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Social Science & Medicine
journal homepage: www.elsevier.com/locate/socscimed
Review article
Trajectories of women's abortion-related care: A conceptual
framework
Ernestina Coasta,∗ , Alison H. Norrisb, Ann M. Moorec, Emily
Freemand
a Dept. of International Development, London School of
Economics and Political Science, Houghton Street, London,
WC2A 2AE, UK
bOhio State University, United States
cGuttmacher Institute, United States
d PSSRU, London School of Economics and Political Science,
UK
A R T I C L E I N F O
Keywords:
Induced abortion
Conceptual framework
Systematic mapping
A B S T R A C T
We present a new conceptual framework for studying

trajectories to obtaining abortion-related care. It assembles
for the first time all of the known factors influencing a
trajectory and encourages readers to consider the ways
these macro- and micro-level factors operate in multiple and
sometimes conflicting ways. Based on presentation
to and feedback from abortion experts (researchers, providers,
funders, policymakers and advisors, advocates)
(n=325) between 03/06/2014 and 22/08/2015, and a systematic
mapping of peer-reviewed literature
(n=424) published between 01/01/2011 and 30/10/2017, our
framework synthesises the factors shaping
abortion trajectories, grouped into three domains: abortion-
specific experiences, individual contexts, and (inter)
national and sub-national contexts. Our framework includes
time-dependent processes involved in an individual
trajectory, starting with timing of pregnancy awareness. This
framework can be used to guide testable hy-
potheses about enabling and inhibiting influences on care-
seeking behaviour and consideration about how
abortion trajectories might be influenced by policy or practice.
Research based on understanding of trajectories
has the potential to improve women's experiences and outcomes
of abortion-related care.
1. Introduction
Abortion is a common feature of people's reproductive lives. An
estimated 56 million induced abortions occur annually (Sedgh et
al.,
2016), of which 54.9% (49.9%–59.4%, 90% C.I.) are unsafe
(Ganatra
et al., 2017). Unsafe abortion is a major public health problem,
espe-
cially in contexts where access to legal abortion is highly
restricted. An
estimated 7.9% (4.7%–13.2%, 95% C.I.) of maternal deaths are

due to
unsafe abortion (Say et al., 2014); unsafe abortion is also a
leading
cause of maternal morbidity. While medical procedures for
inducing
safe abortion are straightforward, whether or not an abortion is
avail-
able or safe or unsafe is influenced by a complex mix of
politics, access,
social attitudes and individual experiences. Up to 40% of
women who
experience abortion complications do not receive sufficient care
(Singh
et al., 2009). Understanding the complexity around obtaining
abortion-
related care is urgently needed, especially in light of the intense
policy
attention abortion receives. Abortion care is a landscape in flux,
with
rapid increases in access to and use of pharmaceuticals to
induce
abortion (Kapp et al., 2017), and shifting national and
international
laws, policies, treaties, protocols and funding provision (Barot,
2017a,
b).
In recent years, research has helped elucidate abortion-related
practices. There is increased recognition of the scale and
consequences
of unsafe abortion, including the costs for both women and
health
systems, in a range of legal settings (Singh et al., 2014).
Inequalities in
accessing abortion-related care have been identified in many

settings,
associated with multiple individual characteristics including,
but not
limited to, age (Shah and Ahman, 2012), marital status
(Andersen et al.,
2015), ethnicity (Dehlendorf and Weitz, 2011), geographic
location
(Jones and Jerman, 2013) and economic circumstances (Ostrach
and
Cheyney, 2014). Women experience multiple, intersecting
inequalities
in access to abortion-related care (Becker et al., 2011). The
critical role
of delays in abortion-related care-seeking (Foster et al., 2008;
Sowmini,
2013) and of what happens when women are denied services are
better
understood (DePiñeres et al., 2017; Gerdts et al., 2014). We
know much
more about attitudes and stigma around abortion (Faúndes et al.,
2013;
Hanschmidt et al., 2016). Making sense of this body of research
so that
it can inform effective policy and help identify salient gaps in
knowl-
edge is a substantial endeavour. We lack synthesis of the known
time-
and context-specific influences on trajectories to abortion-
related care.
Conceptual frameworks of abortion-related care have dealt only
with
discrete aspects of women's experiences, such as determinants
of use of
a safe abortion programme (Benson, 2005) or decisions which
lead
women to experience post-abortion complications (Banerjee and

https://doi.org/10.1016/j.socscimed.2018.01.035
Received 29 August 2017; Received in revised form 23 January
2018; Accepted 24 January 2018
∗ Corresponding author.
E-mail address: [email protected] (E. Coast).
Social Science & Medicine 200 (2018) 199–210
Available online 31 January 2018
0277-9536/ © 2018 The Author(s). Published by Elsevier Ltd.
This is an open access article under the CC BY license
(http://creativecommons.org/licenses/BY/4.0/).
T
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mailto:[email protected]
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Andersen, 2012).
The conceptual framework we propose considers all the factors
in-
fluencing a woman's trajectory to obtaining abortion-related
care (safe
abortion, unsafe abortion and/or post-abortion care). Obtaining
abor-
tion-related care can involve many steps and be non-linear

(Marecek
et al., 2017). We define an abortion trajectory as the processes
and
transitions occurring over time for a pregnancy that ends in
abortion.
We use ‘trajectory’ because it incorporates the concept of time
– critical
for understanding abortion-related care-seeking since safe
abortion
ceases to be an option as pregnancy progresses (the exact limit
varies
depending on context). We use the shorthand descriptor
‘women’ but
acknowledge adolescents and transgender men within that.
Abortion is distinct from other healthcare-seeking behaviour
since:
i) legality and understanding of legal rights overlay an
individual's
pathway to care, ii) women's abortion options are determined by
the
gestational age of the pregnancy, iii) abortion is episodic, not
chronic,
iv) abortion is stigmatised, and v) only women receive abortion-
related
care. Three main groups of health-related theories might be
employed
to understand and explain abortion-related care-seeking:
determinant,
socio-ecological, and pathway. These theories have rarely been
used to
frame research on obtaining abortion-related care.
Theoretically-in-
formed research on abortion has tended to employ explanatory
fra-
meworks related to other domains including stigma (Lipp,

2011), policy
(Aniteye and Mayhew, 2013), lifecourse (Edmeades et al.,
2010), re-
productive agency (Cleeve et al., 2017), reproductive justice
(Katz,
2017), post-colonial feminism (Chiweshe et al., 2017) and
social psy-
chological frameworks (Cockrill and Nack, 2013).
Determinant health-related theories are models that elucidate a
set
of explanatory factors for the use of healthcare (Ajzen and
Fishbein,
1980; Ajzen and Madden, 1986; Andersen, 1995; Bandura,
1977;
Becker, 1974; Rosenstock, 1966). They remain influential in the
framing of research on health care-seeking, health service use
and
health behaviour change (Babitsch et al., 2012; Ricketts and
Goldsmith,
2005). Determinant theories have been criticised for their
underlying
individual rational actor orientation, focusing on characteristics
of
users versus non-users of care but providing little insight into
dynamic
care-seeking processes (Mackian et al., 2004; Pescosolido,
1992). Socio-
ecological models (McLeroy et al., 1988; Stokols, 1996)
consider mul-
tiple levels (e.g.: structural, community, individual) of
influence on
behaviour, and reciprocal causation between behaviour and
social en-
vironments, unlike determinant models that largely
conceptualise

healthcare decision-making and use as an individual-level
process.
However, simple socio-ecological models are limited in their re-
presentation of time-dependent processes and events. Pathway-
based
models, which disaggregate healthcare decision-making into
con-
stituent steps, challenge frameworks that conceive each health
care-
seeking event in isolation (Mackian et al., 2004; Pescosolido,
1992).
Understanding abortion-related care-seeking requires dynamic
process-
oriented perspectives; the circumstances of a pregnancy leading
to an
abortion unfold in the space of a few weeks and can be highly
un-
predictable. Abortion-related care-seeking cannot be understood
only
through a linear course of action; it is a process that responds to
changing circumstances and experiences. The conceptual
framework
we present is a mechanism for showing interrelatedness across
the
various temporal and spatial dimensions that influence and
shape
abortion-related care-seeking for one pregnancy. In this paper
we i)
review all influences on obtaining abortion-related care, ii)
organise
these into a conceptual framework, and iii) discuss how our
framework
can facilitate new research to better understand obtaining
abortion-
related care.

2. Methods
We used an inductive two-step approach to build this conceptual
framework: initial drafting based on expert research and
practice
knowledge, and subsequent systematic evidence mapping of
peer-re-
viewed literature.
We originally conceived the conceptual framework at an
interna-
tional seminar (IUSSP, 2014). Thematic analysis of issues
reported in
the papers presented at the seminar, which included studies
from
Africa, Asia, Latin America and Europe (n=24), along with
authors'
practice knowledge, were used to draft a first iteration of the
frame-
work based on a thematic analysis of issues reported in the
seminar
papers. The first draft of the framework, which was also
informed by
the authors’ practice knowledge, was presented and discussed at
the
end of the seminar. Subsequent iterations of the framework were
in-
tensively discussed among the authors over several months and
pre-
sented to specialist audiences at national and international
meetings
(Table 1) and continually revised following their feedback. This
process
introduced additional components to our framework, such as the
im-

portance of national policies not directly related to health (e.g.
edu-
cation and welfare policies), and elaborated specific
components (e.g.
relief as an impact of abortion on mental health; the addition of
caste-
based inequalities among those shaping social positions on
fertility and
abortion). In addition to individual components, presentation
and
feedback to specialist audiences shaped the structure of the
conceptual
framework, informing our distinction between this framework
and
socio-ecological models and our efforts to present the
framework vi-
sually so as to maximise its utility.
To confirm that the conceptual framework comprehensively cap-
tured all documented influences on obtaining abortion care we
con-
ducted a systematic evidence mapping of English-language
peer-re-
viewed literature. Evidence mapping is an evidence synthesis
methodology that is a variant of the systematic review (Miake-
Lye
et al., 2016); it is a systematic search of a broad field that
describes as
widely as possible all of the literature relating to the topic
without
limiting to studies that assess the strength or direction of
relationships.
It methodically identifies and develops a map of the literature
(Clapton
et al., 2009) and is increasingly used in a range of social
sciences

(Miake-Lye et al., 2016). Evidence mapping can be much more
in-
clusive than a systematic review: our only quality criterion was
that the
study should be published in a peer-reviewed journal. Multiple
refer-
ences based on the same sample were not excluded (as would be
the
case in a systematic review) since data generated from one
study po-
pulation might investigate different issues of relevance.
Three electronic databases [PubMed, ScienceDirect, JSTOR] of
peer-
reviewed literature were searched for items published in English
be-
tween 01/01/2011 and 30/10/2017. These databases were
selected for
their coverage of biomedical and social science research.
Combinations
of relevant search terms were developed and tested for
sensitivity. The
Table 1
Presentations of the conceptual framework to expert audiences
during its development.
Event Participants (N)
International Seminar on Decision-making regarding abortion-
determinants and consequences. Nanyuki, Kenya. 3–5 June
2014.
Abortion researchers (31)
[email protected]: an e-conference. 8–9 June 2015. Abortion

researchers, activists and providers (156)
Ipas. Chapel Hill, NC. June 26, 2015 Abortion researchers and
community advisors (8)
Psychosocial workshop. San Diego, CA. April 29, 2015
Abortion-specific researchers (70)
Population Association of America (2015) Annual Meeting. San
Diego, CA. April 30-May 2, 2015 Social science researchers
(52)
E. Coast et al. Social Science & Medicine 200 (2018) 199–210
200
final combinations of search terms were: (abortion* OR
termination*
OR (menstru* AND regul*)) AND (Deci* OR Pathw* OR
Passage* OR
Rout* OR Course* OR Traject* OR Trail* OR Track* OR
Direction*).
Fig. 1 illustrates the process.
After removing duplicates, all items identified by the search
were
screened on their title and abstract to determine inclusion. Items
were
included if: published in full text in English in a peer-reviewed
journal
between 01/01/2011 and 30/10/2017, and the abstract included
any
factor that either influenced, or was mentioned as potentially
influen-
cing, obtaining abortion care. Non-peer-reviewed items (e.g.
comment,
book review, letters) were excluded. Where inclusion or

exclusion could
not be determined on the basis of title and abstract, the full text
was
screened. Articles were included if they considered trajectories,
or in-
fluences on trajectories, to abortion-related care. Details of
included
items are available [Appendix A Supplementary Data]. We
compared
the full text of each included item (n=424) to the draft
conceptual
framework. Components we identified to be inadequately
captured by
the draft framework were incorporated in subsequent iterations.
These
included both an additional component ‘quality of care’, which
super-
seded a previous inclusion of ‘health workforce treatment of
women’, as
well as amendments to components, such as broadening
‘perception of
provider care’ to ‘perception or experience of provider care’.
All deci-
sions about changes to framework components were made as a
team,
drawing on our reading, expertise and the discussions we had
about the
framework with experts during its development.
Our search methodology has limitations. Language and date re-
strictions mean that including additional languages or years
might have
yielded additional information; however, our search did yield
evidence
from all geographic regions, including research conducted in
non-

English languages but published in English. By focusing on
more re-
cently published evidence (post-2010), our framework reflects a
con-
temporary summary of the field of abortion-related care-seeking
evidence. We searched only three databases, selected for their
range
(biomedical and social science); additional databases might
include
additional evidence, although the number of duplicates
(n=1027)
yielded by our search suggests that our strategy is robust. Our
search
only included abortion-related terms (abortion, termination,
menstrual
regulation); our search will not have yielded articles that
discuss
pregnancy decision making without reference to abortion. Our
mapping
approach means that the relative weight and rigour of evidence
on the
factors identified remain unknown. The final conceptual
framework
represents all aspects of trajectories to abortion-related care as
illumi-
nated by expert researchers, practice knowledge, and in 424
articles.
3. Conceptual framework of trajectories to abortion-related care
A conceptual framework is a set of ideas, presented in a
structured
way to help understand a phenomenon (Reichel and Ramey,
1987). Our
framework (Fig. 2) represents “the main things to be studied”

(Miles
and Huberman, 1994 p.18) with regard to trajectories to
obtaining
abortion-related care. It synthesises influences shaping these
trajec-
tories, grouped in three domains to highlight the individual- and
macro-
contexts shaping abortion-related care:
1. Time-oriented abortion-specific experiences: beginning with
preg-
nancy awareness, events that women may experience in seeking
abortion-related care.
2. Individual contexts: characteristics that influence whether a
woman
obtains abortion-related care, including interpersonal networks.
3. (Inter)national and sub-national contexts: the context within
which
an individual – and her abortion – are situated.
To understand the trajectory of a pregnancy that ends in
abortion, it
must be situated within individual- and macro-contexts; all
three
Fig. 1. Systematic evidence mapping process.
201
domains are interrelated. For example, access to pregnancy

testing
(abortion-specific experiences) might be influenced by a
woman's
wealth (individual context) and the health system (inter/national
con-
text). The framework is globally applicable, capturing concepts
that are
relevant across time and space. For readability, our framework
includes
brief phrases or single words for each component. This
comprehensive
visual overview is the primary contribution of our article. To
illustrate
its relevance across settings, in the following sections we
explicate the
framework's components using examples.
We begin at the individual level – a woman's abortion-specific
ex-
periences, her context and characteristics, and then discuss the
macro-
level influences on trajectories to obtaining abortion-related
care.
Unlike the conceptual framework itself (Fig. 2), this requires us
to
present the three domains in some order. We start with
experiences of a
specific abortion since a woman may have more than one
abortion in
her lifetime, and a single trajectory to obtaining care might be
com-
posed of more than one abortion attempt. Our evidence-based
illus-
tration of each component is preceded by bullet points that
provides
further examples.

4. Abortion-specific experiences
The actions women take on their trajectories to (attempt to) ter-
minate a pregnancy are shaped by factors in their individual
contexts
and by their macro-environments. We consider in this section
the
multiple events that women may experience in obtaining an
abortion.
The trajectory begins with becoming aware of a pregnancy and
ends
with abortion-related care; in between there may be (non-)
disclosure
and negotiation about abortion, seeking resources to obtain the
abortion, and more than one attempt to terminate the pregnancy,
with
sequelae of those attempts. These events may not be linear; for
ex-
ample, a woman may disclose to an individual who provides
informa-
tion that the woman acts upon; this information may not lead to
an
abortion, so the woman might disclose to a different person in
order to
seek different or additional information or resources to procure
an
abortion (Moore et al., 2011b). Emotions about pregnancy,
abortion
and parenting influence all steps of abortion-specific
experience. Each
step is embedded in contexts both micro (individual) and macro;
we
address the importance of these contexts in subsequent sections.

4.1. Awareness of pregnancy
• Timing of awareness (e.g. knowledge of pregnancy symptoms
or
pregnancy testing, denial of pregnancy)
• Access to/use of pregnancy testing (e.g. cost, availability,
source)
• Access to/use of pregnancy diagnostics (e.g. foetal
abnormality, sex
determination)
Decision making around abortion-related care is highly time-
sensi-
tive. Abortion at earlier gestations is safer than later gestations
and laws
and guidelines vary about the maximum gestation at which
abortion is
permitted, under which conditions and with which method. Time
be-
tween conception and awareness of pregnancy is inversely
related to
how much time a woman has to decide about abortion. In many
set-
tings, pregnancy tests are unavailable or unaffordable (Stanback
et al.,
2013) and women's estimation of gestational age – particularly
for
younger and/or nulliparous women - can be incorrect (Foster
and
Kimport, 2013; Janiak et al., 2014).
Fig. 2. A conceptual framework for understanding women's
trajectories in seeking abortion-related care.

202
The timing of action to confirm a pregnancy can be linked to
the
social risks of pregnancy. When a pregnancy is undesirable a
woman
may avoid acknowledging the pregnancy to herself (Sowmini,
2013).
For example, young unmarried women in an Indian study were
less
likely to recognise (or acknowledge) their pregnancy than their
married
counterparts, and unmarried women had higher levels of second
tri-
mester abortions (Jejeebhoy et al., 2010). In addition, the
gestational
age at which diagnostic testing (if available or used) for foetal
ab-
normality and/or sex - factors that may influence whether the
woman
wants an abortion - varies by context (Gawron et al., 2013).
4.2. Disclosure
• Ability to disclose, to whom (e.g. family, friend, partner,
health
professional, provider, acquaintance) and the implications of
that
(e.g. the confidant's knowledge, experience, advice, reaction)
• Negotiation around abortion with (any) others involved in the
de-
cision (e.g. partner, relatives, (potential) abortion providers)

• Reasons for disclosure or non-disclosure (e.g. policies around
partner or parental notification)
• Timing of (any) disclosure(s)
• Emotions about disclosure (e.g. fear of reactions, shame,
stigma,
relief)
Some women do not disclose their pregnancy and take abortion
decisions alone (Bowes and Macleod, 2006). For women who do
dis-
close their pregnancy, the person(s) to whom they disclose may
influ-
ence abortion decisions, be a source of (mis-)information,
and/or pro-
vide access to resources for abortion-related care. Disclosure
may lead
to negotiation about whether or how to abort. Decisions about
dis-
closure are influenced by wider social norms and belief
systems. For
example, both the choice of confidant(s) and their influence are
em-
bedded in the woman's larger context of relationships and
ability to
access resources (Nyanzi et al., 2005). In a study among young
women
in urban Cameroon, disclosure to male partners was influenced
by the
need for financial support for the abortion (Calvès, 2002).
Disclosure
discussions are enmeshed in the macro-context; more limited
abortion
options may necessitate more disclosure in order to seek
information

about care (Rossier, 2007), or disclosure may be enforced due
to
partner or parental notification protocols. Disclosure may lead
to
emotional support around an abortion decision or pressure to
abort or
not abort (Schwandt et al., 2013). Disclosure of pregnancy may
lead to
a range of negative outcomes, including condemnation and
abandon-
ment (Tangmunkongvorakul et al., 2005) or punishment
(Umuhoza
et al., 2013). Fears about the implications of disclosure of the
preg-
nancy or the desire to abort may delay initiating the abortion
(Labandera et al., 2016) or compel a woman to seek a less safe
abortion
(Schuster, 2005).
4.3. Ability to access resources for abortion
• Social/emotional support for/against abortion (e.g. from
partners,
relatives, friends, providers, doula)
• Material/physical resources (e.g. transport, money, childcare,
ability to miss education or work, insurance, commodities, in-
formation)
• Access to abortion provider/method (e.g. border crossing,
journey
time, face-to-face versus web-based provider)
Women's ability to access resources to procure an abortion is
im-
portant in every setting. Social and emotional support for or

against
abortion-related care is linked to whether, and to whom, the
pregnancy
is disclosed. A friend or partner providing support may
influence the
location and type of abortion (Conkling et al., 2015). Access to
financial
resources, frequently linked to social support, may be critical to
a wo-
man's ability to access abortion information and services. In
Latin
American countries where abortion is illegal, access to
economic re-
sources and emotional support were critical for accessing a
medically
supervised medical abortion in a clandestine clinic (Zamberlin
et al.,
2012). One quarter of urban Mozambican women who sought a
first
trimester termination at a public hospital delayed care in order
to have
sufficient funds to pay user fees (Mitchell et al., 2010).
Women's sources
of information extend beyond their social networks to include
adver-
tising, agents, the internet and other clients of abortion
providers
(Gerdts et al., 2017; Osur et al., 2015). The difference between
a safe or
unsafe abortion may be whether someone can pay for a safer
procedure
(Moore et al., 2011b) or whether she can travel to avoid more
re-
strictive laws to locations with more permissive laws (Foster et
al.,

2012). Accessibility of abortion services is multidimensional
and closely
linked to macro-environmental factors including legality,
distance and
cost (Sethna and Doull, 2013) and individual contextual factors
such as
mobility (Azmat et al., 2012).
4.4. Abortion attempt(s)
• Gestational age
• Counseling (e.g. (non-)directed, (un)supportive, waiting
period, re-
ferrals)
• Location abortion sought or conducted (e.g. home,
(un)regulated
facility)
• Type of abortion (e.g. (un)safe, (il)legal, medical, surgical,
self- or
provider-initiated)
• Perception or experience of provider care (e.g. (dis)respectful,
judgmental, confidential, private, pain management, exposure to
protests/harassment)
The complexity and length of abortion trajectories is
heterogeneous,
influenced not only by a woman's context, but also her
experiences
relating to that specific pregnancy, and may range from a legal,
straightforwardly-accessed safe process, to multiple unsafe
attempts
(Coast and Murray, 2016). In some settings, women may have
options

about what kind of abortion to access; in others, women may not
(perceive themselves to) have any choices (Banerjee and
Andersen,
2012). Gestational age at the time of the abortion may have
implica-
tions for the woman's health and affect the type of abortion
provided; if
women present beyond a gestational limit, they can be denied a
legal
abortion (Harries et al., 2015). Especially, but not only, in
contexts
where abortion is stigmatised and/or illegal (or perceived to be
illegal)
in general or at advanced gestational age, women self-induce
using
household objects, traditional methods, and abortion
medications
(Rasch et al., 2014; Vallely et al., 2015).
Abortion trajectories may also be influenced by professional
advice.
Provision of counselling may differ depending upon a woman's
cir-
cumstances (Ramachandar and Pelto, 2002), policies including
man-
dated waiting periods, and the socio-legal (Gerdts and Hudaya,
2016)
and funding (discussed below) context of abortion. Although
good
counselling should be non-directive, this does not necessarily
happen
(Vincent, 2011). Counselling may play an important role in
women's
choice of abortion method (Tamang et al., 2012), however not
all
women who seek abortion want counselling (Cameron and

Glasier,
2013) or the counselling that is provided (Moore et al., 2011a).
A
woman who expects judgemental or disrespectful advice or
counselling
from one provider may seek care elsewhere. The perception and
ex-
perience of negative responses from health practitioners against
women
seeking abortion are widely reported (e.g. Ghana (Schwandt et
al.,
2013), Brazil (Diniz et al., 2012), Vietnam (Nguyễn et al.,
2007)).
When women have a choice about abortion type, their decision
may
be informed by their understandings of abortion-related care
and its
quality, including comfort, pain (Allen et al., 2012), flexibility
of when
the abortion can occur, (perceived) confidentiality, provider
attitudes
towards privacy, and stigmatising provider behaviours
(Labandera
et al., 2016). In some settings, anti-abortion protests outside
abortion
203
providers may affect abortion care-seeking by encouraging
women to
avoid providers where they may have to confront them (Kimport

et al.,
2012a).
4.5. Perceived and experienced outcomes from (attempted)
abortion
• Physical health (e.g. pain, side effects, future fertility,
resulting or
avoidance of morbidity or mortality)
• Mental health (e.g. depression, relief, guilt, shame)
• Socio-economic effects (e.g. out of pocket payments,
legal/penal
consequences, maintaining a relationship, education or
occupation)
Once a woman has …
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$(min_i(x_{i1}),max_i(x_{i1})$.
3. Divide the data into groups depending on whether $x_{i1}
>c$ or $x_{i1}leq c$.
*The midterm project is worth 16 points and due on April 2nd.
You may consult other students in the class to finish the
midterm, but you must submit your own project. You may not
ask for help from me or the teaching assistants.*
**Code Block #1:**
This code block divides the data into groups. The results are
recorded in an $Ntimes N$ matrix where entry $(i,j)$ indicates
whether observation $i$ and $j$ belong to the same cluster. In
this block, I have replaced parts of the code with a question
mark. Make the necessary changes to the code.
```{r}
## you will need to change the path to load the data
out_dat <-
read.csv("~/Dropbox/Teaching/341/data/cluster_outlier_set.csv"
)
getClusters <- function(mydata, J){
N <- nrow(mydata)
K <- ncol(mydata)
cluster_matrix <- matrix(1,N,N)
for (j in c(1:J)){
## 1. sample a dimension (1 point)
#mydim <- sample(1:?,1)
## 2. sample a number c greater than the minimum and less
than the maximum of that dimension (1 point)
#c <- runif(1,min(mydata[,?]),max(mydata[,?]))

## 3. compute a matrix that determines whether the each pair
of points satifies the condition (1 point)
#tmp <- (mydata[,mydim] < c) %*% t(mydata[,mydim] < c) ?
(mydata[,mydim] >= c) %*% t(mydata[,mydim] >= c)
## 4. Update the cluster matrix (1 point)
#cluster_matrix <- ? * tmp
}
return(cluster_matrix)
}
set.seed(341)
mycluster_matrix <- getClusters(out_dat, J = 4)
```
**Code Block #2:**
This code block divides the data into groups. The results are
recorded in an $Ntimes N$ matrix where entry $(i,j)$ indicates
whether observation $i$ and $j$ belong to the same cluster. In
this block, I have replaced parts of the code with an asterik.
Make the necessary changes to the code.
```{r}
## 5. determine the number of groups (1 point)
#unique_row <-
mycluster_matrix[which(!duplicated(mycluster_matrix)),]
#number_groups <- nrow(?)
print(number_groups)

## 6. get the group assignments (1 point)
#mygroups <- apply(unique_row,1,function(x){which(x==1)})
#cluster_assignments <- numeric(nrow(out_dat))
#for (ii in c(1:number_groups)){
# cluster_assignments[mygroups[[ii]]] <- ?
#}
## 7. assign a colour to each group (1 point)
#mycols <- rainbow(n = ?, alpha = .75)
#group_cols <- mycols[cluster_assignments]
## 8. Make a plot the data with the points coloured by cluster
number (1 point)
#plot(out_dat[,c(1,2)],typ="p",col=?,pch = 20)
```
**Code Block #3:** Now, let's repeat this $R=2,500$ times
and average the results of the cluster matrices. Entry $ij$ in the
resulting matrix is the probability that two points belong to the
same cluster, $q_{ij}$. We will set the number of clusters,
$G$, to be equal to the number of clusters in the single run.
Then we will sample from the set of cluster assignments and
plot the results.
In the following code block, I have written a function that
computes the logged probability of a cluster
$$p(C_1,ldots,C_{G}) = prod_{i=1}^N prod_{j<i}
q_{ij}^{mathbf{x}_itext{ and }mathbf{x}_j text{ are in the
same cluster}}* (1-q_{ij})^{mathbf{x}_itext{ and

}mathbf{x}_j text{ are not in the same cluster}}$$
You only have to run this. You needn't worry about how I
derived this.
```{r}
set.seed(641)
R <- 2500
avg_cluster_matrix <- matrix(0,nrow(out_dat),nrow(out_dat))
for (r in c(1:R)){
## 9. call the function (1 point)
#obj <- getClusters(?,J = 4)
## 10. average the results (1 point)
#avg_cluster_matrix <- obj/R ? avg_cluster_matrix
}
## print some entries
avg_cluster_matrix[ 1:10,1:10]
## 11. set the number of clusters equal to that for the single run
(1 point)
#ngroups <- ?
## Sampling from the set of all clusters by changing one point
at a time
## You don't need to understand this part!!!
S <- 250000
set.seed(341)
mycluster <- cluster_assignments
s <- 0
while(s < S){
cluster_proposal <- mycluster
ind <- sample(c(1:nrow(avg_cluster_matrix)),1)

newc <- sample(c(1:ngroups),1)
newvec <- as.numeric(newc == cluster_proposal[-ind])
oldvec <- as.numeric(cluster_proposal[ind] ==
cluster_proposal[-ind])
p1 <- sum(log(newvec*avg_cluster_matrix[ind,-ind] + (1-
newvec)*(1-avg_cluster_matrix[ind,-ind])))
p2 <- sum(log(oldvec*avg_cluster_matrix[ind,-ind] + (1-
oldvec)*(1-avg_cluster_matrix[ind,-ind])))
if(p1 >p2){
mycluster[ind] <- newc
}
s <- s + 1
}
## 12. plot the results (1 point - you can use the other code
block to do this)
```
**Code Block #4:** Challenge: Now compare the results of
the single run to the 2,500 runs. For the two results, compute
the sum of squared residuals given by
$$text{SSR} = sum_{g = 1}^G sum_{i: mathbf{x}_i in
C_g}d(mathbf{x}_i,bar{mathbf{c}}_g)^2$$
where $G$ is the number of groups, $C_g$ is the set of points
in cluster $g$, and $d(mathbf{x}_i,bar{mathbf{c}}_g)$ is the
Euclidean distance between $mathbf{x}_i$ and the mean of its
cluster $bar{mathbf{c}}_g$.

```{r}
## 13. Compute the SSR for the two set of results (2 points)
## 14. In the space below, answer the following question. What
happends to the SSR for a single run of our clustering method
as the number of cuts (J) grows large? Why? (2 points)
```
Journal of Social Work Values & Ethics, Fall 2018, Vol. 15, No.
2 - page 37
Ethnicity, Values, and Value Conflicts of African
American and White Social Service Professionals
Andrew Edwards, MSW, Ph.D.
Cleveland State University, Emeritus
[email protected]
Mamadou M. Seck, Ph.D.
Cleveland State University
[email protected]
Journal of Social Work Values and Ethics, Volume 15, Number
2 (2018)
Copyright 2018, ASWB
This text may be freely shared among individuals, but it may
not be republished in any medium without
express written consent from the authors and advance
notification of ASWB.
Abstract
This aspect of a broader study included 110 (68

White/European American and 42 Black/African
American) social service professionals. The primary
focus of this aspect of the study was to verify the
value orientation or core beliefs of the practitioners
who deliver services to clients through social service
agencies and programs. The conceptualization
of the core beliefs explored the values and value
conflicts in relation to professional practice. The
participants were employed in a Midwestern
metropolitan region. They responded to a survey
instrument that included vignettes, closed-ended
items, scaled responses, as well as either-or type
items. Major categories of the exploration included:
life and death issues, lifestyle, domestic and
social perspectives, value conflicts with the social
work profession, and personal responses to value
conflicts. Specific items measuring values related
to abortion, homosexuality, religiosity, euthanasia,
and corporal punishment were included. Study
results showed statistical significance on 26 issues
as African American participants were compared
with White participants.
Keywords: value conflicts, social work, ethical
dilemmas, ethnicity, professional relationship
Introduction
The complexity of American society (Jarrett,
2000), specifically due to its historic, economic,
social, and ethnic makeup, requires that social
work professionals take their clients’ ethnicity,
values, and professional-client value conflicts
into consideration. Historical dynamics, such as
unproductive treatment, have contributed to the
reluctance of various population groups to engage

with professional service providers. This history
(Barker, 2014) has influenced the adoption of
guidelines that require social workers to be culturally
aware during interventions and recognizing that
diversity-related characteristics have influence upon
an individual’s thoughts, feelings, and behaviors.
Barker (2014) further noted that the concept of
values is influenced by one’s perceptions of what
comprises appropriate principles, practices, and
behaviors. An individual’s personal values are often
considered as a representation of one’s core beliefs
and what an individual may perceive as right.
Therefore, these beliefs do not require supporting
evidence for those who embrace them and may
result in behavioral and attitudinal guidelines. The
expression of values helps individuals to verify
and/or maintain their integrity and self-worth.
Therefore, for the purpose of this study, values were
categorized according to the following: (1) social,
C:UsersRevaedwAppDataLocalMicrosoftWindowsINetCac
heContent.OutlookDownloads[email protected]
2 - page 38
Ethnicity, Values, and Value Conflicts of African American and
White Social Service Professionals
(2) cultural, (3) religious, (4) professional, and
(5) personal values.
Literature Review
The National Association of Social

Workers (NASW) Code of Ethics outlines specific
values and standards for professional practice. As
professionals, it is critical to abide by the standards
of the profession in addition to engaging in efforts
to promote self-awareness. The awareness of one’s
own personal values will allow the social worker
to recognize and confront value dilemmas that may
impede professional practice. As noted, for the
purposes of this study, values were identified across
five categories. The social values category (Barboza,
1998; Sears & Osten, 2005) includes principles,
customs, and beliefs that are generally accepted
as norms of a particular society. These types of
values are regulated by social pressures rather than
public policy. For example, appreciation of loyalty,
honesty, and a work ethic represent social values.
Specific ethnic codes of conduct are expressions
of social values because they are embraced by a
major segment of society and regarded as correct
ways of thinking and behaving. In contrast, cultural
values (Edwards, 2014) is a category that represents
norms and standards integrated into public policy.
In other words, cultural values are institutionalized
as standards for the American culture. For example,
education and equality (Clay, Lingwall, & Stephens,
2012; Imber & VanGeel, 2000) are addressed
through laws that require some form of educational
activity for American youth.
The religious values category (Edwards,
2014; Edwards 2000) reflects behavioral guidelines
for those who identify as members of specific
faith communities. These values are typically
written in doctrinal statements and refer to a type
of holy reference book as the foundation for the

principles. Examples of religious values relate to
sexual behavior, interpersonal behavior, dietary
restrictions, and childrearing methods.
The professional values category consists
of standards and principles designed to regulate the
behavior of those who practice within a specific
profession. For example, the National Association
of Social Workers (NASW, 2017) Code of Ethics
identifies social work values including respecting
the dignity and worth of an individual and one’s
right to self-determination. In contrast, the personal
values category (Edwards, 2014) reflects when
individuals adopt aspects of the previous four value
categories as guiding principles for their lives.
In relation to professional social work
practice, a practitioner may experience an internal
struggle (Edwards, 2014) when compelled to engage
in behaviors or tasks that are contradictory to one
or more aspects of one’s core belief system. As a
result, a value conflict may occur which refers to a
disagreement between one’s core belief system and
that of a group, organization, or society (Edwards
& Allen, 2008). Consequently, some professionals
who face value conflicts when providing services
become perplexed or even omit some tasks
associated with completing their professional
obligation. As a result, value conflicts may hinder
the social worker-client relationship necessary for
appropriate service provision.
Zastro and Kirst-Ashman (2010) suggested
that many decisions, both personal and professional,
are influenced by one’s beliefs about life, freedom,

and protective standards. Furthermore, social work
competence (Segal, Gerdes, & Steiner, 2016)
requires self-awareness and a commitment to
social justice, which supports the need to explore
personal values. As a result, the current study
sought to examine the experiences of Black/African
American and White/European American social
service providers based on their ethnicity, values,
and value conflicts in relation to their personal
beliefs.
Behaviors are an important manifestation
of values particularly when there are conflicts
pertaining to values such as equality and economic
security. However, there may be occasions when
a person must choose one of these values based
upon what it means in relation to a specific
social or economic circumstance. Jacoby (2006)
suggested that values have a hierarchy and may
reorder themselves based upon specific situations.
2 - page 39
Other researchers noted that individuals respond
to complex value-related issues such as abortion
(Alvarez & Brehm, 1995) and homosexuality
(Craig et al., 2005) with ambivalence due to their
underlying beliefs. Therefore, conflicts between
core beliefs and values of an individual may exist
at a personal level yet, at the same time, conflict

with prevailing public perceptions. For example, a
person may hold contradictory perspectives toward
homosexuality such as it is either morally wrong
and/or it could be a result of genetic inheritance
versus choice (Craig et al., 2005).
The research literature provides multiple
examples of value conflicts social service
professionals may experience. Paprocki (2014)
explored when the personal beliefs of psychology
graduate students lead to complications in their
attempts to provide therapy to patients. For example,
certain program administrators expressed challenges
with students who sought to abstain from providing
services to clients in same-sex relationships based
upon religious beliefs. Pertaining to physician-
assisted suicide and euthanasia, Himchak (2011)
suggested that this has a cultural component that is
important when providing services. For example,
reportedly African American, Hispanic, and Asian
populations value respect toward elders resulting in
resistance to physician-assisted suicide. In addition,
regarding the issue of abortion, Denbow (2013)
suggested that welfare and healthcare systems may
have instances of encouraging pregnant women
to engage in abortion. This researcher further
noted that women experiencing poverty encounter
substantially greater difficulties than their more
affluent counterparts in giving birth. Denbow (2013)
also pinpointed that women experiencing abuse,
poverty, and pregnancy could face a multitude
of challenges if they opted to bring pregnancies
to term. Millner and Hanks (2002), discussed the
possibility of value conflicts that clinical providers
could encounter when engaging with clients who
were considering abortion.

However, this current study examines a
comparison of Black/African American and White/
European American social service professionals on
their adherence to several family-related values,
domestic relationship issues, social preferences, and
their experiences with value conflicts in relation to
professional practice.
Method
Participant and data collection
The primary researchers received approval
from the required institutional review board to
conduct a survey of social service professionals.
Combined lists of social service agencies and
programs were used to develop a composite list
of 342 agencies and programs of which 185 were
selected for study participation. The social service
settings included: child welfare and adoptions,
disabilities and rehabilitation services, substance
abuse treatment, family service/counseling, juvenile
corrections, adult corrections, schools, mental health
settings, community development/planning, crisis
intervention, community organization/advocacy,
medical settings, and nursing homes/services for
older adults. The social service administrators as
well as the selected respondents returned, via mail,
the signed participation agreement in a separate
envelope without the questionnaire. Sixty-nine
social service agencies and programs agreed to
participate in this study.
The data collection instrument included
multiple choice, closed-ended, scaled-response, and

a series of one-paragraph value conflict case scenario
items. The value-related variables were generated
from a classroom exercise that undergraduate and
graduate social work students participated in for four
years. This tool was used to examine diversity in
values, the reality of value conflicts, and realization
of issues central to one’s core belief system. The
reoccurring value-related themes generated from
the classroom exercise became the foundation for
constructing the survey instrument for the purpose of
this study. To enhance the validity of the instrument,
it was implemented with two graduate level social
work students and three social workers who were
employed by a community child development center.
2 - page 40
Results
Personal value related to fidelity in
marriage
In response to this issue, there was a
significant difference between African American
participants (71.4%) and White (88.2%) social
service professionals with a chi square result of
χ 2 (1, N = 110) = 4.93, p<.05. This means that the
White respondents were more likely to agree that
their personal values support fidelity in marriage.

Personal value about abstaining from
sexual intercourse prior to marriage
(31%) and White survey participants (5.9%) with
a chi square of χ 2 (1, N = 110) = 12.49, p<.05
indicating that significantly more African American
respondents adhered to the personal value to abstain
from sexual intercourse prior to marriage.
Personal value about maintaining a
meaningful and personal relationship
with God
(92.9%) and White (54.4%) social service
professionals with a chi square of χ 2 (1, N = 110)
= 17.97, p<.05, indicating that African American
survey respondents identified a personal relationship
with God was one of their personal values.
Personal value about attending a church,
mosque, synagogue
survey respondents (71.4%) and White (30.9%)
survey participants with a chi square of χ 2(1, N =
110) = 17.16, p<.05 indicating that significantly
more African American participants agreed that
attending churches, mosques, or synagogues was
one of their personal values.
Personal value about monetary and

financial wealth
significant difference in responses between African
American (31%) and White (10.3%) respondents
with a chi square result of χ 2(1, N = 110) = 7.45,
p<.05 indicating that for African American survey
participants, money and wealth were very important.
Support for homosexual ideology and
lifestyle
In response to this issue, 70.6% of White
participants in the sample agreed to this variable,
compared to 11.9% of African American participants
with a chi square of χ 2(1, N = 110) = 35.81, p<.05,
indicating that significantly more White survey
participants support homosexual ideology and
lifestyle.
Having a belief in salvation or a positive
after-life in eternity
significant difference between African American and
White participants as 88.1% of African Americans
agreed to this variable, compared to 48.5% of White
respondents with a chi square of χ 2 (1, N = 110) =
17.56, p<.05. This indicates that significantly more
African American participants believe in salvation or
a positive after-life in eternity.
Mercy killing, euthanasia, right to
terminate one’s own life, or to assist
others in the act

In response to this issue, there was a significant
difference between White (42.6%) and African
American participants (11.9%) with a chi square of
χ 2 (1, N = 110) = 11.49, p<.05. This indicates that
significantly more White survey respondents support
mercy killing, euthanasia, right to terminate one’s
own life, or to assist others in the act.
Outside of value system to accept or
support abortion as a response to rape
or incest
2 - page 41
(36.6%) and White (15.2%) survey participants
with a chi square of χ 2(2, N = 110) = 6.53, p<.05.
This indicates that African American respondents
believe that abortion in situations of rape or incest
is outside of their value system.
Outside of core value system for a
man to allow a woman to support him
financially
(69%) and White (18.2%) respondents with a

χ 2(2, N = 110) = 29.65, p<.05. This indicates
that significantly more African American survey
participants believe that men should not allow
women to support them financially.
Acceptance of interracial marriage
(14.3%) and White (1.5%) survey participants with
a chi square of χ 2(2, N = 110) = 8.21, p<.05. This
indicates that significantly more African American
survey participants agree with interracial marriage.
Healthy women who refuse to work
outside of the home is outside of core
value system
White respondents, as 26.2% of African Americans
participants, with a chi square of χ 2(2, N = 110) =
African American survey participants believe that
healthy women who refuse to work outside of the
home is outside of their core value system.
Having multiple children without ever
being married is outside of core value
system
significant difference between respondents as 61.9%
of African American respondents in the sample

respondents with a chi square of χ 2(2, N = 110) =
having children without ever being married would
be outside of their core value system.
Supportive of homosexual ideology and
lifestyle is outside of core value system
significant difference between the two groups as
83.3% of African American participants agreed
to this variable, compared to 16.7% of White
participants with a chi square of χ 2(2, N = 110) =
being supportive of homosexual ideologies and
lifestyles would be outside of their core value
system when compared to White respondents.
Frequently using cuss words and vulgar
language is outside of core value system
45.2% of African American participants agreed
to this variable compared to 22.7% of White
participants with a chi square of χ 2(2, N = 110) =
7.33, p<.05 showing that significantly more African
Americans believe that the frequent use of cuss
words and vulgar language in a professional setting
is outside of their core value system.
Some of my core beliefs regarding
human sexuality are not embraced by

the social work profession
26.8% of African American participants responded
with ‘not at all’ compared to 54.7% of White
participants with a chi square of χ 2(4, N = 110)
= 15.94, p<.05. This indicates that significantly
more White participants believe their core beliefs
regarding sexuality are embraced by the social
work profession.
2 - page 42
Some of my cultural beliefs are in
opposition to what is embraced by the
social work profession
47.4% of the African American group responded
with ‘not at all’ to this variable, compared to 75% of
White respondents with a chi square of χ 2(4, N = 110)
= 12.31, p<.05. This indicates that significantly more
White survey respondents believe that their cultural
beliefs are embraced by the social work profession as
compared to the African American group.
My beliefs regarding race are not
embraced by my family of origin (or

those who raised me)
60% of African American participants felt their
beliefs regarding race were ‘not at all’ opposed to
their family of origin in comparison to 47.9% of
White participants with a chi square of χ 2(4, N =
110) = 14.32, p<.05. This indicates that significantly
more African American participants feel that their
beliefs regarding race are not in conflict with the
beliefs of their family of origin as compared to
White participants.
My beliefs regarding religion/spirituality
are not embraced by my family of origin
(or those who raised me)
White professionals as 53.8% of African Americans
responded with ‘not at all’ to the question compared
to 29.5% of White participants with a chi square
of χ 2(4, N = 110) = 19.03, p<.05. This indicates
that significantly more African American survey
respondents feel their beliefs regarding religion/
spirituality are embraced by their family of origin.
My beliefs (acceptance of) regarding
corporal punishment/spanking children is
not embraced by the social work profession
and White survey participants, as 20.5% of African

Americans responded with ‘not at all’ and 37.5%
of White participants with a chi square of χ 2(5, N =
110) = 14.90, p<.05. This indicates that more White
participants feel their beliefs regarding corporal
punishment/spanking children are embraced by the
social work profession.
My beliefs regarding what is appropriate
language and my rejection of cussing and/
or vulgar language are not embraced by
most of the people at the social services
agency where I work (or do my field work)
and White professionals as 30.3% of African
Americans responded with ‘not at all’ compared to
60.9% of White participants with a chi square of
χ 2(4, N = 110) = 13.72, p<.05. This indicates that
significantly more White respondents feel their
beliefs regarding appropriate language and their
rejection of cussing and/or vulgar language in a
professional setting are embraced by the majority
where they work.
Agree to refer clients to religious
organization as a support system
In response to this issue, as described in
a case vignette, there was a significant difference
between African American and White participants as
13.2% of African Americans responded with ‘not at
all’ to this variable in comparison to 39.5% of White
respondents with a chi square of χ 2(4, N = 110) =
African American respondents would agree to refer

individuals to religious organizations as a support
system when compared to White colleagues.
Agree to urge sexual responsibility to
their clients
In response to this issue as described in a case
vignette, there was a significant difference between
African American and White research participants
as 35.3% of African Americans responded with ‘not
at all’ compared to 47.1% of White participants
with a chi square of χ 2(4, N = 110) = 12.91, p<.05.
2 - page 43
This indicates that significantly more African
American respondents would agree at some level to
urge sexual responsibility to their clients than their
White colleagues.
Agree with the advice to client to resist
same-sex affection in public
In response to this issue, as described in
a case vignette, there was a significant difference
between the two groups as 33.3% of African
Americans responded with ‘not at all’ compared
to 46.7% of White colleagues with a chi square of
χ 2(4, N = 110) = 20.99, p<.05. This indicates that
significantly more White research participants

would disagree with advising a client to resist
same-sex affection in public.
When a client chooses an option
contrary to my beliefs I feel loss of
integrity
significant difference between the two (ethnic)
groups as 10.3% of White participants agreed
with this variable as compared to 0% of African
Americans with a chi square of χ 2(1, N = 110)
more White participants feel a loss of integrity
when a client chooses an option contrary to their
own beliefs.
When a client chooses an option
contrary to my beliefs I feel angry
2.4% of African American participants agreed to
this variable in comparison to 14.7% of White
participants with a chi square of χ 2(1, N = 110)
more White research participants feel angry when
a client chooses an option contrary to their beliefs.
Discussion
Throughout this study, a key focus was the
verification that value-related dilemmas may evoke
emotional responses from the professional. The
emotional feeling may influence decision-making

as well as what may represent the perception of
what is identified as normal behavior exhibited
by clients. As a result, this discussion section is
organized around headings that are associated with
value-related issues that are common to professional
social service practice.
Issues related to life and death
The issue of abortion is a multifaceted,
value-related dilemma where there are underlying
causes as well as consequences related to the
decision to accept or reject abortion as an option.
If the response is based upon a fixed moral rule,
then it is referred to as ethical absolutism; if various
situations impact one’s response or behavior, then
the dilemma is referred to as ethical relativism
(Dolgoff, Harrington, & Loewenberg, 2012) which
may suggest that morality is relative to the norms
of one’s culture. Therefore, in the study survey, the
issue of abortion was divided into multiple items:
abortion to save the life of the mother, abortion as a
form of birth control, and abortion as a response to
rape or incest.
There was no statistically significant
difference between African American and White
survey participants regarding their acceptance of
abortion as a method to save the life of the mother
as well as for birth control. Both groups agreed that
abortion was acceptable under lifesaving and birth
control conditions. However, there was a statistically
significant difference between the groups regarding
abortion as a response to rape and incest. African
Americans in the sample suggested that abortion
in response to incest and rape was outside of their

value system. White survey participants suggested
that abortion was acceptable in the context of each of
the three conditions. African American respondents
indicated more of an ethical relativist view since
they chose abortion as the option to save the life of
the mother but also chose to reject abortion as an
option in the case of incest or rape.
Study results show that White survey
participants were more accepting of mercy killing,
euthanasia, and the right to terminate one’s own life
and to assist others in the act of terminating their
lives. Most African American respondents rejected
2 - page 44
mercy killing, euthanasia, and an individual’s
right to assist others in terminating a life. The
issue of African American respondents rejecting
such a practice corresponds with the results that
indicated a high percentage (92.9%) embraced a
value about maintaining a meaningful and personal
relationship with God. They also indicated that they
embraced a value that required attending church,
mosque, or synagogue. This also corresponds with
African American respondents embracing a belief
in salvation or a positive afterlife in eternity. The
concept of religiosity as expressed in the response
to the three survey items may explain the rejection
of mercy killing, euthanasia, and the right to

terminate one’s own life, and to assist others in the
act of terminating their lives. These values related
to religious beliefs may have an impact on their
attitudes toward various lifestyle and domestic
issues and the general social perspective (Ladner,
1998, Boyd-Franklin 2003, Edwards, 2014).
Issues related to lifestyle, domestic, and
social perspectives
Although …
lable at ScienceDirect
Social Science & Medicine 191 (2017) 109e116
Contents lists avai
Social Science & Medicine
journal homepage: www.elsevier .com/locate/socscimed
A good abortion experience: A qualitative exploration of
women's
needs and preferences in clinical care
Anna L. Altshuler a, *, Alison Ojanen-Goldsmith b, Paul D.
Blumenthal a, Lori R. Freedman c
a Stanford University School of Medicine, Dept. Ob/Gyn, 300
Pasteur Dr. HG332, Stanford, CA 94305, USA
b Full Spectrum Doulas, Seattle, WA, USA
c Advancing New Standards in Reproductive Health/University
of California, San Francisco, 1330 Broadway, Suite 1100,
Oakland, CA 94612, USA
a r t i c l e i n f o
Article history:

Received 20 January 2017
Received in revised form
2 September 2017
Accepted 7 September 2017
Available online 8 September 2017
Keywords:
United States
Abortion experience
Abortion stigma
Abortion services
Reproductive justice
Abortion access
Patient-centered care
Abortion normalization
* Corresponding author. Present address: Californ
475 Brannan St #220, San Francisco, CA 94107, USA.
E-mail addresses: [email protected] (A.
com (A. Ojanen-Goldsmith), [email protected][email protected]
(L.R. Freedman).
http://dx.doi.org/10.1016/j.socscimed.2017.09.010
0277-9536/© 2017 The Authors. Published by Elsevier
a b s t r a c t
What do women ending their pregnancies want and need to have
a good clinical abortion experience?
Since birth experiences are better studied, birth stories are more
readily shared and many women who
have had an abortion have also given birth, we sought to
compare women's needs and preferences in
abortion to those in birth. We conducted semi-structured
intensive interviews with women who had
both experiences in the United States and analyzed their
intrapartum and abortion care narratives using

grounded theory, identifying needs and preferences in abortion
that were distinct from birth. Based on
interviews with twenty women, three themes emerged: to be
affirmed as moral decision-makers, to be
able to determine their degree of awareness during the abortion,
and to have care provided in a discreet
manner to avoid being judged by others for having an abortion.
These findings suggest that some women
have distinctive emotional needs and preferences during
abortion care, likely due to different circum-
stances and sociopolitical context of abortion. Tailoring
services and responding to individual needs may
contribute to a good abortion experience.
© 2017 The Authors. Published by Elsevier Ltd. This is an open
access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Many women experience both abortion and birth over the
course of their reproductive lives. In the United States, an
estimated
30% of women have an induced abortion by age 45 (Jones and
Kavanaugh, 2011) and of those women who have had an abor-
tion, 59% have previously given birth (Jerman et al., 2016).
Abortion
represents a transition for pregnant women, moving from the
possibility of bearing that child to proceeding with one's life as
is.
As with birth, how abortion happens matters to women, their
families and communities (Lie et al., 2008; Lyerly, 2013;
Simkin,
1991). However, unlike with birth, researchers and policy
makers
have given less attention to what constitutes a good abortion
experience. This reality may be due to a greater focus on

defending
access to abortion by creating a body of evidence demonstrating
that it does not harmwomen physically or mentally and
improving
ia Pacific Research Institute,
L. Altshuler), [email protected]
u (P.D. Blumenthal), Lori.
Ltd. This is an open access article u
its technical aspects. Fortunately, undergoing an abortion in the
U.S.
is extremely safe (Biggs et al., 2017; Jatlaoui et al., 2016) and
the
process is effective (Ireland et al., 2015), permitting a shift in
focus
to improving other aspects of care quality, namely patient-
centeredness, which encompasses care guided by a patient's
values (Institute of Medicine, 2001). Prior studies suggest that
most
women tend to be satisfied with their care (Taylor et al., 2013;
Tilles
et al., 2016) but some women have challenging experiences
(Kimport et al., 2012; Weitz and Cockrill, 2010), implying that
there
is room for improvement. Accordingly, we must learn
fromwomen
who have sought abortion services about their experiences and
how they would like their care to be.
A qualitative investigation of women's needs and preferences to
improve care has been performed for maternity services and it
offers a preliminary framework for studying abortion due to
their
commonalitiesdboth birth and abortion affect pregnant women
and are two among other reproductive health services that

women's health clinicians provide. Bioethicist and obstetrician
Anne Lyerly examined what constitutes a good birth experience
by
learning from childbearing women about what they valued,
amounting to one of the most comprehensive efforts to date on
this
subject (Lyerly, 2013). She found that the five core domains for
a
nder the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
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A.L. Altshuler et al. / Social Science & Medicine 191 (2017)
109e116110
good birth entail being the principal decider and actively wit-
nessing the birth process (agency); trusting the health provider
and
feeling safe from physical harm in the face of risk, being free
from
unwanted intrusions and feeling at ease (personal security);

having
the birth experience respected as a significant event, being
treated
with dignity and possessing self-respect (respect); maintaining
clear communication and access to information throughout the
birthing process (knowledge); and feeling emotionally
connected
to the baby, loved ones, health professionals and other women
(connectedness) (Lyerly, 2013).
Lyerly found that these domains for a good birth generally
correspond to dimensions needed for individual wellbeing theo-
rized by Powers et al. in their framework for social justice in
health
policy (Powers and Faden, 2006), implying that they are
potentially
broad enough to apply to other areas of healthcare. Moreover,
previous studies on abortion suggest that there are parallels be-
tweenwomen's needs in maternity and abortion care. With
respect
to Lyerly's domain “agency,” researchers have found that
women
value being able to decide to have an abortion to plan their lives
(Andrews and Boyle, 2003; Fielding et al., 2002) and to
determine
how the abortion happens (Elul et al., 2000; Fielding et al.,
2002;
Kerns et al., 2012; Simonds et al., 1998). Elements of “personal
se-
curity” emerged in women's narratives in Kimport et al., in
which
women described a need to feel physically safewhile obtaining
care
in abortion clinics that operated in hostile anti-abortion
environ-
ments (Kimport et al., 2012). Findings from Castle et al. under-

scored the importance that women ascribe to having information
to prepare for an abortion (Castle et al., 1995), consistent with
the
domain “knowledge.” “Connectedness” and “respect” were also
important to women, demonstrated as an appreciation for
compassionate behavior from providers (Kimport et al., 2012;
McLemore et al., 2014; Taylor et al., 2013) and having a sense
of
dignity upheld during abortion care (McLemore et al., 2014;
Weitz
and Cockrill, 2010).
Despite these commonalities in childbirth and abortion, there
are also notable differences, such as women's circumstances at
the
time of pregnancy and the sociopolitical context within which
these reproductive experiences occur. Birth tends to be viewed
as
joyous and physiological (Gaskin, 2011; Lyerly, 2013) and
intra-
partum services arewell-integrated into healthcare: they are
linked
to antepartum and postpartum services, have private and public
insurance coverage, and are accessible to most women (Kaiser
Family Foundation, 2013; Rayburn et al., 2012). By contrast,
abor-
tion is politicized and stigmatized (Joffe, 2013; Norris et al.,
2011).
Services tend to be provided separately from other medical care
in
limited supply at specialized abortion facilities, requiring
amajority
of women to travel far and to pay out of pocket for care (Jerman
et al., 2016; Jones and Jerman, 2014). Given these different
con-
texts for birth and abortion, we sought to examine ways in

which
women's needs and preferences in abortion care differ from
intrapartum care.
2. Methods
The study was conducted in Northern California through semi-
structured intensive interviews from April to December 2014
with women who had individually experienced both birth and
abortion. Participants were recruited through advertisements on
Craigslist, at community colleges and at public libraries that
tar-
geted women residing in a geographical area with multiple birth
and abortion facilities to choose from. We recruited women
from
the community rather than specific medical facilities to solicit
variation in women's clinical experiences and to identify
underly-
ing patterns that were not influenced by a particular medical
setting. We predicted this recruitment strategy would
underrepresent women who had abortions for fetal or maternal
indications given they account for less than 5% of all abortions
(Jatlaoui et al., 2016). We did not view it as a limitation as
those
experiences have been studied (Lafarge et al., 2014). Inclusion
criteria were age 18e49 years, had an abortion in the last 5 years
and a prior birth at any time point in the United States, and not
pregnant at the time of interview. These timeframes were
selected
because it has been demonstrated that women remember their
births accurately and vividly as many as 10e20 years later
(Simkin,
1992) but this information is unknown for abortion. All women
gave informed consent prior to participating and received a $40
gift
card as compensation for their time.

An obstetrician/gynecologist-researcher (AA) who had prior
interview experience and did not know the participants
personally
or professionally conducted interviews in English over the
phone
and in-person in a nonmedical setting. Phone interviews allowed
us to expand recruitment and to accommodate women who had
childcare or transportation difficulties. AA did not identify
herself
as a physician unless asked as she noticed that participants
shared
less comfortably when they viewed her as more authoritative on
the topic (Weiss, 1994). Participants were invited to describe
their
pregnancies by answering open-ended questions regarding the
highs and lows of all their intrapartum and abortion
experiences;
decision to parent or not; selection of the provider and facility;
interactions with the healthcare staff, support people and other
patients; pain management, spiritual or religious support; and
postabortion/postpartum care. Womenwho also wanted to
discuss
their miscarriages did so. We anticipated that many women
would
have had more than one abortion as per national statistics (Jones
et al., 2017) and sought to contextualize their most recent abor-
tion by inquiring about all of their past experiences. After
sharing
their stories, participants were asked to compare their
preferences
in birth and abortion and how they preferred care to have been.
Following the interview, participants completed demographic
questions and a validated Individual Level Abortion Stigma
scale
(ILAS) assessment (Cockrill et al., 2013) (Supplementary

material).
ILAS evaluates the degree of personal stigma from the most
recent
abortion through a series of statements about one's worries
about
judgment, feeling of isolation, self-judgment and sense of com-
munity condemnation. These four areas (sub-scales) are scored
according to the degree of stigma. As the study took place in an
area
with relatively unhindered abortion access and more liberal
abor-
tion views, this scale permitted us to determine whether this
context equated with less individual abortion stigma. To this
end,
we compared our participants’ scores to the scores of a U.S.-
based,
regionally diverse abortion clinic population of women
surveyed
for the development of ILAS.
The content and style of the interview instrument were
informed by consultations with experts in the field, Lyerly's
work,
aforementioned abortion-related studies, a narrative review of
qualitative studies on abortion care (Lie et al., 2008) and a
guide to
abortion counseling (Perrucci, 2012). A full-spectrum doula
from a
different state who is not a medical professional (AOG)
provided a
client-advocate standpoint in the development of the instrument
to complement AA's medical perspective. Full-spectrum doulas
are
individuals trained in providing emotional, physical and
informa-
tional support during birth, miscarriage and abortion.

We used an iterative and flexible process for data collection to
build a grounded theory (Charmaz, 2006). In parallel to
conducting
interviews, AA performed field observations of abortion and
birth
facilities unfamiliar to her to achieve a better understanding of
care
models and processes the participants described. She also spoke
with doulas who provide abortion support in the geographical
area
studied and who have had an abortion themselves to explore
potentially more sensitive questions and concepts in preparation
Table 1
Participants’ characteristics, N ¼ 20.
Age at interview; median, range 32 years (19e42)
Black 7/20 (35%)
Latina 7/20 (35%)
White 4/20 (20%)
Enrolled or completed � Assoc. deg. or vocational school
15/19a (79%)
Religious or spiritual 11/19a (58%)
Family income $25,000/year or less 8/19a (42%)
Married or in a relationship 14/20 (70%)
Age at first pregnancy; median, range 18 years (14e38)
Had given birth before having abortion 11/20 (55%)
Years since last abortion; median, range 3.5 (0e5)
Total number of abortions 34
Abortion care at a specialized abortion facility 26/34 (76%)
Abortion in first trimester 30/34 (88%)
Medication abortion 6/34 (18%)
Abortion for fetal or woman's health reasons 3/34 (9%)

Total number of births 31
Total number of adoptions 1
a Among those who answered question.
Table 2
Individual Level Abortion Stigma scale comparison.
Scale This study
N¼16-19a
Mean (SD)
Cockrill et al., 2013
N¼629-643a
Mean (SD)
Full scale
(range 0-3.5)
1.6 (0.67)
n¼16
1.35 (0.63)
Worries about judgment
(range 0-3)
1.19 (1.00)
n¼19
0.86 (0.86)
Isolation
(range 0-3.5)

1.32 (0.65)
n¼18
1.21 (0.81)
Self-judgment
(range 0-4)
2.26 (0.97)
n¼18
2.0 (1.03)
Community condemnation
(range 0-4)
1.95 (1.15)
n¼19
1.85 (1.07)
a Those who answered the relevant questions.
109e116 111
for interviews with participants. Each interview influenced the
direction and depth of inquiry of subsequent interviews.
Interviews
were conducted until no new iterations of theoretical concepts
emerged.
All interviews were audio-recorded, professionally transcribed
verbatim, checked for transcription accuracy and de-identified
prior to analysis. We utilized Dedoose® 6.2.10 software to code
and facilitate analysis of qualitative data, and STATA®14.0 to
perform descriptive statistics. Early in the interview process, we

developed a codebook using a priori codes influenced by
Lyerly's
birth framework (Lyerly, 2013; Namey and Lyerly, 2010), codes
that
emerged from AA's analytic memos and independent initial
coding
by AA and AOG of five thematically different interviews. Once
a
preliminary codebook was agreed upon, AA coded the
remainder of
the transcripts. She continued to refine the codebook with AOG
as
new concepts and analyses emerged and consulted with LF to
develop a theoretical perspective on the data.
In our initial analysis, we categorized all codes into Lyerly's
five
domains for a good birth and then, using grounded theory, we
modified and expanded these domains according to our birth
and
abortion data (details not discussed here) (Kelle, 2013). We per-
formed comparisons at the individual level (what each
participant
valued in her abortion and birth experiences) and how these
values
applied to the entire group of participants. We discovered phe-
nomena in the abortion narratives that either did not emerge
from
the birth narratives or provided a distinct perspective for
abortion
care. These phenomena are this work's focus. Given its
exploratory
nature aimed to broaden our understanding of a good abortion
experience, we sought to capture variations rather than
common-
alities, and this intention is reflected in the selection of

quotations.
This project was approved by Stanford School of Medicine
Institu-
tional Review Board (IRB-29296) and is reported according to
Standards for Reporting Qualitative Research (O'Brien et al.,
2014).
3. Results
Twenty-four women participated. Four of them did not meet all
the eligibility criteria and were excluded from this analysis: one
participant had an abortion nine years ago and three participants
reported having an induced abortion, though per their
narratives,
they were miscarriages. The remaining twenty women
contributed
the experiences of 34 induced abortions, 31 births and 6
miscarriages.
Twelve of the twenty interviews were conducted by telephone
and the richness of these interviews was similar to in-person in-
terviews. Average interview durationwas 70 min. A majority of
the
participants were black or Latina, in a romantic relationship and
spiritual or with a religious affiliation (Table 1). Thirteen
partici-
pants were first pregnant by age eighteen and six of these
women
ended that pregnancy. A majority of abortions occurred in the
first
trimester andwere performed at a specialized abortion facility
via a
surgical procedure for non-medical indications. All births
occurred
at a hospital and 68% were vaginal deliveries.

According to the Individual Level Abortion Stigma scale, the
degree of personal stigma of the participants was similar
(slightly
higher) in each sub-scale and the full scale compared to the
larger
national sample of women who were surveyed for development
of
this instrument (Table 2) (Cockrill et al., 2013). A higher
number
reflects higher stigma.
In general, participants described their experiences as good
during birth and abortion care when they did not have to
compromise their emotional wellbeing in the process. Needs and
preferences in abortion differed from birth in three ways:
women
appreciated being affirmed as moral decision-makers by
providers,
having a choice about their degree of presence during an
abortion,
and receiving care in a discreet manner to avoid judgment from
others for obtaining an abortion. Three pregnancies were ended
for
maternal or fetal indications and the aforementioned aspects of
care also emerged in those women's narratives.
3.1. Moral decision-maker
For each pregnancy experience, participants were asked to
reflect on making the decision to become a parent, to have an
abortion or to pursue adoption. Irrespective of what they
decided,
women felt that the decision they made was the right one given
their circumstances even if, in retrospect, they wished they had
chosen differently. For some women, the decision carried some
degree of emotional discomfort, such as sadness,

disappointment
or anxiety about the future, especially in circumstances when a
pregnancy occurred at an inopportune time (e.g., unstable rela-
tionship or insufficient financial or other resources).
Unique to abortion decision-making, however, were instances of
moral conflict. While some participants felt that their reasons
for
having an abortion were valid and sufficient, they struggled
with
the belief that having an abortion was at odds with being a good
person. This belief stemmed from the notion that a woman's
intrinsic biological responsibility is to become a mother and
anti-
abortion views that predominated in their communities of up-
bringing. Moral conflict undermined some participants'
decision-
making capacity and surfaced during clinical care, coloring
their
abortion experiences.
For instance, Gaby (39 years old; 2 abortions, 3 births)
described
ending a multifetal pregnancy, revealing she was certain about
her
109e116112
decision but morally conflicted (all names are pseudonyms).
She
explained that parenting was not an option because she lacked a
stable job and housing and suffered from depression. Gaby had
contemplated adoption and had pursued it in a different
pregnancy

but decided against it this time. She feared that the children
would
have been separated and regarded this possibility as devastating.
Gaby talked about the seriousness with which she weighed her
alternatives and the significance of what she was undertaking:
I had to make a real life-changing decision. I mean, it's not easy
… I don't think we just get up to just say, okay, today, you
know
what, I'm going to … kill a baby. You don't think like that. You
look at all the things…. and I just didn't want to bring the kids
in
like that.
Even though having an abortion challenged her idea of herself
as
a moral decision-maker, she cited moral values in her reasoning.
As
she contrasted continuing the pregnancy with abortion, she real-
ized that to “kill a baby” was a less harmful, less morally prob-
lematic situation than continuing the pregnancy and risking the
separation of her children. Yet, during her abortion care, Gaby
lacked someonewho could witness and validate these moral
values
that guided her decision:
I felt like the doctor was judging the person, my character … he
didn't treat me like a person, an individual. He treated me like,
‘Get on up on the table. Let's get this over with because you
ain't
nothing.’ You know, ‘Look at you… you're paying $500 to get
rid
of something you made.’ That's the way I felt …. At least [he
could have] assured me that he know[sic] that what I'm going
through is not easy. I think that's what I was looking for.

Although the doctor did not actually tell her she was “nothing,”
she felt that his behavior was judgmental and dehumanizing. He
did not recognize her as a person grappling with a real-life
moral
decision. Instead, she perceived him as thinking of her abortion
as
an impersonal business transaction. Gaby had hoped that the
doctor would appreciate the difficulty of the decision for her
and
see her as a person confronted with a moral quandary.
Like Gaby, Katherine (31 years old; 2 abortions, 1 birth) felt
morally conflicted about having an abortion and wished the
med-
ical personnel had identified this conflict and supported her.
Katherinewas 15 years old at the time and feared getting kicked
out
of the house if her mother found out about her pregnancy. When
Katherine walked up to the abortion clinic, a woman emerged
from
a group of protesters holding signs plastered with images of
macerated fetuses. She raised a cross to Katherine's head and
declared, “May God forgive you for murdering your child.” This
interaction affected Katherine: she had not thought of the six-
week
pregnancy as her child but at this moment began to wonder if
this
womanwas right, whether she was committing murder. While
she
still planned to end her pregnancy, she entered the clinic feeling
overwhelmed, questioning the morality of her decision. Looking
back as an adult, she wished care had been provided differently:
[The doctor] looks at me and he looks at my chart and he's like,
“How old are you?” And I was like, “15.” He's like, “Wow.”
That

was just like a horrible experience. It was already a bad enough
day, and what an insensitive thing for a doctor to say to some-
one, a young girl who's obviously already completely like
freaked out and upset …. Nobody at any time did or said any-
thing that made me feel like [having an abortion] was okay, like
other women go through this, like you're not a bad person. It
was just the opposite. I felt judged … felt like everything I was
doing was wrong.
To have moral clarity, Katherine needed help reconciling the
aggressive anti-abortion messaging outside the clinic with what
an
abortion actually was. However, she did not achieve such under-
standing. On the contrary, the doctor’s negative response to her
age
and the lack of compassionate care led her to conclude that
shewas,
indeed, doing something morally wrong. She wished that her
providers had normalized her decision to have an abortion and
acknowledged it as moral.
In contrast, other participants who also had a moral conflict
considered their interactions with medical personnel valuable if
they felt that their decisionwas respected and viewed as moral.
For
example, Sofia (19 years old; 1 abortion, 1 birth) felt comforted
during her abortion care. She became pregnant for the second
time
when she was three months postpartum. She knew she could not
raise two children as she was already struggling to provide for
her
son. Sofia's parents pleaded with her to allow them to adopt this
potential child, as she recounted: “[God] gives you children
because
they're a blessing and a gift. You have a gift and you're going to
throw it away? Don't kill it and let me adopt it. It'll have our
last

name …. He or she will know that you're their mom but you
won't
have to take no [sic] responsibility for it.” She felt distraught by
this
proposal because she took her obligation as a mother seriously
and
could not imagine not raising her own child. Sofia decided that
ending the pregnancy was the right course of action for her,
though
she felt morally conflicted. She valued her conversation with
the
doctor, whose words she retold: “‘You're not doing a horrible
thing.
I know why you're doing it …. Do not feel bad. Like this is for
your
life, to better your life.’” She also remembered the medical
staff's
conduct, “They didn't make you feel bad that you were doing it
….
They were like supporting you.” Sofiawas grateful that her
decision
to end the pregnancywas validated and understood asmoral by
her
providers.
Likewise, Natalie (37 years old; 3 abortions, 1 birth) had a
helpful interaction with a medical assistant prior to the
abortion.
She was trying to end the relationship with her boyfriend and
did
not want to have another child with him. She shared, “I was
crying
and [the medical assistant] was just like, ‘Don't, you're not
doing
anything wrong …. You're not a bad person.’ And I had even
told

her … ‘I have a kid and I can't believe I'm doing this.’” Her
conflict
stemmed for the idea that as a mother, when pregnant, she had a
moral and biological obligation to continue that pregnancy as
she
had first-hand experience what an embryo inside her could
become. Thus, she appreciated how the medical assistant saw
her
as a moral decision-maker in this context.
Participants took their responsibility to determine the outcome
of their pregnancies seriously and tended to feel that theymade
the
best decision for their circumstances, whether they chose
abortion,
parenting or adoption. They wanted to be respected as decision-
makers. Yet, some women did not view their decision to have an
abortion as moral based on their understanding of morality, and
they were sensitive to negative judgment from medical
personnel
for this decision, whether perceived or actual. When medical
personnel recognized this conflict and affirmed the decision as
moral, women tended to assess this part of their experience
positively.
3.2. Presence
In birth and abortion, women used pain medicine not only to
alleviate physical pain but also to control their awareness and
engagement in the process. Participants generally described
birth
as a joyous event, worthy of witnessing and sharingwith others
and
wanted to maintain a sense of presence. Some needed labor sup-
port or an epidural to relieve their physical discomfort to

109e116 113
emotionally experience birth. In abortion, women's reasons to
maintain or lessen their sense of presence were more nuanced,
reflecting women's diverse emotional needs specific to abortion
care. They determined how present they wanted to be with their
selection of pain medicine and abortion method. The methods
include removing the pregnancy via a surgical procedure
(hence-
forth referred to as “procedure”) or by taking abortifacient
medi-
cations (“medication abortion”).
Some women preferred to be less mentally aware during the
abortive process, especially if they were struggling emotionally
or
morally and feared that witnessing some part of it would further
affect …
Sociology Compass 9/5 (2015): 365–378, 10.1111/soc4.12256
Abortion Counselling in Britain: Understanding the
Controversy
Lesley Hoggart*
Health and Social Care, The Open University
Abstract
This article reviews literature from a number of disciplines in
order to provide an explanation of the
political controversy attached to the provision of abortion
counselling. It will show how this is an area

of health policy debate in which women’s reproductive bodies
have become a setting for political strug-
gle. The issue of abortion counselling in Britain has undergone
a number of discursive shifts in response to
political manoeuvring and changing socio-legal framing of
abortion. In particular, the article shows how
much of the controversial reframing of abortion counselling was
a tactical shift by political actors opposed
to abortion per se, and this work is critiqued for not
contextualising abortion. The article then focuses on
women’s abortion experiences and discusses research that
shows how women’s decision-making
processes, and responses to an abortion, are related to gendered
socio-cultural contexts: the extent to
which women having an abortion feel they have transgressed
societal norms and values, for example, is
likely to affect their abortion experiences. Finally, it is
suggested that providing a non-judgemental
context, and challenging negative discourses on abortion, may
be the most effective way of minimising
the possibility of negative emotions.
Introduction
This article examines the issue of abortion counselling as a site
of policy debate, in which
women’s reproductive bodies have become a setting of political
struggle. In seeking to
understand why a seemingly straightforward subject –whether
women undergoing an abortion
should have access to counselling services – has become so
contentious, it is necessary to con-
sider a wide range of other issues. An over-arching requirement
is to consider how the debate
is socio-culturally located. This means understanding that
policy debates on abortion counsel-

ling are conceptualised differently within different socio-legal
frameworks; within gendered
social norms; and within contentious political discourses. Even
the phrase itself – abortion
counselling – has been subject to a number of discursive shifts
and invested with multiple mean-
ings which are complex and malleable. Above all, as this paper
will show, different strands of
academic debate around abortion counselling customarily
proceed from particular political
positioning, and with an eye to the political implications of
research interpretations. There is
an undeniable relationship between political beliefs on abortion
and intellectual framing on
the issue of abortion counselling. These broader sociological
issues frame this paper, which
focuses on Britain1 as a case study explicating the relationship
between socio-cultural contexts
and different politics, policies and practices.
Britain, in recent years, has experienced repeated f lurries of
political debate and activity
around the issue of pre-abortion counselling. Between October
2006 and June 2007, two
Ten Minute Rule Bills that proposed mandatory counselling
were rejected by the British
Parliament, and in 2012, the MPs Frank Field and Nadine
Dorries proposed amendments to
the National Health Service (NHS) and Social Care Bill 2011
which would have removed
© 2015 John Wiley & Sons Ltd.
counselling services from abortion providers and obliged

women to receive counselling from
‘independent’ bodies before an abortion.2
Abortion counselling as an issue is worthy of exploration
because, as the paper also sets out,
developments in this area affect abortion provision and thus
have an effect upon women under-
going an abortion. Although a straightforward policy question
would address what provision
should look like in this area, such questions have always been
bound up in wider political
debates about the morality of abortion and views on its legal
status. In academia, important
contributions to the debate, from sociology, have come from
Ellie Lee, who has consistently
shown how sociological constructions – of women, of abortion
and of abortion providers –
have informed the legal regulation of abortion in Britain (Lee
1998, 2003a,b, 2004). Kristin
Luker (1984, 1996) and Rosalind Petchesky (1986) have
pioneered sociological work in this
area internationally. Although fundamentally an issue of
concern to political sociologists, many
more disciplines are involved in contributing towards literature
of relevance to the issue of
abortion counselling, including important contributions from
psychology (Boyle 1997;
MacLeod 2011); law ( Jackson 2001; Sheldon 1997); and policy
research (Allen 1985; Hoggart
2003, 2012; Rowlands 2008). This paper reviews three areas of
literature, all of which straddle
these disciplines. Firstly, it considers how policy and health-
focused literature contributes
towards understandings about what is meant by counselling in
the context of abortion.
Secondly, it looks at literature that has sought to explain, and

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