Findings and interpretation
Retrospective assessments showed that respondents experienced various worries and fears before the abortion and felt moderately to poorly prepared. Various events that occurred during the abortion were unexpected, illustrating general unpreparedness and lack of sufficient preparatory information. Many searched the Web for information but found it difficult to identify high-quality information; contact with low-quality information further hindered uptake of sufficient and appropriate preparatory information.
Strengths and weaknesses
Some methodological limitations of the study should be considered when interpreting the findings. This was an exploratory study with a convenience sample recruited through Web-based means, i.e., public discussion boards and social media. It is possible that the sample deviated from clinical samples. Web-based recruitment is associated with selection bias and limited external validity because of the non-representativeness of Internet users who visit the platforms used for recruitment and the risk of self-selection of respondents, also referred to as the volunteer effect [7 Eysenbach G, Wyatt J. Using the Internet for surveys and health research. J Med Internet Res. 2002;4:E13.]. Use of the Web is widespread in Sweden [23 Davidsson P, Findahl O. Swedes and the Internet 2016: survey about the Internet habits of Swedes (in Swedish); 2016. [cited 2016 Nov 22]. Available from: www.iis.se/docs/Svenskarna_och_internet_2016.pdf] and we recruited respondents via different discussion boards and social media. Nevertheless, this was an exploratory study and we acknowledge the limited transferability due to the Web-based recruitment. It is possible that the women who participated in the study had difficult abortion experiences, which potentially could explain the results in relation to other studies that have indicated overall high satisfaction with abortion care [15 Makenzius M, Tydén T, Darj E, et al. Women and men’s satisfaction with care related to induced abortion. Eur J Contracept Reprod Health Care. 2012;17:260–269.]. On the other hand, the Web-based recruitment strategy might have given voice to women who are otherwise hard to reach and unheard in research because they are not followed up. It is important to explore the views of women with problematic abortion experiences; thus, the findings of this study may be considered complementary to larger quantitative studies illustrating high satisfaction with abortion care.
A large proportion of the sample had received a university education and most were born in Sweden. While there was some variation with regard to abortion type, a higher proportion of respondents had a surgical abortion or a second-trimester medical abortion compared with the wider Swedish population [18 The National Board of Health and Welfare. Abortion statistics (in Swedish); 2018. [cited 2018 Aug 6]. Available from: www.socialstyrelsen.se/statistik/statistikefteramne/aborter]. Thus, the transferability of this study may be limited with regard to abortion type, and the findings should primarily be considered hypothesis generating. Research indicates that sociodemographic characteristics are associated with experience of abortion, including educational level [24 Taylor D, Postlethwaite D, Desai S, et al. Multiple determinants of the abortion care experience: from the patient’s perspective. Am J Med Qual. 2013;28:510–518.]. We acknowledge that more exploratory studies are needed among immigrants or women with lower educational levels.
This study explored retrospective descriptions; almost half the sample underwent the abortion ≥5 years prior to study participation. It is possible that the recollections in some cases differed from the actual experiences or that some clinical routines have changed over time. Thus, participants’ recollections may not fully reflect their experiences of the abortion at the time, since memory effects and biases could have played a role. The findings of this study should be interpreted as complementary to studies that investigate abortion-related experiences closer in time to the abortion. On the other hand, the elapsed time since the abortion might have resulted in a higher degree of reflection about the experience; indeed, many participants provided vivid and detailed descriptions, indicating that they were able to clearly recollect their experience. The questions used in the survey referred to overall abortion-related experiences. Thus, respondents with experience of different types of abortion could provide answers that corresponded to one of their abortions. While this made it possible for them to provide comprehensive responses to the open-ended questions, the rating-scale questions illustrate the overall recollection and not in relation to each of their previous abortions.
The study used qualitative latent content analysis, meaning that the data were interpreted for overarching threads and underlying meaning [21 Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24:105–112.,22 Graneheim UH, Lindgren B-M, Lundman B. Methodological challenges in qualitative content analysis: a discussion paper. Nurse Educ Today. 2017;56:29–34.]. In order to approach the data from different perspectives, two of the authors scrutinised the primary analysis made by the last author. We acknowledge that these analyses involved interpretations of human experiences, and the findings need to be considered with this in mind.
Similarities and differences in relation to other studies
In line with previous reports [1 Lowenstein L, Deutcsh M, Gruberg R, et al. Psychological distress symptoms in women undergoing medical vs. surgical termination of pregnancy. Gen Hosp Psychiatry. 2006;28:43–47.,3–5 Andersson I-M, Christensson K, Gemzell-Danielsson K. Experiences, feelings and thoughts of women undergoing second trimester medical termination of pregnancy. PloS One. 2014;9:e115957.
Jones K, Baird K, Fenwick J. Women’s experiences of labour and birth when having a termination of pregnancy for fetal abnormality in the second trimester of pregnancy: a qualitative meta-synthesis. Midwifery. 2017;50:42–54.
Kanstrup C, Mäkelä M, Hauskov Graungaard A. Women’s reasons for choosing abortion method: a systematic literature review. Scand J Public Health. 2018;46:835–845.], the findings show that women who undergo induced abortion experience various worries and fears, including psychosocial aspects. This highlights the fact that induced abortions often involve emotional difficulties [2 Carlsson T, Bergman G, Karlsson A-M, et al. Experiences of termination of pregnancy for a fetal anomaly: a qualitative study of virtual community messages. Midwifery. 2016;41:54–60.] and psychological distress, which later abates over time [25 Bradshaw Z, Slade P. The effects of induced abortion on emotional experiences and relationships: a critical review of the literature. Clin Psychol Rev. 2003;23:929–958.]. Adequate professional psychosocial support, including respectful and non-judgemental attitudes of health professionals, is essential to the provision of high-quality abortion care [8 Dennis A, Blanchard K, Bessenaar T. Identifying indicators for quality abortion care: a systematic literature review. J Fam Plann Reprod Health Care. 2017;43:7–15.]. According to a previous Swedish study, one in four women is not completely satisfied with her abortion care; the most decisive factor associated with high satisfaction included the human aspects of care [15 Makenzius M, Tydén T, Darj E, et al. Women and men’s satisfaction with care related to induced abortion. Eur J Contracept Reprod Health Care. 2012;17:260–269.]. It is problematic that some respondents expressed fear of mistreatment and that several did indeed experience unexpectedly poor treatment from health professionals. Health professionals who work in abortion care stress the importance of imparting sufficient knowledge and showing empathy towards women [11 Andersson I-M, Gemzell-Danielsson K, Christensson K. Caring for women undergoing second-trimester medical termination of pregnancy. Contraception. 2014;89:460–465.]. The fact that respondents raised issues related to professional treatment illustrates that psychosocial treatment is essential in abortion care and emphasises the importance of addressing pre-abortion fears and worries.
Many respondents reported feeling unprepared, especially for a second-trimester medical abortion, and recalled various unexpected events related to the abortion. Although moderate overall satisfaction with information was reported, participants simultaneously described receiving insufficient and inaccurate information that was incongruent with their actual experience. Previous studies reported that women found abortion-related physical symptoms to be worse than they had expected before the procedure, including vaginal bleeding and physical pain [16 Petersen MN, Jessen-Winge C, Møbjerg A. Scandinavian women’s experiences with abortions on request: a systematic review. JBI Database Syst Rev Implement Rep. 2018;16:1537–1563.]. Preparatory information delivered in a concise and unbiased manner before an induced abortion is highly appreciated among women [10 Lafarge C, Mitchell K, Fox P. Termination of pregnancy for fetal abnormality: a meta-ethnography of women’s experiences. Reprod Health Matters. 2014;22:191–201.]. However, research has shown that some health professionals who work in abortion care experience challenges communicating with their clients [11 Andersson I-M, Gemzell-Danielsson K, Christensson K. Caring for women undergoing second-trimester medical termination of pregnancy. Contraception. 2014;89:460–465.,12 Mauri PA, Ceriotti E, Soldi M, et al. Italian midwives’ experiences of late termination of pregnancy. A phenomenological-hermeneutic study. Nurs Health Sci. 2015;17:243–249.]. The findings highlight the importance of adequate training and mentorship for health professionals [11 Andersson I-M, Gemzell-Danielsson K, Christensson K. Caring for women undergoing second-trimester medical termination of pregnancy. Contraception. 2014;89:460–465.] to enable them to adequately support women seeking an abortion.
A large proportion of the respondents used the Web to search for supplemental information, which is in line with results of previous reports [13 Carlsson T, Bergman G, Wadensten B, et al. Experiences of informational needs and received information following a prenatal diagnosis of congenital heart defect. Prenat Diagn. 2016;36:515–522.,26 Foster AM, Wynn LL, Trussell J. Evidence of global demand for medication abortion information: an analysis of www.medicationabortion.com. Contraception. 2014;89:174–180.]. The Web is a widely used tool for accessing health-related information among the public [27 Kummervold PE, Chronaki CE, Lausen B, et al. eHealth trends in Europe 2005–2007: a population-based survey. J Med Internet Res. 2008;10:e42.,28 Fox S, Duggan M. Health online; 2013. [cited 2019 Jul 15]. Available from: www.pewinternet.org/2013/01/15/health-online-2013] and has the potential to offer highly accessible and tailored information, independently of geographical limitations [29 Cline RJ, Haynes KM. Consumer health information seeking on the Internet: the state of the art. Health Educ Res. 2001;16:671–692.]. Research indicates, however, that those who search for health-related Web-based information find it difficult to identify reliable sources [13 Carlsson T, Bergman G, Wadensten B, et al. Experiences of informational needs and received information following a prenatal diagnosis of congenital heart defect. Prenat Diagn. 2016;36:515–522.,30 Carlsson T, Melander Marttala U, Wadensten B, et al. Quality of patient information websites about congenital heart defects: mixed-methods study of perspectives among individuals with experience of a prenatal diagnosis. Interact J Med Res. 2017;6:e15.,31 Eysenbach G, Köhler C. How do consumers search for and appraise health information on the World Wide Web? Qualitative study using focus groups, usability tests, and in-depth interviews. BMJ. 2002;324:573–577.], and, further, that some consumers are insufficiently able to assess the reliability and trustworthiness of Web-based sources [31 Eysenbach G, Köhler C. How do consumers search for and appraise health information on the World Wide Web? Qualitative study using focus groups, usability tests, and in-depth interviews. BMJ. 2002;324:573–577.,32 Peterson G, Aslani P, Williams KA. How do consumers search for and appraise information on medicines on the Internet? A qualitative study using focus groups. J Med Internet Res. 2003;5:e33.]. This illustrates the risk of contact with poor quality, biased information, described by some respondents. Descriptive studies have reported various issues related to the quality of websites in the field of obstetrics and gynaecology [33–35 Fioretti BTS, Reiter M, Betrán AP, et al. Googling caesarean section: a survey on the quality of the information available on the Internet. BJOG: Int J Obstet Gy. 2015;122:731–739.
Carlsson T, Axelsson O. Patient information websites about medically induced second-trimester abortions: a descriptive study of quality, suitability, and issues. J Med Internet Res. 2017;19:e8.
Mercer MB, Agatisa PK, Farrell RM. What patients are reading about noninvasive prenatal testing: an evaluation of Internet content and implications for patient-centered care. Prenat Diagn. 2014;34:986–993.]. Moreover, widespread dissemination of misinformation about induced abortions on the Web has been reported [36 Rowlands S. Misinformation on abortion. Eur J Contracept Reprod Health Care. 2011;16:233–240.], echoing respondents’ descriptions. When consulting women seeking an abortion, health professionals should address the potential difficulties of trying to identify relevant websites and emphasise the risk of contact with low-quality misinformation on the Web. Taken together, the findings illustrate the need to develop an accessible Web-based informational tool that contains honest and accurate high-quality information. This information needs to correspond to the preferences of the intended audience, i.e., women seeking abortion, and be written by trustworthy authors.