The journey of people accessing first trimester abortion in Aotearoa New Zealand: health consumers’ perspectives

Introduction

Aotearoa New Zealand (NZ) achieved abortion law reform with introduction of the Abortion Legislation Act 2020.¹ This removed abortion from the Crimes Act 1961,² placing abortion under the jurisdiction of health, and gave people the autonomy to have an abortion up to 20 weeks’ gestation. People can now self-refer, abortion can be provided by a range of health practitioners, and there is no longer a requirement for ‘licensed’ premises.¹ Law change paved the way for telemedicine early medical abortion (EMA), which is provided by a national telemedicine abortion service, DECIDE.³ Yet inequitable access to abortion remains.⁴

The findings of the 2023 Abortion Services Annual Report identified inequitable access to abortion for Māori and Pacific people, people living rurally and in socio-economically deprived regions.⁴ NZ is yet to see abortion care delivered according to the vision of legislation change. For example, primary care provision of abortion has the potential to improve access to abortion care.⁵ Primary care practitioners have many transferrable skills to provide first-trimester abortion, including contraception.⁶ However, primary care is not adequately funded to do so.⁵

This study aimed to describe the journey of people accessing first-trimester abortion care post law reform in NZ to identify how abortion services can be developed to deliver optimal first-trimester abortion care. Capturing the voices of people accessing abortion is important to inform the design and delivery of future abortion services.

Methods

This was a qualitative study informed by phenomenology with the intent of exploring the participants’ abortion experience within their broader social context. This methodology provides rich data to describe and interpret the lived experience of the individual’s journey. For this research, the beginning of the journey was determined by the individual and continued to the point of their interview. Despite the focus on the individual’s journey, it is impossible to separate the researcher from the findings as they are based on the researcher’s interpretation of the individual’s narrative.⁷ The Principal Investigator of this project acknowledges her position as a healthcare practitioner with a pro-choice stance.

Participants were recruited via a separate related national survey to determine people’s abortion experiences and how abortion access can be improved.⁸ People aged ≥14 years attending abortion clinics across NZ from September 2022 to December 2023 were eligible to complete an anonymous Qualtrics online survey. At the end of the survey, participants were invited to enter their contact details (on a separate survey form to protect anonymity) to be contacted for an interview. Wāhine who indicated their ethnicity as Māori or Pacific on the permission-to-contact form were contacted by Māori or Pacific researchers from the separate but related study.⁸ Consequently, all Māori or Pacific participants were recruited into the other study, resulting in no Māori or Pacific participants in this study. Furthermore, the national survey was unable to recruit potential participants from DECIDE, which is likely a contributing factor as to why none of the participants had accessed a telemedicine abortion.

Potential participants were contacted by phone approximately 4 weeks after their abortion to see if they remained interested in an interview. A verbal explanation of the study was provided, and if they agreed, an information sheet and consent form were emailed with a secure video conferencing link. All interviews were conducted via video conferencing, although participants had the option of a phone interview if video conferencing was not possible. There was no option for in-person interviews.

Interviews commenced with a welcome and confirmation of consent. Consistent with a phenomenological approach, participants were encouraged to take the lead. The interviewer prompted participants to expand on certain points if needed with questions such as ‘Can you tell me more about that?’ The interviewer avoided leading participants, but if input was required, more specific questions were asked, for example, ‘how did you find out where to get an abortion’ (see Box 1 for further sample questions). After the interview, participants were offered a $30 debit card koha.

Interviews were conducted via Zoom videoconferencing and recorded. Otter.ai was used for transcription. Participants were informed about the use of this software in the participant information sheet, and it was also outlined on the consent form. Transcripts were checked for accuracy and then uploaded to NVivo 12,⁹ a qualitative analysis program. Transcripts were read using a reflexive, inductive approach to form codes, which were refined to develop broader themes.¹⁰ A reflexive approach values the subjectivity of the researcher in the interpretation¹¹ and in this way is compatible with a phenomenological methodology.

Results

Nine people agreed to be contacted for this study. One potential participant withdrew, and one participant was deemed to have withdrawn after not attending three pre-scheduled interviews. Seven interviews were conducted. Results revealed four main themes: (1) decision making; (2) barriers to access; (3) abortion as a societal issue; and (4) empathy and advocacy. Main themes contained sub-themes.

Discussion

Results indicate that the first-trimester abortion journey for people in this study is influenced by a range of personal and societal factors. Findings identified the importance of reliable and non-judgemental information to inform decision-making, that barriers remain to equitable access to abortion despite law reform, societal abortion stigma has a negative impact on the abortion experience, and the positive impact of supportive people on the abortion journey.

Fielding, Edmunds and Schaff found that ‘women base their decision to have an abortion on their current life setting, even though having an abortion may conflict with their moral or religious beliefs.’¹² As shown in the current study, people who choose abortion often describe the reasoning for their decision, and due to abortion stigma, may struggle to see their decision as moral. However, other literature shows that people value the autonomy of deciding their pregnancy outcome and desire affirmation from abortion providers that they are capable, moral decision makers.¹³

People requesting abortion may have decided on a preferred method before accessing care. For many, the internet is a source of reliable information about abortion as well as forums with biased discussion.¹⁴ Social networks are also sources of advice, with people recommending a method they have experienced themselves.¹⁵ Previous experience of abortion can influence future preference for the abortion method,¹⁶ and it is important that health practitioners establish the person’s rationale for their choice and their information needs.¹⁷

Participants in this study reported a preference for surgical abortion due to negative impressions of EMA. Studies of EMA experiences report conflicting findings, with some people feeling unprepared for the pain and bleeding, while others feel well prepared and the effects manageable.^18–23 People opting for abortion want a full explanation of what to expect and what to do in specific situations.¹⁹ Providing more information about pain and use of analgesia, individualised to the person’s knowledge and previous experiences, would improve the medical abortion experience. A patient-centred approach to care and a process of shared decision-making are also important aspects of contraception counselling.²⁴

Our research identified situations suggestive of post-abortion contraception coercion. This is a form of reproductive coercion which Upadhyay et al. define as ‘to take action to promote or prevent a pregnancy.’²⁵ Participants reported pressure to choose any contraception and receiving selective information regarding LARC. In the literature, perceived contraception coercion includes: feeling pressured to start contraception, pressure to choose a LARC or not being offered a range of options, health practitioner bias towards a method(s), and insufficient time to consider options.^26–28 Studies show that while many people are receptive to contraception at the time of their abortion, others consider this as feeling judged or coerced.²⁶ The New Zealand Aotearoa Abortion Clinical Guidelines (The NZ Abortion Guidelines) recommend contraception provision at the time of abortion.²⁹ Abortion providers may feel further obligated to provide contraception due to barriers to access in primary care.⁴ However, the potential for reproductive coercion in contraceptive counselling and provision needs to be acknowledged. It can be mitigated by taking a patient-centred approach to care,²⁴ which is an important aspect of comprehensive abortion care.³⁰ Comprehensive abortion care includes provision of the abortion, offer of contraception, follow-up care and appropriate management of complications,³⁰ and is essential to reproductive health.³¹

This study identified barriers to accessing comprehensive abortion care, including lack of health services, rurality, cost of services, and requirements for diagnostic tests. Research shows that access to abortion can be improved by integration into primary care and is supported by the World Health Organisation.^30,32 However, more research is required to identify facilitators and barriers to primary care provision of first-trimester abortion in NZ. Previous studies have shown that access can be facilitated by expanding provision of abortion by nurses and midwives which has been shown to be safe and acceptable.³³ Telemedicine abortion can reduce barriers by eliminating travel time and costs, particularly for those living rurally.³⁴ The finding that the majority of participants were required to have blood tests, swabs, and ultrasound is inconsistent with the New Zealand Abortion Guidelines, which recommend that these should be performed based on individual clinical need.²⁹ Abortion services may wish to audit people’s pre-abortion diagnostics to ensure this does not pose a barrier to care.

Abortion stigma is perpetuated in multiple ways, including abortion silence.³⁵ People who have abortions may keep their stories secret, leading to a perception that abortion is rare, which compounds abortion stigma. This subsequently increases the need for people to maintain silence.³⁵ More work is required to develop interventions to break down negative socio-cultural messages and to create a ‘culture of support’ into abortion services.³⁶ This may assist in decision making, address abortion myths and false information and provide people with validation regarding their decision. Such a culture would strengthen individual resilience and ability to cope with any external negative influences.³⁶ A culture of support resonates with the finding that people experiencing abortion value supportive staff and support people. This is consistent with findings from other studies that satisfaction with the abortion care experience is increased by non-judgemental staff and the presence of patient advocates.³⁷

Many people still perceive abortion as morally wrong. Both the person seeking abortion and those providing care may be described as ‘murderers’.³⁵ This study showed the impact of such sentiments on people’s abortion experience. In addition, abortion is associated with the act of sex, which society still regards with moral judgement.³⁸ Some participants reported a reluctance to share their abortion experience with friends and family for fear of ‘slut shaming’. The virgin – ‘slut’ continuum is a gendered moral lens through which female sexual activity is judged.³⁸ To complicate this concept, contemporary society values the concepts of choice, freedom and self-determination.³⁹ Within such society females are not only judged by their sexual behaviour, but also the degree of control they exert over their sexual behaviour which paves the way for ‘slut’ shaming and blaming.³⁸

The findings of this study are limited by the exclusion of Māori and Pacific Peoples’ voices. However, this data was collected by an allied study undertaken by Māori and Pacific researchers.⁸ In addition, none of the participants accessed their abortion by telemedicine, which is a vital service to increase access to care. A strength of this study is that it features the voices of people who experienced abortion both pre- and post-law reform and describes people’s first-hand experience of first-trimester abortion in NZ. To date, this is the first study of its kind in NZ.

This study identifies areas of strength in abortion provision that can be used to enhance current and future abortion services. The findings also indicate areas for development including, streamlining the abortion journey, how information is provided regarding EMA, how contraception counselling is undertaken in the context of abortion, and to the bigger picture, addressing societal abortion stigma.