Monday, January 17, 2011

Maybe you should ask, "Why did we make her wait so long?"

I'd wanted to write a good solid post expanding on my last one -- about why some women "wait so long" to have an abortion -- and connecting the dots to social justice. It is Martin Luther King day, after all, and while we ought to be carrying his goals of racial and economic justice in our minds every day, it always helps to describe the links aloud. But: I've been getting sick this weekend and today I woke up with puffy eyes and that underwater feeling in my head and it's making me feel dizzy. I'm going to limit this to my research summaries, because you're smart and insightful enough to connect the dots yourself, and because I can't see my keyboard very well. 


In 2008 researchers at ANSIRH published an unusual study of delay in obtaining abortion care [PDF]. For purposes of analysis, they divided the process into three stages -- between the first missed period and the first pregnancy test; between the first pregnancy test and the first call to an abortion provider; and between that first call and actually having the abortion -- and then identified the circumstances that were closely associated with longer time for each stage. The factors associated with delay varied based on stage. In the first stage, significant delay before the pregnancy test occurred for women who were obese, weren't sure of the date of their last period, were assessed as being in denial about pregnancy or "afraid of an abortion," abused drugs or alcohol, or had had a second-trimester abortion in the past. (A lot of these seem logical, don't they?) 

However, these were not significantly associated with delay in the second stage; rather, women had a longer stage 2 if they had had trouble obtaining MediCal (California's health insurance for low-income residents, which includes coverage for in-state abortion care), and if they had "had difficulty with their decision to terminate this pregnancy." In the third stage, delay in having the abortion itself was associated with (again) having had a second-trimester abortion in the past; having been initially referred to some other clinic than the study site; having an unsupportive partner; and having had difficulty coming up with the money to pay for an abortion. 

So logistical barriers emerge in stage 2 and 3, and especially economic ones. Social/emotional barriers are still present, but different from in stage 1. (Understandably you might delay your call to the clinic if you're having a hard time deciding what to do with your pregnancy; you might try to reconcile a reticent partner to your decision before you head to the appointment -- or your partner might be actively trying to prevent you from getting there!) 

(Additional interesting findings from the last stage: what shortened the time between calling a clinic and having an abortion? (1) Nausea and vomiting [heh, shocker]; (2) having had “difficulty deciding” to seek an abortion. That is, if a woman struggled with her decision, she was likely to have a longer time than other women between taking a pregnancy test and calling a clinic, and a shorter time than other women between calling a clinic and having an abortion.) 


From several of the same California researchers, a 2006 multivariate logistic regression study: "Delays in suspecting and testing for pregnancy cumulatively caused 58% of second-trimester patients to miss the opportunity to have a first-trimester abortion. Women presenting in the second trimester experienced significantly more delaying factors, with logistical delays occurring significantly more frequently for these women (63.3% versus 30.4%). Factors associated with second-trimester abortion were delay in obtaining state insurance, difficulty locating a provider, initial referral elsewhere, and uncertainty about last menstrual period." Interestingly, second-trimester abortion was associated with both having had a prior second-trimester abortion and never having had an abortion before. 


In 2006 the Guttmacher Institute published a study on timing and reasons for delay [PDF] as well. They broke the process into more steps, and measured median time for each. 
-From the last menstrual period to suspecting pregnancy: 33 days (which makes sense if you imagine the average 28-day cycle then add about a week for your first missed period); it was a week longer for minors than for adults (which also makes sense if you consider how irregular most young people's cycles are)
-From suspecting pregnancy to confirming pregnancy (pregnancy test or sonogram): 4 days
-From confirming the pregnancy to deciding to have an abortion: zero days
-From deciding to have an abortion to first attempting to obtain abortion services (calling to make an appointment): 2 days
-From first attempting to obtain abortion services to obtaining the abortion: 7 days
...So that's 48 days right there (and that's just adding up medians, meaning half of women have a longer delay in each of these steps), yet I think somehow a lot of people hear "seven weeks" and think that's a really long time to "wait." I saw an actual published writer write that abortions should only be legal up til six weeks because "forty-two days is plenty of time to decide to have an abortion." Reality to actual published writer, please come in. 

58% of women reported that they would have rather had the abortion sooner, and these women were asked about the reasons for the delay they experienced (women could give multiple reasons). Most commonly, these respondents said: 
-It took a long time to find out about the pregnancy: 36%
-It took a long time to decide to have an abortion: 39%
It took a long time to make arrangements: 59%. Poor women were about twice as likely to be delayed by difficulties in making arrangement. (This includes money, referrals, appointments, transportation, judicial bypass for minors, legally required waiting periods, etc.) 

Patients mentioned a lot of other reasons, including:
-As partial response to Frances Kissling's question, 0.2% stated they found out late about a fetal anomaly (but this isn't broken up by trimester or week; I still think the later abortion patients she was asking about would give this response more often). 
-Only 2% said they "didn't think it was important to have it earlier." (Granted, this doesn't include possible similar answers from the 41% of women who didn't say they'd have rather had the abortion earlier, but I imagine a lot of those 41% had theirs quite early. I wish I could see a full data set on this.) 

I highly recommend reading the rest of this article because it has a section on qualitative findings from in-depth interviews that I just couldn't do justice here. Among other things, it shares the words of women who "knew right away" that they were decided on seeking an abortion, and of  women who found it a "hard decision" and took longer to feel firm in their choice.** 


What about demographic characteristics? Poor women with no insurance coverage for abortion, black women, and young women are likely to have later abortions than other women. However, being poor and lacking insurance coverage disproportionately co-occur with being black and being young. In some studies, each of these effects persists even after controlling for the others; in other studies, they confound one another and only the poverty/insurance effect remains significant. 

I think you can guess what I was going to say about all that. To make a long story short: justice in healthcare access must include attention to reproductive matters. If you care about making a more just society, please express support for public funding for contraception and abortion; donate to your local abortion fund; work to reduce stigma against both abortion and pregnancy; combat racist, ageist and classist stereotypes of appropriate motherhood; and learn about domestic violence and sexual assault prevention. 

**If you want to read more about abortion decision-making, here are some articles to try [unfortunately a few only give the abstract for free]: 
2010: Kjelsvik M. Pregnant and ambivalent. First-time pregnant women’s experience of the decision-making process related to completing or terminating pregnancy – a phenomenological study. 
2005: Finer LB et al. Reasons US women have abortions: quantitative and qualitative perspectives.
1985: Faria G, Barrett E, Goodman LM. Women and abortion: attitudes, social networks, decision-making.
1984: Friedlander ML, Kaul TJ, Stimel CA. Abortion: predicting the complexity of the decision-making process. 
(And if anyone can find the following in English, let me know:) 
1999: Tornbom M et al. Decision-making about unwanted pregnancy.
1990: Ytterstad TS, Tollan A. The decision process in induced abortion. 

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