Can someone be both pro-life and pro-choice? Results from a national survey of US adults.

"Pro-life" and "pro-choice" are closely associated with discussions about abortion; we refer to the extent that people identify with these terms as "abortion identity." Most polling measures present pro-life and pro-choice as mutually exclusive options, but there is a dearth of information about people who might simultaneously endorse both (or neither) labels. METHOD: We administered a survey to adults in the United States (n = 580) that included two different formats for participants to select their abortion identity: a categorical item with response options ranging from strongly pro-choice to strongly pro-life (and "both" and "neither") and two separate items (sliders) that asked people the extent to which they identify with each term. We asked participants endorsing both pro-life and pro-choice to some extent on the slider items to explain their responses in an open-ended item. We used logistic regression to examine the relationship between participants' socio-demographic characteristics and the likelihood of dual identification slider scores; we analyzed open-ended data for content and themes. RESULTS: On the sliders, more than 64% of participants identified as both pro-life and pro-choice to some extent. Variability existed between people's abortion identity on the close-ended items and their response to the open-ended questions. Among those with mixed abortion identities, participants described abortion as a serious and undesirable option but reflected positively on notions of personal choice and bodily autonomy. CONCLUSIONS: Our findings demonstrate complexity in measuring people's endorsement of abortion identity labels. We recommend developing more nuanced and consistent measures to assess abortion attitudes.

People's perception of changes in their abortion attitudes over the life course: A mixed methods approach.

Research examining the extent that people's attitudes toward abortion vary across the life course is mixed. Some studies do not show a strong relationship between abortion attitudes and life stage, while others do find strong associations in both directions-older age associated with both more and less favorable attitudes toward legal abortion. Taken together, these findings suggest that individual attitudes toward abortion are static for some but malleable for others. Little is known about the prevalence, reasons, and directionality of attitude changes. This explanatory sequential mixed methods study investigates people's perceptions of whether, how, why, and for whom their abortion attitudes may have changed over their life course. We qualitatively investigated the reasons (e.g., experiences, life events) that triggered changes in respondents' abortion attitudes and quantitatively explored the sociodemographic factors associated with the perceived direction of those changes. The quantitative data come from a 2020 online survey completed by 1501 English and Spanish-speaking adults in the US. Qualitative data were collected from a subsample (n = 24) of the survey respondents who indicated interest in a follow-up in-depth interview. Our findings indicate that access to information and knowledge played an important role in changing abortion attitudes across a spectrum of support or opposition. For those who indicated becoming more opposed to abortion over time, experiencing parenthood was an important trigger for change and family/religious upbringing were key to shaping attitudes. For those who became more supportive of abortion over time, empathy for women was an important trigger for change and disagreeing with or distancing oneself from family/religious upbringing were key to shaping their attitudes. If attitudinal change occurs, becoming more supportive of abortion over the life-course is more common than becoming more opposed, however there are some nuances across age and gender. Understanding the different factors that influence attitudinal change regarding abortion has important implications for public opinion research and possible ramifications for abortion legality.

A Mixed-Methods Approach to Understanding the Disconnection between Perceptions of Abortion Acceptability and Support for Roe v. Wade among US Adults.

The relationship between people's attitudes about abortion acceptability and the Supreme Court decision in Roe v. Wade-two distinct but related issues-has not been rigorously explored. The authors used a mixed-methods approach for analyzing in-depth interviews to better understand how participants' feelings toward abortion acceptability are related to perceptions of whether abortion should be legal. The authors then assessed (1) correlations between abortion acceptability and different measures of support for Roe v. Wade, and (2) how the phrasing of survey items related to Roe v. Wade may evoke different responses via an online survey fielded in 2018. The study's qualitative results highlight that there is a disjuncture between people's moral feelings toward abortion and their attitudes toward abortion legality. The study's quantitative results further demonstrate that correlations between abortion acceptability and support for Roe v. Wade are moderate, and the differences in responses to the phrasing of survey items related to Roe v. Wade are moderated by knowledge. The authors recommend that when researchers develop survey items, they avoid ambiguities of abortion as a general construct, especially when public opinion measures on abortion are employed for research and the design of social and health policy and practice.

Integrating mifepristone into primary care in Canada's capital: A multi-methods exploration of the Medical Abortion Access Project.

OBJECTIVES: Following the 2017 introduction of mifepristone in Canada and both ensuing regulatory changes and increased demand for medication abortion care, Planned Parenthood Ottawa created the Medical Abortion Access Project (MAAP). This study aimed to document outcomes, identify facilitators and barriers, and distill learnings from an initiative that sought to recruit and support primary care clinicians in providing mifepristone/misoprostol in Canada's capital. STUDY DESIGN: We employed a multi-methods evaluation strategy that included reviewing MAAP-related documents, evaluating the project log, and conducting in-depth interviews with clinicians at 5 sites. In the final analytic phase, we integrated the findings from the different evaluation components. RESULTS: From May 2017 through July 2018, the MAAP helped 14 primary care facilities in Ottawa become medication abortion providers; 9 began providing mifepristone/misoprostol to existing patients and 5 began offering mifepristone/misoprostol to the public. The program recruited 4 new pharmacies to stock the combination package and trained 2 sonography clinics in abortion-related protocols. Program participants identified patient demand as a key driver of medication abortion provision but required information and logistical support from the MAAP to operationalize service delivery. New abortion providers reflected positively on the community of practice that the MAAP created, which enabled them to offer and receive technical and emotional support from colleagues across the city. CONCLUSIONS: A number of primary care clinicians in Ottawa were able to successfully integrate medication abortion care into their practices with MAAP support. Future research should explore whether this type of community-based intervention can be replicated in other settings. IMPLICATIONS: Evidence-based regulation of mifepristone by health authorities is a critical step to increasing access to medication abortion care. However, deregulation alone was insufficient to integrate medication abortion services into primary care in Ottawa. Community-based programs like the MAAP can help providers make sense of shifting regulations and practice guidelines, overcome logistical barriers, and ultimately increase access to this medically necessary service. Establishing and facilitating communities of practice is especially important for new primary care providers.

Incidents of violence and disruption reported by the National Abortion Federation's Canadian members in 2017.

OBJECTIVE: To explore violence and disruption events reported by Canadian facilities providing abortion care in 2017, when only 3 provinces had passed safe access zone legislation. METHODS: We reviewed self-reported data from 16 of 38 Canadian members of the National Abortion Federation. RESULTS: Twelve facilities in 7 provinces reported 571 instances of picketing (97%), trespassing (1%), threats of harm (0.2%), and harassing calls/mail/emails (2%); 4 facilities reported no incidents. Freestanding clinics reported more picketing than hospital-based facilities. DISCUSSION: Abortion providing facilities in Canada experienced picketing and other kinds of violence and disruption in 2017. These data serve as a baseline for future studies.

"We have to make sure you meet certain criteria": exploring patient experiences of the criminalisation of abortion in Australia.

INTRODUCTION: Nine different sets of laws govern abortion in Australia, and the criteria for an abortion to be considered lawful varies considerably by jurisdiction. We explored how the criminal status of abortion affected patients' experiences in accessing care in a country where abortion services are widely available. METHODS: We conducted qualitative, in-depth interviews with 22 people who had an abortion in Australia since 2009 across a variety of legal contexts. We audio-recorded all interviews and transcribed them in their entirety. We carried out content and thematic analyses of the interviews using deductive and inductive techniques. RESULTS: At the time of their procedures, more than half of our participants (n = 13) obtained their abortion in a state or territory that had criminal sanctions associated with procuring an abortion and required abortion seekers to meet strict legal requirements to access care. In general, participants reported confusion about the legal status of abortion. Participants who had an abortion in criminalised settings described significant negative emotional impacts that were directly linked to the law. They were often required to fit their abortion story into a state-mandated narrative. Further, the criminalisation of abortion meant that some participants felt they could not be honest with clinicians for fear of being denied care. The participants were overwhelmingly in support of decriminalisation of abortion and increased consistency of the legal status of the procedure across Australia. CONCLUSIONS: The criminalisation of abortion in some Australian states negatively impacts patients' emotional wellbeing, undermines the patient-clinician relationship, and perpetuates abortion stigma. In the absence of legislative reform, training for clinicians - including abortion providers and general practitioners - to explain the implications of the legal status to their patients appears warranted. Patient-centred resources, such as a website with state-specific information, could fill an important knowledge gap for the public.

Attitudes of US adults toward using telemedicine to prescribe medication abortion during COVID-19: A mixed methods study.

OBJECTIVES: We explored public opinion about using telemedicine to provide medication abortion during the COVID-19 pandemic in 2020. We also investigated the associations between socio-demographic characteristics and support for using telemedicine in this context and explored factors that influenced respondents' attitudes on the topic. STUDY DESIGN: In a nationally representative, web-based survey of US adults (n = 711), we asked open- and closed-ended questions about using telemedicine to prescribe medication abortion during COVID-19. We used multinomial logistic regression to assess the relationship between socio-demographic characteristics, endorsement of abortion labels, and political affiliation and support for telemedicine in this circumstance. Then, we conducted content and thematic analyses with the open-ended data to explore what influenced respondents' opinions. RESULTS: Overall, 332 (44%) of respondents supported using telemedicine for medication abortion during the pandemic; 237 (35%) opposed and 138 (21%) were unsure. Respondents who identified as prochoice were more likely to support using telemedicine for abortion during the pandemic than those who identified as prolife were to oppose it in this context (RRR 2.95; 95% CI 1.31-6.64). Via our content and thematic analysis, we identified that concerns about safety, the legitimacy of telemedicine, and the belief that abortion should occur as early in the pregnancy as possible influenced respondents' beliefs about using telemedicine for medication abortion. CONCLUSIONS: More respondents supported using telemedicine for medication abortion during COVID-19 than opposed it. Among respondents who expressed support, most thought that medication abortion was safe and that telemedicine was equivalent to the in-person provision of care. IMPLICATIONS: There appears to be support among US adults for the provision of medication abortion via telemedicine during COVID-19. Policymakers may consider public sentiment as well as clinical evidence when considering legislation about abortion.

"I didn't doubt my choice, but I felt bad": A qualitative exploration of Canadian abortion patients' experiences with protesters.

OBJECTIVES: Although a body of research has focused on violence, disruption, and harassment targeting abortion clinics and clinic staff, little research has explored Canadian abortion patients' experiences with protesters. Through this national qualitative study we aimed to address this gap. METHODS: Between 2012 and 2016, we conducted in-depth interviews with 305 Canadian women who had an abortion in the previous five years. Thirty participants reported encountering protesters when seeking abortion care. We focused on this sub-set of interviews and analyzed these data for content and themes using inductive and deductive techniques. RESULTS: Across the country, participants reported encountering protesters holding signs, chanting slogans, and shouting insults. These interactions were concentrated at clinics in New Brunswick, Newfoundland and Labrador, and Ontario. Although no participants reported that these encounters made them reconsider their decision, they did report that seeing and interacting with protesters was at times unsettling, stigmatizing, and frustrating. Participants who struggled with the decision to have an abortion and those who made the decision in the context of health issues or violence found these encounters especially upsetting. Participants discussed how their interactions with protesters and the additional security measures put in place by clinics contrasted with their experiences accessing other kinds of health care and they wished that the protesters had not been there. CONCLUSIONS: For some Canadian abortion patients, encountering protesters is upsetting and stigmatizing. Exploring ways to minimize interactions between protesters and those seeking abortion care, such as enacting and enforcing safe access zone legislation, appears warranted. IMPLICATIONS: Although several Canadian provinces have enacted safe access zone laws, these do not currently exist across all jurisdictions. In addition to protecting clinics and clinic staff, implementation of these buffer zones have the potential to improve some patients' experiences obtaining a medically necessary and essential service.

"It gives you autonomy over your own choices": A qualitative study of Canadian abortion patients' experiences with mifepristone and misoprostol.

OBJECTIVES: The gold standard of medication abortion, mifepristone and misoprostol, became available in Canada in 2017 as a combination pack under the trade name Mifegymiso®. We aimed to document people's experiences deciding to use and accessing medication abortion and generate insights for how information and services could be improved. METHODS: We conducted semi-structured, in-depth interviews with 64 people who had used the mifepristone/misoprostol regimen to induce an abortion in seven different Canadian provinces. We used ATLAS.ti to manage our data, which we analyzed for content and themes using inductive and deductive techniques. RESULTS: The overwhelming majority of participants reflected positively on their experience with mifepristone/misoprostol for early abortion. Most people reported that medication abortion offered increased autonomy, privacy, and convenience compared with instrumentation procedures and especially liked being able to have the abortion in a comfortable and familiar environment. The small number of participants who reflected more negatively on their experiences generally did not feel well informed about what to expect. Several participants reported that the media served as a key information source for finding and accessing services. CONCLUSIONS: Although our sample of Canadian abortion patients appear to be highly satisfied with the mifepristone and misoprostol regimen, there are several avenues by which medication abortion care could be improved. Providing more detailed information about pain management and the products of conception and lifting up the voices and stories of those who have used mifepristone and misoprostol could help patients manage expectations and would likely be welcomed. IMPLICATIONS: Changes to the Mifegymiso® product monograph since its introduction seem to have addressed a number of barriers described by early users of mifepristone and misoprostol. Continued engagement with clinicians to ensure that the process is not overly medicalized appears warranted.

"We've got rights and yet we don't have access": Exploring patient experiences accessing medication abortion in Australia.

OBJECTIVES: Across Australia, multiple strategies have emerged to decentralize abortion care and increase access to mifepristone, including incorporating medication abortion into primary care and offering the mifepristone and misoprostol regimen via telemedicine. We aimed to explore the experiences of patients accessing medication abortion care across these different health service delivery formats and different geographic areas. STUDY DESIGN: We conducted in-depth interviews with 22 people from across Australia who had used mifepristone for abortion. We audio-recorded and transcribed all interviews and managed our data with ATLAS.ti. We used deductive and inductive techniques to analyze these data for content and themes. RESULTS: Although participants were generally satisfied with the abortion care they received, many described medication abortion care in Australia as inaccessible and confusing to find. Our participants incurred variable and often significant financial costs when obtaining their abortion and many reported that their interactions with general practitioners when trying to locate an abortion provider were uninformative and stigmatizing. Participants were enthusiastic about obtaining medication abortion through a variety of service delivery modalities, including telemedicine, and believed these strategies could increase equitable and affordable access. CONCLUSIONS: Barriers to finding and accessing abortion care persist across Australia. Efforts to challenge the over-regulation of mifepristone, increase the affordability of medication abortion, and enhance training opportunities to educate a variety of clinicians about medication abortion and support provision from a range of providers appear warranted. IMPLICATIONS: The continued over regulation of mifepristone creates barriers for incorporating medication abortion into primary care settings and has significant implications for patient access and abortion stigma. Regulatory reform and provider education and training have the potential to improve abortion patients' experiences with medication abortion.

Put a Ring in It: Exploring Women's Experiences with the Contraceptive Vaginal Ring in Ontario.

BACKGROUND: Although the contraceptive vaginal ring (CVR) has been available in Canada since 2001, overall use and availability remain low compared with other combined hormonal contraceptive methods. We aimed to explore women's experiences with the CVR in Ontario as well as factors that influenced their decisions to choose the method and continue/discontinue use. METHODS: We conducted a multimethod qualitative study that consisted of an anonymous online survey and in-depth telephone interviews with a subset of survey participants. We used descriptive statistics to analyze the survey data and analyzed our interviews for content and themes using both deductive and inductive techniques. RESULTS: From May to July 2015, we received 103 survey responses and conducted 29 in-depth interviews. Many participants described positive experiences with the CVR and found it to be an especially convenient method. Women who discontinued use of the CVR cited high costs, access barriers, and negative media reports as important factors in their decision. Our participants primarily relied on their physicians for contraceptive information but did not feel fully informed about potential side effects. Several women identified the CVR as an "in between" method in the transition from oral contraceptive pills to the intrauterine device. CONCLUSIONS: Our findings suggest that the CVR represents a convenient and desirable contraceptive option for some women. However, participants expressed a desire for health care providers to provide more comprehensive information about a full range of contraceptive methods. Improving access to a full range of low-cost contraceptives in Ontario seems to be warranted.

Exploring Canadian Women's Multiple Abortion Experiences: Implications for Reducing Stigma and Improving Patient-Centered Care.

BACKGROUND: Roughly one-third of all abortions in Canada are subsequent abortions. However, few published reports showcase women's voices or explore women's experiences on this topic. Our study aimed to understand better the ways that women who have had multiple abortions talk about and view those experiences. METHODS: Between 2012 and 2016, we conducted in-depth interviews with 41 Canadian women who had a total of 87 abortions in the 5 years preceding the interviews. We audio-recorded and transcribed all English- and French-language interviews and analyzed our data for content and themes using a multiphased iterative approach and inductive and deductive techniques. RESULTS: Women described their abortion experiences as unique life events, even in cases when the overarching circumstances surrounding the pregnancies were similar. Participants recalled multiple factors that influenced their decisions to terminate, including their relationship status; level of support from family and friends; financial situation; health status; previous reproductive health, pregnancy, and abortion experiences; and desire to parent. In general, a previous abortion demystified the abortion process but did not play a significant role in decision making. Women described intensified feelings of shame and both internalized and externalized stigma surrounding their decision to have more than one abortion. However, the overwhelming majority were confident in their decisions. CONCLUSIONS: The often-used phase "repeat abortion" fails to capture women's experiences and the complex decision making surrounding each pregnancy. Efforts to reframe the narrative of multiple abortions, including among health care providers, could help reduce the amplified stigma associated with having more than one lifetime abortion.

"If I ever did have a daughter, I wouldn't raise her in New Brunswick:" exploring women's experiences obtaining abortion care before and after policy reform.

INTRODUCTION: New Brunswick (NB)'s Regulation 84-20 has historically restricted funded abortion care to procedures deemed medically necessary by two physicians and performed in a hospital by an obstetrician-gynecologist. However, on January 1, 2015, the provincial government amended the regulation and abolished the "two physician rule." OBJECTIVES: We aimed to document women's experiences obtaining abortion care in NB before and after the Regulation 84-20 amendment; identify the economic and personal costs associated with obtaining abortion care; and examine the ways in which geography, age and language-minority status condition access to care. METHODS: We conducted 33 semistructured telephone interviews with NB residents who had abortions between 2009 and 2014 (n=27) and after January 1, 2015 (n=6), in English and French. We audiorecorded and transcribed all interviews and conducted content and thematic analyses using ATLAS.ti software to manage our data. RESULTS: The cost of travel is significant for NB residents trying to access abortion services. Women reported significant wait times which impacted the disclosure of their pregnancy and the gestational age at the time of the abortion. Further, many women reported that physicians refused to provide referrals for abortion care. Even after the amendment to 84-20, all participants reported that they were required to have two physicians approve their procedure. CONCLUSIONS: The funding restrictions for abortion care in NB represent a profound inequity. Amending Regulation 84-20 was an important step but failed to address the fundamental issue that clinic-based abortion care is not funded and significant barriers to access persist. IMPLICATIONS: NB's policies create unnecessary barriers to accessing timely and affordable abortion care and produce a significant health inequity for women in the province. Further policy reforms are required to ensure that women are able to get the abortion care to which they are entitled.

Exploring Canadian women's knowledge of and interest in mifepristone: results from a national qualitative study with abortion patients.

INTRODUCTION: Although Canada decriminalized abortion in 1988, significant disparities in access to services and an uneven geographic distribution of providers persists. Health Canada registered mifepristone, the gold standard of medication abortion, in July 2015. Our study explored Canadian women's knowledge of, interest in, and perspectives on mifepristone prior to registration. METHODS: From November 2012 through July 2015 we conducted in-depth interviews with 174 Anglophone and Francophone women from Alberta, Manitoba, New Brunswick, Ontario, and Quebec about their abortion experiences and their opinions about medication abortion. We purposively recruited participants from different age cohorts and different regions within each study province to explore a range of perspectives. We analyzed these interviews for content and themes related to mifepristone using both deductive and inductive analytic techniques. RESULTS: The overwhelming majority of participants had no knowledge of mifepristone at the time of the interview. However, after providing a brief description of an evidence-based mifepristone/misoprostol regimen, more than half of the participants reported that they would have considered this method had it been available at the time of their abortion and most would have been comfortable receiving medication abortion care from a family physician or nurse practitioner. Most women supported the approval of mifepristone and felt Canadian women would benefit from having more options for early pregnancy termination. CONCLUSION: Although knowledge of mifepristone among recent abortion patients was low, considerable interest in medication abortion exists. Expanding awareness-raising efforts and supporting the approval of evidence-based regimens and provision of mifepristone appears warranted. IMPLICATIONS: The approval and introduction of mifepristone for early abortion in Canada promises to increase options and access. Creating tailored and culturally and contextually resonant messages about mifepristone is of high priority. Promoting evidence-based protocols and the inclusion of a full range of qualified professionals in service provision is also warranted.

Toll free but not judgment free: evaluating postabortion support services in Ontario.

INTRODUCTION: Crisis pregnancy centers (CPCs) account for the majority of advertised postabortion support providers in Ontario, Canada's largest and most populous province. Although the deceptive tactics used by CPCs to dissuade women from seeking abortion care are well documented, their provision of postabortion support has not been previously explored. Our study aimed to fill this gap. METHODS: In 2014-2015, we conducted a mystery client study with 17 postabortion support providing organizations in Ontario. We used a predetermined character profile and set of prompts to seek phone-based services. Each interaction began with "I'm looking to talk to someone about my abortion." The interactions developed organically and mimicked the experience of a woman seeking postabortion support. We audio recorded and transcribed all interactions and used both inductive and deductive analytic techniques in our evaluation. RESULTS: We spoke with three secular and three religiously affiliated talklines, one sexual health center and 10 CPCs offering phone-based support. Although all counselors effectively used active listening techniques such as supportive utterances and attentive silences, the interactions with lay counselors from religious talklines and CPCs contained shaming and stigmatizing language and medically inaccurate information. These interactions appear to be premised on the counselors' belief that abortion is traumatic and always requires a grieving process, regardless of the client's expressed feelings and needs. CONCLUSIONS: The expanded provision of postabortion support by CPCs in Ontario represents a new method for these organizations to pathologize abortion. Our findings suggest that their services are judgmental and shaming, thereby contributing to abortion stigma. IMPLICATIONS: Postabortion support services appear to be a new frontier by which CPCs are able to stigmatize and pathologize abortion. Increasing awareness of and access to existing nonjudgmental, nondirective postabortion services appears warranted.

No Exceptions: Documenting the Abortion Experiences of US Peace Corps Volunteers.

Since 1979, US federal appropriations bills have prohibited the use of federal funds from covering abortion care for Peace Corps volunteers. There are no exceptions; unlike other groups that receive health care through US federal funding streams, including Medicaid recipients, federal employees, and women in federal prisons, abortion care is not covered for volunteers even in cases of life endangerment, rape, or incest. We interviewed 433 returned Peace Corps volunteers to document opinions of, perceptions about, and experiences with obtaining abortion care. Our results regarding the abortion experiences of Peace Corps volunteers, especially those who were raped, bear witness to a profound inequity and show that the time has come to lift the "no exceptions" funding ban on abortion coverage.