How do women seeking abortion choose between surgical and medical abortion? Perspectives from abortion service providers
Abstract
Background
Depending on availability, many Australian women seeking an abortion will be faced with the choice between surgical or medical abortion. Little is known about the factors that influence Australian women's choice of method.
Aim
Through the perspectives of abortion service providers, this study aimed to explore the factors that contribute to Australian women's decision to have a surgical or medical abortion.
Materials and Methods
In 2015, in-depth interviews were conducted with fifteen Victorian-based key informants (KIs) directly providing or working within a service offering medical abortion. Ten KIs were working at a service that also provided surgical abortion. Interviews were semi-structured, conducted face-to-face or over the telephone, transcribed verbatim and analysed thematically.
Results
KIs described varying levels of awareness of medical abortion, with poorer awareness in regional areas. When it comes to accessing information, women were informed by: their own research (often online); their own experiences and the experiences of others; and advice from health professionals. Women's reasons for choosing surgical or medical abortion range from the pragmatic (timing and location of the method, support at home) to the subjective (perceived risk, emotional impact, privacy, control, and physical ability).
Conclusions
Women benefit from an alternative to surgical abortion and are well-placed to choose between the two methods, however, challenges remain to ensure that all women are enabled to make an informed choice. KIs identify the need to: promote the availability of medical abortion; address misconceptions about this method; and increase general practitioner involvement in the provision of medical abortion.
Introduction
It has been estimated that around one in four pregnancies in Australia ends in abortion, with approximately 80 000 women having an abortion each year.1, 2 Depending on availability, many Australian women seeking an abortion will be faced with the choice between a surgical or medical abortion (using mifepristone and misoprostol). Little is known about the factors that influence Australian women's decision to choose an abortion method. International research indicates that women choose a surgical abortion because it is more convenient and faster, to be unaware of the procedure as it is occurring, and because they are sceptical about medications or concerned about the potential side effects of medications.3-5 Women who choose to have a medical abortion typically do so because they have a fear of surgical procedures or general anaesthesia, they feel that medical abortion is safer and more natural than surgical abortion, and because it affords them a more private experience.3-9 Other reasons women choose medical abortion are because it can be performed at an earlier gestation, it gives women the opportunity to potentially verify their expulsions, and can be undertaken in the home environment.6, 10
To date, no research has explored the reasons why Australian women choose to have either a surgical or a medical abortion. Through the perspectives of abortion service providers, this study aimed to explore Australian women's level of knowledge of the two methods, their sources of information and the factors that contribute to their decision to have a surgical or medical abortion.
Materials and Methods
A decision was made to focus on the state of Victoria, as differing abortion laws in other states affect the service models which can be offered. Interviews with key informants (KIs) working in Victorian health services were undertaken. KIs were sourced through researcher networks and snowball sampling. Fifteen KIs either directly providing or working within a service that provided medical abortion were invited to take part and all agreed. An effort was made to identify KIs affiliated with a variety of health organisations in a range of locations. Ethics approval was obtained through the University of Melbourne Human Research Ethics Committee.
A semi-structured interview schedule was developed to explore KI perceptions of how women gather information on abortion methods and why women choose surgical or medical abortion. Interviews were conducted face-to-face or over the telephone, lasted between 30 minutes and 2 hours, and were recorded and transcribed verbatim. Thematic analysis of the data was undertaken by Danielle Newton using a progressive process of classifying, comparing, grouping and refining groupings of text segments to create and then clarify the definition of categories, or themes, within the data.11 In order to ensure reliability, Louise Keogh independently coded a sub-section of transcripts and cross-checked these with the findings of Danielle Newton. Discrepancies were discussed and a mutually agreeable interpretation was reached.
Results
Characteristics of participants
As shown in Table 1, the majority of key informants were female (n = 12), either GPs (n = 4) or obstetrician & gynaecologists (n = 3), employed by a sexual and reproductive health service (n = 6) or public hospital (n = 4), and were based in a metropolitan area (n = 10). All KIs were providing a medical abortion service at their health service. Ten KIs were working at a service that also provided surgical abortion.
Characteristic | Number (N = 15) |
---|---|
Gender | |
Female | 12 |
Organisationa | |
Sexual and reproductive health service | 6 |
Hospital | |
Public hospital | 4 |
Private hospital | 1 |
General Practice | 2 |
Community health service | 1 |
Reproductive health service | 1 |
Youth health service | 1 |
Sexual health service | 1 |
Professional background | |
General Practitioner | 4 |
Obstetrician & Gynaecologist | 3 |
Primary Health Care Nurse | 2 |
Psychologist | 1 |
Sexual Health Physician | 1 |
Medical Practitioner | 1 |
Service Manager | 3 |
Geographical location | |
Metropolitan | 10 |
Regional | 5 |
- a A number of KIs were employed by multiple organisations.
Factors that inform women's decision-making
Illustrative quotes related to each of the themes are presented in Table 2.
Level of awareness of medical abortion |
“…generally when women come in they are delighted to learn for the first time that there is a medical option, and it's just a matter of going to the local pharmacy”. (ID8, General Practitioner, General Practice, Regional) “They're often surprised that it's an option. Yeah sometimes it's us telling them, do you realise that you have this option and they are like ‘oh’”. (ID14, General Practitioner, Community Health Service, Regional) |
How do women access information about abortion method choice? | |
Prior online research |
“…a lot of [women] came in with very, very good information. Most of the best information came from the [….] website. And when you look up [….] that's one of the first websites that pops up…So most [women] were already quite sure that they wanted a medical, or they wanted a surgical because of these reasons. And they could actually list the reasons off of why they wanted each one. And most of the time their knowledge was quite sound.” (ID11, Primary Health Care Nurse, General Practice, Regional) “Most [women] have been well researched and usually have been on the net and understand about all of it”. (ID18, Medical Practitioner, Sexual and Reproductive Health Service, Metropolitan) |
Women's experiences and experiences of others |
“What we're finding now is that the word is out there that [medical abortion] is not the be all and end all, that there are problems with it. I see patients now who say oh I would never go through that again, it's too painful, I couldn't cope…”. (ID19, General Practitioner, Sexual and Reproductive Health Service, Metropolitan) “Like we've certainly had some women that they tend to have had a friend, or they know someone that's had it done, and…it was fine, nothing wrong with it, there was no problem. Others will say look she had, my friend had a horrendous experience and I'm not sure how I feel about it. But I guess that's where our job comes in, to say that well, you know everyone's a little bit different”. (ID13, Primary Health Care Nurse, Community Health Service, Regional) |
Advice from health professionals |
“So what I try and give them choice, but I'm also not backward in saying to some women in some circumstances, look I really think that you would be better to go surgical. And they're the women that are not coping at all with it, and don't want to have anything do with it. Why would they then want to go home, and over a 48 hour period make themselves bleed and have incredible pain, and be reminded of it all…Sometimes with very young girls, especially if they have a very young partner, say they're both 17. That's a big ask for them to go home, say over a weekend, the guy can't stand the sight of blood because he's never had to. He doesn't know how to manage a period let along that sort of thing”. (ID15, Sexual Health Physician, Sexual and Reproductive Health Service, Metropolitan) “If someone walked into my rooms and said doctor I'm pregnant I can't really continue with the pregnancy and I'm under eight weeks, tell me about surgical, tell me about medical. I very simply over simplify the situation and I would say if you walk through the front door and say ‘I want a medical’ then you'll walk in the front door with a problem and you leave with the problem. If you came in and said ‘I want surgical’, you walk in the problem and 99 times out of 100 you walk out without a problem. But I appreciate the fact that you want something done in the confines of your own home and the privacy of your own home and your body not invaded and all those sort of reasons; I accept that, and I'm happy to push on if that's what they want”. (ID18, Medical Practitioner, Sexual and Reproductive Health Service, Metropolitan) |
Level of awareness of medical abortion
While KIs mostly felt that women were well informed about their options for abortion, and all were aware of surgical abortion, they also described women attending health services, particularly in regional areas, who were unaware of an alternative to surgical abortion – “…when they come in with an unexpected pregnancy wanting a termination then it's when I put the two options to them. That is the first time that they have heard of [medical abortion] usually”. KIs described other women who had heard of medical abortion but did not expect to be able to access this in their regional community. This was often attributed to services not promoting the availability of medical abortion – “I mean nobody knows that we provide a service. We can't publicise that otherwise we'd have protestors outside our front door”.
Key informants also described some common misconceptions about medical abortion; some women believed that taking one pill makes their pregnancy “just disappear”; or that the experience is just like having a “heavy period”. As one KI stated, “there's quite often misinformation about it…and not being aware that it can feel like a miscarriage, it can be quite painful and quite a traumatic experience with quite a lot of bleeding”.
How do women access information about abortion method choice?
Prior online research
Key informants reported that women often attend health services with a “fairly clear idea that they either want one [method] or the other” and can rarely be swayed from this decision. This decision is frequently informed by prior internet research and this information is mostly “quite sound”. In these situations, KIs view their role as one of facilitation.
Women's experiences and experiences of others
Key informants said that women who had undergone a previous abortion frequently chose an abortion method based on their own prior experiences with one or both methods, while other women were influenced by the experiences of their friends or family members, using this information to make a decision. KIs believe that women are sometimes misinformed by anecdotal evidence and see it as their duty to address misconceptions and ensure that women have accurate information.
Advice from health professionals
Key informants held strong views about the methods most suitable for their patients. Surgical abortion was seen as preferable for younger women lacking good support networks or women with limited experience with pain and bleeding. Women with mental health issues and women struggling to cope with an unplanned pregnancy were also seen as better candidates for a surgical abortion. Due to the degree of unpredictability associated with medical abortion, KIs felt that this method was most suited to women living in safe housing where at least one person was at home to support them through the process. Despite holding strong views, KIs generally did not “steer women in one direction or the other”. Only a small number of KIs shared their views about the method they believed would be most suitable for women; ultimately accepting whatever choice women decided to make.
Key informants emphasised the importance of ensuring women were in possession of accurate information about both methods so they could make an informed decision. They also described the importance of being open with women about the range of symptoms they might experience so that women were able to distinguish between expected symptoms and symptoms requiring urgent medical attention.
Reasons women choose surgical or medical abortion
Illustrative quotes related to each of the themes are presented in Table 3.
Pragmatic reasons | |
Time and location |
“So we tend to be fairly upfront about it. Yeah, you're having a miscarriage, that's the way it works, it makes you have a miscarriage. You have bleeding, you pass a clot, you can't go to work on that day. It can be a bit unpredictable. Yeah and some women are quite happy with that, you know their situation is okay. But if you know you feel like whoa, geez, I can't take three or four days off work, it's too difficult, then they choose to have a surgical procedure instead. But I think you have to be very clear about what's involved, what the pros and cons are”. (ID19, General Practitioner, Sexual and Reproductive Health Service, Metropolitan) “I mean, we see women who have got no childcare and you'd have to have childcare to be able to do it [medical abortion]. You can't be dropping your kids off at school while you're bleeding…” (ID12, Obstetrician & Gynaecologist, Public Hospital, Metropolitan) |
Support at home |
“You also need to have support a bit. I mean you should have support when you come home from a surgical too, but I've had people choosing a surgical over a medical because they didn't have anyone, or they weren't in a position where they could be at home and do that at home. Either that they didn't want the person to know who was at home, or they were on their own and they didn't want to do it on their own, and they felt better having a surgical”. (ID10, Medical Practitioner, Youth Health Service, Sexual and Reproductive Health Service & Public Hospital, Metropolitan) “… you'd have to make an assessment that home needs to be okay, it needs to be safe, it needs to be comfortable. If there are other people there, they probably need to know what's happening because it can be a bit full on. We also need to know that women have support if something goes wrong, or women if they have children, they've got a backup if something goes wrong, if they start haemorrhaging for instance, they need to go to hospital. The very rare complications, we do need to know, so you try to make an assessment that that's going to be okay. Whereas the surgical is very straightforward and controlled. It's done, it's over”. (ID1, Service Manager, Public Hospital, Metropolitan) |
Subjective reasons | |
Perceived risk |
“Well often their first suggestion about medical abortion from the patient is that's less invasive. So those people that have got a bit of a thing about theatre or anaesthetics that sort of thing, that they're very keen to do it [medical abortion]”. (ID9, Service Manager, Sexual and Reproductive Health Service, Metropolitan) “…a lot of women they just like the fact that a medical – it's like a more natural – it's like a miscarriage. I don't know, I think psychologically some women feel that's a bit better and also just the sort of convenience and things and not having the general anaesthetic”. (ID3, General Practitioner, Sexual and Reproductive Health Service, Metropolitan) |
Perceived emotional impact |
“…it [bleeding or spotting] can be psychologically a bit traumatising for women if they just wanted it to be an event that they put behind them and there might be this visual flag every day of some blood”. (ID12, Obstetrician & Gynaecologist, Family Planning Services, Metropolitan) “Sometimes it can be those people that think oh well it's not quite as bad I'm taking a pill and I'm not actually having a surgery done, so … they think that it's the lesser of the two evils if you know what I mean…they think that oh it's not really an abortion because I'm not having surgery I'm just taking some tablets, and I'm very early and it's – I don't know how they justify it in their mind, but they can actually justify it more easily in their mind than actually having the surgical procedure, and I think that's the bottom line to it”. (ID9, Service Manager, Sexual and Reproductive Health Service, Metropolitan) |
Perceived privacy |
“Well some women come in thinking that they'd like a medical abortion and then when they've got the information they realise oh in fact that doesn't really fit with my circumstances. Yes, so for example someone thinks that well they can keep it secret within their household but it's probably easier to keep secret if you come in and you have a surgical abortion and it's one day and then the next day you're generally quite okay really, not too bad”. (ID5, Psychologist, Sexual and Reproductive Health Service, Metropolitan) “…even the women who came in hesitant about which way they were wanting to go, almost all of them picked medical because…they didn't have to go through an “abortion clinic”…they didn't have to have people shouting at them from across the road. They didn't need to be seen. It's just at a GP. They're just going to their doctor and they're just getting some tablets.” (ID11, Primary Health Care Nurse, General Practice, Regional) |
Perceived control |
“I think there are some women that will do anything to avoid surgery and like the idea that it's the more natural process that can occur at home and they have some control over”. (ID2, Service Manager, Sexual and Reproductive Health Service, Metropolitan). “So they've [women who have had medical abortions] been really, really good. I think it's been a positive experience…I think it's been nice for [women] to…have a little bit more control over it all”. (ID6, Medical Practitioner, Sexual Health Service, Regional) |
Perceived physical ability | “I think some women because of sexism, in part because of that, and because of lots and lots of things, are often terrified of pain, terrified of their bodies doing things that are harder, feel that they couldn't do it, those women are way more likely to have a surgical than a medical…but I think there are lots of people who you can see have been made to feel less – to have less agency in their own life in a way, to be less empowered, to feel comfortable with their body, all these things which we want all women to have, and not all women have them, and that you need those things to feel that – you've got to have some capacity to be able to roll up your sleeves and think your body can do something and that you can do it”. (ID10, General Practitioner, Public Hospital & Youth Health Service, Metropolitan) |
Pragmatic reasons
Time and location
Key informants believed that women's choice of method was frequently determined by their schedule and the resources available to them and that women generally opt for the method that best fits with their life or schedule. For example, they described surgical abortion as preferable to women who wished to minimise the amount of time they are away from work or children. A commonly reported scenario is that of women with children who elect to have a surgical abortion because of “not feeling as though they could have…a whole day where they could just be left alone by the kids”. Women often choose medical abortion for similarly pragmatic reasons – “most [women] work during the week, so they'll tend to choose to do it [medical abortion] on the weekend, which they can't do through surgical termination”.
Support at home
Key informants felt that women should only have a medical abortion if they have a support person who is willing to assist them through the process and be available if “something goes wrong”. Many women do not have this support and choose to have a surgical abortion instead.
Subjective reasons
Perceived risk
Key informants believed that women often opt for a medical abortion because it is perceived to be more “natural”, less medicalised, and less invasive. Given that medical abortion does not involve an anaesthetic, many women view it as posing less risk to their health than surgical abortion.
Perceived emotional impact
According to KIs, some women perceive medical abortion as being akin to having a miscarriage and therefore view it as a natural process, saying it is “less like having an abortion” because it involves taking tablets rather than undergoing a surgical procedure. There was a perception among KIs that this attitude enabled women to distance themselves from the act and to “justify [having an abortion] more easily in their mind”.
They also described women who chose to have a surgical abortion because they felt unable to cope with the prolonged symptoms of a medical abortion. These can be “psychologically a bit traumatising for women”, especially if women are experiencing ambivalence about their decision to have an abortion.
Perceived privacy
Key informants perceived that women often opt for the method that affords them the most private experience. Due to the ongoing stigma of abortion, some women choose to hide their abortion from family members and friends. Some women perceive surgical abortion as easier to conceal because it is completed in one day rather than several days, taking less time away from normal routines. For other women, a medical abortion allows them to undertake the process in the “privacy of their own home”. Medical abortion can also be accessed through community health services or GP clinics where the reason for women's attendance will be unknown to observers.
Perceived control
Key informants felt that women often seek a sense of control over their abortion experience. Compared to surgical abortion, medical abortion gives these women a greater sense of control and this sense of control is a major factor in women having a positive abortion experience.
Perceived physical ability
Key informants perceived that women with greater confidence and trust in their own bodies were more likely to choose medical abortion. These women were perceived to be more empowered with a greater capacity to “roll up [their] sleeves and think [their] body can do something”.
Discussion
These findings highlight the individualised nature of the choice of abortion method. While KIs perceived that there were some general principles that could be applied to women's choice, they also acknowledged the importance of subjective factors for women. It seems likely that the same set of circumstances will be interpreted very differently by two different women, depending on, for example, their need for privacy and/or how important they perceive the experience being ‘natural.’ These findings reinforce the need to acknowledge subjective factors in health care decisions, as much as the pragmatic and practical ones. Some of the common principles, similar to those found in previous international studies are: KIs perceived that women select the method that best fits with their other commitments and activities6, 12; and availability of support at home is a determining factor. The more subjective factors that also play a role in women's decisions (also found in previous international studies)13-18 are: women choose medical abortion because they perceive it to be more natural, less medicalised and less invasive than surgical abortion; women choose the method that gives them the greatest sense of control and privacy; women with greater confidence and trust in their bodies are more likely to choose medical abortion; and women opt for the method that has the least emotional impact. For example, as identified in our study and in previous research,6, 7 medical abortion is viewed as akin to having a miscarriage enabling women to emotionally distance themselves from the act of having an abortion.
A difference in our findings, compared to the international research, was the absence of reports that women were sceptical about medications or concerned about the potential side effects of medications.3-5 Instead, the explanations offered by KIs tended to emphasise positive factors, that motivated women to choose one procedure over another, rather than the negative factors, that acted as deterrents to choosing a procedure.
The importance of the health professional role is highlighted in this study. Women frequently present to health services with a clear preference for a particular method. Women often undertake their own research or, as found in previous international research,9, 15, 19 are informed by their own or friends and/or acquaintances experiences with one or both methods. Health professionals consider themselves to have a responsibility to ensure that women have accurate information about both methods so that women are able to make an informed choice. With regards to medical abortion in particular, KIs believe that women should be well-informed about the range of potential symptoms so they are able to judge between those expected and those requiring medical attention. An interesting finding of this study is that while most health professionals held strong views about the method most suitable for particular women (ie younger women, women with mental illness, women with limited experience with pain and bleeding etc.); only a small number actually shared these views with women. Health professionals appeared to have a strong desire to support women to make autonomous and informed decisions irrespective of their own beliefs regarding the most appropriate method for women. There was, however, little acknowledgement that women might be influenced by the views of health professionals in more indirect ways. For example, by the manner in which information about the two methods is conveyed to women.
A finding of concern is that KIs believe that women, particularly in regional areas, are often unaware of an alternative to surgical abortion or they do not know that medical abortion is available in their health service or region. This finding highlights the need for greater community understanding of medical abortion. In order to choose, women need to know, not only that an alternative to surgical abortion exists, but how and where they can access this method. Community awareness of the option of medical abortion must be improved in conjunction with the development and implementation of strategies to increase the number of medical practitioners choosing to become certified prescribers of Mifepristone. Women's access to medical abortion can potentially be increased by the development of strategies to increase GP interest and uptake in becoming providers.
The results of our study must be interpreted in the context of the following methodological limitations. Firstly, we purposively targeted Victorian health professionals with expertise and experience in abortion service provision. To ensure that diverse views were represented, we recruited health professionals from a range of public and private health services in both metropolitan and regional areas. Unfortunately the views of rurally-based health professionals are not represented in this study. It is possible that the experiences and perceptions of rural health professionals differ from those practicing in metropolitan or regional settings. Secondly, being a qualitative study, we were unable to systematically compare differences in themes/experiences/perceptions across the various groups of health professionals. Thirdly, the findings of this study are specific to Victoria. Given the variation in abortion laws across Australian states and territories, the findings from this study may not be generalizable to states and territories with differing laws.
Conclusion
The findings of this research suggest that women appreciate having a choice of method, are well placed to choose between methods, and do so for a variety of different reasons. However, challenges remain to ensure that all women have a choice and are enabled to make that choice. Further research is needed to explore the perspectives of women attending abortion services.
Acknowledgement
We wish to acknowledge the Brenda Jean Brown Trust for funding this research.