How, when and where? A systematic review on abortion decision making in legally restricted settings in sub-Saharan Africa, Latin America, and the Caribbean.

BACKGROUND: With increasing global availability of medication abortion drugs, a safer option exists for many women to terminate a pregnancy even in legally restrictive settings. However, more than 22,000 women die each year from unsafe abortion, most often in developing countries where abortion is highly legally restricted. We conducted a systematic review to compile existing evidence regarding factors that influence women's abortion-related decision making in countries where abortion is highly legally restricted. METHODS: We searched ten databases in two languages (English and Spanish) for relevant literature published between 2000 and 2019 that address women's decision-making regarding when, where and how to terminate a pregnancy in sub-Saharan African, Latin American and the Caribbean countries where abortion is highly legally restricted. RESULTS: We identified 46 articles that met the review's inclusion criteria. We found four primary factors that influenced women's abortion-related decision-making processes: (1) the role of knowledge, including of laws, methods and sources; (2) the role of safety, including medical, legal and social safety; (3) the role of social networks and the internet, and; (4) cost affordability and convenience. CONCLUSIONS: The choices women make after deciding to terminate a pregnancy are shaped by myriad factors, particularly in contexts where abortion is highly legally restricted. Our review catalogued the predominant influences on these decisions of when, where and how to abort. More research is needed to better understand how these factors work in concert to best meet women's abortion needs to the full limit of the law and within a harm reduction framework for abortions outside of legal indications.

What attributes of abortion care affect people's decision-making? Results from a discrete choice experiment.

OBJECTIVES: We aimed to measure both stated and experimentally "revealed" abortion provision preferences among US people with capacity for pregnancy. STUDY DESIGN: In July 2022, we recruited US residents assigned female sex at birth and aged 18 to 55 years using Prolific, an online survey hosting platform. We asked participants what first-trimester abortion method and delivery model they would prefer. We also assessed abortion care preferences with a discrete choice experiment, which examined the relative importance of the following care attributes: method, distance, wait time for appointment, delivery model (telehealth vs in-clinic), and cost. RESULTS: More than half of the 887 respondents (59%) self-reported a slight (22%) or strong (37%) preference for medication compared to aspiration abortion; 11% stated no preference. Our discrete choice experiment found that cost and wait time had a greater effect on hypothetical decision-making than did method and delivery model (discrete choice experiment average importances = 44.3 and 23.2, respectively, compared to 15.9 and 8.2, respectively). Simulations indicated that holding other attributes constant, respondents preferred medication to aspiration abortion and telehealth to in-clinic care. CONCLUSIONS: This study, the first to examine abortion preferences in the United States, using a discrete choice experiment, demonstrates the importance of wait time and cost in abortion care decision-making. Our work indicates that for this population, factors related to health care financing and organization may matter more than clinical aspects of care. IMPLICATIONS: Although people in this study preferred medication to aspiration abortion and telehealth to in-clinic care, wait time and cost of care played a greater role in care decision-making. Focusing solely on clinical aspects of care (i.e., method, delivery model) may ignore other attributes of care that are particularly important for potential patients.

Welcomed Pregnancies: Characteristics and Patterns of Adjusting to Unwanted, Unplanned, Untimely or Otherwise Difficult Pregnancies.

Background Women facing problematic pregnancies, defined as "unplanned, mistimed, unwanted, or otherwise difficult," either have abortions or make adjustments to welcome these pregnancies. These adjustments are understudied. Pregnancy resource centers that provide counseling and services to assist in the process of welcoming pregnancies have been the focus of controversy due to their refusal to counsel or refer for abortions. This survey of a national population of women seeks to quantify changes in attitudes toward problematic pregnancies that are not aborted and to gauge levels of contact with pregnancy help centers and perceptions of harm or benefits attributed to those contacts. Methodology A national research firm was enlisted to obtain 1,000 surveys completed by female residents of the United States aged 41-45, inclusive. Women reporting a history of abortion were surveyed along one path. For those who did not have abortions but reported a problematic pregnancy, questions were presented to assess changes in attitude toward their pregnancy from the date they first learned they were pregnant to 90 days later, their considerations of abortion, whether they had contact with a pregnancy help center, and their assessment of that contact on either harming or improving their lives. Results Among 275 respondents who had no history of abortion but had ultimately welcomed a problematic pregnancy, 112 (40.7%) had been at higher risk of abortion. Positive attitudes toward their pregnancies increased most rapidly for women who had been at higher risk of abortion but were lower on the day they first learned they were pregnant. Overall, 34 (12.4%) reported they had contacted a pregnancy help center that did not refer for abortions. Another 37 (13.5%) were uncertain if they had contacted an organization fitting that description. Both groups reported the contact improved their lives, on average. Negative assessments were uncommon and all were of a small degree. Conclusions Women facing problematic pregnancies who did not choose abortion experienced rapid improvements in feelings of wantedness, timeliness, acceptance, welcoming, and desirability toward the pregnancy. The rate of improvement was most rapid among those who had investigated and considered abortion. Women reporting contact with pregnancy help centers almost always assess it as having improved their lives.