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Abstract

Background:

Models of abortion care have changed significantly in the last decade, most markedly during the COVID-19 pandemic, when home management of early medical abortion with telemedical support was approved in Britain.

Objective:

Our study aimed to examine women’s satisfaction with abortion care and their suggestions for improvements.

Design:

Qualitative, in-depth, semi-structured interviews.

Methods:

A purposive sample of 48 women with recent experience of abortion was recruited between July 2021 and August 2022 from independent sector and National Health Service abortion services in Scotland, Wales and England. Interviews were conducted by phone or via video call. Women were asked about their abortion experience and for suggestions for any improvements that could be made along their patient journey – from help-seeking, the initial consultation, referral, treatment, to aftercare. Data were analyzed using the Framework Method.

Results:

Participants were aged 16–43 years; 39 had had a medical abortion, 8 a surgical abortion, and 1 both. The majority were satisfied with their clinical care. The supportive, kind and non-judgmental attitudes of abortion providers were highly valued, as was the convenience afforded by remotely supported home management of medical abortion. Suggestions for improvement across the patient journey centred around the need for timely care; greater correspondence between expectations and reality; the importance of choice; and the need for greater personal and emotional support.

Conclusion:

Recent changes in models of care present both opportunities and challenges for quality of care. The perspectives of patients highlight further opportunities for improving care and support. The principles of timely care, choice, management of expectations, and emotional support should inform further service configuration.

Plain Language Summary

How can patients’ experience of abortion care in Britain be improved?

Provision of abortion care and support in Britain has changed in recent decades. The COVID-19 pandemic also brought called for new ways of managing early medical abortions, at home, with remote support. We wanted to know how women in Britain felt about this kind of abortion care, and what ideas they had to make it better. Between July 2021 and August 2022, we spoke with 48 women who had recently had an abortion in Scotland, Wales and England. Some received got care from independent clinics, and some from the National Health Service (NHS). We talked to them over the phone or through video calls. We asked about their experiences, and what could be done to improve different parts of their care journey – from looking fo asking for help, the first appointment, the treatment, to the follow-up care. Most women generally felt satisfied with how they were taken care of by the medical staff. They appreciated the supportive, kind and non-judgmental attitude of the health professionals providing abortion care. They also liked the convenience of telemedicine and remote care, which made it easier to have a medical abortion at home. The changes in provision of abortion care and support have mostly had positive effects on women’s experience. Yet the feedback from women interviewed shows that there are still more opportunities to make improvements, focusing on prompt care, offering choices of abortion method and location, managing expectations better, and providing more emotional support. These principles should guide how services are set up in the future.

Keywords

abortion COVID-19 patient-centred care person-centred care sexual and reproductive health telemedicine

Introduction

The landscape of abortion provision in Britain has changed markedly in the 21st century. The advent of medical abortion distinctly reshaped models of care.¹ Prior to 2017, almost all medical abortions in the country were carried out in clinical facilities. Between 2017 and 2018 across England, Scotland and Wales, the second medical abortion pill (misoprostol) was approved for home use, following clinic administration of the first abortion medication (mifepristone).^2
–4 The coronavirus disease-19 (COVID-19) pandemic led to yet more changes: in March 2020, governments across Britain issued a temporary approval for the self-administration of the first abortion medication, mifepristone, at home, with telemedical support – a measure made permanent in 2022.^5
–7

The proportion of all abortions in Britain that were medically induced nearly doubled between 2010 and 2020, with a concomitant decrease in surgical abortions.^8,9 In 2021, medical abortions accounted for 88% of all abortions carried out across Britain, and more than half of all abortions were managed at home.¹⁰

Changes in models of care of this magnitude clearly have implications for the patient experience. Yet the pace of the developments left little time to explore the extent to which they may have impacted on quality of care. Patient-centredness is widely recognized as an important element and is a key component of the WHO framework of quality of care.¹¹ Patient-centredness, or person-centredness, is defined as the dimension of care which incorporates the perspectives of patients and is respectful of, and responsive to, their needs and preferences.^12
–14 Despite person-centredness being related to favourable outcomes of abortion care, there is little consensus on how it should be defined or measured.¹⁵ Standard person-centred measures for quality of abortion care are lacking,^14,16
–20 especially outside of health facilities. As a result, most quantitative studies resort to using simple questions of satisfaction to measure person-centredness in quality of abortion care, an indicator widely considered too diffuse to capture aspects of abortion care of importance to patients.^15
–19

More empirical investigation is needed to establish which components of the care experience, at which stages of the abortion pathway, are important – not only to develop metrics by which quality of care can be measured, but to design strategies by which it can be enhanced. The perspectives of patients are crucial to enabling benefits of the new models of care to be sustained and costs to be mitigated. In this article, we report on data collected in the SACHA Study: Shaping Abortion for Change (www.lshtm.ac.uk/sacha), which was designed to create an evidence base to inform health service configuration for abortion provision. We draw on the data from qualitative interviews with patients with recent experience of abortion to explore how current models of care might be optimized at all stages of the patient journey, from decision-making and help-seeking, through consultation and referral, to procedure and aftercare.

Method

Nature

Qualitative study.

Sampling

A purposive sample of 48 women with recent (past 2–8 weeks) experience of abortion was recruited between July 2021 and August 2022 from six sites in Britain: three independent sector services commissioned by the NHS (a telemedicine hub in the North of England, and in-person clinics in London and Southwest England); and NHS sites in Scotland, Wales and England (London). Inclusion criteria were: age 16 years and above, ability to give informed consent, UK residence, and abortion for reasons other than foetal anomaly. Exclusion criteria were: age below 16 years and abortion for reasons of foetal anomaly. To ensure diversity in the sample in terms of demographic characteristics and abortion experiences, the demographic profile of the recruited sample was regularly reviewed, and underrepresented groups were specifically targeted (for instance, non-White and non-British participants, and those below the age of 18 years).

Participant recruitment

Clinic or telehub staff introduced the study to women who had decided to have an abortion and consented to treatment. Patients who expressed interest were offered options for initiating participation. These included speaking to a researcher on site; being supplied with the researcher’s details to make direct contact themselves; or, with permission, passing their details to the researchers to follow-up.

Data collection

Semi-structured, in-depth, 60- to 90-min interviews were carried out by phone or video call according to the participant’s preference and, with their permission, were audio-recorded and transcribed. Consent to participate in the study was recorded in the interview by taking the participant line-by-line through the consent form and recording their responses. Transcripts of the interviews together with the consent form were stored on a secured server and password protected. A £20 high-street voucher was offered in appreciation for the participants’ time. Women were asked to reflect on their abortion experience and, where relevant, to suggest possible improvements across the patient journey – from the decision to have an abortion to aftercare.

Data analysis

Data were analyzed using the Framework Method, a method that is well adapted to answering policy-related research questions and allows both deductive data analysis, based on predetermined themes relevant to the research question, and inductive analysis, of additional themes emerging from the data.^21,22 An initial matrix was created into which summary data were entered, by case and by code. We analyzed the findings across the patient journey (Figure 1), exploring how experience of care at each of its stages could have been improved, together with suggestions as to how that could be achieved. Codes relating to the patient journey – from help-seeking, through consultation, referral and procedure, to aftercare – were used to frame the charting process. Textual data relevant to the research question addressed in this article were identified and selected for thematic analysis and independently coded by M.L. and K.W. The researchers discussed codes attached to text segments, reaching agreement on categories and subthemes. Emerging themes were then shared, and agreed and added iteratively to the matrix as analysis progressed, going back and forth between data and interpretation. We followed the Consolidated criteria for Reporting Qualitative research (COREQ) guidelines when preparing the article.

Figure 1.

Stages of the patient pathway.

Results

We interviewed 48 women aged 16–43 years. Five women who initially agreed to participate in the study did not attend the interview. Of those taking part, 39 had had a medical abortion, 8 a surgical abortion, and 1 both. Characteristics of the participants are presented in Table 1.

Table 1.

Characteristics of the sample.

ID	Abortion method	Age (years)	Ethnicity	Children	Previous abortions	Abortion location
01	Home MA	31–35	White British	No	No	England
02	Home MA	26–30	White British	No	No	England
03	Home MA	21–25	British Bangladeshi	No	Yes	England
04	Home MA	26–30	White British	No	No	England
05	Home MA	36–40	White British	Yes	Yes	England
06	Home MA	36–40	White British	Yes	Yes	England
07	Home MA	41–45	White British	Yes	Yes	England
08	Home MA	31–35	White British	No	Yes	England
09	Home MA	21–25	White British	No	No	Wales
10	Home MA	31–35	White British	No	Yes	Scotland
11	Home MA	21–25	White British	No	No	Scotland
12	Home MA	26–30	White Irish	No	Yes	England
13	Home MA	21–25	White British	No	No	England
14	Home MA	26–30	White British	Yes	No	Scotland
15	Home MA	31–35	White British	Yes	No	Scotland
16	Home MA	31–35	White Polish	No	No	Scotland
17	Home MA	26–30	White British	No	No	Scotland
18	Home MA	36–40	White Canadian	No	No	Scotland
19	Home MA	21–25	White British	No	No	Scotland
20	Surgical	36–40	Not specified, Hungarian	Yes	Yes	England
21	Home MA	36–40	Not specified	Yes	No	Scotland
22	Home MA	26–30	White British	No	Yes	Scotland
23	Surgical	26–30	White British	No	Yes	Scotland
24	Home MA	26–30	White British	No	No	Scotland
25	Home MA	26–30	White British	Yes	Yes	England
26	Surgical	21–25	White British	No	No	England
27	Surgical	31–35	White British	Yes	No	Scotland
28	Home MA	26–30	White Hungarian	No	Yes	Scotland
29	Home MA	21–25	Pacific Islander	No	No	Scotland
30	Home MA	31–35	White British	No	No	England
31	Home MA	36–40	White British	No	Yes	Scotland
32	Home MA	16–20	White British	No	No	Scotland
33	Home MA	31–35	White British	Yes	Yes	England
34	Home MA	36–40	White British	Yes	Yes	England
35	Home MA	31–35	White British	Yes	No	England
36	Surgical	36–40	Black African	Yes	No	England
37	Home MA	21–25	White British	No	No	England
38	Home MA	16–20	White Asian	No	No	England
39	Home MA	21–25	White British	No	No	Wales
40	Surgical	31–35	Asian Nepali	Yes	Yes	England
41	Surgical	21–25	White German	No	Yes	England
42	Surgical	31–35	Black British	No	No	England
43	Home MA	16–20	Asian Afghani	No	No	England
44	Home MA	16–20	White British	No	No	Wales
45	MA at hospital	21–25	White British	No	No	Scotland
46	MA at hospital	16–20	White British	No	No	Scotland
47	Home MA	16–20	White British	No	No	Scotland
48	Home MA (failed) + surgical	21–25	Middle Eastern	No	No	England

A dominant theme in accounts was the high level of satisfaction with, and appreciation of, the care received, widely described as ‘faultless’ (6), ‘easy and simple’ (23), ‘very positive’ (24), ‘ideal for me’ (25) and ‘pretty much flawless’ (26). Several women asserted they would not have changed anything about it (7, 17, 27-29). Some reported being ‘grateful’ 17, 25, 30-32, even if their pathway had its issues:

If I had to ever do that again, I would hope it was the exact same experience that I have had. (11)

Decision-making

Most patients reported being certain they wanted to have an abortion, and needing no support from health professionals in making the decision whether to continue the pregnancy. Additional help with making this decision tended to be needed where there was some ambivalence around pregnancy options – in those instances, patients emphasized that counselling should be clearly signposted on the clinic website or by health professionals and accessible in a timely manner. One woman who requested decision-making counselling was unable to access it during the window for medical abortion at home (i.e. below 12 weeks), her preferred abortion method:

I made the decision to phone the clinic. Before I had to think, I just wanted help in the decision making. [The clinic] offered me a choices appointment. [. . .] But it was so far away. The appointment was so far away, and I didn’t want to wait. (14)

Help-seeking

Information about abortion services was generally easily found through online searches, from previous experience of abortion, or from friends and family. The ability to identify an abortion provider quickly, with a prompt response, was universally seen as vital. Not all women were aware of the possibility of self-referral, and a few believed it was necessary to first attend a general practice appointment. Despite some accounts of a supportive reception by General Practitioners (GPs), they were not the first point of contact for most women. In some instances, this was because women were concerned that the GPs may not be sufficiently well informed about abortion, or that they may be judgmental:

[The GP] couldn’t even pronounce [the name of the abortion provider]. I was like, how are you a GP, how do you not know what [name of independent provider] is? (33)

I remember sitting down in my GP office and [. . .] the GP knew that I had had a surgical abortion, and said ‘I’m really disappointed to hear that’ [. . .]. I know not everybody thinks the same, but [. . .] it was a real kick in the teeth, having to justify why I’d done what I’d done. (6)

In other instances, the factor deterring patients from seeking help from their GP was the fear of delays in obtaining an appointment. Timeliness was seen as a critical factor at this point in the pathway and self-referral was seen as a major advantage in this respect, ‘cutting out the middleman’ (2). Delays in finding help were a source of considerable stress, in one case driving the patient to book appointments privately and self-fund their scan or procedure. Accessing care in a timely manner was of major concern where there was a preference for medical abortion at home (which was only possible up to 10 weeks in England and Wales, and 12 weeks in Scotland), and to avoid living with an unwanted pregnancy any longer than was necessary:

I didn’t want to experience any of the side effects of pregnancy because I knew I wasn’t keeping the baby, and I didn’t want to go through it all for nothing (26)

Consultation and referral

Abortion clinic staff were highly praised for their approach to patients at the stage of consultation, described as ‘respectful’ (9, 26), ‘welcoming’ (7) and ‘supportive’ (22, 34, 35). Before interacting with the clinic, many patients had expected to be judged, but instead met non-stigmatizing attitudes and reassurance. Appointments described most favourably featured extensive explanation of the upcoming procedure. Strategies noted as effective included being emailed a leaflet and having the provider talk them through it step-by-step, and being provided with videos describing the procedure. Patients described difficulties with the information provided where there were discrepancies between written and verbal information, for example lack of clarity on the correct administration of medications, or confusion over whether an ultrasound scan was needed.

Almost all women had their initial consultation by phone, and appreciated the speed, convenience, and privacy associated with receiving care via telemedicine. Nonetheless, the option to choose between a remote or an in-person consultation was held to be important:

I’m for it [telemedical appointments], but I think again maybe people need to be given the choice. There might be some people who feel really nervous, and they’d prefer that face-to-face. I think people should be given choices. (36)

Even among women who appreciated the practicality of a remote consultation, there were some who would still have preferred more personal contact. In this respect, video calls were suggested as a helpful alternative to a phone call.

At the stage of the consultation, the importance of having choice of abortion method was also highlighted:

Being offered [the choice] between the medical and surgical [abortion] this time was nice [. . .] even though I already knew what I wanted to do [. . .]. Because it’s not just about saying ‘it’s your choice to keep the baby or not’, you also decide how you want that to happen, and I think that’s quite empowering. (30)

Most women were satisfied with the method they received and had been made aware of the options: ‘[the health professional] explained each one, or what each entailed’ (28); ‘they did give me the option, but I was quite settled on surgical really’. (21) However, this was not universally the case, and perceptions of whether a choice had been offered varied. Some patients were not aware that they had, or did not feel they were given, a choice of method:

I don’t think it was explained to me. I remember checking it on Google, what the options were, and then I remember knowing that if it is early, then you can have medical. If it is later then you have the other. (37)

There was a sense in these accounts of medical abortion having been presented as the preferred option, and of less information having been provided about surgical methods. Some patients even thought medical abortion was mandatory before a specific gestational age: ‘I think that [medical abortion] was the only option because I was only six weeks’. (19)

I don’t think I really know enough about the surgical abortion really. [. . .] I didn’t realise that was an option [. . .] even when you’re early. (27)

A couple of patients mentioned they would have welcomed more information about the option of having a surgical abortion:

I wasn’t really told about the surgical, when I rang the clinic [. . .] I can’t remember if they asked if I wanted medical or surgical, but they went straight for it, and I wasn’t really told about the surgical. I do think I would have liked more information about [it]. (38)

I’d read about [surgical abortion], but it kind of sounded like they didn’t [. . .] it didn’t really seem like it was getting offered to me as an option. They seem to be much keener on the pills more. (39)

Reports of patients not having accepted the advice to have a medical abortion were uncommon:

The nurse was pressing more for a medical one, she said that would probably be a bit easier, but I told her that I would rather wait and have a surgical one. (34)

The timing from the consultation to treatment was generally fast, particularly for those eligible for home-managed medical abortion:

It was very straightforward and easy. [. . .] it was over the phone, so I got an appointment fairly quickly and easily. And then going and picking up the medication was very straightforward.³⁷

Delays were rare, but where they occurred, they seemed mostly consequent on health conditions requiring interaction between abortion care with general healthcare, and the lack of coordination between the two. One woman suffering fibroids reported referral uncertainty and delays; similar issues were shared by a patient with ulcerative colitis, and one with a serious heart condition:

[The abortion clinic] had to [. . .] assess my care and establish whether I could take a pill at home [. . .]. They were going to get back to me after a week, but they never did. [. . .] The hospital would say go and speak to your GP. The GP would then say no it’s the hospital. The GP would then admit me to another hospital for another scan. [. . .] Everybody was telling me different things and I was just getting more and more frustrated, more and more upset. (36)

Waiting times for surgical abortion were generally longer: ‘I had to wait three weeks until I went into the hospital’;²³ another patient reported having waited nearly 2 months for surgery. (40) The issue of surgery slots filling up was raised, as these were often available only 1 day a week. While patients attributed the wait times to the overburdened health system, particularly during COVID-19, they also emphasized the time-critical nature of abortion. One suggestion was made that the distress of the wait could be eased by a phone check-in from the clinical staff to reassure the patient that their procedure was upcoming.

The support provided by the clinical staff was sufficient for most: ‘extremely helpful [. . .] always putting things in place for support’, (47) ‘supportive, kind [. . .] made me feel reassured’. (35) There were others who felt that the emotional significance of their abortion needed more recognition, or for the support to be more tailored to their needs: ‘it would be nice to see someone face to face to talk about feelings’, (25) ‘I never got asked once by anybody how I was doing mentally’. (35) It appeared that not all patients knew clinics offered counselling. Personal and emotional support offered was not always taken up either because the waiting times were too long or because women doubted their eligibility:

It was mentioned but it was not offered. I think it was like if you need an emergency there is a help line where you can contact and talk to someone. I didn’t think it was encouraged. (37)

A suggested alternative to counselling provided by healthcare professionals was the creation of opportunities to talk to other women who had experienced abortion:

I needed more support, but maybe from people around me instead of medical people. [. . .] My partner did stay on the phone with me, but I would have preferred to talk to a woman [. . .] I think I did need more support [. . .] maybe from someone who went through the same thing. (25)

In some instances, emotional support was sourced via informal Internet forums, for example, Reddit. A major advantage of such fora was the combination of anonymity with personal experience: ‘there are people on Reddit, you can reach out to them, and usually they are quite [. . .] they are a stranger but at the same time that helps’.(3) One participant suggested that clinical services could valuably put patients in touch with a support group: ‘to be able to speak to other girls who have gone through the same thing [. . .] [I] didn’t know any[one] that’s gone through it [and] felt really lonely’. (35)

The need for personal accounts of abortion to be available on clinic websites was raised by several participants: especially since abortion is rarely disclosed and discussed. A video narrating a patient’s journey, from discovering the pregnancy to having the abortion, which was available on one clinic’s websites, was mentioned as particularly valuable (24, 29):

It’s reassuring to hear others’ stories [. . .]. Whatever experience someone has, it’s sort of nice to know that [. . .] a lot of people are going through it, the same as you. (8)

Treatment

Medical abortion

Of the 40 women who had a medical abortion, all but 2 managed it at home. Overall, women welcomed the convenience and comfort afforded by home management, the sense of autonomy and privacy it provided, and the possibility to experience it in their ‘safe space’ (42):

It was easy. It was comforting to know that I didn’t have to put myself through any sort of procedure or being put to sleep or having someone down there doing something. It was almost like my body just did it itself. (26)

Those able to make comparisons with a previous abortion experience identified advantages over a clinic-based procedure:

I tidied up, I watched tele, and just got on with my normal stuff [. . .] whereas in hospital I remember it being a lot more uncomfortable [. . .] because you’re sat in a room with about 10 other people and doing nothing. (28)

Downsides of home management primarily centred around the lack of supervision, and consequently reassurance, that could have been offered in clinical facilities. Where anxiety was reported, it was associated with pain and bleeding, and exacerbated by disparities between expectations and reality. A few women experienced only minor, ‘bearable’ (26) pain, ‘nothing different really to a period pain’. (28) For the majority interviewed, however, the pain was more severe than anticipated: ‘the pain was crazy [. . .] it was killing me’, (29) felt like ‘giving birth’. (31, 38) In many cases, women felt unprepared for the level of pain they experienced: ‘I can’t remember exactly but it I’m pretty sure it was like, ‘it [paracetamol and ibuprofen] should ease the discomfort’ [. . .] [while] I remember thinking at the time, I’d rather be dead than feel this pain’.(35)

They didn’t tell me to take painkillers before taking the second pill (. . .) so when it started happening, I had terrible pain. (37)

Language used at the consultation, such as ‘discomfort’, ‘cramping’ and ‘pain like period pain’ was considered not to reflect adequately the reality of the experience.

Several women felt that the necessity of taking the pain relief provided (or purchased over the counter) should have been made clearer by the health professionals, especially to those who do not routinely use painkillers:

They didn’t really explain the codeine at all, [. . .] I hardly touched it when I probably should have just made the most of the fact that it was there. [. . .] I think they could have gone into a little bit more detail about what was actually going to happen [. . .] like, by the way, it’s going to be excruciating. (39)

Women reported having resorted to several self-sourced remedies, such as breathing techniques, distractions, such as TV, and hot water bottles.

Similarly, many patients were unprepared for the extent of bleeding experienced. For one participant, it was reportedly profuse enough to soak her mattress. (31) Some did not feel prepared for seeing the products of conception – which depending on gestation can range from a blood clot to visible pregnancy tissue – nor confident as to how to dispose of them:

I feel like they did sugarcoat it a little bit [. . .] they could have spoken to me about it a bit more [about what to do with it after]. They didn’t inform me that what comes out may look like a baby. (42)

The availability of a 24-h post-abortion helpline appeared to have mitigated some of the anxieties and lessened the mismatch between expectations and reality.

While most patients would have chosen the same abortion method again, several would have opted for surgical over medical abortion, if they were to choose again: ‘if [I] was to get pregnant again, I might just [. . .] get surgery, because that was so bad’ (35); ‘if I look back now, possibly [surgical] would have been a better option’. (42)

It was recognized that practitioners were well-intentioned in avoiding presenting worst-case scenarios, but an unintended consequence of this seemed to have been a suboptimal experience for some. A common view was that practitioners should be more candid about the full spectrum of possible experiences: ‘I would have liked more information, and possibly more options about pain management’ (43). Having access to the accounts of other patients was also thought to be helpful in helping to manage expectations:

I would have liked to access a website or a folder or a handbook that I could read about other people’s experiences. Then I could read about somebody who literally didn’t feel anything and someone who mentioned the worse. So, then I can be prepared for the different scenarios, and then no matter what happened, I would know, like, it’s normal what is happening [. . .]. The experience wasn’t articulated enough and that was hard. (37)

Reading other patients’ accounts was also seen as a means of addressing the lack of emotional support, as was the possible provision of additional sources of support during the abortion, particularly for those without a personal support network to rely on:

It would be good if there was some sort of service where they could provide someone or put you in touch with somebody who is a volunteer who is happy to sit and wait. (10)

Surgical abortion

Reasons for having a surgical abortion included personal preference, later gestational age, inappropriate domestic environment for medical abortion and health conditions precluding the option of a medical abortion. Perceived advantages of surgical procedures included not having to be personally and actively involved in the procedure. The issues with surgical abortion centred mainly around longer waiting times. The problem of mismatched expectations was raised less frequently in relation to surgical abortion because of the direct presence of health professionals throughout the procedure. Clear information and easily understandable language, especially around anaesthesia, were considered vital:

Local [sic: conscious] sedation [. . .] was a misleading term because it was just a bit of anaesthetic, so it was quite painful. (32)

The only information that I was really given is that the recovery time for the local anaesthetic was quicker [than conscious sedation] so that’s what I went for. I’m getting the impression now that it’s a lot more painful than conscious sedation would have been. [. . .] Yeah, I wasn’t quite prepared for it to be quite so painful. (43)

Aftercare

Few women had medical concerns following their abortion. Where they were expressed, they centred around ensuring completion of the procedure and receiving adequate emotional support. Help sheets with contact details in case of problems were seen as useful. Some patients would have appreciated more clinical reassurance, and a proactive follow-up call from the clinical providers, to ensure that their procedure had been successful. The need for emotional support was again stressed, even if signalled by, again, a simple check-in call with possible signposting:

So, I feel like it’s a nice idea to, maybe, contact them afterwards just to see how it went and a reminder that there is someone there for them if they need them. (27)

I feel like I didn’t have the support afterwards to talk to someone heart to heart, on how to understand that, or how to process that or know that it is normal. [. . .] it would have been better if I had a few appointments, even over the phone, [. . .] [so that someone] checked on me and how I feel. (37)

An important aspect of aftercare was contraceptive advice and provision. Patients’ views on when the best time to discuss contraception varied. Some preferred to have it arranged as soon as possible; others wanted to delay these conversations until their abortion was complete. Satisfaction with the contraceptive provision was highest when a range of options was available and sufficient time was dedicated to discussing them. The extent of choice was largely dependent on the procedure. Surgical abortion facilitated easier access to long-acting reversible contraception, which could be inserted during surgery. Women who had a medical abortion at home were often provided with only condoms or the contraceptive pill, as these could be placed in their home medication pack. Where the preferred contraceptive method had not been provided by the abortion clinic, obtaining an appointment at a sexual health clinic or general practice was sometimes difficult and introduced delays:

[The abortion clinic] told me that I could have whatever contraception I wanted [. . .] but then it was a nightmare actually, to get done. [. . .] I’d had to sort out childcare, I’d had to get work covered. [. . .] I wouldn’t say there was anything wrong with how I had my abortion. I’d say the problem was [. . .] the sexual health system. I think that needs improving. (26)

Themes across the patient journey

Dominant themes emerging from these accounts include the need for timely care, for greater consistency between expectations and the reality of the abortion experience, for choice, and for more personal and emotional support.

Concern for timeliness was most pronounced before the actual procedure. For the minority of patients who required help in making a decision about the outcome of pregnancy, it needed to be offered early enough to be feasibly considered. Prompt care and support was most crucial at the stage or referral and consultation when time was of the essence in limiting the time in which the patient was obliged to needed to be pregnant and also leaving options open with regard to method. Post-procedure, the issue of timeliness re-emerged at the point of receiving contraceptive advice, when delays in obtaining an appointment outside of the abortion service were not uncommon.

The problem of dissonance between expectations and reality was usually experienced at the stage of the procedure. The need for choice was also most typically expressed in relation to the abortion procedure itself, but it was also raised in relation to options relating to a remote or an in-person consultation; to medical or surgical abortion and to contraceptive methods post-abortion. Emphasis on the importance of quality interpersonal interaction and emotional support spanned the entire patient journey, and was a prominent feature of both positive and negative appraisals of aspects of the abortion experience.³⁷

Discussion

Summary of findings

The overwhelming majority of participants in this qualitative study reflected positively on their abortion experience. They valued the respectful and non-judgmental way in which they were treated, and the reassurance and empathy they received. Those who had a medical abortion at home appreciated the privacy and autonomy afforded by home management, and the convenience and comfort of being in a familiar environment. Those who had a surgical abortion, although often faced with more barriers to timely access to the procedure, were also largely content with their experience. Suggestions for improvement centred on four main themes: provision of timely care and support; consistency between expectations and the reality of the abortion experience; the exercise of choice in mode of consultation, nature of abortion procedure and its location and emotional support before, during and after the abortion.

Strengths and limitations

Our study sample was drawn from across Britain and from a range of providers – both independent and NHS. We captured a range of procedures and recruited participants from different ethnic and socioeconomic backgrounds. In eliciting accounts of abortion experience, we encouraged reflection across all stages of the patient journey, from decision-making about pregnancy options to aftercare. A strength of the study is that women were asked to comment not only on their preferences but also to suggest how these might be addressed.

In terms of limitations of the study, the number of adolescents was smaller than hoped for and, despite efforts to do so, we did not manage to recruit participants from Northern Ireland. We cannot be sure that the sample of women was not biased towards more positive or more negative views and experiences.

That fieldwork took place at the time of greatest impact of the COVID-19 epidemic in Britain can be seen as both a strength and a limitation of the study. The changes to protocols contingent on the pandemic, unforeseen at the study’s design stage, meant that women’s reports did not reflect what had previously been normal service delivery. Face-to-face contact was rarer, and access to surgical abortion and to long-acting contraception was more limited than usual. However, since early medical abortion at home with telemedical support was subsequently made permanent in Britain, the study opportunely provided a means by which the new models of care could be evaluated, so helping to inform future practice developments and research.

Interpretation and contextualization

The high levels of satisfaction with abortion care in Britain have been reflected in research by others.^25,26,27,28 Of interest in the context of this enquiry are the specific features of the abortion experience reported as impacting positively and negatively on the abortion experience, the extent to which they appear contingent on changes in models of care and the suggestions made by patients for improving their experience.

Timely care

The need to expedite the abortion process swiftly is clearly critical to patient satisfaction. Timely care, important in all areas of healthcare, is especially relevant to abortion care. The earlier the abortion is carried out, the safer it is,³⁷ the wider the choice of method, and the more limited the period in which the stress of an unwanted pregnancy is endured. Timely care also has benefits for the health system: NICE estimates a 1-day reduction in the average waiting time for abortion could save the NHS £1.6 million per year in the costs of procedures and treating adverse events.²⁹ Guidelines for abortion care for England state that women should wait no longer than a week for the initial assessment, and no longer than a week from assessment to their procedure.²⁹

Our data showed that home management of medical abortion was advantageous in this respect and allowed for swift provision of care. Routine statistics support this finding: the trend towards home management of medical abortion has occurred simultaneously with a trend towards earlier abortion.^30,31 Delays in the process were mostly reported by those having surgical abortions due to fewer available surgical appointments, particularly where other hospital care was needed due to underlying health conditions.

Appeals by our participants for reassurance to reduce anxiety during the waiting time align with the recommendations made in recent literature.²⁷ Patients’ suggestions for measures to reduce delays included widening and updating informational sources; raising awareness of the possibility of self-referral; and ensuring that health professionals other than specialist abortion providers had the necessary knowledge to signpost appropriately to avoid confusion over which services should be approached. The recommendations made in national abortion care guidelines for streamlined, integrated services and centralized referral²⁹ are of particular relevance in the context of England and Wales, where three major independent providers all have separate booking systems, with no clear indication to patients as to which they should opt for, even though sole-provider contracts remain in many areas.³²

Consistency between expectations and reality

As others have shown, ensuring consistency between women’s expectations and their actual experience is crucial to patient satisfaction.^33,34 Instances running counter to the generally high levels of satisfaction reported in our study included lack of anticipation, and therefore preparation, for the level of pain and bleeding. This applied to surgical abortion too, but was more pronounced in the context of medical abortion at home, as has been shown in other studies.³⁵ The need to adequately prepare patients is particularly significant given the transfer of responsibility for self-management of medical abortion.³⁶

Reports of severe pain among women in our study are in line with the estimates of between half and three-quarters of such patients reporting moderate to high levels of pain.^{37,38,39,40,41} The effectiveness of any pain-management strategy will depend in large part on how prepared patients are to anticipate requiring its use. The non-use of the offered analgesia by some women in our study is consistent with the findings of studies showing ineffective use of painkillers during home-managed medical abortion: nearly 25% used no analgesia at all.⁴² Evidence on the pain-management strategies for medical abortion is limited – with the strongest evidence being for prophylactic high-dose ibuprofen, which was not reported by anyone in our sample.³⁸ Additional research on the efficacy of various methods of pain relief is needed.^43,38

The inadequacy of language reportedly used by health professionals in the consultation to describe extremes of pain and bleeding has been noted in previous research and may signal a tension between providers’ desire to reassure and minimize distress and the patients’ need for clarity and forewarning.²⁶ This problem does not, however, appear to be confined to remotely supported medical abortion: other research has shown that patients who received medication abortion through telemedicine ranked their communication with the clinicians more favourably than did those in traditional, in-clinic settings.⁴⁴

The plea from our participants for greater candour from the healthcare professionals in describing the range of possible experiences is consistent with increasing recognition of the need for transparency in healthcare.^45,46 Clearer descriptions of the range of experiences with respect to pain, bleeding and products of conception would have enabled patients to make more informed decisions on method and location of care. The provision of diverse patient stories and the use of online discussion platforms on which a range of experiences can be shared, possibly moderated and included in service websites, have additional potential in this respect.^{25,26,34,38,36,41,42,43,47}

Provision of patient choice

The importance of overall choice, highlighted by our participants at several points in the abortion path, resonates with other empirical evidence.^33,48 While many of the women we interviewed would have changed nothing about their abortion experience, a few claimed that, in hindsight, they might have chosen an alternative abortion method. Studies comparing satisfaction levels in medical and surgical abortion^49
–51 suggest that, were all women able to fully exercise choice, the proportion of abortions that are medically induced could be lower than the current rate in Britain of almost 9 in 10.

The finding that the home environment does not always allow sufficient privacy – to vocalize expressions of pain, for example, or to deal with bleeding – lends weight to the suggestion that services need to ensure the possibility of carrying out a medical abortion in the clinic or hospital, and also that the legally permitted premises for abortion⁴⁷ should be extended to include appropriate non-clinical settings away from home.²⁵

The importance of a choice of procedure where feasible is emphasized in Royal College of Obstetricians and Gynaecologists guidelines⁵² and identified as an area of care requiring improvement in Britain.^53,54 The rationale for prioritizing medical over surgical abortion where feasible was clear during the pandemic when personal contact had to be restricted to protect patients and staff. During the COVID-related disruptions, face-to-face appointments were only available if clinically required, and services might have expected negative COVID tests or isolation prior to surgical procedure, which in turn could have caused delays to care. However, the suggestion in our data that medical abortion may have been encouraged as the preferred, or even the default, option, is corroborated by other contemporary studies.^33,55,56

An unintended consequence of the high prevalence of medical abortion in Britain – accounting for 87% of all abortions carried out in England and Wales and 99% in Scotland in 2021^57,58 – could potentially be a decline in the availability of surgical abortion even when it is necessary. The reasons for that are various: from insufficient numbers of patients to make surgical lists affordable, to the scarcity of opportunities for health professionals to learn surgical skills.^55,56 This has implications beyond just abortion care, as surgical pregnancy termination skills are essential also in miscarriage management and obstetric emergencies overall.^32,26,29

Emotional and personal support

The need expressed by the participants in our study for greater access to emotional and interpersonal support, in addition to clinical care – at the consultation, at the procedure itself and during the aftercare – has been raised by others.^59
–61 Emotionally supportive care has been identified as a key component of quality of care⁶² but has received little attention in healthcare contexts. A possible explanation is that, despite its importance, it is difficult to define in practical terms. The concept of ‘social connectedness’ suggested in the study by Hoggart et al.,³³ described as ‘a broad and complex concept, which formulates a sense of belonging and closeness with others and the perceived availability of support’ accommodates many of the dimensions revealed as important to our participants, a respectful and non-judgmental approach, expressions of care and empathy; provision of reassurance, and the communication of reliable information and realistic expectations. Afulani et al.¹⁴ propose the concept of person-centredness, instead of patient-centredness, to highlight the importance of such holistic approaches and to avoid objectifying and reducing the person to a mere recipient of medical care, in this instance of abortion care.

According to the patients’ accounts, explicit signposting to available support at all stages of the abortion experience is essential, but it also needs to be sufficiently prompt to benefit patients at the time at which it is needed. Calls were made for real-life accounts of experiences of abortion patients to be incorporated into the health service websites; for opportunities to connect with other abortion patients on supervised Internet forums; and for peer-support structures to help reduce feelings of isolation. The benefits of such approaches are evidenced for other health issues^33,34,35 and may be even greater in the context of abortion, which is rarely talked openly about and is heavily stigmatized.^63
–65

There is evidence on the effectiveness of assistance from abortion doulas in surgical abortion, but consideration might be given to assessing its potential for medical abortion in patients without personal support networks.⁶⁶ While there already exists a charity in the United Kingdom providing an abortion talkline, awareness of it remains low, with no one in our sample having known they could seek support there, which calls for better signposting.(https://www.abortiontalk.com/)

Strategies emerging from women’s reflections may have the capacity to address more than one area for improvement. Addressing the need for emotional support may help to alleviate pain;^13,67 for example, clear explication of the range of possible abortion experienced may help prepare patients for specific outcomes in addition to facilitating more informed choices; and story-sharing can help with both preparing for the practicality of abortion and lessening the feeling of emotional isolation in the process.

Conclusion

Recent changes in models of care have benefitted women having abortions. The perspectives of women with recent experience of abortion help to identify a number of adjustments with the potential to further increase these benefits. They include measures to address the need for more timely care; for greater choice in consultation mode, abortion procedure and contraceptive method; closer consonance between expectations of the abortion experience and its actuality; and for emotional care and support.

Our findings are likely to be of value in efforts to conceptualize and measure person-centred elements of quality of care and to design interventions to improve it. For the first, the four interconnected elements of quality of care identified as meaningful to patients in this study will help establish key domains to be included in a conceptual framework for quality of care. Second, our data will contribute to the measurement of person-centredness of quality of care. We anticipate that our study will contribute to the growing body of work in measuring and operationalizing person-centred abortion care.

Our hope is that these data will help health professionals, commissioners, and policymakers to improve the quality of abortion care. The rapid increase in home management of medical abortion in Britain and in other countries presents both challenges and opportunities for person-centred abortion care, exposing a tension between the benefits afforded in terms of autonomy and self-regulation on one hand, and the potential costs in terms of supportive interactions with healthcare professionals and the unintended consequences for the health system on the other. The perspectives of patients are crucial to making adjustments to the provision of abortion care and support, which will enable benefits of the new models of abortion care to be sustained, and the costs to be mitigated.

Supplemental Material

sj-docx-1-whe-10.1177_17455057241242675 – Supplemental material for How can patient experience of abortion care be improved? Evidence from the SACHA study

Supplemental material, sj-docx-1-whe-10.1177_17455057241242675 for How can patient experience of abortion care be improved? Evidence from the SACHA study by Maria Lewandowska, Rachel Scott, Rebecca Meiksin, Jennifer Reiter, Natasha Salaria, Patricia A Lohr, Sharon Cameron, Melissa Palmer, Rebecca S French, Kaye Wellings and the SACHA Study Team in Women’s Health

Footnotes

Acknowledgements

The authors thank all the women who generously dedicated their time and thoughts and shared their experiences, and the clinic staff who actively recruited participants and supported the study. They also thank the Shaping Abortion for Change (SACHA) Study team as a whole for contributing their ideas that were instrumental to this research: Annette Aronsson, Paula Baraitser, Caroline Free, Louise Keogh, Clare Murphy, Wendy Norman, Jill Shawe, Sally Sheldon, and Geoffrey Wong. They would also like to thank the Advisory Group of the SACHA Study for supporting the development of this study, and the stakeholders who helped to contextualize findings and prioritize areas for improvement in abortion care in Britain.

Declarations

ORCID iDs

Maria Lewandowska

Rachel Scott

Rebecca Meiksin

Jennifer Reiter

Natasha Salaria

Patricia A Lohr

Sharon Cameron

Melissa Palmer

Rebecca S French

Supplemental material

Supplemental material for this article is available online.

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