Women’s decision-making related to induced abortion – a cross sectional study during a period of Covid-19 pandemic, in Sweden


Introduction

According to the World Health Organisation, comprehensive abortion care is an essential health care service [1]. In Sweden, abortion is classified as a procedure that cannot be delayed, and is permitted regardless of the reason, until the 18th gestational week (GW). Thereafter, induced abortion is permitted until the GW 21 + 6 with permission from the National Board of Health and Welfare [2]. With 18 abortions per 1,000 women* in 2021, Sweden has the highest rate of abortions in the Nordic countries [3]. The majority (61%) were performed before the seventh GW, and 96% of all induced abortions were medical abortions [2].

According to Swedish law, women do not have to report the reason(s) for requesting an abortion [2]. Previous studies have found financial concerns to be a primary reason motivating a woman to seek an abortion globally [4–6]. Different circumstances often influence the ultimate decision and its perceived difficulty; examples include relationship problems or feeling that one’s family is complete [4–6], as well as a personal history of mental disorders [7]. The abortion-decision may be perceived as challenging, but long-term negative emotional consequences are limited in most cases [8].

Sweden is a highly secular country, yet abortion care can provoke existential thoughts regardless of one’s background [9]. Swedish abortion care is often perceived as neutral and rational to perhaps maintain a certain decorum, although this may not be appreciated by all abortion-seeking women [9]. Women’s perceptions of abortion decision-making are relatively unexplored in Sweden. However, Makenzius et al. [10] showed that about four in ten abortion-seeking women perceived the abortion decision as difficult.

The Covid-19 pandemic led to unforeseeable challenges for reproductive health care globally, resulting in limited access to abortion and contraceptive services in many countries [11,12]. As shown in a letter based on findings from the current study, access to services in Sweden seems to have been stable [13]. However, the pandemic may have influenced the abortion-decision for more than one in ten women [13]. Therefore, the present study was conducted to add nuance to abortion-seeking women’s experiences during times of crises, but also as a follow-up to previous studies about this topic in Sweden [4,6]. Reasons behind abortion and the level of difficulty to decide on abortion should be continuously evaluated to improve abortion counselling and care satisfaction, but also to consider societal efforts to prevent unintended pregnancies.

The aim of this study was to investigate women’s decision-making before having a first trimester induced abortion, reasons behind their decision, and predictors for perceiving the decision as difficult, during a period of Covid-19 in Sweden.

Materials and methods

A multi-centre cross-sectional survey was conducted from January to June 2021 among women seeking an abortion, at seven family planning clinics in urban and sub-urban areas in Sweden. The women were asked to voluntarily participate by the clinic staff, and those who agreed to participate filled out an anonymous paper questionnaire. The return of the questionnaire to the staff was regarded as informed consent.

The questionnaire was constructed by Larsson et al. [4] and revised by Makenzius et al. [6], in collaboration with experts and abortion-seeking women during both instances and tested to strengthen the validity.

The questionnaire investigates experiences among abortion-seeking women and their background characteristics (). The main outcome for the current sub-study was women’s perception of the difficulty in deciding to have the abortion (using a 7-point Likert scale), and secondary outcomes were with whom they discussed the decision (), and reasons motivating their decision (). An additional background question was added to specifically investigate whether the Covid-19 pandemic had affected the decision.

Table 1. Characteristic of the participants.

Table 2. With whom the women had discussed the abortion decision (option to report more than one category), divided by age group.

Table 3. Reasons for the abortion decision (option to report more than one reason) among abortion-seeking women (n = 623).

Statistical analysis

Univariate data were presented in frequencies and percentages, and bivariate analyses were performed using one sample T-test and χ2 two-tailed tests. How the women perceived the abortion decision was rated from ‘very easy’ = 1 to ‘very difficult’ = 7, and dichotomised as ‘easier’ (score 1–4) and ‘more difficult’ (score 5–7). The rated well-being before and after finding out about the pregnancy were ‘very good’ = 1, ‘neither good, nor poor’ = 2, ‘sort of poor’ = 3, and ‘very poor’ = 4. These were dichotomised into: ‘good’ (scored 1–2), and ‘poor’ (scored 3–4). Multivariate analysis () was conducted to exclude possible confounding factors for perceiving the abortion decision as difficult, by using factors showing significant associations in univariate analysis (age, country of birth [dichotomised ‘born in a Nordic Country’/‘born outside the Nordic countries’]), if having discussed the decision with someone, if desiring (more) children in the future, partner’s hesitance to have a child, and whether the Covid-19 pandemic had affected the decision (dichotomised ‘no’/‘yes’ [yes, a lot/yes, to some extent]). A p-value < .05 was considered significant for all analyses. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for the multivariate analysis. IBM SPSS Statistics 27 was used for all analyses.

Table 4. Odds of perceiving the abortion decision as more difficult (score 5–7; 7-point Likert scale). Out of 623 women, 582 were included in the analysisa.

Ethical considerations

Women received oral and written information that participation was entirely voluntary and that deciding to participate would not affect their present or potential future care. As the questionnaire did not include any personal data, no formal ethical approval was needed, as decided by the Swedish Ethical Review Authority (2020–05951).

Results

In total, 1,029 abortion-seeking women visited these seven clinics. Out of these, 670 (65%) women were asked to participate, and among these, 623 (93%) agreed to participate (Figure 1). Staff’s lack of time and women showing ambivalence about the abortion decision were the main reasons for not asking a woman to participate.

Figure 1. Flowchart – Abortion seeking women.

The internal non-response rate varied between 1 and 3%. The mean age was 28.9 years, and median, 29 years (range 16–47 years). How they perceived the abortion decision was rated from ‘very easy’ = 1 to ‘very difficult’ = 7, and distributed as 1 = 78 (12.5%), 2 = 70 (11.2%), 3 = 84 (13.5%), 4 = 90 (14.4%), 5 = 92 (14.8%), 6 = 79 (12.7%), and 7 = 121 (19.4%). The mean score was 4.2, the median 4.0, and SD 2.0. Scores from 1 to 4 were labelled as having perceived the decision as easier (n = 322; 52%), and scores from 5 to 7 (292;48%) as having perceived the decision as being more difficult. shows the background data of the study population, divided into the two groups perceiving the abortion decision as ‘easier’ and ‘more difficult’.

Discussion about the abortion decision

shows with whom the women had discussed the abortion decision, divided by age groups. The youngest women had less often discussed the decision with their partner, but more often with their parents compared to the older age groups (p < .001 and p = .011, respectively). There were no significant differences between women who found the abortion decision as difficult or not, with regard to with whom the women had discussed the abortion decision.

Reasons behind the abortion-decision

shows that the most common reason for the abortion decision was poor economy (166;27%), followed by pregnancy too early in the relationship (154;25.1%), want to work first (147;23.9%), want to study first (132; 21.5%), uncertain about relationship with partner, (104;16.9%), and being too young (104; 16.9%). In addition to the 21 pre-specified response alternatives, about 13% (n = 79) opted to write their reasons as free text (not shown in , as most were clarifications about already stated pre-specified options).

Sub-analyses showed that those who perceived the abortion decision as easy also more commonly reported reasons such as family completed (25.1%), want to work first (21.5%), and too young (16.9%), compared to those who considered the decision as more difficult (p = .006, p < .001 and p < .001, respectively). Women who stated the abortion decision as being more difficult more often reported spacing between children (12.5%), and partner’s hesitance (11.9%), as reasons for the abortion compared to those who perceived the abortion decision as easier (p = .007 and p < .001, respectively).

shows the odds of perceiving the abortion decision as more difficult. Age >30 (OR = 2.22), being born outside the Nordic countries (OR = 2.23), having discussed the decision with someone (OR = 2.42), desiring (more) children in the future (OR = 1.96), not sure if desiring (more) children in the future (OR = 1.90), partner’s hesitance to have a child (OR= 3.18), and the ongoing Covid-19 pandemic (OR = 2.08) were significantly associated with perceiving the abortion decision as more difficult.

Discussion

The decision to terminate an unintended pregnancy varies in its perceived difficulty and the reasons motivating the choice. About half of the women in our study scored 5–7 (48%), suggesting that the decision was perceived as more difficult compared to the other half, who scored 1–4. This differs from a previous study conducted in Sweden in 2009 (using the same 7-point Likert scale), where 39% of the participants scored 5–7 [10]. In the same study, 40% scored 1–2 [10], compared to 23.7% in the current study. Reasons behind this escalation in perceived difficulty may in part be due to the anxiety provoked by the pandemic, as those who reported that Covid-19 had to some extent affected the abortion decision perceived the decision as more difficult compared to those who denied any influence of Covid-19 on their decision.

With regard to Covid-19, more than one in ten women presenting for an abortion reported that the pandemic had more or less affected their decision. We have previously reported that Covid-19 related reasons for deciding on abortion were connected to fear of the virus (for oneself and for the sake of the foetus), economic constraints, or that women wanted to be vaccinated before carrying a pregnancy to term [13]. It is difficult to determine exact variations in perceived difficulty when deciding on abortion and the reasons behind possible changes; however, our study adds nuance to the effect the pandemic had on reproductive choices.

Among those who perceived the abortion decision as more difficult, it was also more common to report poor mental well-being after finding out they were pregnant, compared to those who perceived the decision as easier. Yet no significant difference in self-rated mental well-being was reported before finding out they were pregnant between the two groups. This may imply that abortion causes poorer mental well-being for some women. However, it should be noted that previous research has not found any evidence of an increased risk of mental disorders after a first trimester induced abortion [8].

One out of five in our study recorded the abortion decision as very difficult (score 7). This heavily weighted score may emphasise the intensity experienced by some facing this dilemma. It is a strength that this current study in part reflects the feelings of those who were contemplating an abortion but may or may not have continued with the procedure, thereby revealing the decision-making process for all women presenting at the abortion clinic. The feelings of decision difficulty may also reflect the ongoing international debate on abortion, which has become charged in recent years in high-income countries where abortion rights are threatened, such as Poland and the United States [14,15]. The lasting impression of these major legal setbacks on the political environment and on individuals’ views has yet to be quantified, however, certain effects are already observed. An example is the case of Croatia, where the introduction of conscience objection within abortion care resulted in a shift towards more conservative views on abortion amongst the younger generation [16].

The abortion decision should be made solely by the woman, yet this study showed that more than one in ten women reported her partner’s hesitance to have a child as an influencing factor. This was subsequently associated with greater decision difficulty, which concurs with previous research that found pressure from one’s partner strongly linked to negative emotional distress post-abortion [17,18]. A study conducted in Sweden in 1997 found that one in ten women presenting for an abortion, in fact, continued with the pregnancy if the initial reasoning depended on her partner’s opinion [19].

We found that decision difficulty was more likely reported by those born outside of the Nordic countries. This result may speak to the different degrees of acceptance of abortion in countries with less liberal abortion policies or more conservative social norms, or within cultures or religions that frown upon premarital sex or abortion. Indeed, a previous study conducted in the Netherlands found that participants in the high decision-difficulty group were more likely to be personally opposed to abortion [18]. In countries with more restrictive abortion laws, many women struggle to access comprehensive abortion care due to societal stigma surrounding abortion and the lack of youth-friendly services [11,16,20,21]. This stigma may transverse the border and continue to affect a woman’s decision-making and personal convictions, even after moving abroad.

Those in our study who perceived the abortion decision as difficult had also more frequently discussed the abortion decision with someone, which has been previously shown [18]. There was a clear age division; not only was the abortion decision perceived as easier the younger the woman, but younger participants more often had spoken with their parents. Older participants, on the other hand, more often consulted their partner. It could be considered positive that those who perceive the decision as difficult actively seek social support. Discussion with others can be proactive, yet negative attitudes expressed by peers can also greatly influence the woman’s decision [18,22,23]. Peers who believe it is the right choice to terminate the pregnancy may persuade someone who is ambivalent to go through with the abortion, thus provoking a feeling of powerlessness during the decision-making process [18,23].

The women in our survey could write or refer to multiple reasons for having an abortion, which enables reflections of the multifactorial nature of abortion decisions. Reasons provided by the participants’ varied, but were in fact identical to those reported over a period of 20 years [4,6]. A literature review summarising abortion decision-making found that material reasons, including financial concerns, were cited as motivations in nearly all articles reviewed [24]. Financial concerns may also reflect other life circumstances, such as being an adolescent [25] or a student, a single parent or already having many children [24]. It is worth noting that the pandemic had a negative financial impact on many individuals and households, as reported worldwide. This result raises the question of whether some of these unintended pregnancies would be desired if economic and social programmes were improved. A previous study (2009) found that some abortion-seeking women reported that economic support would have allowed them to continue with the pregnancy, implying structural societal aspects may need to be addressed in the prevention of unintended pregnancy [6].

Certain factors or reasons for deciding on abortion have been linked to emotional consequences in the future and are therefore critical to understand in order to improve abortion care. A previous study found that financial concerns and pressure from one’s partner led to more emotional distress post-abortion than, for example, the reason ‘having enough children’ [26]. Those who have mental health issues, such as depression and anxiety, prior to an abortion have a greater risk of depression post-abortion, although the number who reported depression pre-abortion had decreased significantly post-abortion [27]. Indeed, similar findings were shown by Rocca et al. [28]. Nevertheless, the complex decision-making process and feelings of ambivalence may lead to severe emotional distress for a select few [8,27,28]. Clinicians who work with abortion care must be aware of the implications on women’s emotional well-being during the decision-making process, but also after the procedure.

Our study strengthens previous findings that socio-economic factors greatly influence reproductive choices and should guide policymakers to take these factors into consideration when identifying changes to reproductive health policy. Clinicians should be aware of factors influencing decision difficulty, such as background, age, and family circumstances, particularly during a pandemic. Our findings also confirm that an abortion is not often a decision taken lightly and disproves arguments that abortion availability results in casual abortion decision-taking.

Limitations

Sweden has liberal abortion policies where easy access to abortion and contraceptive counselling is guaranteed. In countries where access to contraceptives and/or abortion is limited or even illegal, the decision-making process may be further complicated by cultural stigmas or legal obstacles and could thereby influence the perceived difficulty of the abortion decision. Furthermore, Sweden is a country with a well-functioning health care system. Thus, it can be assumed that maternal health risks are seldom motivating factors for an early abortion. Caution should therefore be taken when drawing conclusions from this study to other countries with more restrictive abortion policies or worse maternity health care.

Around one-third of abortion-seeking women at the seven clinics were not asked to participate in the study. Reasons for this were lack of Swedish language skills, displaying ambivalence, or time constraints among the women and the staff. Exclusion of women who did not speak Swedish may have introduced a selection bias that omitted a large portion of the population, as 8.4% living in Sweden are non-Swedish citizens and may not have a strong command of the language [29].

Conclusion

This study sheds light on the multifactorial decision-making process among abortion-seeking women. Deciding to undergo an abortion can be an easy procedure for some women, and a difficult one for others, and may even result in negative mental well-being for a select few. The most common predictors for perceiving the abortion decision as difficult were their partner’s hesitance, being born outside of the Nordic countries, having discussed the decision with someone, age 30+, the ongoing pandemic, and desiring (more) children in the future. This valuable insight could aid in directing sexual and reproductive health services to underserved populations and in enhancing contraceptive compliance. Improving clinicians’ understanding of abortion decision-making could inform and promote satisfactory counselling beyond normal medical routines.



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