of their past experiences. After sharing
their stories, participants were asked to compare their preferences
in birth and abortion and how they preferred care to have been.
Following the interview, participants completed demographic
questions and a validated Individual Level Abortion Stigma scale
(ILAS) assessment (Cockrill et al., 2013) (Supplementary material).
ILAS evaluates the degree of personal stigma from the most recent
abortion through a series of statements about one’s worries about
judgment, feeling of isolation, self-judgment and sense of com-
munity condemnation. These four areas (sub-scales) are scored
according to the degree of stigma. As the study took place in an area
with relatively unhindered abortion access and more liberal abor-
tion views, this scale permitted us to determine whether this
context equated with less individual abortion stigma. To this end,
we compared our participants’ scores to the scores of a U.S.-based,
regionally diverse abortion clinic population of women surveyed
for the development of ILAS.

The content and style of the interview instrument were
informed by consultations with experts in the field, Lyerly’s work,
aforementioned abortion-related studies, a narrative review of
qualitative studies on abortion care (Lie et al., 2008) and a guide to
abortion counseling (Perrucci, 2012). A full-spectrum doula from a
different state who is not a medical professional (AOG) provided a
client-advocate standpoint in the development of the instrument
to complement AA’s medical perspective. Full-spectrum doulas are
individuals trained in providing emotional, physical and informa-
tional support during birth, miscarriage and abortion.

We used an iterative and flexible process for data collection to
build a grounded theory (Charmaz, 2006). In parallel to conducting
interviews, AA performed field observations of abortion and birth
facilities unfamiliar to her to achieve a better understanding of care
models and processes the participants described. She also spoke
with doulas who provide abortion support in the geographical area
studied and who have had an abortion themselves to explore
potentially more sensitive questions and concepts in preparation

Table 1
Participants’ characteristics, N ¼ 20.

Age at interview; median, range 32 years (19e42)
Black 7/20 (35%)
Latina 7/20 (35%)
White 4/20 (20%)
Enrolled or completed � Assoc. deg. or vocational school 15/19a (79%)
Religious or spiritual 11/19a (58%)
Family income $25,000/year or less 8/19a (42%)
Married or in a relationship 14/20 (70%)
Age at first pregnancy; median, range 18 years (14e38)
Had given birth before having abortion 11/20 (55%)
Years since last abortion; median, range 3.5 (0e5)
Total number of abortions 34
Abortion care at a specialized abortion facility 26/34 (76%)
Abortion in first trimester 30/34 (88%)
Medication abortion 6/34 (18%)
Abortion for fetal or woman’s health reasons 3/34 (9%)

Total number of births 31
Total number of adoptions 1

a Among those who answered question.

Table 2
Individual Level Abortion Stigma scale comparison.

Scale This study
N¼16-19a
Mean (SD)

Cockrill et al., 2013
N¼629-643a
Mean (SD)

Full scale
(range 0-3.5)

1.6 (0.67)
n¼16

1.35 (0.63)

Worries about judgment
(range 0-3)

1.19 (1.00)
n¼19

0.86 (0.86)

Isolation
(range 0-3.5)

1.32 (0.65)
n¼18

1.21 (0.81)

Self-judgment
(range 0-4)

2.26 (0.97)
n¼18

2.0 (1.03)

Community condemnation
(range 0-4)

1.95 (1.15)
n¼19

1.85 (1.07)

a Those who answered the relevant questions.

A.L. Altshuler et al. / Social Science & Medicine 191 (2017) 109e116 111

for interviews with participants. Each interview influenced the
direction and depth of inquiry of subsequent interviews. Interviews
were conducted until no new iterations of theoretical concepts
emerged.

All interviews were audio-recorded, professionally transcribed
verbatim, checked for transcription accuracy and de-identified
prior to analysis. We utilized Dedoose® 6.2.10 software to code
and facilitate analysis of qualitative data, and STATA®14.0 to
perform descriptive statistics. Early in the interview process, we
developed a codebook using a priori codes influenced by Lyerly’s
birth framework (Lyerly, 2013; Namey and Lyerly, 2010), codes that
emerged from AA’s analytic memos and independent initial coding
by AA and AOG of five thematically different interviews. Once a
preliminary codebook was agreed upon, AA coded the remainder of
the transcripts. She continued to refine the codebook with AOG as
new concepts and analyses emerged and consulted with LF to
develop a theoretical perspective on the data.

In our initial analysis, we categorized all codes into Lyerly’s five
domains for a good birth and then, using grounded theory, we
modified and expanded these domains according to our birth and
abortion data (details not discussed here) (Kelle, 2013). We per-
formed comparisons at the individual level (what each participant
valued in her abortion and birth experiences) and how these values
applied to the entire group of participants. We discovered phe-
nomena in the abortion narratives that either did not emerge from
the birth narratives or provided a distinct perspective for abortion
care. These phenomena are this work’s focus. Given its exploratory
nature aimed to broaden our understanding of a good abortion
experience, we sought to capture variations rather than common-
alities, and this intention is reflected in the selection of quotations.
This project was approved by Stanford School of Medicine Institu-
tional Review Board (IRB-29296) and is reported according to
Standards for Reporting Qualitative Research (O’Brien et al., 2014).

3. Results

Twenty-four women participated. Four of them did not meet all
the eligibility criteria and were excluded from this analysis: one
participant had an abortion nine years ago and three participants
reported having an induced abortion, though per their narratives,
they were miscarriages. The remaining twenty women contributed
the experiences of 34 induced abortions, 31 births and 6
miscarriages.

Twelve of the twenty interviews were conducted by telephone
and the richness of these interviews was similar to in-person in-
terviews. Average interview duration was 70 min. A majority of the
participants were black or Latina, in a romantic relationship and
spiritual or with a religious affiliation (Table 1). Thirteen partici-
pants were first pregnant by age eighteen and six of these women
ended that pregnancy. A majority of abortions occurred in the first
trimester and were performed at a specialized abortion facility via a
surgical procedure for non-medical indications. All births occurred
at a hospital and 68% were vaginal deliveries.

According to the Individual Level Abortion Stigma scale, the
degree of personal stigma of the participants was similar (slightly
higher) in each sub-scale and the full scale compared to the larger
national sample of women who were surveyed for development of
this instrument (Table 2) (Cockrill et al., 2013). A higher number
reflects higher stigma.

In general, participants described their experiences as good
during birth and abortion care when they did not have to
compromise their emotional wellbeing in the process. Needs and
preferences in abortion differed from birth in three ways: women
appreciated being affirmed as moral decision-makers by providers,
having a choice about their degree of presence during an abortion,

and receiving care in a discreet manner to avoid judgment from
others for obtaining an abortion. Three pregnancies were ended for
maternal or fetal indications and the aforementioned aspects of
care also emerged in those women’s narratives.

3.1. Moral decision-maker

For each pregnancy experience, participants were asked to
reflect on making the decision to become a parent, to have an
abortion or to pursue adoption. Irrespective of what they decided,
women felt that the decision they made was the right one given
their circumstances even if, in retrospect, they wished they had
chosen differently. For some women, the decision carried some
degree of emotional discomfort, such as sadness, disappointment
or anxiety about the future, especially in circumstances when a
pregnancy occurred at an inopportune time (e.g., unstable rela-
tionship or insufficient financial or other resources).

Unique to abortion decision-making, however, were instances of
moral conflict. While some participants felt that their reasons for
having an abortion were valid and sufficient, they struggled with
the belief that having an abortion was at odds with being a good
person. This belief stemmed from the notion that a woman’s
intrinsic biological responsibility is to become a mother and anti-
abortion views that predominated in their communities of up-
bringing. Moral conflict undermined some participants’ decision-
making capacity and surfaced during clinical care, coloring their
abortion experiences.

For instance, Gaby (39 years old; 2 abortions, 3 births) described
ending a multifetal pregnancy, revealing she was certain about her

A.L. Altshuler et al. / Social Science & Medicine 191 (2017) 109e116112

decision but morally conflicted (all names are pseudonyms). She
explained that parenting was not an option because she lacked a
stable job and housing and suffered from depression. Gaby had
contemplated adoption and had pursued it in a different pregnancy
but decided against it this time. She feared that the children would
have been separated and regarded this possibility as devastating.
Gaby talked about the seriousness with which she weighed her
alternatives and the significance of what she was undertaking:

I had to make a real life-changing decision. I mean, it’s not easy
… I don’t think we just get up to just say, okay, today, you know
what, I’m going to … kill a baby. You don’t think like that. You
look at all the things …. and I just didn’t want to bring the kids in
like that.

Even though having an abortion challenged her idea of herself as
a moral decision-maker, she cited moral values in her reasoning. As
she contrasted continuing the pregnancy with abortion, she real-
ized that to “kill a baby” was a less harmful, less morally prob-
lematic situation than continuing the pregnancy and risking the
separation of her children. Yet, during her abortion care, Gaby
lacked someone who could witness and validate these moral values
that guided her decision:

I felt like the doctor was judging the person, my character … he
didn’t treat me like a person, an individual. He treated me like,
‘Get on up on the table. Let’s get this over with because you ain’t
nothing.’ You know, ‘Look at you … you’re paying $500 to get rid
of something you made.’ That’s the way I felt …. At least [he
could have] assured me that he know[sic] that what I’m going
through is not easy. I think that’s what I was looking for.

Although the doctor did not actually tell her she was “nothing,”
she felt that his behavior was judgmental and dehumanizing. He
did not recognize her as a person grappling with a real-life moral
decision. Instead, she perceived him as thinking of her abortion as
an impersonal business transaction. Gaby had hoped that the
doctor would appreciate the difficulty of the decision for her and
see her as a person confronted with a moral quandary.

Like Gaby, Katherine (31 years old; 2 abortions, 1 birth) felt
morally conflicted about having an abortion and wished the med-
ical personnel had identified this conflict and supported her.
Katherine was 15 years old at the time and feared getting kicked out
of the house if her mother found out about her pregnancy. When
Katherine walked up to the abortion clinic, a woman emerged from
a group of protesters holding signs plastered with images of
macerated fetuses. She raised a cross to Katherine’s head and
declared, “May God forgive you for murdering your child.” This
interaction affected Katherine: she had not thought of the six-week
pregnancy as her child but at this moment began to wonder if this
woman was right, whether she was committing murder. While she
still planned to end her pregnancy, she entered the clinic feeling
overwhelmed, questioning the morality of her decision. Looking
back as an adult, she wished care had been provided differently:

[The doctor] looks at me and he looks at my chart and he’s like,
“How old are you?” And I was like, “15.” He’s like, “Wow.” That
was just like a horrible experience. It was already a bad enough
day, and what an insensitive thing for a doctor to say to some-
one, a young girl who’s obviously already completely like
freaked out and upset …. Nobody at any time did or said any-
thing that made me feel like [having an abortion] was okay, like
other women go through this, like you’re not a bad person. It
was just the opposite. I felt judged … felt like everything I was
doing was wrong.

To have moral clarity, Katherine needed help reconciling the
aggressive anti-abortion messaging outside the clinic with what an
abortion actually was. However, she did not achieve such under-
standing. On the contrary, the doctor’s negative response to her age
and the lack of compassionate care led her to conclude that she was,
indeed, doing something morally wrong. She wished that her
providers had normalized her decision to have an abortion and
acknowledged it as moral.

In contrast, other participants who also had a moral conflict
considered their interactions with medical personnel valuable if
they felt that their decision was respected and viewed as moral. For
example, Sofia (19 years old; 1 abortion, 1 birth) felt comforted
during her abortion care. She became pregnant for the second time
when she was three months postpartum. She knew she could not
raise two children as she was already struggling to provide for her
son. Sofia’s parents pleaded with her to allow them to adopt this
potential child, as she recounted: “[God] gives you children because
they’re a blessing and a gift. You have a gift and you’re going to
throw it away? Don’t kill it and let me adopt it. It’ll have our last
name …. He or she will know that you’re their mom but you won’t
have to take no [sic] responsibility for it.” She felt distraught by this
proposal because she took her obligation as a mother seriously and
could not imagine not raising her own child. Sofia decided that
ending the pregnancy was the right course of action for her, though
she felt morally conflicted. She valued her conversation with the
doctor, whose words she retold: “‘You’re not doing a horrible thing.
I know why you’re doing it …. Do not feel bad. Like this is for your
life, to better your life.’” She also remembered the medical staff’s
conduct, “They didn’t make you feel bad that you were doing it ….
They were like supporting you.” Sofia was grateful that her decision
to end the pregnancy was validated and understood as moral by her
providers.

Likewise, Natalie (37 years old; 3 abortions, 1 birth) had a
helpful interaction with a medical assistant prior to the abortion.
She was trying to end the relationship with her boyfriend and did
not want to have another child with him. She shared, “I was crying
and [the medical assistant] was just like, ‘Don’t, you’re not doing
anything wrong …. You’re not a bad person.’ And I had even told
her … ‘I have a kid and I can’t believe I’m doing this.’” Her conflict
stemmed for the idea that as a mother, when pregnant, she had a
moral and biological obligation to continue that pregnancy as she
had first-hand experience what an embryo inside her could
become. Thus, she appreciated how the medical assistant saw her
as a moral decision-maker in this context.

Participants took their responsibility to determine the outcome
of their pregnancies seriously and tended to feel that they made the
best decision for their circumstances, whether they chose abortion,
parenting or adoption. They wanted to be respected as decision-
makers. Yet, some women did not view their decision to have an
abortion as moral based on their understanding of morality, and
they were sensitive to negative judgment from medical personnel
for this decision, whether perceived or actual. When medical
personnel recognized this conflict and affirmed the decision as
moral, women tended to assess this part of their experience
positively.

3.2. Presence

In birth and abortion, women used pain medicine not only to
alleviate physical pain but also to control their awareness and
engagement in the process. Participants generally described birth
as a joyous event, worthy of witnessing and sharing with others and
wanted to maintain a sense of presence. Some needed labor sup-
port or an epidural to relieve their physical discomfort to

A.L. Altshuler et al. / Social Science & Medicine 191 (2017) 109e116 113

emotionally experience birth. In abortion, women’s reasons to
maintain or lessen their sense of presence were more nuanced,
reflecting women’s diverse emotional needs specific to abortion
care. They determined how present they wanted to be with their
selection of pain medicine and abortion method. The methods
include removing the pregnancy via a surgical procedure (hence-
forth referred to as “procedure”) or by taking abortifacient medi-
cations (“medication abortion”).

Some women preferred to be less mentally aware during the
abortive process, especially if they were struggling emotionally or
morally and feared that witnessing some part of it would further
affect them. In the case of a procedure, some women wanted to be
asleep and sought a facility that offered anesthesia. Such facilities
are not the norm as most procedures are performed while a woman
is awake with local, oral or intravenous pain medicine because
achieving a state of unconsciousness (with general anesthesia or
monitored anesthesia care) is rarely medically necessary and is
typically reserved for medically complex scenarios. For example,
Isabel (35 years old; 4 abortions, 3 births) explained her rationale
for being asleep during an abortion:

I don’t even think you’re awake for laser eye surgery, are you? …
You’re awake for birth. Birth is not a medical procedure in the
same way … I guess because it’s giving life and, the welcoming,
you need to be conscious for that. I prefer not to be awake [for an
abortion]. It works too heavy on me, the afterthoughts of it all. I
just couldn’t imagine accidentally looking over and seeing
something.

Isabel viewed abortion as more like other surgeries than a
reproductive process akin to birth. She believed that being
conscious during an abortion had only negative possibilities, such
as seeing some aspect of the procedure that could trigger additional
emotional pain.

Some women were willing to accept additional risks of anes-
thesia to make the process less mentally trying. For instance,
Katherine (31 years old; 2 abortions, 1 birth; previously quoted
describing her abortion at age 15, now describing a recent abortion)
was awake during her procedure and reasoned why she would have
preferred to have been asleep:

A lot of people go under general anesthesia every day …. I
would’ve accepted the risk to be able to just go to sleep and
wake up and it’s done …. Because it’s an awful experience … it’s
painful. And you do kind of go into that experience feeling like
guilt and shame about what you’re doing. You just kind of like
fall asleep and wake up, and it’s over.

Katherine explained that feelings of guilt came from her up-
bringing, viewing abortion as morally wrong. She deemed the op-
portunity to be asleep as a temporary relief from these emotions.

Some women who witnessed the abortive moment uninten-
tionally (as Isabel had feared) remembered it negatively, particu-
larly if they wanted to have a child but their life circumstances
made it not possible. This witnessing sometimes occurred during
medication abortions when women saw the pregnancy tissue. A
medication abortion is commonly completed in a private setting,
such as one’s home, and entails the woman inducing expulsion of
the pregnancy with medications. Depending on the room’s setup,
sometimes it is also possible to see the pregnancy being removed
during a procedure, as Carla (28 years old; 1 birth, 2 abortions)
recalled, “You could see everything …. I even see [sic] my own baby
… and I still call it my baby, they put my baby in a jar, that they had
just slurped out of me … it was gruesome for me to see.” At eight

weeks of gestation, it is unlikely that the fetal form was perceptible,
but she witnessed the precise moment when her pregnancy ended.
The procedural approach appeared disturbingly ordinary (slurping,
jar) and felt disrespectful to the embryo/her baby, which was
“gruesome” for her as its mother. Consequently, when she had
another abortion a few years later, she went to a facility that
allowed her to be asleep and she described it as a better experience
because she felt less emotional pain.

In contrast, some women wanted to be engaged in the abortion
process and preferred having a medication abortion or being awake
during the procedure as Laila (34 years old; 2 abortions, 3 births)
described:

I couldn’t see anything but the nurse … I could hear the doctor
… they slowly tell you what’s going on and how much time is
left and they talk you through it the whole time …. I felt good
’cause … it made me feel more in control and at ease, knowing
they’re being very patient and considerate and caring and
they’re talking you through it so you don’t feel lost and alone.

Laila, like Carla, felt a strong sense of loss from ending her
pregnancy and feared seeing the abortion happen. However, Laila
assessed her experience positively because the procedure was done
in a way that prevented her from seeing the pregnancy removal
while allowing her to be awake and to hear the medical team guide
her through the process, making her feel cared for.

Other women preferred to be alert for the procedure to ensure it
was performed safely and respectfully. Facilities that were difficult
to find, were surrounded by anti-abortion protesters or looked
neglected in their appearance, contributed to women’s concerns
about their safety before their clinical experience began. These
fears continued if the medical personnel did not provide assurance
of safety as Raquel (29 years old, 3 abortions, 1 birth) remembered:

It kind of creeped me out, the place, ‘cause I’ve never heard of this
clinic in the city …. My mom and my boyfriend came with me but
when I went into the back room I was by myself with the doctor
and his assistant … the place looked really old … I just felt kind of
weird in that place. And then when they started the procedure
[the doctor] asked me did I want … what puts you asleep or
something, and I didn’t feel comfortable there so I said no.

Being by herself during the procedure in that setting made her
feel vulnerable and she declined sedation to see that nothing
dangerous was done to her. In subsequent pregnancies Raquel
ended, she had medication abortions to have full control over her
physical environment. In contrast, other participants who were
disturbed by their surroundings could let go of their fears when
medical personnel reassured them that care would be provided in a
professional manner.

Lastly, some participants preferred to be present for the abortion
to fully experience it and satisfy their curiosity. Participants who
felt this way tended not to view the abortion as emotionally or
morally challenging. For instance, Jacqueline (22 years old, 1 abor-
tion, 1 birth) shared:

I kind of wanted to actually see what was happening. I just
wanted to be there …. It sounds weird but I wanted to actually
experience it … I wanted to know what this was. I mean … if
anybody else had to go through this and I was the person to talk
to about it … I could tell them exactly what happens.

It was important to Jacqueline to stay awake to take the mystery
out of an abortion procedure and to be able to share her experience

A.L. Altshuler et al. / Social Science & Medicine 191 (2017) 109e116114

with others in the future.
Although in birth women generally wanted to be fully engaged,

in abortion they differed in how present they wanted to be. At
times, women’s preferences were influenced by the way they were
treated by medical personnel and by how they perceived the clin-
ical environment. Some women preferred to be less present if they
were struggling emotionally or morally or feared witnessing the
abortive moment. They tended to prefer to have an abortion pro-
cedure while asleep. Others wanted to maintain a sense of presence
to feel safe, to receive emotional support and to have a say in or to
see what the abortion entailed. They tended to decline sedating
medicine or chose a medication abortion.

3.3. Discreet care

A need for privacy emerged in the participants’ birth and
abortion narratives, motivated by a desire for modesty and in-
timacy and an effort to decrease emotional discomfort from seeing
others suffer. Some participants felt that being in communal spaces
with other women such as waiting rooms, recovery rooms or
shared postpartum rooms forced them to be part of other’s expe-
riences, which was often physically and emotionally uncomfortable
as some women were visibly upset, nauseated or in pain. This issue
was raised more often in the abortion narratives due to more time
spent in group settings during abortion care.

Distinctive to abortion narratives, however, some participants
feared judgment from others for having an abortion, which did not
occur for giving birth, and it influenced their preference for
receiving care discreetly. Participants most sensitive to judgment
tended to be those women who felt ashamed for being pregnant
and needing an abortion. Some participants who went to medical
facilities that provided abortion services exclusively reported
feeling exposed because the visit’s purpose could not be confi-
dential. One participant, Elisa (38 years old; 1 abortion, 2 births)
explained that she began feeling judged outside the abortion clinic
by anti-abortion protesters and she continued to feel uncomfort-
able after she entered the clinic:

It’s an abortion clinic, so you go there and you know that that
person is getting an abortion … From the time you make it there
… I was pretty embarrassed by it, because I walked into the
clinic and I feel like all eyes on me, and I feel like everybody
knows … and who knows what they’re thinking …. it’s some
stuff that I’m very discreet about …. So, when … those types of
situations arise, I just don’t like that feeling … there’s no privacy
at all.

She felt self-conscious for needing an abortion and susceptible
to the negative judgment of others, including clinical staff and other
women having abortions, which compromised her ability to feel at
ease.

Moreover, living in smaller communities often posed the risk of
seeing familiar people, which compounded fears of judgment. For
instance, Danielle (34 years old; 1 abortion, 1 birth) recalled, “It’s
embarrassing. Because … I knew a lot of people in there …. And I
feel irresponsible. Because that’s something you want to be
discreet, not [involve] everybody in the neighborhood.” She felt
that needing an abortion reflected poorly on her and having people
from her community witness her perceived shortcomings added
another layer of discomfort.

Some participants also felt that being in a group setting rein-
forced their sense of shame about having an abortion and felt that it
could have been avoided if care was provided more discreetly. For
example, Faye (24 years old; 2 abortions, 3 births) received care at a
busy abortion clinic and compared the type of experience she

would have preferred to her actual experience:

You go in. [I would have preferred not to have] a big line because
there was[sic] a lot of people. Like are they scheduling us all to
have an abortion together? … And something done privately,
not where you’re ashamed … Like you literally have to be on the
list to get into the building even and you have to show the se-
curity guard your ID …. When I was put in the recovery room
after [the abortion], there was no privacy. Like it was rows of
girls in beds …. That was my main thing, was there was no
privacy.

She viewed the security measures and being grouped with other
women as ways of shaming her for having an abortion. She
preferred to have been by herself to avoid this additional burden.

To decrease the possibility of feeling exposed, some participants
purposely went to medical facilities that provided a variety of
reproductive health services. Others had a medication abortion
instead of a procedure like Teresa (29 years old,1 abortion, 2 births),
who elaborated about her choice: “I don’t want anyone to know
about this, besides the person that gives me the pill. And I want to
take the pill, go home and be alone …. I was so ashamed of
everything going on, that I had even gotten pregnant.” At the time
of this pregnancy, Teresa’s boyfriend was in jail for assaulting her.
She felt ashamed of their relationship and of being pregnant and
prioritized having as few people as possible know about her
circumstances.

While the need for discretion to avoid judgment from others
was important to some participants, it was not absolute. There were
some who appreciated sharing some aspect of the experience with
other women also having abortions. They described the supportive
environment created when women could all be together in one
room, before and after the abortion, as Marcia (34 years old; 2
abortions, 2 births) articulated:

I felt that I had a support group …. I’d rather be in the room with
other people that’s[sic] going through the same thing …. I think I
would’ve been uneasy just laying there in the room by myself
and thinking about what I just done. So, with the other ladies in
the room with me … helped me through that process.

For Marcia, being with others took away a sense of iso-
lationdthe perception that she was the only one ending her
pregnancy. In this facility, women were not permitted to be
accompanied by someone they knew and they waited in a more
intimate space, facilitating these interactions.

In summary, some participants felt vulnerable to judgment from
others for having an abortion and desired to receive care in a
discreet manner. In birth, discreet care was also important, but not
for the sake of avoiding judgment for their decision to have a child.
While some participants preferred for the facility to be structured
in such a way that their reason for seeking care was unknown, other
participants appreciated sharing their experiences with other
women also having abortions if they felt a sense of camaraderie.

4. Discussion

We consider abortion as a normal reproductive experience, like
birth, that pregnant women undergo and sought to explore what
women need to have a good clinical experience. Lyerly’s framework
for a good birth provided a useful foundation for our inquiry,
demonstrating that many elements that women value in birth also
emerge in abortion. These findings suggest that approaching
abortion care from this inclusive perspective may be a way to

A.L. Altshuler et al. / Social Science & Medicine 191 (2017) 109e116 115

improve care quality. Yet, as previous studies have demonstrated,
the stigmatized and contested context of abortion can make
women’s experience especially sensitive (Kimport et al., 2012;
Shellenberg and Tsui, 2012), influencing how they perceive their
care and how they assess their experience. We found three ele-
ments distinct to abortion care, some of which may be related to
the stigma that surrounds abortion: to be affirmed as moral
decision-makers, to be able to determine their degree of presence
during the abortion process, and to have care provided in a discreet
manner to avoid being judged by others for having an abortion.

Our analysis offers several recommendations for abortion care
providers. Providers may consider approaching each woman as if
she might have additional emotional needs, recognizing that some
women have internalized abortion stigma (especially in settings
where women are targeted by anti-abortion protesters and pol-
icies) and others feel sad about not being able to have that potential
child. Providers may further tailor care as they learn more about a
patient’s specific needs. Women value determining the outcome of
their pregnancy and being respected as decision-makers by pro-
viders. Some women explicitly describe moral considerations that
bring them to abortion (such as concerns for their families and
what life may be like for the potential child), and decide to have an
abortion, yet struggle to see it as moral decision due to conceptions
that abortion is immoral or un-biological. In these cases, women
also value being affirmed as moral decision-makers by their
providers.

It is also helpful for providers to recognize that preferences for
pain medicine and degree of presence are related yet distinct and
need to be explored separately. Conversations about what having
an abortion may be like both physically and emotionally may unveil
some of a woman’s concerns, offering the provider insight as to
how to explain the abortion methods and analgesia options and to
help her make an informed decision. Additionally, managers may
investigate ways that they can offer women discreet care and in-
crease feelings of safety within their logistical and legal constraints,
such as being explicit with patients about the purpose of security
measures and aspects of care that may be interpreted as stigma-
tizing, maintaining patient privacy when possible, creating more
intimate settings, and personalizing care.

The study was conducted in a geographical area known for
better comprehensive reproductive healthcare access compared to
other areas in the United States, creating a unique opportunity to
discuss a good abortion experience, which would be more difficult
where women struggle to access abortion care and may have lower
expectations for quality. Interestingly, according to our ILAS data,
participants had a similar level of individual abortion stigma
compared to a national cohort of women obtaining abortions at
specialized facilities (Cockrill et al., 2013), suggesting that our
findings may be applicable in other areas of the U.S. Furthermore,
better access may not necessary equate with less stigma or better
access alone may not counteract abortion stigma.

While this analysis presents opportunities for improving abor-
tion care, there are some limitations. We focused on women who
had experienced both birth and abortion and who received first
trimester abortion services in specialized facilities for nonmedical
indications [which describes most women who have abortions in
the U.S. (Jerman et al., 2016).], whose preferences may be different
from women who do not match these characteristics. For instance,
women who have never given birth may have different expecta-
tions for care and women who obtain abortions from their medical
providers rather than providers unknown to them (such as at
specialized facilities) may express their concerns about judgment
differently. Lastly, this work is exploratory rather than conclusive
and there may be other ways that women’s needs and preferences
in abortion differ from birth that are not captured here.

Despite these limitations, a strength is the racial and ethnic
diversity of the participants, like the diversity of the geographic
region for study recruitment. Another strength is studying abortion
in a normalizing way, achieved by interviewing women from the
community in a non-medical environment, viewing participants as
experts of their narratives and by studying abortion and birth ex-
periences together, creating a broader forum to talk about a good
reproductive experience. Approaching abortion as a reproductive
experience in this way not only may contribute to improving
abortion care for individuals. In addition, it may help to elevate its
status to that of other reproductive services and thereby, more
broadly, benefit communities.

Acknowledgements

Sylvia Bereknyei, Danielle Bessett, Janine Bruce, Alma Gonzalez,
Katrina Kimport, Alissa Perrucci, Karen Scrivner, Tracy Weitz,
Khristina Wenzinger, Jennifer Wolf. This study was funded by So-
ciety of Family Planning Research Fund (SFPRF). The views and
opinions expressed are those of the authors and do not necessarily
represent the views and opinions of SFPRF.

Appendix A. Supplementary data

Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2017.09.010.

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A good abortion experience: A qualitative exploration of women’s needs and preferences in clinical care

1. Introduction
2. Methods
3. Results
3.1. Moral decision-maker
3.2. Presence
3.3. Discreet care
4. Discussion
Acknowledgements
Appendix A. Supplementary data
References

Sociology Compass 9/5 (2015): 365–378, 10.1111/soc4.12256

Abortion Counselling in Britain: Understanding the
Controversy

Lesley Hoggart*
Health and Social Care, The Open University

Abstract
This article reviews literature from a number of disciplines in order to provide an explanation of the
political controversy attached to the provision of abortion counselling. It will show how this is an area
of health policy debate in which women’s reproductive bodies have become a setting for political strug-
gle. The issue of abortion counselling in Britain has undergone a number of discursive shifts in response to
political manoeuvring and changing socio-legal framing of abortion. In particular, the article shows how
much of the controversial reframing of abortion counselling was a tactical shift by political actors opposed
to abortion per se, and this work is critiqued for not contextualising abortion. The article then focuses on
women’s abortion experiences and discusses research that shows how women’s decision-making
processes, and responses to an abortion, are related to gendered socio-cultural contexts: the extent to
which women having an abortion feel they have transgressed societal norms and values, for example, is
likely to affect their abortion experiences. Finally, it is suggested that providing a non-judgemental
context, and challenging negative discourses on abortion, may be the most effective way of minimising
the possibility of negative emotions.

Introduction

This article examines the issue of abortion counselling as a site of policy debate, in which
women’s reproductive bodies have become a setting of political struggle. In seeking to
understand why a seemingly straightforward subject – whether women undergoing an abortion
should have access to counselling services – has become so contentious, it is necessary to con-
sider a wide range of other issues. An over-arching requirement is to consider how the debate
is socio-culturally located. This means understanding that policy debates on abortion counsel-
ling are conceptualised differently within different socio-legal frameworks; within gendered
social norms; and within contentious political discourses. Even the phrase itself – abortion
counselling – has been subject to a number of discursive shifts and invested with multiple mean-
ings which are complex and malleable. Above all, as this paper will show, different strands of
academic debate around abortion counselling customarily proceed from particular political
positioning, and with an eye to the political implications of research interpretations. There is
an undeniable relationship between political beliefs on abortion and intellectual framing on
the issue of abortion counselling. These broader sociological issues frame this paper, which
focuses on Britain1 as a case study explicating the relationship between socio-cultural contexts
and different politics, policies and practices.
Britain, in recent years, has experienced repeated flurries of political debate and activity

around the issue of pre-abortion counselling. Between October 2006 and June 2007, two
Ten Minute Rule Bills that proposed mandatory counselling were rejected by the British
Parliament, and in 2012, the MPs Frank Field and Nadine Dorries proposed amendments to
the National Health Service (NHS) and Social Care Bill 2011 which would have removed

counselling services from abortion providers and obliged women to receive counselling from
‘independent’ bodies before an abortion.2

Abortion counselling as an issue is worthy of exploration because, as the paper also sets out,
developments in this area affect abortion provision and thus have an effect upon women under-
going an abortion. Although a straightforward policy question would address what provision
should look like in this area, such questions have always been bound up in wider political
debates about the morality of abortion and views on its legal status. In academia, important
contributions to the debate, from sociology, have come from Ellie Lee, who has consistently
shown how sociological constructions – of women, of abortion and of abortion providers –
have informed the legal regulation of abortion in Britain (Lee 1998, 2003a,b, 2004). Kristin
Luker (1984, 1996) and Rosalind Petchesky (1986) have pioneered sociological work in this
area internationally. Although fundamentally an issue of concern to political sociologists, many
more disciplines are involved in contributing towards literature of relevance to the issue of
abortion counselling, including important contributions from psychology (Boyle 1997;
MacLeod 2011); law ( Jackson 2001; Sheldon 1997); and policy research (Allen 1985; Hoggart
2003, 2012; Rowlands 2008). This paper reviews three areas of literature, all of which straddle
these disciplines. Firstly, it considers how policy and health-focused literature contributes
towards understandings about what is meant by counselling in the context of abortion.
Secondly, it looks at literature that has sought to explain, and engage with, why counselling
came to feature as part of what Rickie Solinger (1998) has termed ‘Abortion Wars’. Finally, it
will look at a body of literature that sheds light on the provision of abortion counselling, from
the perspectives of women who have abortions.

What is meant by counselling?

The legal framework for abortion in Britain is the 1967 Abortion Act. This Act, as amended by
the Human Fertilisation and Embryology Act 1990, permits abortion up to 24weeks in specific
circumstances (when two doctors agree that continuing with the pregnancy would be more
harmful to the physical or mental health of the pregnant woman or any existing children of
her family than if the pregnancy was aborted). After 24weeks, an abortion is permitted if it is
necessary to save the woman’s life; it will prevent grave, permanent injury to the physical or
mental health of the pregnant woman; or there is a substantial risk that if the child were born,
it would suffer from serious physical or mental anomalies.3 In law, at no gestational point do
women have the right to an abortion on request. However, as Lee (2003b) has noted, a
‘socio-legal gap’ gradually emerged between law and practice such that the wishes of women
came to be prioritised. This is evident by reviewing the British government’s health information
website, NHS Choices, which simply lists one of the reasons that a woman might decide to have
an abortion as ‘personal circumstances’.4 This unresolved tension between law and practice,
though, means that abortion practice as it has developed does not have a firm legal foundation
and may be vulnerable to changing political circumstances. It also legitimises the attempts by
those interest groups who are opposed to abortion to claim that the law is f louted (Lee 2003b).
In Britain, abortion counselling is an area of abortion practice that has been developed as part

of abortion services. It is not required by law and is not legally regulated. There is, accordingly,
significant room for disparate and shifting definitions of abortion counselling. Nevertheless, a
body of research has studied these issues and clarified both what women should expect with
respect to abortion counselling and how to define and develop these services.
Following the 1967 Abortion Act, a Committee on the Working of the Abortion Act (the

Lane Committee) was set up by the government in order to examine the workings of the
Act. The conclusions of the Lane Committee (Lane 1974), as well as a paper authored by

366 Abortion Counselling

one Lane commissioner (Cheetham 1977), revealed considerable confusion around what was
meant by abortion counselling. The report noted uncertainties about the objectives and pur-
poses of counselling, and then offered a broad definition: counselling was described as the pro-
vision of an opportunity for women to discuss their situation and to obtain information,
explanations and advice. The literature has noted that the Lane Committee was particularly
concerned to ensure that every effort should be made to provide women equality of access to
abortion within the NHS, at a time when some women were being turned away arbitrarily
(Wivel 1998). As abortion services were being developed in the 1970s, abortion counselling
was thus primarily envisaged in the context of ensuring that all women who are considering
an abortion are provided with enough information with which to make an informed decision,
that this should be free from pressure from other people, and that equality of access should be
ensured (Lee 2003b).
In the 1980s, the Department of Health and Social Security commissioned a national evalu-

ation of Counselling services for sterilisation, vasectomy, and termination of pregnancy. To date, the only
study solely on these issues, it was a large multi-stranded project with a clear focus on the expe-
riences of service users on the counselling they had received, and the extent to which they felt
they required counselling (Allen 1985). This focus marked a shift towards a multifaceted under-
standing of counselling that moved beyond the Lane-based consensus of ensuring informed
consent and equality of access. The research found considerable variance about what was meant
by counselling as a specific activity and pointed to an important distinction between the role of
abortion providers in ensuring that women were making an ‘informed decision’ to proceed, or
otherwise, with an abortion; and therapeutic counselling which may be necessary for women
who are ambivalent about their decision. The first discussion is always necessary, whilst thera-
peutic counselling may, or may not, be needed or appreciated. Indeed, Allen also reported:
‘Many women thought that abortion should be easier and quicker to get, and that counselling
should be available for those who wanted it but not overdone’ (Allen 1985: 342). Allen is here
drawing attention to one of the most notable findings in the study: that many women felt they
were being over-counselled about a decision they had already made. A large number of women
talked about making their own decision after considering their own circumstances and not
needing to talk to anyone in the process.
There have been no further large scale studies of abortion counselling provision in the UK,

though other studies and policy developments have led to further refinement of what is
understood by counselling. Myra Hunter presented a model of counselling for obstetrics and
gynaecology (including abortion) in which she distinguished between providing information
and emotional support to all women and providing specific support to women who are
distressed for any reason (Hunter 1994). Similarly, Jane Read (1995) considered different types
of counselling in abortion: information counselling, implications counselling, support counsel-
ling and therapeutic counselling; and also suggested similar needs for women undergoing
abortion to those seeking assisted conception. Neither of these important books, written
primarily for practitioners by practicing therapists, single out women who have an abortion as
being in particular need of counselling. What they are clear about is that if some women need
therapeutic counselling, this is a distinctive need that should not be confused with information
and general support that all women should expect from all these services, and this reflected a
more nuanced understanding than the Lane consensus.
With respect to abortion research more generally, this has simultaneously helped shape, and

responded to, shifts in understandings, and practices, of abortion counselling. In a review of
relevant literature from 1967 onwards, Rowlands (2008) sought to identify research studies
(internationally) with some findings of relevance to the issue of abortion counselling. In his
systematic review, he noted that the term ‘counselling’ is used widely and indiscriminately

Abortion Counselling 367

and is frequently used to describe the activity of simply providing information. He drew
attention to the need to distinguish between different types of counselling ranging from general
support and information (as proposed by Lane) through to therapeutic counselling. He also
noted, however, that much of the research focuses on what has been described as ‘decision
counselling’, which has often been proposed as counselling in a more therapeutic sense. Many
of the papers in the review introduced the notion of ambivalence to studies on abortion
decision-making, a concept that will be further explored later in this paper. Noting that whilst
‘hard evidence’ for the beneficial effects of such decision counselling is rare, and that there was
no evidence that this should be a mandatory service for all women, Rowlands also observed that
a general agreement emerged from the 1970s onwards that this service, seeking to assist those
with difficulties making decision about the outcome of a pregnancy, should be provided. This
is indeed the direction in which abortion policy and provision has moved, in Britain, a direction
which illustrates a sometimes fraught, but nonetheless significant, relationship between research
and policy developments.
The policy approach is evident in guidelines that have been generated specifically for

abortion service provision. The RCOG (Royal College of Obstetricians & Gynaecologists)
collates evidence and sets standards for care in abortion (including counselling requirements).
The RCOG’s Guidelines, first published in 2000, (RCOG 2011) distinguish between three
domains: the first is information needs as discussed earlier (the need for clinicians to have
accurate knowledge about medical complications associated with abortion, to ensure that dis-
cussion with woman can allow for valid consent to be given by them); the second is to state that
all women should be offered the opportunity to discuss their decision with a non-directive
counsellor, and/or clinician; and thirdly, it recommended that additional counselling be made
available for women who request it.
The Department of Health regulates counselling provision in all abortion units through

Required Standard Operating Principles (RSOPs) for termination of pregnancy services
(DoH 2013a). These draw on the RCOG Guidelines and state (p. 20) that, ‘All women
requesting an abortion should be offered the opportunity to discuss their options and choices
with a trained counsellor and this offer should be repeated at every stage of the care pathway.
Post abortion counselling should also be available for those women who require it’. Indepen-
dent sector agencies, primarily the British Pregnancy Advisory Service (bpas) and Marie Stopes
International (MSI), have increasingly provided the majority of NHS funded procedures
(Lee 2005; Lee and Ingham 2010). At both these agencies, two types of counselling are
available: all women are offered ‘decision counselling’ (either by telephone or in-person)
as part of their advice and information session, and therapeutic counselling is made available
for any woman who may request it. This sector has developed a particular category of staff,
the ‘admin counsellor’ who (together with medical personnel) has responsibility for information
provision and ‘decision counselling’. Women who need it have access to staff trained and
specialised in therapeutic counselling (Lee 2003b).
This overview has shown that (apart from those opposed to abortion) a policy consensus has

emerged, and that this consensus does inform abortion providers: therapeutic counselling for
women considering an abortion should be available for those women who may need it, but this
should not to be confused with discussions that facilitate informed consent, or with discussions
designed to establish women’s comfort with their decision (sometimes called options, or
decision, counselling). Although these latter discussions may be facilitated by a trained counsel-
lor, this is not essential, and they do not constitute therapeutic counselling. Decision counselling
is potentially confusing, as for the most part, it will not involve therapeutic counselling; but, if
women are experiencing difficulties with abortion decision-making, for any of a number of
what could be complex reasons, then therapeutic counselling should be available. As will be

368 Abortion Counselling

shown later, the research on women’s abortion decision-making suggests that such counselling
would almost certainly not be needed by the majority of women.

Why did abortion counselling emerge as a controversial issue?

Given that the purpose and scope of abortion counselling has been both expanded and clarified
since the Lane Committee, and detailed guidance exists, why does it regularly emerge in Britain
as a controversial issue? An exploration of the literature on the politics of abortion and on
debates around ‘Post-Abortion Syndrome’ (PAS) can shed light on this conundrum. Although
these are international issues, and this literature is not confined to Britain, this paper will
continue to apply the research to the British case study.
Following the 1967 Abortion Act, anti-abortion organisations began campaigning against

abortion provision in Britain, at first concentrating on campaigns supporting legislation drafted
to restrict existing provision. A series of Private Members Bills, all of which would have seriously
curtailed women’s right to an abortion in one way or another, were introduced in the 1970s and
1980s. All prompted vociferous and confrontational political campaigns for and against the
legislation; all were defeated (Hoggart 2000). During this period, organisations opposed to
abortion, such as SPUC (Society for the Protection for the Unborn Child) and then LIFE, very
much focused on the right to life of what they conceptualised as the ‘innocent baby’, and
abortion politics was dominated by a discourse of competing rights, with campaigners in favour
of retaining abortion rights campaigning in favour of ‘a woman’s right to choose’ (Himmelweit
1988; Hoggart 2003). The oppositional viewpoints in this conflict are generally referred to in
academic literature on abortion as pro-choice and anti-choice (Cannold 2002).
A number of academics have analysed how anti-choice activists were obliged to rethink their

strategy when it became clear that the (‘innocent baby’) foetal discourse was not effective
(Cannold 2002; Lee 2001, 2003a,b). Throughout the 1970s and into the 1980s, opinion polls
had indicated that a majority of the population supported liberal abortion law, and it became
increasingly clear that large numbers of people were not going to be persuaded by appeals based
on positioning women seeking an abortion as immoral murderers. So, from the mid-1980s, a
new anti-choice strategy, characterised by Leslie Cannold as a ‘women-centred strategy’, was
developed: ‘a key task of the anti-choice women-centred strategy is to replace the fetus with
the guilt-ridden, self-hating, grief-stricken, victimised and finger-pointing “woman hurt by
abortion” as the summarising image of what is wrong with abortion’ (Cannold 2002, p. 173).
This strategy not only constructed abortion as an innately traumatic event that may cause
psychological damage, but portrayed women seeking an abortion as inherently vulnerable
and susceptible to duress. This was a conscious and significant tactical and discursive shift
amongst activists campaigning to restrict abortion. Recent debates on abortion counselling need
to be understood in the light of these political developments. The research evidence on these
issues will now be examined in a little more detail.
The argument for PAS, and its diagnostic criteria, has been traced by Ellie Lee (2001) to the

work of an American, Vincent Rue, who proposed it as a form of post-traumatic stress disorder
(PTSD) (Rue 1995). More recently, the mantle has been taken up by Priscilla Coleman.
Coleman’s claims that quantitative research has shown an increased risk of mental health prob-
lems after abortion were published in The British Journal of Psychiatry (Coleman 2011) but have
since been widely discredited.5 These discussions are relevant to the pre-abortion counselling
debate because, as noted earlier, some anti-choice activists made a discursive shift to focus on
the possibility of post-abortion psychological distress, and this incorporated the argument that
women will suffer if they have been insufficiently ‘counselled’ about the negative impact of
abortion. Indeed, Coleman’s paper was explicitly referred to by Nadine Dorries in the House

Abortion Counselling 369

of Commons when she was seeking to introduce additional abortion counselling requirements.6

This conceptualisation of counselling is quite different from the decision counselling proposed
in the health service research discussed earlier, in which there is a strong emphasis on the need
for the counselling to be non-judgemental. An extra stimulus for anti-choice activists in Britain
to adopt this strategy is that suggesting that abortion causes psychological damage also challenges
one of the main criteria for abortion: continuing with the pregnancy would involve a greater
risk to the woman’s physical or mental health than ending the pregnancy.
There is now a large amount of international literature discussing the possible negative

psychological consequences of abortion in which pro-choice academics have devoted a
significant amount of energy to critically analysing the claims that abortion causes mental health
problems (Steinberg and Finer 2011). There are two main issues to note about this discussion.
First, there is a lack of robust research evidence supporting the concept of PAS. As noted by a
panel commissioned by the American Psychological Association to investigate the psychological
consequences of abortion, the majority of studies suffer from methodological problems (Major
et al. 2009). This is because it is virtually impossible to compare a cohort of women who have an
abortion to a valid comparison group (Steinberg and Russo 2008).7 Second, the research that
purportedly demonstrates PAS has been widely discredited for not taking into consideration
the social, cultural and health care contexts within which an abortion takes place, as well as
events confounded with abortion (sexual abuse, for example) that may themselves be associated
with negative mental health outcomes (Dagg 1991; Lee 2003a; Steinberg and Russo 2008). In
2008, a review of the literature (Charles et al. 2008) concluded that the claim that abortion leads
to mental health problems had been discredited by high quality research. More recently, the
research on abortion and mental health has also been systematically reviewed for the Academy
of Medical Royal Colleges, which concluded that there was no difference in mental health
problems between women with unwanted pregnancies who gave birth and those who had
an abortion (AMRC 2011).
Although this may appear to be a purely academic debate, critiques of PAS have demon-

strated how anti-abortion bias has affected the way in which data are interpreted. Dervious
and Russo (2000) show how in research that claims to identify PAS, any negative mental health
outcomes that may be identified in women following an abortion are: firstly, mis-labelled as
psychological sequelae when they are correlates; secondly, attributed to the abortion, rather
than an unwanted pregnancy; and, thirdly, taken out of context. In addition, the anti-choice call
for abortion counselling, drawing on the concepts ‘post-abortion syndrome’ and ‘abortion
trauma’, not only elides pre- and post-abortion counselling, but also blurs the distinction
between information provision and obtaining informed consent, and counselling.
This particular focus of much pro-choice research and scholarship has thus been reactive,

making it difficult for researchers to focus on what women actually want. Further, there is a
notable absence of a clear consensus on the most appropriate framework to deploy when
researching women’s abortion experiences. As Mary Boyle (2000) has pointed out, the heated
debates that take place about abortion, often from polarised positions, make it politically diffi-
cult for researchers to explore the complexity of women’s abortion emotions, behaviour and
needs. Indeed, she cautions against research that is focused upon whether women do, or do
not, experience negative outcomes following an abortion or whether or not women seeking
an abortion could be described as vulnerable, on the grounds that this keeps research within
an agenda which focuses on abortion’s intrinsic potential to harm women (Boyle 2002). In
Britain, this is an especially pertinent point because, as Lee (2003b) has pointed out, the justifi-
cation of legal abortion enshrined in the 1967 Act is very much based on the construction of
women as psychologically vulnerable victims. So there are a number of factors that discourage
pro-choice researchers from dwelling on abortion and emotions. Others, however, have

370 Abortion Counselling

pointed out that the polarisation can cause pro-choice researchers to deny any possibility of
negative or ambivalent emotions following an abortion, suggesting that such a denial of some
women’s feelings may not be welcomed by women themselves (Cannold 2002). More recently,
there has been greater willingness to tackle such issues, often within the context of theorising
abortion-related stigma, and with an underlying assumption that an exploration of the full range
of post-abortion emotions does not, of necessity, lead to an anti-choice interpretation of the
research (Cockrill and Nack 2013; Hoggart 2012; Quinn and Chaudoir 2009).
Although such considerations have made research challenging, there has been interest

amongst pro-choice researchers and abortion providers in examining women’s abortion
experiences. From this research, it is possible to analyse the issue of abortion counselling from
the perspectives of women who have abortions.

Women’s abortion experiences: who needs counselling?

Although few research studies have focused specifically on counselling, there is a body of
research that has considered women’s abortion decision-making, abortion experiences and their
expressed needs. The socio-legal context outlined above, in which understandings of abortion
counselling have become more nuanced over the years, and yet are still not legally defined or
regulated, forms the backdrop to the research in Britain.
A particularly important theme in research on women’s abortion experiences is the value

women place on providers being clearly non-judgemental. In particular, information provision
and staff attitudes (kindliness and acting in a manner that reduces women’s feelings of anxiety
and isolation) feature in women’s reports (Harden and Ogden 1999; Lee et al. 2004). Rowlands
(2008) also points out that the research indicates that women value being given clear
information about abortion procedures at the pre-abortion consultation, and a recent study
has shown that women value an uncomplicated referral process (Brown 2013).
Research on abortion decision-making has shown that women take a range of issues into

consideration and generally make their decision based on their own individual circumstances
at a particular moment in time (Purcell et al. 2014; Rowlands 2008). It has been noted also that
the most usual experience is where women discuss their situation with friends, parents and
family members and have already made their decision, before they approach a medical
professional, or abortion provider (Brown 2013; Kumar et al. 2004). It has been argued that
the research evidence indicates that whilst women may be distressed when faced with an
unwanted pregnancy, more are comfortable with their decision that is often assumed in public
debate (Boyle 2000; Hadley 1996), thus echoing findings of Allen’s (1985) counselling study.
Another area where there is some agreement is in the recognition that it is women who may

be ambivalent about their decision who are most likely to express a need for therapeutic
counselling. Research has shown that ambivalent women are at higher risk of poor psycholog-
ical outcomes than non-ambivalent women (Ashton 1980; Cameron 2010; Hare and Heywood
1981). And Rowlands’ (2008) international review points out that most studies have shown that
ambivalence has been shown to be a predictor of poor outcomes, but he is careful to point out
that ‘feelings of ambivalence are an indication that abortion has a price, which implies that it is a
more or less painful solution to an unwanted pregnancy’ (Rowlands 2008: 176). As we have
seen, this does not mean that the abortion itself has caused poor psychological outcomes: abor-
tion needs to be compared with continuation of pregnancy for this case to be made. (Kirkman
et al. 2009) also conducted a review of the literature on reasons women give for an abortion and
concluded that ambivalence was evident, and abortion was chosen because continuing with the
pregnancy was assessed by the women as having adverse effects on their own lives and the lives
of significant others. Purcell et al. (2014) have characterised the ambivalence they found in their

Abortion Counselling 371

study as women struggling with a dual candidacy: they are candidates for abortion and they are
also candidates for motherhood, and sometimes this is a difficult decision; in this study, despite
ambivalence, the women were comfortable that they had made the right decision for them-
selves. The literature on ambivalence indicates that women who are unsure of their decision
may need extra time and help, and maybe sometimes therapeutic counselling. The previous sec-
tion has shown that official guidance and abortion providers have taken this into consideration.
There is another body of work, however, with a pro-choice perspective, which suggests that

the extent of women’s need for therapeutic counselling may have been underestimated (Ashurst
and Hall 1989; Dana 1987; Walker 1990). This work can be traced back to feminist approaches
to counselling offered by the Women’s Therapy Centre during the 1980s and 1990s. The Cen-
tre viewed therapeutic counselling to be a necessary intervention that enabled feelings surround
abortion to be addressed (Dana 1987). It was also argued that abortion can be experienced as part
of a process of psychological maturation, and counselling can help in this respect. Some more
recent contributions from the counselling profession have echoed the position developed by
feminists regarding the role that therapeutic counselling could play in pushing abortion towards
being a positive, rather than a negative, experience (Brien and Fairbairn 1996; Hodson 2002).8

As there have been no recent studies on the provision and content of abortion counselling, it is
not possible to judge whether this particular focus has influenced the content, and affect, of
therapeutic counselling. There is, however, research evidence to support the claim that abortion
can be a positive experience, showing how making such an important decision, and exercising
autonomy, can – in and of itself – empower women (Harden and Ogden 1999). This research
suggests that positive experiences associated with abortion, such as non-judgemental treatment,
or feeling empowered, can contribute towards positive feelings. Conversely, an association can
be seen between negative abortion experiences, whatever may cause the negativity, and
negative emotions (Boyle and McEvoy 1998). Negative emotions clearly can make the need
for therapeutic counselling more likely. The socio-cultural context within which abortion takes
place is therefore of central importance to the debate on abortion counselling. With this in
mind, it is worth pointing out that although abortion services have improved considerably in
Britain since the 1970s, the political discourse has lagged behind.
National statistics show that over the years, there has been an increase in NHS funded abor-

tions provided by the independent sector; and that an increasing proportion of these abortions
are carried out earlier in pregnancy.9 Such improvements have been facilitated by sexual health
policy developments going back to the formulation of a National Strategy for Sexual Health and
HIV (DoH 2001), a strategy that sought to improve access to abortion services and has recently
been updated (DoH 2013b). However, as has been pointed out, these developments can be
characterised as ‘abortion pragmatism’ (Lee 2013): that is, they are based on an understanding
that abortion needs to be tolerated in order to prevent ‘undesirable’ childbearing – particularly
amongst teenagers. Within this agenda, it is still possible to frame abortion as morally undesir-
able: by proposing that contraceptive services might be improved on the basis of reducing the
abortion rate, for example (Hoggart 2012). Such framing does not challenge what has been
termed the ‘awfulisation’ of abortion (Hadley 1996), and ‘abortion negativity’ (Lee et al.
2004) and can have an impact on services. It has recently been claimed by a leading abortion
provider that the political environment in Britain makes it difficult to press for significant
improvements in abortion care (Furedi 2014). In addition, some research has suggested that
‘abortion negativity’ can contribute towards abortion-seeking women experiencing ambiva-
lence pre- and post-abortion (Rowlands 2008). Such negativity is also an important part of a
cultural context which can engender post-abortion regret for some women (Hoggart 2012).
Some studies have shown how abortion providers may play a role in differentially constructing
the legitimacy of abortions for different ‘types’ of women (Benyon-Jones 2013), whilst others

372 Abortion Counselling

have argued that providers themselves are subject to stigma and that the public discourse on
abortion prevents them from challenging this stigma (Harris et al. 2013).
Comparative analysis has also shown how women’s cultural affiliations and beliefs have an

impact on their emotional experiences and post-termination feelings (Bennett 2001; Kero
et al. 2004; Lafaurie et al. 2005). When abortions take place within a context of moral disap-
proval, this is likely to impact negatively upon women’s decision-making and experiences
(Boyle and McEvoy 1998; Kumar et al. 2009). Relatively recently, researchers have begun to
theorise one aspect of this negativity through an exploration of how abortion stigma is gener-
ated in different contexts, what forms it takes and what the consequences are for women seeking
an abortion. Stigma has been defined as ‘a negative attribute ascribed to women who seek to
terminate a pregnancy that marks them, internally or externally, as inferior to ideals of woman-
hood’ (Kumar et al. 2009: 628). As such, the theorisation of abortion stigma draws on work that
has pointed to gender-specific meanings of abortion in relation to motherhood (Luker 1984),
and other constructs of the ‘feminine’. As Cockrill and Nack (2013: 975) put it: ‘Abortion
can signal multiple transgressions, including participating in sex without a desire for procreation,
an unwillingness to become a mother, and/or a lack of maternal-fetal bonding’. These meanings
vary according to different contexts.
The stigma associated with women challenging particular gendered norms of sexuality and

motherhood through undergoing an abortion has been linked to the decision-making process
as well as subsequent reproductive behaviour (Tsui 2011). Similarly, a recent UK study has
shown non-disclosure of abortion is related to women’s perceptions of abortion as potentially
stigmatising (Astbury-Ward et al. 2012). Norris et al. (2011) have stressed the importance of
legal restrictions as an additional cause of abortion stigma, and this, of course, would vary
according to different jurisdictions. In the UK, this is particularly relevant to Northern Ireland
where legal restrictions result in thousands of women travelling, mainly to England and Wales,
to obtain abortions, or purchasing the ‘abortion pill’ illegally.10 The moral conservatism,
gendered social norms and religious legitimation associated with these restrictions have
undoubtedly contributed towards especially negative experiences for women undergoing an
abortion (Bloomer and Fegan 2014; Bloomer and O’Dowd 2014; Boyle 1997).
Internationally, studies have found that abortion-related stigma can generate fear and guilt

and contribute to feelings of shame in moralistic societies. Although the stigma of abortion
was perceived similarly in both legally liberal and restrictive settings, it was more evident in set-
tings where abortion is highly restricted, and this affected disclosure (Cockrill and Nack 2013;
Major and Gramzow 1999; Quinn and Chaudoir 2009; Schellenberg et al. 2011).

Discussion

This overview of the literature has shown how abortion counselling debates and controversies
are fundamentally political, thus reflecting political divisions over abortion itself, and subject to
change. This is evidently true on a number of different levels.
In the first instance, the debate itself has its roots in the attempted construction of abortion as

inherently psychologically damaging and is most strongly articulated in the creative develop-
ment of the notion of Post-Abortion Syndrome (PAS). This discourse positions women as vul-
nerable, at risk of abortion-induced trauma, and therefore in need of therapeutic counselling.
Legislative attempts to enforce pre-abortion counselling in which women can reflect upon their
decision are not value-free but are linked to this anti-abortion agenda.
However, as has also been shown, some pro-choice feminist practitioners and scholars have

suggested that counselling, both pre- and post-abortion, may be beneficial for women. This
confluence of extremely dichotomous positions around the perceived need for abortion

Abortion Counselling 373

counselling calls for further exploration. Understanding that this is not a shared – but rather a
contested – position is the starting point: those who support abortion and call for counselling
do so from a perspective of helping abortion-seeking women (who may be experiencing
emotional difficulties) make a decision that is right for them. Within this framing of counselling,
some feminists have proposed therapeutic counselling in order that women can become
empowered in their abortion process. By way of contrast, those who oppose abortion and call
for counselling are anticipating that this may discourage women from having an abortion, or, at
the very least, make it more difficult for them to do so. These are very different policy positions.
Nevertheless, the confluence is striking. The two groupings are unlikely bedfellows, and this

only be understood by analysing political contexts and positionings. A further indication of the
contentious political nature of these debates has been tensions within pro-choice research
around the value of therapeutic counselling, and also concerning abortion-related emotions.
Much of the research in this area is either concerned to dispute any connection between
abortion and adverse psychological outcomes or reluctant to engage in the issue of emotions,
particularly post-abortion emotions. This reluctance is largely due to an unwillingness to
unwittingly contribute towards the ‘awfulisation’ of abortion. It is only comparatively recently,
in a body of work emanating from the United States on abortion-related stigma, that women’s
emotions are being fore-fronted in abortion research.
There is less disagreement amongst supporters of abortion rights about decision counselling,

in all probability because such counselling is a central aspect of facilitating women’s reproductive
choice. Taken as a whole, the research indicates that women considering abortion have a wide
range of emotional responses to their situation. Many – possibly most –make their decision
rapidly and are comfortable with their decision (Rowlands 2008). Some women may experi-
ence ambivalence and decision counselling may be helpful to them.
This review has also shown how women’s decision-making processes, and responses to an

abortion, are related to gendered socio-cultural contexts. In particular, the work on abortion-
related stigma has shown how general shared features across different contexts – such as gen-
dered norms of sexuality and motherhood – form a backdrop to abortion decision-making
and experiences. Moving to another level, the research has shown how different contexts –
taking into account, for example, socio-legal jurisdictions, the extent of moral conservatism,
and different manifestations of abortion stigma – are likely to impact differentially on women
considering an abortion.
A final way in which politics intrudes is to hamper an evidence-based development of abor-

tion services through creating a political environment in which abortion policy and provision
are contested terrain. Those opposed to abortion portray it as a moral wrong to be prevented,
either by introducing a more restrictive legislative framework or making the process of
obtaining an abortion more difficult, through imposing pre-abortion counselling, for example.
Politicians and policy-makers who have embraced a pragmatic acceptance of abortion invariably
find it difficult to avoid a moralistic framing of abortion, such that whilst necessary, it is
nevertheless undesirable. It has been argued that medical advances in the abortion field, and a
significant body of research on women’s abortion experiences, could lead to continual
improvements in provision; yet, political tensions create a policy climate which is not conducive
for the further development of evidence-based abortion services (Furedi 2014).

Conclusion

This paper has shown how debate around abortion counselling customarily proceeds from par-
ticular political positioning. In Britain, following legalisation of abortion in limited circum-
stances in 1967, early ‘abortion wars’ were concentrated on legislative attempts to amend the

374 Abortion Counselling

1967 Abortion Act in a restrictive manner. In parallel, those who were concerned to implement
the Act focused on equality of access, and abortion counselling was viewed as a way of enabling
women to access abortion. Moving into the 1980s and beyond, understandings of abortion
counselling, however, changed and became a primary battleground. In the British Parliament,
attempts to change current provision are consistently fronted by well-known anti-abortionists.
Within the pro-choice, and also abortion provider, community, there is no overall consensus on
the extent to which abortion counselling may be called for, though there is an acknowledge-
ment of the importance of decision counselling to facilitate informed choice. Only those writing
from an anti-choice perspective have disagreed with the general consensus that therapeutic
counselling should be a voluntary activity openly available to all women.
There currently is a pragmatic acceptance of the need for abortion in Britain, and the attempts

to generate causal theories about abortion engendering psychological damage have been thor-
oughly discredited. It is probably no accident that recently research has begun to focus more sys-
tematically on women’s experiences and needs, rather than simply responding to anti-choice
discourses. In the United States, research on abortion-related stigma is leading to the develop-
ment of creative interventions to combat stigma (Cockrill et al. 2013; Hessini 2014; Martin et al.
2014; Shellenberg et al. 2014). Although Britain is very different to the United States in terms of
the pragmatic acceptance of abortion, the research still indicates that a societal level acceptance
of the viewpoint that abortion is morally undesirable can adversely affect women. The research
evidence leads logically to the suggestion that women’s abortion experiences might be
improved by a determined effort to normalise, or de-stigmatise, abortion. Such developments
would have the potential to make abortion decision-making less stressful and also decrease
the likelihood of post-abortion distress, thus lessening the need for decision counselling or
therapeutic counselling.

Short Biography

Dr. Lesley Hoggart is a Senior Lecturer in the Faculty of Health and Social Care at the Open
University. She specialises in qualitative research and spent many years working in the qualita-
tive research group at the Policy Studies Institute. Her research interests are focused on repro-
ductive health, abortion policy and politics, teenage pregnancy and sexual health. Her
publications include Feminist Campaigns for Birth Control and Abortion Rights in Britain,
(The Edwin Mellen Press 2002); 2013. Hoggart, L. and Newton, V. ‘The contraceptive
implant: understanding how experiencing side effects may challenge bodily control and lead
to removal’, Reproductive Health Matters, 21(41) pp. 196-204; Hoggart, L., Newton, V. and
Dickson, J. (2013) ‘“I think it depends on the body, with mine it didn’t work”: explaining
young women’s decisions to request subdermal contraceptive implant removal.’ Contraception.
Hoggart, L. (2012) ‘“I’m pregnant … what am I going to do?” An examination of value judge-
ments and moral frameworks in teenage pregnancy decision making.’ Health, Risk and Society.
14:6 pp 533–549. Hoggart, L. and Phillips, J. (2011) ‘Teenage pregnancies that end in abortion:
what can they tell us about contraceptive risk-taking?’ Journal of Family Planning and Reproductive
Health Care, 37 pp. 97–102. She is currently convening an ESRC Seminar Series on
Understanding the Young Sexual Body, in collaboration with King’s College London, Institute
of Education, Anglia Ruskin University and Cardiff University.

Notes

* Correspondence address: Lesley Hoggart, Health and Social Care, The Open University, Walton Hall, Milton Keynes,
MK7 6AA, UK. E-mail: Lesley.Hoggart@open.ac.uk

Abortion Counselling 375

1 This focus on Britain (England, Wales and Scotland), rather than the United Kingdom (England, Wales, Scotland and
Northern Ireland), is because the 1967 Abortion Act specifically excludes Northern Ireland from its jurisdiction.
2 http://www.publications.parliament.uk/pa/cm201011/cmhansrd/cm110907/debtext/110907-0001.htm#11090754000002.
3 http://www.legislation.gov.uk/ukpga/1967/87/section/1.
4 http://www.nhs.uk/Conditions/Abortion/Pages/Introduction.aspx.
5 http://www.legislation.gov.uk/ukpga/1967/87/section/1.
6 http://www.publications.parliament.uk/pa/cm201011/cmhansrd/cm110907/debtext/110907-0001.htm#11090754001604.
7 The closest semi-experimental research possible on this topic is currently being undertaken by a team of researchers at the
University of California, San Francisco. The Turnaway Study is comparing outcomes of women who have been denied an
abortion because they are beyond the legal time limit to women who have obtained an abortion ‘just in time’, before
reaching the limit. http://www.ansirh.org/research/turnaway.php.
8 See also recent papers available on the pro-choice forum website: Everett; Paterson and Ross.
9 www.parliament.uk/briefing-papers/sn04418 .
10 http://www.theguardian.com/world/2013/mar/10/northern-irish-women-risk-jail-over-abortion-drug-use.

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378 Abortion Counselling

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Journal of Social Work Values & Ethics, Fall 2018, Vol. 15, No. 2 – page 37

Ethnicity, Values, and Value Conflicts of African
American and White Social Service Professionals
Andrew Edwards, MSW, Ph.D.
Cleveland State University, Emeritus
revaedw@roadrunner.com

Mamadou M. Seck, Ph.D.
Cleveland State University
m.seck@csuohio.edu

Journal of Social Work Values and Ethics, Volume 15, Number 2 (2018)
Copyright 2018, ASWB

This text may be freely shared among individuals, but it may not be republished in any medium without
express written consent from the authors and advance notification of ASWB.

Abstract

This aspect of a broader study included 110 (68
White/European American and 42 Black/African
American) social service professionals. The primary
focus of this aspect of the study was to verify the
value orientation or core beliefs of the practitioners
who deliver services to clients through social service
agencies and programs. The conceptualization
of the core beliefs explored the values and value
conflicts in relation to professional practice. The
participants were employed in a Midwestern
metropolitan region. They responded to a survey
instrument that included vignettes, closed-ended
items, scaled responses, as well as either-or type
items. Major categories of the exploration included:
life and death issues, lifestyle, domestic and
social perspectives, value conflicts with the social
work profession, and personal responses to value
conflicts. Specific items measuring values related
to abortion, homosexuality, religiosity, euthanasia,
and corporal punishment were included. Study
results showed statistical significance on 26 issues
as African American participants were compared
with White participants.

Keywords: value conflicts, social work, ethical
dilemmas, ethnicity, professional relationship

Introduction
The complexity of American society (Jarrett,

2000), specifically due to its historic, economic,
social, and ethnic makeup, requires that social
work professionals take their clients’ ethnicity,
values, and professional-client value conflicts
into consideration. Historical dynamics, such as
unproductive treatment, have contributed to the
reluctance of various population groups to engage
with professional service providers. This history
(Barker, 2014) has influenced the adoption of
guidelines that require social workers to be culturally
aware during interventions and recognizing that
diversity-related characteristics have influence upon
an individual’s thoughts, feelings, and behaviors.
Barker (2014) further noted that the concept of
values is influenced by one’s perceptions of what
comprises appropriate principles, practices, and
behaviors. An individual’s personal values are often
considered as a representation of one’s core beliefs
and what an individual may perceive as right.
Therefore, these beliefs do not require supporting
evidence for those who embrace them and may
result in behavioral and attitudinal guidelines. The
expression of values helps individuals to verify
and/or maintain their integrity and self-worth.
Therefore, for the purpose of this study, values were
categorized according to the following: (1) social,

C:\Users\Revaedw\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\Downloads\revaedw@roadrunner.com

mailto:m.seck@csuohio.edu

Journal of Social Work Values & Ethics, Fall 2018, Vol. 15, No. 2 – page 38

Ethnicity, Values, and Value Conflicts of African American and White Social Service Professionals

(2) cultural, (3) religious, (4) professional, and
(5) personal values.

Literature Review
The National Association of Social

Workers (NASW) Code of Ethics outlines specific
values and standards for professional practice. As
professionals, it is critical to abide by the standards
of the profession in addition to engaging in efforts
to promote self-awareness. The awareness of one’s
own personal values will allow the social worker
to recognize and confront value dilemmas that may
impede professional practice. As noted, for the
purposes of this study, values were identified across
five categories. The social values category (Barboza,
1998; Sears & Osten, 2005) includes principles,
customs, and beliefs that are generally accepted
as norms of a particular society. These types of
values are regulated by social pressures rather than
public policy. For example, appreciation of loyalty,
honesty, and a work ethic represent social values.
Specific ethnic codes of conduct are expressions
of social values because they are embraced by a
major segment of society and regarded as correct
ways of thinking and behaving. In contrast, cultural
values (Edwards, 2014) is a category that represents
norms and standards integrated into public policy.
In other words, cultural values are institutionalized
as standards for the American culture. For example,
education and equality (Clay, Lingwall, & Stephens,
2012; Imber & VanGeel, 2000) are addressed
through laws that require some form of educational
activity for American youth.

The religious values category (Edwards,
2014; Edwards 2000) reflects behavioral guidelines
for those who identify as members of specific
faith communities. These values are typically
written in doctrinal statements and refer to a type
of holy reference book as the foundation for the
principles. Examples of religious values relate to
sexual behavior, interpersonal behavior, dietary
restrictions, and childrearing methods.

The professional values category consists
of standards and principles designed to regulate the
behavior of those who practice within a specific

profession. For example, the National Association
of Social Workers (NASW, 2017) Code of Ethics
identifies social work values including respecting
the dignity and worth of an individual and one’s
right to self-determination. In contrast, the personal
values category (Edwards, 2014) reflects when
individuals adopt aspects of the previous four value
categories as guiding principles for their lives.

In relation to professional social work
practice, a practitioner may experience an internal
struggle (Edwards, 2014) when compelled to engage
in behaviors or tasks that are contradictory to one
or more aspects of one’s core belief system. As a
result, a value conflict may occur which refers to a
disagreement between one’s core belief system and
that of a group, organization, or society (Edwards
& Allen, 2008). Consequently, some professionals
who face value conflicts when providing services
become perplexed or even omit some tasks
associated with completing their professional
obligation. As a result, value conflicts may hinder
the social worker-client relationship necessary for
appropriate service provision.

Zastro and Kirst-Ashman (2010) suggested
that many decisions, both personal and professional,
are influenced by one’s beliefs about life, freedom,
and protective standards. Furthermore, social work
competence (Segal, Gerdes, & Steiner, 2016)
requires self-awareness and a commitment to
social justice, which supports the need to explore
personal values. As a result, the current study
sought to examine the experiences of Black/African
American and White/European American social
service providers based on their ethnicity, values,
and value conflicts in relation to their personal
beliefs.

Behaviors are an important manifestation
of values particularly when there are conflicts
pertaining to values such as equality and economic
security. However, there may be occasions when
a person must choose one of these values based
upon what it means in relation to a specific
social or economic circumstance. Jacoby (2006)
suggested that values have a hierarchy and may
reorder themselves based upon specific situations.

Journal of Social Work Values & Ethics, Fall 2018, Vol. 15, No. 2 – page 39

Ethnicity, Values, and Value Conflicts of African American and White Social Service Professionals

Other researchers noted that individuals respond
to complex value-related issues such as abortion
(Alvarez & Brehm, 1995) and homosexuality
(Craig et al., 2005) with ambivalence due to their
underlying beliefs. Therefore, conflicts between
core beliefs and values of an individual may exist
at a personal level yet, at the same time, conflict
with prevailing public perceptions. For example, a
person may hold contradictory perspectives toward
homosexuality such as it is either morally wrong
and/or it could be a result of genetic inheritance
versus choice (Craig et al., 2005).

The research literature provides multiple
examples of value conflicts social service
professionals may experience. Paprocki (2014)
explored when the personal beliefs of psychology
graduate students lead to complications in their
attempts to provide therapy to patients. For example,
certain program administrators expressed challenges
with students who sought to abstain from providing
services to clients in same-sex relationships based
upon religious beliefs. Pertaining to physician-
assisted suicide and euthanasia, Himchak (2011)
suggested that this has a cultural component that is
important when providing services. For example,
reportedly African American, Hispanic, and Asian
populations value respect toward elders resulting in
resistance to physician-assisted suicide. In addition,
regarding the issue of abortion, Denbow (2013)
suggested that welfare and healthcare systems may
have instances of encouraging pregnant women
to engage in abortion. This researcher further
noted that women experiencing poverty encounter
substantially greater difficulties than their more
affluent counterparts in giving birth. Denbow (2013)
also pinpointed that women experiencing abuse,
poverty, and pregnancy could face a multitude
of challenges if they opted to bring pregnancies
to term. Millner and Hanks (2002), discussed the
possibility of value conflicts that clinical providers
could encounter when engaging with clients who
were considering abortion.

However, this current study examines a
comparison of Black/African American and White/
European American social service professionals on

their adherence to several family-related values,
domestic relationship issues, social preferences, and
their experiences with value conflicts in relation to
professional practice.

Method
Participant and data collection
The primary researchers received approval

from the required institutional review board to
conduct a survey of social service professionals.
Combined lists of social service agencies and
programs were used to develop a composite list
of 342 agencies and programs of which 185 were
selected for study participation. The social service
settings included: child welfare and adoptions,
disabilities and rehabilitation services, substance
abuse treatment, family service/counseling, juvenile
corrections, adult corrections, schools, mental health
settings, community development/planning, crisis
intervention, community organization/advocacy,
medical settings, and nursing homes/services for
older adults. The social service administrators as
well as the selected respondents returned, via mail,
the signed participation agreement in a separate
envelope without the questionnaire. Sixty-nine
social service agencies and programs agreed to
participate in this study.

The data collection instrument included
multiple choice, closed-ended, scaled-response, and
a series of one-paragraph value conflict case scenario
items. The value-related variables were generated
from a classroom exercise that undergraduate and
graduate social work students participated in for four
years. This tool was used to examine diversity in
values, the reality of value conflicts, and realization
of issues central to one’s core belief system. The
reoccurring value-related themes generated from
the classroom exercise became the foundation for
constructing the survey instrument for the purpose of
this study. To enhance the validity of the instrument,
it was implemented with two graduate level social
work students and three social workers who were
employed by a community child development center.

Journal of Social Work Values & Ethics, Fall 2018, Vol. 15, No. 2 – page 40

Ethnicity, Values, and Value Conflicts of African American and White Social Service Professionals

Results
Personal value related to fidelity in

marriage
In response to this issue, there was a

significant difference between African American

participants (71.4%) and White (88.2%) social
service professionals with a chi square result of
χ 2 (1, N = 110) = 4.93, p<.05. This means that the White respondents were more likely to agree that their personal values support fidelity in marriage.

Personal value about abstaining from
sexual intercourse prior to marriage

In response to this issue, there was a
significant difference between African American

(31%) and White survey participants (5.9%) with
a chi square of χ 2 (1, N = 110) = 12.49, p<.05 indicating that significantly more African American respondents adhered to the personal value to abstain from sexual intercourse prior to marriage.

Personal value about maintaining a
meaningful and personal relationship
with God

In response to this issue, there was a
significant difference between African American
(92.9%) and White (54.4%) social service
professionals with a chi square of χ 2 (1, N = 110)
= 17.97, p<.05, indicating that African American survey respondents identified a personal relationship with God was one of their personal values.

Personal value about attending a church,
mosque, synagogue

In response to this issue, there was a
significant difference between African American
survey respondents (71.4%) and White (30.9%)
survey participants with a chi square of χ 2(1, N =
110) = 17.16, p<.05 indicating that significantly more African American participants agreed that attending churches, mosques, or synagogues was one of their personal values.

Personal value about monetary and
financial wealth

In response to this issue, there was a
significant difference in responses between African
American (31%) and White (10.3%) respondents
with a chi square result of χ 2(1, N = 110) = 7.45,
p<.05 indicating that for African American survey participants, money and wealth were very important.

Support for homosexual ideology and
lifestyle

In response to this issue, 70.6% of White
participants in the sample agreed to this variable,
compared to 11.9% of African American participants
with a chi square of χ 2(1, N = 110) = 35.81, p<.05, indicating that significantly more White survey participants support homosexual ideology and lifestyle.

Having a belief in salvation or a positive
after-life in eternity

In response to this issue, there was a
significant difference between African American and
White participants as 88.1% of African Americans
agreed to this variable, compared to 48.5% of White
respondents with a chi square of χ 2 (1, N = 110) =
17.56, p<.05. This indicates that significantly more African American participants believe in salvation or a positive after-life in eternity.

Mercy killing, euthanasia, right to
terminate one’s own life, or to assist
others in the act

In response to this issue, there was a significant
difference between White (42.6%) and African
American participants (11.9%) with a chi square of
χ 2 (1, N = 110) = 11.49, p<.05. This indicates that significantly more White survey respondents support mercy killing, euthanasia, right to terminate one’s own life, or to assist others in the act.

Outside of value system to accept or
support abortion as a response to rape
or incest

In response to this issue, there was a
significant difference between African American

Journal of Social Work Values & Ethics, Fall 2018, Vol. 15, No. 2 – page 41

Ethnicity, Values, and Value Conflicts of African American and White Social Service Professionals

(36.6%) and White (15.2%) survey participants
with a chi square of χ 2(2, N = 110) = 6.53, p<.05. This indicates that African American respondents believe that abortion in situations of rape or incest is outside of their value system.

Outside of core value system for a
man to allow a woman to support him
financially

In response to this issue, there was a
significant difference between African American
(69%) and White (18.2%) respondents with a
χ 2(2, N = 110) = 29.65, p<.05. This indicates that significantly more African American survey participants believe that men should not allow women to support them financially.

Acceptance of interracial marriage
In response to this issue, there was a

significant difference between African American
(14.3%) and White (1.5%) survey participants with
a chi square of χ 2(2, N = 110) = 8.21, p<.05. This indicates that significantly more African American survey participants agree with interracial marriage.

Healthy women who refuse to work
outside of the home is outside of core
value system

In response to this issue, there was a
significant difference between African American and
White respondents, as 26.2% of African Americans
agreed to this variable, compared to 4.5% of White
participants, with a chi square of χ 2(2, N = 110) =
11.99, p<.05. This indicates that significantly more African American survey participants believe that healthy women who refuse to work outside of the home is outside of their core value system.

Having multiple children without ever
being married is outside of core value
system

In response to this issue, there was a
significant difference between respondents as 61.9%
of African American respondents in the sample
agreed to this variable, compared to 31.8% of White
respondents with a chi square of χ 2(2, N = 110) =

10.78, p<.05. This indicates that significantly more African American survey participants believe that having children without ever being married would be outside of their core value system.

Supportive of homosexual ideology and
lifestyle is outside of core value system

In response to this issue, there was a
significant difference between the two groups as
83.3% of African American participants agreed
to this variable, compared to 16.7% of White
participants with a chi square of χ 2(2, N = 110) =
48.23, p<.05. This indicates that significantly more African American survey participants believe that being supportive of homosexual ideologies and lifestyles would be outside of their core value system when compared to White respondents.

Frequently using cuss words and vulgar
language is outside of core value system

In response to this issue, there was a
significant difference between the two groups as
45.2% of African American participants agreed
to this variable compared to 22.7% of White
participants with a chi square of χ 2(2, N = 110) =
7.33, p<.05 showing that significantly more African Americans believe that the frequent use of cuss words and vulgar language in a professional setting is outside of their core value system.

Some of my core beliefs regarding
human sexuality are not embraced by
the social work profession

In response to this issue, there was a
significant difference between the two groups as
26.8% of African American participants responded
with ‘not at all’ compared to 54.7% of White
participants with a chi square of χ 2(4, N = 110)
= 15.94, p<.05. This indicates that significantly more White participants believe their core beliefs regarding sexuality are embraced by the social work profession.

Journal of Social Work Values & Ethics, Fall 2018, Vol. 15, No. 2 – page 42

Ethnicity, Values, and Value Conflicts of African American and White Social Service Professionals

Some of my cultural beliefs are in
opposition to what is embraced by the
social work profession

In response to this issue, there was a
significant difference between the two groups as
47.4% of the African American group responded
with ‘not at all’ to this variable, compared to 75% of
White respondents with a chi square of χ 2(4, N = 110)
= 12.31, p<.05. This indicates that significantly more White survey respondents believe that their cultural beliefs are embraced by the social work profession as compared to the African American group.

My beliefs regarding race are not
embraced by my family of origin (or
those who raised me)
In response to this issue, there was a

significant difference between the two groups as
60% of African American participants felt their
beliefs regarding race were ‘not at all’ opposed to
their family of origin in comparison to 47.9% of
White participants with a chi square of χ 2(4, N =
110) = 14.32, p<.05. This indicates that significantly more African American participants feel that their beliefs regarding race are not in conflict with the beliefs of their family of origin as compared to White participants.

My beliefs regarding religion/spirituality
are not embraced by my family of origin
(or those who raised me)

In response to this issue, there was a
significant difference between African American and
White professionals as 53.8% of African Americans
responded with ‘not at all’ to the question compared
to 29.5% of White participants with a chi square
of χ 2(4, N = 110) = 19.03, p<.05. This indicates that significantly more African American survey respondents feel their beliefs regarding religion/ spirituality are embraced by their family of origin.

My beliefs (acceptance of) regarding
corporal punishment/spanking children is
not embraced by the social work profession
In response to this issue, there was a

significant difference between African American

and White survey participants, as 20.5% of African
Americans responded with ‘not at all’ and 37.5%
of White participants with a chi square of χ 2(5, N =
110) = 14.90, p<.05. This indicates that more White participants feel their beliefs regarding corporal punishment/spanking children are embraced by the social work profession.

My beliefs regarding what is appropriate
language and my rejection of cussing and/
or vulgar language are not embraced by
most of the people at the social services
agency where I work (or do my field work)
In response to this issue, there was a

significant difference between African American
and White professionals as 30.3% of African
Americans responded with ‘not at all’ compared to
60.9% of White participants with a chi square of
χ 2(4, N = 110) = 13.72, p<.05. This indicates that significantly more White respondents feel their beliefs regarding appropriate language and their rejection of cussing and/or vulgar language in a professional setting are embraced by the majority where they work.

Agree to refer clients to religious
organization as a support system
In response to this issue, as described in

a case vignette, there was a significant difference
between African American and White participants as
13.2% of African Americans responded with ‘not at
all’ to this variable in comparison to 39.5% of White
respondents with a chi square of χ 2(4, N = 110) =
17.93, p<.05. This indicates that significantly more African American respondents would agree to refer individuals to religious organizations as a support system when compared to White colleagues.

Agree to urge sexual responsibility to
their clients

In response to this issue as described in a case
vignette, there was a significant difference between
African American and White research participants
as 35.3% of African Americans responded with ‘not
at all’ compared to 47.1% of White participants
with a chi square of χ 2(4, N = 110) = 12.91, p<.05.

Journal of Social Work Values & Ethics, Fall 2018, Vol. 15, No. 2 – page 43

Ethnicity, Values, and Value Conflicts of African American and White Social Service Professionals

This indicates that significantly more African
American respondents would agree at some level to
urge sexual responsibility to their clients than their
White colleagues.

Agree with the advice to client to resist
same-sex affection in public
In response to this issue, as described in

a case vignette, there was a significant difference
between the two groups as 33.3% of African
Americans responded with ‘not at all’ compared
to 46.7% of White colleagues with a chi square of
χ 2(4, N = 110) = 20.99, p<.05. This indicates that significantly more White research participants would disagree with advising a client to resist same-sex affection in public.

When a client chooses an option
contrary to my beliefs I feel loss of
integrity
In response to this issue, there was a

significant difference between the two (ethnic)
groups as 10.3% of White participants agreed
with this variable as compared to 0% of African
Americans with a chi square of χ 2(1, N = 110)
= 4.62, p<.05. This indicates that significantly more White participants feel a loss of integrity when a client chooses an option contrary to their own beliefs.

When a client chooses an option
contrary to my beliefs I feel angry
In response to this issue, there was a

significant difference between the two groups as
2.4% of African American participants agreed to
this variable in comparison to 14.7% of White
participants with a chi square of χ 2(1, N = 110)
= 4.38, p<.05. This indicates that significantly more White research participants feel angry when a client chooses an option contrary to their beliefs.

Discussion
Throughout this study, a key focus was the

verification that value-related dilemmas may evoke
emotional responses from the professional. The
emotional feeling may influence decision-making

as well as what may represent the perception of
what is identified as normal behavior exhibited
by clients. As a result, this discussion section is
organized around headings that are associated with
value-related issues that are common to professional
social service practice.

Issues related to life and death
The issue of abortion is a multifaceted,

value-related dilemma where there are underlying
causes as well as consequences related to the
decision to accept or reject abortion as an option.
If the response is based upon a fixed moral rule,
then it is referred to as ethical absolutism; if various
situations impact one’s response or behavior, then
the dilemma is referred to as ethical relativism
(Dolgoff, Harrington, & Loewenberg, 2012) which
may suggest that morality is relative to the norms
of one’s culture. Therefore, in the study survey, the
issue of abortion was divided into multiple items:
abortion to save the life of the mother, abortion as a
form of birth control, and abortion as a response to
rape or incest.

There was no statistically significant
difference between African American and White
survey participants regarding their acceptance of
abortion as a method to save the life of the mother
as well as for birth control. Both groups agreed that
abortion was acceptable under lifesaving and birth
control conditions. However, there was a statistically
significant difference between the groups regarding
abortion as a response to rape and incest. African
Americans in the sample suggested that abortion
in response to incest and rape was outside of their
value system. White survey participants suggested
that abortion was acceptable in the context of each of
the three conditions. African American respondents
indicated more of an ethical relativist view since
they chose abortion as the option to save the life of
the mother but also chose to reject abortion as an
option in the case of incest or rape.

Study results show that White survey
participants were more accepting of mercy killing,
euthanasia, and the right to terminate one’s own life
and to assist others in the act of terminating their
lives. Most African American respondents rejected

Journal of Social Work Values & Ethics, Fall 2018, Vol. 15, No. 2 – page 44

Ethnicity, Values, and Value Conflicts of African American and White Social Service Professionals

mercy killing, euthanasia, and an individual’s
right to assist others in terminating a life. The
issue of African American respondents rejecting
such a practice corresponds with the results that
indicated a high percentage (92.9%) embraced a
value about maintaining a meaningful and personal
relationship with God. They also indicated that they
embraced a value that required attending church,
mosque, or synagogue. This also corresponds with
African American respondents embracing a belief
in salvation or a positive afterlife in eternity. The
concept of religiosity as expressed in the response
to the three survey items may explain the rejection
of mercy killing, euthanasia, and the right to
terminate one’s own life, and to assist others in the
act of terminating their lives. These values related
to religious beliefs may have an impact on their
attitudes toward various lifestyle and domestic
issues and the general social perspective (Ladner,
1998, Boyd-Franklin 2003, Edwards, 2014).

Issues related to lifestyle, domestic, and
social perspectives
Although White participants were more likely

to agree that their personal values supported fidelity
in marriage, more African American participants
adhered to the personal value of abstaining from
sexual intercourse prior to marriage and were more
likely to agree to urge sexual responsibility for
their clients. The findings revealed that although
the overwhelming majority of the two groups
indicated that they did not embrace abstaining from
sexual intercourse prior to marriage, statistically
more African American participants embraced
that view as well as that of being supportive of
interracial marriage. In addition, African American
participants suggested that having multiple children
without ever being married was outside of their core
value system. Furthermore, this corresponds to the
impact of cultural religiosity.

The results indicated that White respondents
showed statistically significant results pertaining
to embracing a value that was supportive of
homosexual ideology and lifestyle. In contrast,
African American participants indicated that they

did not support homosexuality as it was outside of
their value system. Consequently, White participants
were more likely to disagree with advising a client to
resist same-sex affection in public. In other words,
certain White respondents would not recommend a
client to resist same-sex affection in public. This was
in response to a scenario in the survey describing a
same-sex couple that shared a vehicle to go to their
places of employment. As one of the men dropped
his partner off at his place of employment before
continuing to his own place of employment, the
men engaged in a kiss while in the parking lot as
children observed them. The survey respondents
were asked, to what degree did they believe that
the couple should restrain their public display of
affection? There was a significant difference in the
responses of the two groups, as African American
participants tended to believe that the men should
resist demonstrating their affection in public. This
was also consistent with two other items in the
survey which indicated that African American
participants did not feel supportive of homosexual
ideology and believed that homosexuality was
outside of their value system.

Statistically significant results indicated
that more African American participants did not
accept a woman’s option to refuse to work outside
of the home (being a stay-at-home mother). In a
similar question, African American participants
suggested that men should not allow women to
support them financially. This issue related to
working to earn money was reflected in another
question regarding the centrality of money and
financial wealth in the belief system. In both
sub-samples, the majority of the two groups of
respondents did not embrace money and wealth
as a personal value as these issues did not show
a strong level of importance to be central to their
value system.

Regarding the frequency of using cuss words
and vulgar language, even though the majority
of the two groups rejected it as a value, more
African American participants showed statistically
significant results that using such language was
outside of their value system.

Journal of Social Work Values & Ethics, Fall 2018, Vol. 15, No. 2 – page 45

Ethnicity, Values, and Value Conflicts of African American and White Social Service Professionals

Issues related to value conflicts with the
social work profession and family
More White respondents indicated that their

personal core beliefs as well as their cultural beliefs
were embraced by the social work profession.
African American participants showed statistically
significantly results that certain of their core and
cultural beliefs were not embraced by the social
work profession. In addition, corporal punishment
(spanking) seems to be a value with race-related
divergence. A survey item was used to ascertain the
degree to which the individual’s belief regarding
spanking was embraced by the social work
profession. A statistically significant number of
White participants indicated that the social work
profession embraced their acceptance of spanking.
Also, there was an ordinal scale for the respondents
to indicate to what degree their beliefs regarding
race were embraced by their family of origin (or
those who raised the respondent). A significant
number of African American participants indicated
that their beliefs regarding race were not in conflict
with the beliefs of their family of origin.

Issues related to social workers’ value
conflicts and emotional responses
There was a vignette describing a scenario

with a client who felt hopeless, helpless, in
despair, and who verbally indicated that he did
not have a reason to continue living. The value
dilemma was whether it was appropriate to make
a referral to a faith-based organization for support
services. There was a significant difference
between the two groups of respondents as the
African American participants tended to believe
that it would be appropriate to make a referral to
a faith-based organization for support services.
This was consistent with other responses
indicating that African American participants
had a greater identification and expression
concerning religiosity.

Another scenario in the survey described
a male client who, while married to his current
wife, maintained active sexual involvement with
several other women and fathered two children

outside of marriage. His wife was aware of his
sexual behavior but did not complain. They have
two pre-adolescent children in their household. The
husband’s sexual behavior was not related to the
reason he was referred to the social service agency.
The dilemma was whether or not it was appropriate
for the social worker to challenge the man to accept
a more responsible sexual attitude. There was
a significant difference concerning this issue as
African American participants believed that they
should urge the client to accept a more responsible
sexual attitude.

If social workers experience value
conflicts when providing services to clients, the
conflicts may have an emotional impact on the
professional. Therefore, the survey included items
for the respondent to identify which emotions they
experienced when a client chose an option that was
contrary to the professional’s belief system. Both
groups of respondents were similar in identifying
feelings such as guilt, depression, feeling
ineffective, and feeling unaffected. However, two
emotional responses, loss of integrity and anger,
showed statistical significance in prevalence as
reported by White respondents as compared to
African American participants.

Limitations
Although two ethnic groups were included in

the study, a limitation is that the sample size was small
and concentrated within a metropolitan region, which
limits the generalizability of the findings. Another
possible limitation is that the study participants with
social work degrees may have a greater sensitivity
to diversity and value-related issues due to their
educational training and standards outlined by the
NASW Code of Ethics. In addition, since there were
no survey items to distinguish study participants
with a social work degree from participants without
a social work degree, values or elements of the core
belief system of those with a social work degree as
compared to those with degrees in other related areas
could not be distinguished.

Journal of Social Work Values & Ethics, Fall 2018, Vol. 15, No. 2 – page 46

Ethnicity, Values, and Value Conflicts of African American and White Social Service Professionals

Implications for Social Work
Practice
The research findings are deemed useful

for social workers as they further develop methods
related to relationship building and addressing value
conflicts in the social worker-client dyad across
ethnic and cultural groups. Issues related to value
conflicts may contribute to cognitive dissonance and
the resulting frustration could be expressed through
various defense mechanisms (e.g. displacement,
projection, and denial). Therefore, it is important
for social workers to be able to identify and
understand their core values and to determine ways
to reconcile the variations, distortions, and rigidity
among various belief systems. If social workers
lack understanding of their own core belief systems
or do not contain them while interacting with a
client, then challenges may occur in the professional
relationship. Five problematic issues that may take
place when there is value conflict between the
practitioner and client include (Edwards & Allen,
2008; Edwards, 2014) challenges in establishing
rapport, decreased service quality, professional
burnout, social worker’s sense of integrity loss,
and a negative impact on a client’s right to self-
determination by imposing one’s own values.
Therefore, it is essential for social workers to be
aware of the significance of their value orientations.

This study highlights major value-
related issues that may contribute to limiting the
effectiveness of social work practice. This study also
emphasizes the need for stressing value conflicts,
value incongruence, and the need for self-awareness
in social work education. The concepts and value-
related issues may serve as areas for self-examination
as well as topics for classroom discussion and
homework activities. In addition to implications
for university teaching and application for those in
professional social work practice, the data presented
in this research may be helpful for those who conduct
in-service trainings for professionals to address
specific ways to implement ethical and value-related
decision-making processes that are related to race
and ethnicity.

In conclusion, social workers need a
meaningful understanding of the variations related
to values that are embraced by diverse groups.
This understanding may facilitate and enhance
interpersonal relationships and allow professionals to
conceptualize life issues that shape clients’ decision-
making processes. Although the participants for this
study may have received a form of social service
education, the research results indicate that there are
value-related conflicts associated with ethnicity and
practice decisions. The NASW Code of Ethics outlines
standards of practice which highlight cognizance of
social justice, self-awareness, and appreciation for
diversity. The underlying issues explored through
this study are related to emphasizing the key tenants
embedded in the NASW Code of Ethics. To further
enhance the knowledge related to the findings of this
current study, recommendations for areas of future
research include a larger sample size with broader
demographics including various locations and ethnic
groups. A larger sample size would also allow for the
examination of possible difference between social
workers as compared to social service professionals
with an academic degree in a related field.

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Contents lists available at ScienceDirect

Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Review article

rajectories of women’s abortion-related care: A conceptual framework

Ernestina Coasta,∗, Alison H. Norrisb, Ann M. Moorec, Emily Freemand

a Dept. of International Development, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
bOhio State University, United States
cGuttmacher Institute, United States
d PSSRU, London School of Economics and Political Science, UK

A R T I C L E I N F O

Keywords:
Induced abortion
Conceptual framework
Systematic mapping

A B S T R A C T

We present a new conceptual framework for studying trajectories to obtaining abortion-related care. It assembles
for the first time all of the known factors influencing a trajectory and encourages readers to consider the ways
these macro- and micro-level factors operate in multiple and sometimes conflicting ways. Based on presentation
to and feedback from abortion experts (researchers, providers, funders, policymakers and advisors, advocates)
(n=325) between 03/06/

201

4 and 22/08/2015, and a systematic mapping of peer-reviewed literature
(n=424) published between 01/01/2011 and 30/10/2017, our framework synthesises the factors shaping
abortion trajectories, grouped into three domains: abortion-specific experiences, individual contexts, and (inter)
national and sub-national contexts. Our framework includes time-dependent processes involved in an individual
trajectory, starting with timing of pregnancy awareness. This framework can be used to guide testable hy-
potheses about enabling and inhibiting influences on care-seeking behaviour and consideration about how
abortion trajectories might be influenced by policy or practice. Research based on understanding of trajectories
has the potential to improve women’s experiences and outcomes of abortion-related care.

1. Introduction

Abortion is a common feature of people’s reproductive lives. An
estimated 56 million induced abortions occur annually (Sedgh et al.,
2016), of which 54.9% (49.9%–59.4%, 90% C.I.) are unsafe (Ganatra
et al., 2017). Unsafe abortion is a major public health problem, espe-
cially in contexts where access to legal abortion is highly restricted. An
estimated 7.9% (4.7%–13.2%, 95% C.I.) of maternal deaths are due to
unsafe abortion (Say et al., 2014); unsafe abortion is also a leading
cause of maternal morbidity. While medical procedures for inducing
safe abortion are straightforward, whether or not an abortion is avail-
able or safe or unsafe is influenced by a complex mix of politics, access,
social attitudes and individual experiences. Up to 40% of women who
experience abortion complications do not receive sufficient care (Singh
et al.,

200

9). Understanding the complexity around obtaining abortion-
related care is urgently needed, especially in light of the intense policy
attention abortion receives. Abortion care is a landscape in flux, with
rapid increases in access to and use of pharmaceuticals to induce
abortion (Kapp et al., 2017), and shifting national and international
laws, policies, treaties, protocols and funding provision (Barot, 2017a,
b).

In recent years, research has helped elucidate abortion-related

practices. There is increased recognition of the scale and consequences
of unsafe abortion, including the costs for both women and health
systems, in a range of legal settings (Singh et al., 2014). Inequalities in
accessing abortion-related care have been identified in many settings,
associated with multiple individual characteristics including, but not
limited to, age (Shah and Ahman, 2012), marital status (Andersen et al.,
2015), ethnicity (Dehlendorf and Weitz, 2011), geographic location
(Jones and Jerman, 2013) and economic circumstances (Ostrach and
Cheyney, 2014). Women experience multiple, intersecting inequalities
in access to abortion-related care (Becker et al., 2011). The critical role
of delays in abortion-related care-seeking (Foster et al., 2008; Sowmini,
2013) and of what happens when women are denied services are better
understood (DePiñeres et al., 2017; Gerdts et al., 2014). We know much
more about attitudes and stigma around abortion (Faúndes et al., 2013;
Hanschmidt et al., 2016). Making sense of this body of research so that
it can inform effective policy and help identify salient gaps in knowl-
edge is a substantial endeavour. We lack synthesis of the known time-
and context-specific influences on trajectories to abortion-related care.
Conceptual frameworks of abortion-related care have dealt only with
discrete aspects of women’s experiences, such as determinants of use of
a safe abortion programme (Benson, 2005) or decisions which lead
women to experience post-abortion complications (Banerjee and

https://doi.org/10.1016/j.socscimed.2018.01.035
Received 29 August 2017; Received in revised form 23 January 2018; Accepted 24 January 2018

∗ Corresponding author.
E-mail address: e.coast@lse.ac.uk (E. Coast).

Social Science & Medicine 200 (2018) 199–

210

Available online 31 January 2018
0277-9536/ © 2018 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/BY/4.0/).

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https://www.elsevier.com/locate/socscimed

https://doi.org/10.1016/j.socscimed.2018.01.035

mailto:e.coast@lse.ac.uk

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Andersen, 2012).
The conceptual framework we propose considers all the factors in-

fluencing a woman’s trajectory to obtaining abortion-related care (safe
abortion, unsafe abortion and/or post-abortion care). Obtaining abor-
tion-related care can involve many steps and be non-linear (Marecek
et al., 2017). We define an abortion trajectory as the processes and
transitions occurring over time for a pregnancy that ends in abortion.
We use ‘trajectory’ because it incorporates the concept of time – critical
for understanding abortion-related care-seeking since safe abortion
ceases to be an option as pregnancy progresses (the exact limit varies
depending on context). We use the shorthand descriptor ‘women’ but
acknowledge adolescents and transgender men within that.

Abortion is distinct from other healthcare-seeking behaviour since:
i) legality and understanding of legal rights overlay an individual’s
pathway to care, ii) women’s abortion options are determined by the
gestational age of the pregnancy, iii) abortion is episodic, not chronic,
iv) abortion is stigmatised, and v) only women receive abortion-related
care. Three main groups of health-related theories might be employed
to understand and explain abortion-related care-seeking: determinant,
socio-ecological, and pathway. These theories have rarely been used to
frame research on obtaining abortion-related care. Theoretically-in-
formed research on abortion has tended to employ explanatory fra-
meworks related to other domains including stigma (Lipp, 2011), policy
(Aniteye and Mayhew, 2013), lifecourse (Edmeades et al., 2010), re-
productive agency (Cleeve et al., 2017), reproductive justice (Katz,
2017), post-colonial feminism (Chiweshe et al., 2017) and social psy-
chological frameworks (Cockrill and Nack, 2013).

Determinant health-related theories are models that elucidate a set
of explanatory factors for the use of healthcare (Ajzen and Fishbein,
1980; Ajzen and Madden, 1986; Andersen, 1995; Bandura, 1977;
Becker, 1974; Rosenstock, 1966). They remain influential in the
framing of research on health care-seeking, health service use and
health behaviour change (Babitsch et al., 2012; Ricketts and Goldsmith,
2005). Determinant theories have been criticised for their underlying
individual rational actor orientation, focusing on characteristics of
users versus non-users of care but providing little insight into dynamic
care-seeking processes (Mackian et al., 2004; Pescosolido, 1992). Socio-
ecological models (McLeroy et al., 1988; Stokols, 1996) consider mul-
tiple levels (e.g.: structural, community, individual) of influence on
behaviour, and reciprocal causation between behaviour and social en-
vironments, unlike determinant models that largely conceptualise
healthcare decision-making and use as an individual-level process.
However, simple socio-ecological models are limited in their re-
presentation of time-dependent processes and events. Pathway-based
models, which disaggregate healthcare decision-making into con-
stituent steps, challenge frameworks that conceive each health care-
seeking event in isolation (Mackian et al., 2004; Pescosolido, 1992).
Understanding abortion-related care-seeking requires dynamic process-
oriented perspectives; the circumstances of a pregnancy leading to an
abortion unfold in the space of a few weeks and can be highly un-
predictable. Abortion-related care-seeking cannot be understood only
through a linear course of action; it is a process that responds to
changing circumstances and experiences. The conceptual framework
we present is a mechanism for showing interrelatedness across the
various temporal and spatial dimensions that influence and shape

abortion-related care-seeking for one pregnancy. In this paper we i)
review all influences on obtaining abortion-related care, ii) organise
these into a conceptual framework, and iii) discuss how our framework
can facilitate new research to better understand obtaining abortion-
related care.

2. Methods

We used an inductive two-step approach to build this conceptual
framework: initial drafting based on expert research and practice
knowledge, and subsequent systematic evidence mapping of peer-re-
viewed literature.

We originally conceived the conceptual framework at an interna-
tional seminar (IUSSP, 2014). Thematic analysis of issues reported in
the papers presented at the seminar, which included studies from
Africa, Asia, Latin America and Europe (n=24), along with authors’
practice knowledge, were used to draft a first iteration of the frame-
work based on a thematic analysis of issues reported in the seminar
papers. The first draft of the framework, which was also informed by
the authors’ practice knowledge, was presented and discussed at the
end of the seminar. Subsequent iterations of the framework were in-
tensively discussed among the authors over several months and pre-
sented to specialist audiences at national and international meetings
(Table 1) and continually revised following their feedback. This process
introduced additional components to our framework, such as the im-
portance of national policies not directly related to health (e.g. edu-
cation and welfare policies), and elaborated specific components (e.g.
relief as an impact of abortion on mental health; the addition of caste-
based inequalities among those shaping social positions on fertility and
abortion). In addition to individual components, presentation and
feedback to specialist audiences shaped the structure of the conceptual
framework, informing our distinction between this framework and
socio-ecological models and our efforts to present the framework vi-
sually so as to maximise its utility.

To confirm that the conceptual framework comprehensively cap-
tured all documented influences on obtaining abortion care we con-
ducted a systematic evidence mapping of English-language peer-re-
viewed literature. Evidence mapping is an evidence synthesis
methodology that is a variant of the systematic review (Miake-Lye
et al., 2016); it is a systematic search of a broad field that describes as
widely as possible all of the literature relating to the topic without
limiting to studies that assess the strength or direction of relationships.
It methodically identifies and develops a map of the literature (Clapton
et al., 2009) and is increasingly used in a range of social sciences
(Miake-Lye et al., 2016). Evidence mapping can be much more in-
clusive than a systematic review: our only quality criterion was that the
study should be published in a peer-reviewed journal. Multiple refer-
ences based on the same sample were not excluded (as would be the
case in a systematic review) since data generated from one study po-
pulation might investigate different issues of relevance.

Three electronic databases [PubMed, ScienceDirect, JSTOR] of peer-
reviewed literature were searched for items published in English be-
tween 01/01/2011 and 30/10/2017. These databases were selected for
their coverage of biomedical and social science research. Combinations
of relevant search terms were developed and tested for sensitivity. The

Table 1
Presentations of the conceptual framework to expert audiences during its development.

Event Participants (N)

International Seminar on Decision-making regarding abortion-determinants and consequences. Nanyuki, Kenya. 3–5 June
2014.

Abortion researchers (31)

Abortion@LSE: an e-conference. 8–9 June 2015. Abortion researchers, activists and providers (156)
Ipas. Chapel Hill, NC. June 26, 2015 Abortion researchers and community advisors (8)
Psychosocial workshop. San Diego, CA. April 29, 2015 Abortion-specific researchers (70)
Population Association of America (2015) Annual Meeting. San Diego, CA. April 30-May 2, 2015 Social science researchers (52)

E. Coast et al. Social Science & Medicine 200 (2018) 199–210

200

final combinations of search terms were: (abortion* OR termination*
OR (menstru* AND regul*)) AND (Deci* OR Pathw* OR Passage* OR
Rout* OR Course* OR Traject* OR Trail* OR Track* OR Direction*).
Fig. 1 illustrates the process.

After removing duplicates, all items identified by the search were
screened on their title and abstract to determine inclusion. Items were
included if: published in full text in English in a peer-reviewed journal
between 01/01/2011 and 30/10/2017, and the abstract included any
factor that either influenced, or was mentioned as potentially influen-
cing, obtaining abortion care. Non-peer-reviewed items (e.g. comment,
book review, letters) were excluded. Where inclusion or exclusion could
not be determined on the basis of title and abstract, the full text was
screened. Articles were included if they considered trajectories, or in-
fluences on trajectories, to abortion-related care. Details of included
items are available [Appendix A Supplementary Data]. We compared
the full text of each included item (n=424) to the draft conceptual
framework. Components we identified to be inadequately captured by
the draft framework were incorporated in subsequent iterations. These
included both an additional component ‘quality of care’, which super-
seded a previous inclusion of ‘health workforce treatment of women’, as
well as amendments to components, such as broadening ‘perception of
provider care’ to ‘perception or experience of provider care’. All deci-
sions about changes to framework components were made as a team,
drawing on our reading, expertise and the discussions we had about the
framework with experts during its development.

Our search methodology has limitations. Language and date re-
strictions mean that including additional languages or years might have
yielded additional information; however, our search did yield evidence
from all geographic regions, including research conducted in non-
English languages but published in English. By focusing on more re-
cently published evidence (post-2010), our framework reflects a con-
temporary summary of the field of abortion-related care-seeking

evidence. We searched only three databases, selected for their range
(biomedical and social science); additional databases might include
additional evidence, although the number of duplicates (n=1027)
yielded by our search suggests that our strategy is robust. Our search
only included abortion-related terms (abortion, termination, menstrual
regulation); our search will not have yielded articles that discuss
pregnancy decision making without reference to abortion. Our mapping
approach means that the relative weight and rigour of evidence on the
factors identified remain unknown. The final conceptual framework
represents all aspects of trajectories to abortion-related care as illumi-
nated by expert researchers, practice knowledge, and in 424 articles.

3. Conceptual framework of trajectories to abortion-related care

A conceptual framework is a set of ideas, presented in a structured
way to help understand a phenomenon (Reichel and Ramey, 1987). Our
framework (Fig. 2) represents “the main things to be studied” (Miles
and Huberman, 1994 p.18) with regard to trajectories to obtaining
abortion-related care. It synthesises influences shaping these trajec-
tories, grouped in three domains to highlight the individual- and macro-
contexts shaping abortion-related care:

1. Time-oriented abortion-specific experiences: beginning with preg-
nancy awareness, events that women may experience in seeking
abortion-related care.

2. Individual contexts: characteristics that influence whether a woman
obtains abortion-related care, including interpersonal networks.

3. (Inter)national and sub-national contexts: the context within which
an individual – and her abortion – are situated.

To understand the trajectory of a pregnancy that ends in abortion, it
must be situated within individual- and macro-contexts; all three

Fig. 1. Systematic evidence mapping process.

E. Coast et al. Social Science & Medicine 200 (2018) 199–210
201

domains are interrelated. For example, access to pregnancy testing
(abortion-specific experiences) might be influenced by a woman’s
wealth (individual context) and the health system (inter/national con-
text). The framework is globally applicable, capturing concepts that are
relevant across time and space. For readability, our framework includes
brief phrases or single words for each component. This comprehensive
visual overview is the primary contribution of our article. To illustrate
its relevance across settings, in the following sections we explicate the
framework’s components using examples.

We begin at the individual level – a woman’s abortion-specific ex-
periences, her context and characteristics, and then discuss the macro-
level influences on trajectories to obtaining abortion-related care.
Unlike the conceptual framework itself (Fig. 2), this requires us to
present the three domains in some order. We start with experiences of a
specific abortion since a woman may have more than one abortion in
her lifetime, and a single trajectory to obtaining care might be com-
posed of more than one abortion attempt. Our evidence-based illus-
tration of each component is preceded by bullet points that provides
further examples.

4. Abortion-specific experiences

The actions women take on their trajectories to (attempt to) ter-
minate a pregnancy are shaped by factors in their individual contexts
and by their macro-environments. We consider in this section the
multiple events that women may experience in obtaining an abortion.
The trajectory begins with becoming aware of a pregnancy and ends
with abortion-related care; in between there may be (non-) disclosure
and negotiation about abortion, seeking resources to obtain the

abortion, and more than one attempt to terminate the pregnancy, with
sequelae of those attempts. These events may not be linear; for ex-
ample, a woman may disclose to an individual who provides informa-
tion that the woman acts upon; this information may not lead to an
abortion, so the woman might disclose to a different person in order to
seek different or additional information or resources to procure an
abortion (Moore et al., 2011b). Emotions about pregnancy, abortion
and parenting influence all steps of abortion-specific experience. Each
step is embedded in contexts both micro (individual) and macro; we
address the importance of these contexts in subsequent sections.

4.1. Awareness of pregnancy

• Timing of awareness (e.g. knowledge of pregnancy symptoms or
pregnancy testing, denial of pregnancy)

• Access to/use of pregnancy testing (e.g. cost, availability, source)
• Access to/use of pregnancy diagnostics (e.g. foetal abnormality, sex
determination)

Decision making around abortion-related care is highly time-sensi-
tive. Abortion at earlier gestations is safer than later gestations and laws
and guidelines vary about the maximum gestation at which abortion is
permitted, under which conditions and with which method. Time be-
tween conception and awareness of pregnancy is inversely related to
how much time a woman has to decide about abortion. In many set-
tings, pregnancy tests are unavailable or unaffordable (Stanback et al.,
2013) and women’s estimation of gestational age – particularly for
younger and/or nulliparous women – can be incorrect (Foster and
Kimport, 2013; Janiak et al., 2014).

Fig. 2. A conceptual framework for understanding women’s trajectories in seeking abortion-related care.

E. Coast et al. Social Science & Medicine 200 (2018) 199–210

202

The timing of action to confirm a pregnancy can be linked to the
social risks of pregnancy. When a pregnancy is undesirable a woman
may avoid acknowledging the pregnancy to herself (Sowmini, 2013).
For example, young unmarried women in an Indian study were less
likely to recognise (or acknowledge) their pregnancy than their married
counterparts, and unmarried women had higher levels of second tri-
mester abortions (Jejeebhoy et al., 2010). In addition, the gestational
age at which diagnostic testing (if available or used) for foetal ab-
normality and/or sex – factors that may influence whether the woman
wants an abortion – varies by context (Gawron et al., 2013).

4.2. Disclosure

• Ability to disclose, to whom (e.g. family, friend, partner, health
professional, provider, acquaintance) and the implications of that
(e.g. the confidant’s knowledge, experience, advice, reaction)

• Negotiation around abortion with (any) others involved in the de-
cision (e.g. partner, relatives, (potential) abortion providers)

• Reasons for disclosure or non-disclosure (e.g. policies around
partner or parental notification)

• Timing of (any) disclosure(s)
• Emotions about disclosure (e.g. fear of reactions, shame, stigma,
relief)

Some women do not disclose their pregnancy and take abortion
decisions alone (Bowes and Macleod, 2006). For women who do dis-
close their pregnancy, the person(s) to whom they disclose may influ-
ence abortion decisions, be a source of (mis-)information, and/or pro-
vide access to resources for abortion-related care. Disclosure may lead
to negotiation about whether or how to abort. Decisions about dis-
closure are influenced by wider social norms and belief systems. For
example, both the choice of confidant(s) and their influence are em-
bedded in the woman’s larger context of relationships and ability to
access resources (Nyanzi et al., 2005). In a study among young women
in urban Cameroon, disclosure to male partners was influenced by the
need for financial support for the abortion (Calvès, 2002). Disclosure
discussions are enmeshed in the macro-context; more limited abortion
options may necessitate more disclosure in order to seek information
about care (Rossier, 2007), or disclosure may be enforced due to
partner or parental notification protocols. Disclosure may lead to
emotional support around an abortion decision or pressure to abort or
not abort (Schwandt et al., 2013). Disclosure of pregnancy may lead to
a range of negative outcomes, including condemnation and abandon-
ment (Tangmunkongvorakul et al., 2005) or punishment (Umuhoza
et al., 2013). Fears about the implications of disclosure of the preg-
nancy or the desire to abort may delay initiating the abortion
(Labandera et al., 2016) or compel a woman to seek a less safe abortion
(Schuster, 2005).

4.3. Ability to access resources for abortion

• Social/emotional support for/against abortion (e.g. from partners,
relatives, friends, providers, doula)

• Material/physical resources (e.g. transport, money, childcare,
ability to miss education or work, insurance, commodities, in-
formation)

• Access to abortion provider/method (e.g. border crossing, journey
time, face-to-face versus web-based provider)

Women’s ability to access resources to procure an abortion is im-
portant in every setting. Social and emotional support for or against
abortion-related care is linked to whether, and to whom, the pregnancy
is disclosed. A friend or partner providing support may influence the
location and type of abortion (Conkling et al., 2015). Access to financial
resources, frequently linked to social support, may be critical to a wo-
man’s ability to access abortion information and services. In Latin

American countries where abortion is illegal, access to economic re-
sources and emotional support were critical for accessing a medically
supervised medical abortion in a clandestine clinic (Zamberlin et al.,
2012). One quarter of urban Mozambican women who sought a first
trimester termination at a public hospital delayed care in order to have
sufficient funds to pay user fees (Mitchell et al., 2010). Women’s sources
of information extend beyond their social networks to include adver-
tising, agents, the internet and other clients of abortion providers
(Gerdts et al., 2017; Osur et al., 2015). The difference between a safe or
unsafe abortion may be whether someone can pay for a safer procedure
(Moore et al., 2011b) or whether she can travel to avoid more re-
strictive laws to locations with more permissive laws (Foster et al.,
2012). Accessibility of abortion services is multidimensional and closely
linked to macro-environmental factors including legality, distance and
cost (Sethna and Doull, 2013) and individual contextual factors such as
mobility (Azmat et al., 2012).

4.4. Abortion attempt(s)

• Gestational age
• Counseling (e.g. (non-)directed, (un)supportive, waiting period, re-
ferrals)

• Location abortion sought or conducted (e.g. home, (un)regulated
facility)

• Type of abortion (e.g. (un)safe, (il)legal, medical, surgical, self- or
provider-initiated)

• Perception or experience of provider care (e.g. (dis)respectful,
judgmental, confidential, private, pain management, exposure to
protests/harassment)

The complexity and length of abortion trajectories is heterogeneous,
influenced not only by a woman’s context, but also her experiences
relating to that specific pregnancy, and may range from a legal,
straightforwardly-accessed safe process, to multiple unsafe attempts
(Coast and Murray, 2016). In some settings, women may have options
about what kind of abortion to access; in others, women may not
(perceive themselves to) have any choices (Banerjee and Andersen,
2012). Gestational age at the time of the abortion may have implica-
tions for the woman’s health and affect the type of abortion provided; if
women present beyond a gestational limit, they can be denied a legal
abortion (Harries et al., 2015). Especially, but not only, in contexts
where abortion is stigmatised and/or illegal (or perceived to be illegal)
in general or at advanced gestational age, women self-induce using
household objects, traditional methods, and abortion medications
(Rasch et al., 2014; Vallely et al., 2015).

Abortion trajectories may also be influenced by professional advice.
Provision of counselling may differ depending upon a woman’s cir-
cumstances (Ramachandar and Pelto, 2002), policies including man-
dated waiting periods, and the socio-legal (Gerdts and Hudaya, 2016)
and funding (discussed below) context of abortion. Although good
counselling should be non-directive, this does not necessarily happen
(Vincent, 2011). Counselling may play an important role in women’s
choice of abortion method (Tamang et al., 2012), however not all
women who seek abortion want counselling (Cameron and Glasier,
2013) or the counselling that is provided (Moore et al., 2011a). A
woman who expects judgemental or disrespectful advice or counselling
from one provider may seek care elsewhere. The perception and ex-
perience of negative responses from health practitioners against women
seeking abortion are widely reported (e.g. Ghana (Schwandt et al.,
2013), Brazil (Diniz et al., 2012), Vietnam (Nguyễn et al., 2007)).

When women have a choice about abortion type, their decision may
be informed by their understandings of abortion-related care and its
quality, including comfort, pain (Allen et al., 2012), flexibility of when
the abortion can occur, (perceived) confidentiality, provider attitudes
towards privacy, and stigmatising provider behaviours (Labandera
et al., 2016). In some settings, anti-abortion protests outside abortion

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203

providers may affect abortion care-seeking by encouraging women to
avoid providers where they may have to confront them (Kimport et al.,
2012a).

4.5. Perceived and experienced outcomes from (attempted) abortion

• Physical health (e.g. pain, side effects, future fertility, resulting or
avoidance of morbidity or mortality)

• Mental health (e.g. depression, relief, guilt, shame)
• Socio-economic effects (e.g. out of pocket payments, legal/penal
consequences, maintaining a relationship, education or occupation)

Once a woman has obtained or attempted an abortion, she may
require treatment for abortion complications. Physical health con-
sequences of abortion are almost entirely confined to events following
unsafe abortion (Gerdts et al., 2015). Whether and how a woman who
needs post-abortion care seeks it has parallels to those factors that in-
fluenced obtaining the abortion: recognition of the need for care (post-
abortion complications) (Ngoc et al., 2014), availability or cost of post-
abortion care (Leone et al., 2016), and social support for managing
complications (Lubinga et al., 2013). Delays in initiating or receiving
post-abortion care, which might be due to practitioners withholding
care or women withholding information or both, are an established
cause of maternal morbidity and mortality. A woman may experience a
range of emotional sequelae after an abortion, including relief, regret,
ambivalence, shame and guilt (Andersson et al., 2014; Subramaney
et al., 2015) that may change over time (Rocca et al., 2015). In many
settings, women worry about their future fertility following a termi-
nation (Moore et al., 2011c).

4.6. Emotions about pregnancy, childbearing or abortion

• Reasons for choosing abortion (e.g. foetal anomaly, social, eco-
nomic, health [including HIV status], age, parity)

• Individual’s and others’ (e.g. partners’, parents’, in-laws’, friends’,
medical professionals’, counsellors’) emotions and advice

• Emotions (e.g. ambivalence, certainty) about pregnancy or child-
bearing or abortion

Women may have conflicting and changing emotions about being
pregnant, childbearing, and abortion (Aiken and Potter, 2013;
Andersson et al., 2014), which may be influenced by reactions received
or anticipated from disclosure. A pregnancy has short- and long-term
economic and opportunity costs for women; these may be exacerbated
when the pregnancy is unintended (Gipson et al., 2008). Individual
circumstances influence whether abortion provides a better outcome
for a woman than bearing a child at that time, and women give many
reasons for having an abortion. For example, in Bangladesh, women
and their husbands described challenging life circumstances (poor
health, poverty) that influenced their decisions to terminate (Gipson
and Hindin, 2008). In some contexts, a pregnancy with close birth
spacing may be unacceptable; evidence from Ghana suggests that child
spacing played an important role in some women’s abortion trajectories
(Oduro and Otsin, 2014). These intersecting realities (social, cultural,
economic, health) may influence women’s feelings about abortion
(Biggs et al., 2013), and their self-efficacy to achieve one (Kavanagh
et al., 2012). For abortions due to foetal abnormality, emotions may be
additionally complex (Lafarge et al., 2013).

5. Individual context

The individual level domain focuses on the characteristics of an
individual that influence if, where and how she obtains abortion-related
care, including her interpersonal networks. The experiences related to
abortion-related care for a pregnancy (a woman may have more than
one abortion in her lifetime) are shaped by a woman’s context at that

point in time: her knowledge and beliefs about abortion (which may
change over time) and her characteristics at the time of the pregnancy.
This next framework domain considers how factors associated with a
woman’s individual context combine, and are affected by other do-
mains, to influence an abortion trajectory.

5.1. Knowledge & beliefs about abortion

• Awareness of possibility and sourcing of abortion care (e.g. pre-ex-
isting knowledge/knowledge sought as a result of pregnancy)

• Ability to seek accurate information about safe abortion-related care
• Knowledge about abortion (e.g. methods, legality)
• Perceptions and knowledge of abortion consequences (e.g. risks
[health, social, penal], benefits, side effects, social, economic, legal,
relationship, health)

• Beliefs about morality of abortion (e.g. faith, internalised stigma)
Women use a range of networks to access abortion information

(Carlsson et al., 2016; Kimport et al., 2012b; Osur et al., 2015), but
their ability to obtain accurate information about abortion varies
(Ramos et al., 2015). Knowledge about the possibility and sourcing of
abortion-related care might include prior experience or exposure to
abortion from social networks (Arambepola and Rajapaksa, 2014). Low
levels of knowledge about abortion legality may act as a barrier to
accessing abortion services (Marlow et al., 2014).

Women’s perceptions about the consequences – positive and nega-
tive – of care-seeking may be linked to their reasons for seeking an
abortion (Gipson et al., 2011; Ralph et al., 2014). How women, and
others involved, make sense of relative risks is important for under-
standing trajectories (Izugbara et al., 2015). Trajectories are ad-
ditionally shaped by the need to maintain secrecy (Marlow et al., 2014)
or fear of prosecution (Schuster, 2010). Whether the need to maintain
secrecy is out of fear of punishment from others or fear of exposure – for
socially-unsanctioned sex or abortion – can shape her trajectory. Con-
struction and experiences of stigma are multiple and overlapping
(Orner et al., 2011) and can impact delays in obtaining an abortion or
post-abortion care, and how that care is sought (Izugbara et al., 2015).
These trajectories may be influenced by women’s strategies to manage
their religious and moral beliefs (Cockrill et al., 2013; Schuster, 2005)
and internalised stigma (Kebede et al., 2012; Palomino et al., 2011).

5.2. Individual characteristics

• Socio-economic, demographic and health characteristics (e.g. age,
wealth, education, sexuality, gender identity, ethnicity/race, lan-
guage, legal status [e.g. legal minor, refugee, undocumented mi-
grant], partnership type [e.g. (non-)marital, (non-)consensual, ro-
mantic, commercial, transactional, incestuous], pre-existing health
condition [e.g. HIV, substance abuse])

• Partner/family/community context (e.g. status in household, family
role [e.g. daughter-in-law])

• Fertility intentions (e.g. non-use of contraception, contraceptive
failure, parity, sex of foetus)

• Life course aspirations (e.g. education, employment, fertility, part-
nership)

• Self-efficacy/agency (e.g. autonomy, power)
Individual characteristics, that is, a woman’s social location, as-

pirations and efficacy, influence abortion-related trajectories in mul-
tiple and intersecting ways. These include: education (DaVanzo and
Rahman, 2014), age (Clyde et al., 2013), economic status (Sundaram
et al., 2012), experience of violence (Nguyen et al., 2012; Perry et al.,
2015), health including pre-existing conditions such as HIV status or
mental illness (Barbosa et al., 2012; van Ditzhuijzen et al., 2015),
partner characteristics (Chibber et al., 2014), previous experience of
abortion (Asplin et al., 2013), ethnicity or race (Cowan, 2013), parity

E. Coast et al. Social Science & Medicine 200 (2018) 199–210

204

(Puri et al., 2011), sexual orientation and gender identity (Beaumonis
and Bond-Theriault, 2017) and religiosity (Liang et al., 2013). Re-
lationship expectations have implications for the consequences of
pregnancy, while the roles played by men in women’s trajectories are
heterogeneous, from non-involvement to mutual decision-making
(Freeman et al., 2017). Women’s aspirations – or others’ aspirations for
them – including (future) fertility, education, employment and re-
lationships can contribute to the decisions around abortion (Gbagbo
et al., 2015; Gomez-Scott and Cooney, 2014). In contexts where women
have control over their fertility decisions, women’s autonomy or self-
efficacy to obtain an abortion is mediated by factors such as age
(Domingos et al., 2013) or mobility (Azmat et al., 2012).

The extent and direction of the influence of individual social, eco-
nomic, demographic and health characteristics depends on context.
Abortion access for young people who have not reached the age of
majority varies by regulations about parental notification (Kavanagh
et al., 2012). The role of men’s involvement in abortion trajectories
reflects not only the type of relationship in which the pregnancy oc-
curred but also the gendered norms and roles of the woman’s culture.
Women may seek abortion to prevent anticipated negative relationship
consequences (Vallely et al., 2015). Fertility decision-making power
may not rest with the pregnant woman, and others (e.g. her partner,
mother-in-law, mother) may be important influencers (MacQuarrie and
Edmeades, 2015; Madkour et al., 2013). Individual characteristics in-
tersect to affect women’s trajectories; a study of women who had an
abortion in the Netherlands found that, compared to women without
prior mental disorders, women with a psychiatric history were more
likely to score lower on abortion-specific self-efficacy (van Ditzhuijzen
et al., 2015).

6. The (inter)national and sub-national context

This framework domain describes the context within which an in-
dividual woman – and her abortion – is situated. It includes components
operating at a range of scales, from an individual’s community to in-
ternational influences. Abortion-specific and individual-level factors
occur within and are shaped by (and shape) macro-level structural and
institutional environments. Influences include (il)legality of abortion,
punishment of those who violate laws, accessibility of safe abortion,
and normative constructs of abortion and fertility.

6.1. Structural and institutional environment

• Legal/penal/regulatory environment (sub-national, national, re-
gional, international) (e.g. penalties for providers/procurers of
abortion; constitution; (non-)commitment to regional/international
treaties; treatment protocols [including gestational limits, mandated
waiting times/referrals]; commodities registration, marketing and
licensing)

• Government (e.g. law enforcement, judicial role, resources [e.g. fi-
nancial, human])

• Civil society: position and influence
• Faith-based institutions: position and influence
• Role of institutional environment in personal decision-making
• Anti/pro-natalist and associated policies (e.g. education, employ-
ment)

• Fragility of state (e.g. (post-)conflict, crisis)
Institutions (e.g. political, governmental, faith-based, private, civil

society) operate and interact at global, regional, multilateral, national
and sub-national levels to shape availability of abortion care in local
contexts. The influence of institutions on each other, and each in-
stitution’s position on abortion, is interwoven. International institutions
can shape the availability of abortion in other national and sub-national
contexts, both ideologically and financially. For example, the issue of a
USA Presidential Memorandum that reinstated and extended the

‘Mexico City Policy’ in 2017 prevents non-governmental organisations
and agencies operating anywhere in the world from providing, referring
or giving information about abortion services if they receive federal
funding for any part of their work, regardless of local context (laws,
bills of rights) or the professional codes of health practitioners em-
ployed in these organisations (Singh and Karim, 2017). Abortion is
regulated almost everywhere; to date only Canada has effectively de-
criminalised abortion (Berer, 2017). Regulation is heterogeneous re-
garding abortion methods and gestational limits, including the grounds
upon which second trimester abortions can occur (Boland, 2010). Laws
may be made nationally or sub-nationally, and might apply to specific
geographic regions (Sánchez Fuentes et al., 2008) or population sub-
groups (Grindlay et al., 2011). The legal position on abortion might be
specified in penal codes, but is also set out in health legislation, court
decisions, constitutions, or clinical guidelines (WHO, 2017), and may
change over time (Bergallo and Ramón Michel, 2016) or be affected by
international convention (Daly, 2011). For example, priorities for
health services may change in conflict settings (Palmer and Storeng,
2016), along with social rules governing sexual behaviour, increasing
risks of unwanted pregnancy and unsafe abortion (McGinn and Casey,
2016). Abortion for rape victims is legal under the Geneva Conventions,
customary international law, and international humanitarian law re-
gardless of national laws, but provision is variable (GCJ, 2011).

However, legal position only partly determines access to abortion
care (Berer, 2013). Policymakers and service providers alike have may
low levels of knowledge about abortion legality, influencing how and
whether they provide care (Moore et al., 2014). Inaccurate knowledge
of the law may prevent otherwise willing practitioners from providing
legal services (Ramos et al., 2014), while practitioners may provide
services clandestinely despite legal restrictions (Pheterson and Azize,
2005). Abortion regulation may be at best difficult to understand, and
at worse contradictory (Boland, 2010) so that arbiters of law them-
selves, including police and prosecutors, lack clarity about what is (il)
legal (Suh, 2014). Where abortion is legally restricted, there may be
punishments specified for providers and/or procurers; these punish-
ments may be rarely enforced or enforced unequally (Bankole et al.,
2008). Abortion laws, policies and services shift in response to re-
ligious, societal and political change (Hodes, 2013). National and in-
ternational civil society includes advocates for both increased and re-
duced access to abortion services (Berer, 2017; Castle, 2011). For
example, following legal reform in Colombia, feminist civil society or-
ganisations used strategic litigations to counter backlash from institu-
tions opposed to abortion (Ruibal, 2014). Communities mobilise (and
can be mobilised); an intervention to educate communities about gy-
naecologic uses for misoprostol in Kenya and Tanzania, where abortion
is legally restricted, showed it was possible to share information
without political backlash (Coeytaux et al., 2014). Transnational ad-
vocacy is increasingly used to increase the visibility and scale of
abortion debates and information (Stevenson, 2014).

Faith-based organisations influence access to abortion depending on
the dominance of religion(s) in a setting, the extent to which religion
influences governance and health service delivery, and permissibility of
abortion within religious teaching and local interpretation (Al-Matary
and Ali, 2014). For example, the Roman Catholic Church has a strong
stance against abortion yet its influence on national laws and policies is
stronger in Catholic Latin America, where abortion is severely re-
stricted, than in Catholic Western Europe, where abortion is widely
available (Blofield, 2008). Religious institutions’ messages on abortion
can have multiple influences including how a woman perceives the
morality of abortion and how women who have abortions are treated by
society. Faith-based organisations may also shape abortion trajectories
as healthcare providers (Eisenberg and Leslie, 2017). Institutional in-
fluence on reproduction, including abortion, range from coercive and/
or explicit mandates to implicit disincentives or inducements (Barot,
2012). These might be linked to policies, such as school exclusion of
pregnant pupils, or legality of anti-abortion protests.

E. Coast et al. Social Science & Medicine 200 (2018) 199–210

205

6.2. Health system

• Formal (e.g. finance [public, private, insurance], infrastructure,
governance, health information, training, investment priorities,
provision for conscientious objection, commodities [including drug
regulation, marketing and distribution], human resources, stigma/
harassment experienced by providers, diagnostic testing, abortion
conditionality, parental/spousal notification)

• Informal (e.g. alternative and/or illegal providers [e.g. traditional
healers or herbalists, unlicensed doctors or pharmacists], self-ad-
ministration of abortion)

• Quality of care (e.g. health workforce treatment of women, acces-
sibility of (il)legal and/or (un)safe services, privacy, confidentiality)

Trajectories to abortion care are shaped by complex health systems
that incorporate formal and informal components, government and
non-government provision, infrastructure (e.g. where health facilities
are located and how they receive resources, including commodities),
flows of information (e.g. health messages about where, how and for
whom abortion is provided), and level of investment. For example,
access to safe abortion is influenced by who is legally permitted to
provide services. In many settings only doctors provide services; where
services are delivered by mid-level providers, safe abortion care has
become more accessible (Berer, 2009). Less- or un-regulated abortion
care is delivered by a range of practitioners, including public sector
practitioners with private clinics at their homes, herbalists, traditional
birth attendants, and pharmacists (Norris et al., 2016). The safety of
abortion provided outside of the formal health system or by less-regu-
lated providers varies. Informal abortion may be sought because: these
services are more established; of limited knowledge regarding how to
access care from formal health systems; of understandings about quality
of care provided within each system; or, because of perceptions or ex-
pectations of poor and/or non-confidential treatment within formal
systems. Health system financing (e.g. free, subsidised, insurance, co-
payments) affects how abortion-related care is sought and paid for
(Foster and Kimport, 2013). Funding and services in some settings can
be tied to laws and policies of donor countries (Barot, 2017b). Health
systems may delay or act as barriers to women seeking abortion care,
including requirements such as multiple referrals or follow-up visits,
mandatory diagnostics (including ultrasound), or waiting times, par-
ental or spousal notification (discussed above), and conditionality
(French et al., 2016; Janiak et al., 2014).

Abortion-related care is additionally shaped by providers’ attitudes
and practice, which may reflect (in)adequate training (Birdsey et al.,
2016; Holcombe et al., 2015). The kind of treatment women expect to
receive from providers, including judgemental or punitive attitudes,
influences where and when abortion care is sought. Provider attitudes
towards abortion influence the availability of abortion care – both
numbers of practitioners and information about finding them (Harries
et al., 2009). Providers may support abortion where it is legally pro-
hibited (Vasquez et al., 2012), or refuse to provide abortion where it is
legal (Harries et al., 2009). Conscientious objection to abortion may
reflect stigma or violence providers themselves perceive or experience
(Holcombe et al., 2015), and/or serve to further stigmatise abortion
care-seeking.

Registration, marketing and distribution of drugs for inducing
abortion influence the availability of abortion, as well as the safety of
medical abortions. Within formal systems, factors including funding,
communication across different parts of the health system, and the lo-
cality and accessibility of healthcare facilities, influence drug supply
chains. Drug accessibility may be dependent upon inclusion in essential
drugs lists stocked in public facilities and provided through the national
government (Ipas, 2009) and availability for ‘off-label’ use (Fernandez
et al., 2009). For example, in the Palestinian territories, where abortion
is permitted only to save the life of the pregnant woman or when the
embryo is unviable, pharmacists provide misoprostol to women under a

greater variety of circumstances than what is legally allowed (Hyman
et al., 2013). Availability of abortion drugs is not correlated with leg-
ality of abortion: unregulated abortion using drugs is delivered by a
range of practitioners, including public sector practitioners who have
private clinics at their homes, herbalists, traditional birth attendants,
and pharmacists (Norris et al., 2016). Vendors may have limited
knowledge about effective doses, dispense drugs without reliable
knowledge of gestational age, and provide insufficient instructions
about side effects and risks, or where to seek help for complications
(Lara et al., 2011; Sneeringer et al., 2012). Poor control of drug mar-
keting and subsequent misuse of abortion drugs is particularly likely
when abortion is prohibited (Coêlho et al., 1993). However legal pro-
vision of information about illegal off-label use is a harm reduction
approach to unsafe abortion used in some settings (Hyman et al., 2013).
When drugs are acquired clandestinely, they may be counterfeit
(Powell-Jackson et al., 2015). Features of health systems related to the
quality of abortion-related care influence women’s experiences, in-
cluding choice of location or type of treatment (Hedqvist et al., 2016)
and privacy and confidentiality (McLemore et al., 2015), discussed
above. There is little agreement, however, about what constitutes
quality abortion care and the indicators to assess it (Dennis et al.,
2016).

6.3. Knowledge environment

• Access to/availability of information (e.g. safety, availability, legal,
financial)

• Quality of information (e.g. (in)correct, (non-)directive)
• Technology (e.g. mobile phone, internet)
• Media (e.g. broadcast, print, social, representations of abortion)
• Knowledge source (e.g. politicians, activists, community leaders,
health professionals, peer educators, journalists, medical profes-
sional/activist organisations)

The knowledge environment includes general discourses around
abortion and the specific information someone might know or seek
about abortion-related care (Andersson et al., 2014). This framework
component captures the importance of knowledge-sharing norms, dif-
ferential access to knowledge (mediated by individual contexts, such as
wealth, education, language), availability, penetration and types of
knowledge-sharing technologies (e.g. internet, phones) and the effec-
tiveness of knowledge-delivery systems for determining individuals’
understanding of the legal, financial and practical availability of
abortion. Who delivers messages, how they are delivered, and the
content of those messages shape the knowledge environment (Purcell
et al., 2014) and may affect service availability and use (MacFarlane
et al., 2017) or changes in laws and policies (Umuhoza et al., 2013).
Information about abortion may be appropriate to the population’s in-
formation literacy skills or it may be concealed. In the USA, information
may be obscured by facilities (e.g.: “crisis pregnancy centers”) that
advertise services for women with unintended pregnancies but deliver
counselling to dissuade women from having abortions (Rosen, 2012).
Information about abortion can include explanations about safety or
side effects of medical abortion. In South Africa, mobile phone mes-
sages to support women using misoprostol at home for early medical
abortion significantly reduced women’s anxiety and improved pre-
paredness for abortion symptoms (Constant et al., 2014).

6.4. Socio-cultural context

• Norms and acceptability of abortion (e.g. presence of stigma or
shame, religious influence)

• Fertility norms (e.g. family size, gender preferences, birth spacing)
• Norms and (in)equalities (e.g. gender, race, ethnicity, wealth, caste,
social class)

E. Coast et al. Social Science & Medicine 200 (2018) 199–210

206

Socio-cultural context includes a broad range of factors influencing
abortion trajectories, and is tightly linked to other components such as
the influence of institutions or healthcare practitioners’ willingness to
provide abortion services. Norms about abortion acceptability, in-
cluding stigma and shame, are shaped by (in)equalities (e.g. gender,
race, ethnicity). In Ghana, women who seek care following an unsafe
abortion report social stigma leading to fear, shame and embarrassment
which influenced their abortion decision-making (Tagoe-Darko, 2013).
Norms are reproduced through discourse (media, popular, medical),
institutions, communities and personal experiences (Kebede et al.,
2012). In rural South Africa, discussion about abortion revealed that
legal abortion was considered to be destructive of traditional culture,
strongly associated with a colonialist endeavour, and harmful to in-
tergenerational and gender relations (Macleod et al., 2011). Inequities
in access to abortion-related services may be affected by individual or
group characteristics, such as ethnicity or religion (Liang et al., 2013;
Sethna and Doull, 2013).

In some settings, while abortion might be normatively shameful, it
might be perceived as less shameful than a pregnancy in some cir-
cumstances (Johnson-Hanks, 2002). In other contexts, the reverse re-
lationship may prevail (Fordyce, 2012). Socio-cultural context influ-
ences whether sex-selective abortion is present, reflecting norms around
sex preference and family size (Bongaarts and Guilmoto, 2015) and
attitudes of providers, institutions and society (Hohmann et al., 2014).

7. Conclusions

We present a conceptual framework of women’s trajectories to ob-
taining abortion-related care (Fig. 2). This integrative framework helps
develop understandings of women’s abortion-related care-trajectories in
a way that identifies discrete components while at the same time re-
presenting the integration of components operating (sometimes in
conflict) at macro- and micro levels. Previous research on women’s
trajectories to abortion – including that conducted by the authors – has
tended to focus on specific aspects of trajectories. In assembling for the
first time all of the explanatory factors influencing a woman’s abortion
trajectory, our framework can be used to test theories and generate
hypotheses relevant to obtaining abortion-related care.

Our inductive approach to framework building generated a con-
ceptual framework from evidence. Our framework builds on char-
acteristics of other models of health-related behaviour. The three do-
mains – abortion-specific, individual, (inter)national – have
characteristics similar to a socio-ecological model. However, our fra-
mework is not a simple socio-ecological model because it additionally
incorporates time-dependent processes specific to abortion. The start of
any abortion trajectory begins with pregnancy awareness. In this re-
spect, our framework incorporates aspects of pathway models, ac-
knowledging the dynamic care-seeking processes that can be involved
in terminating a pregnancy. The framework is not limited by the in-
dividual rational actor-oriented framing of determinant models.

Our conceptual framework is built on expert consultation and a
systematic literature mapping. Our systematic approach is sufficiently
robust and comprehensive to assert that the framework includes the
known universe of factors affecting women’s trajectories to abortion-
related care. Our conceptual framework will need to be modified to
reflect future empirical and theoretical evidence generation.

The conceptual framework marks a significant step forward for how
researchers might conceptualise and understand trajectories to abortion
care. By specifying and linking influences, our framework can be used
to inform research design and analyses, across epistemologies, meth-
odologies, and contexts. Each component of our framework can be re-
searched in isolation; and by considering the ways in which each
component may be affected by other components, we may gain fuller
insight into factors influencing women’s trajectories. Our framework
components are flexible to adapt to the (sometimes rapidly) changing
landscape of abortion care-seeking such as the rapid increase in self-use

of medical abortion (Kapp et al., 2017). It situates the abortion trajec-
tory for a pregnancy, highlighting the critical role played by timing of
pregnancy awareness, and identifying the set of processes involved in
an individual trajectory, including multiple abortion attempts. This
identification suggests testable hypotheses about how abortion trajec-
tories might be influenced by policy or practice.

Our conceptual framework can be used to assess how, why and with
what consequences, women’s abortion-related trajectories are shaped.
Every component of our framework allows for testing hypotheses about
how abortion trajectories might be influenced by modifications to, for
example, the legal system, policy environment or individual behaviour.
Such interventions have the potential to impact abortion-related mor-
bidity and mortality outcomes.

Acknowledgements

Partial funding towards the development of this paper was from
ESRC/DFID (ES/I032967/1 and ES/L007827/1). With thanks to
Samantha Lattof and Joe Strong, for their research assistance. For cri-
tical suggestions, we thank the two anonymous reviewers of this paper.
With thanks to the funders and organisers of the IUSSP Special Seminar
on Abortion Decision-Making, at which this paper was originally con-
ceived.

Appendix A. Supplementary data

Supplementary data related to this article can be found at http://dx.
doi.org/10.1016/j.socscimed.2018.01.035.

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Trajectories of women’s abortion-related care: A conceptual framework

Introduction
Methods
Conceptual framework of trajectories to abortion-related care
Abortion-specific experiences
Awareness of pregnancy
Disclosure
Ability to access resources for abortion
Abortion attempt(s)
Perceived and experienced outcomes from (attempted) abortion
Emotions about pregnancy, childbearing or abortion
Individual context
Knowledge & beliefs about abortion
Individual characteristics
The (inter)national and sub-national context
Structural and institutional environment
Health system
Knowledge environment
Socio-cultural context
Conclusions
Acknowledgements
Supplementary data
References

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