The initial Phase 1 search conducted in 2019 yielded 11,620 articles. After removing duplicates in EndNote, we imported 6787 articles into Covidence, which identified a further 17 duplicates, and screened the titles and abstracts of 6770 unique articles. We identified 95 potentially relevant articles and retrieved the full text manuscript for further evaluation. After completing full text reviews, we excluded 59 articles from the sample, leaving 36 articles that met study inclusion criteria. The Phase 2 search began with 2043 articles, of which 1874 were imported into Covidence for title and abstract screening, after duplications were removed. We identified 23 potentially relevant articles and reviewed the full text of each manuscript; of these, ten were included.
See Fig. 1 for the flow diagram of the search.
Of the 46 studies included in the systematic review, 40 were qualitative, four employed a mix of quantitative and qualitative methods, and two were exclusively quantitative. Our analysis synthesized findings from primary research conducted across 21 countries: twelve countries in sub-Saharan Africa and nine in Latin America and the Caribbean. The studies varied greatly with regard to methodological rigor and depth of analysis. Most studies (n = 20) met the high-quality rating on our CASP quality assessment tool while 18 articles were rated medium quality and eight were rated low quality. The characteristics of the 46 studies included in our synthesis are reported in Table 1, along with their CASP assessment rating.
Thematic findings
The findings of this review are organized across four broad themes: (1) the role of knowledge; (2) the role of safety; (3) role of social networks and the internet, and; (4) cost, affordability and convenience. In addition to direct quotes from participants cited in the reviewed studies, we use quotes from authors that summarize findings from their own research.
The role of knowledge
The role of knowledge factored prominently into women’s decisions regarding how, when, and where to terminate their pregnancy. This included aspects broadly related to knowledge of the abortion law and knowledge of methods and sources of abortion. These two categories of knowledge acted upon women’s abortion-related decisions directly and indirectly as described below.
Knowledge of law
Knowledge of abortion laws affected women’s abortion-related decision-making by impacting their perceived or actual choices [30,31,32,33,34,35,36,37,38,39,40]. The impact of one’s knowledge of the abortion law varied by what those views entailed. Women’s understanding that abortion was broadly illegal, regardless of whether their knowledge was accurate, was associated with fear of potential legal or other repercussions of seeking care at a formal health facility. Thus, perceptions of illegality restricted women’s choices were linked to use of less medically safe (as distinct from socially or legally safe) abortion methods and sources [31,32,33, 36, 37]. This perception is illustrated by one woman in Atkaro et al. [31] I knew that it is illegal to have an abortion in Ghana and so I could not have gone to any facility to have by pregnancy terminated. All my friends that I asked only recommended some herbal mixture called agbeve for me… Although I know I could bleed to death from terminating my own pregnancy, I didn’t have a choice or options. So, I used the agbeve herbal mixture.
Many women who were unsure of the law or who had anxiety about whether their situation qualified as a legal indication tended to seek abortion outside the formal health sector [31,32,33, 36, 37]. As Izugbara et al. [36] summarized: Respondents generally believed that abortion is illegal in Kenya, mentioning the Kenyan media, religious leaders, health providers, family, friends, and schools as sources of their information on the criminality of abortion. Given the presumed illegality of abortion in Kenya, safe abortion was also understood in terms of procedures and providers that shielded women from the law and arrest.
As such, not knowing the legality of abortion or the exceptions in the law presented barriers to timely care [33]. Conversely, learning about conditions under which women could seek or be eligible for legal abortion services tended to positively impact women’s abortion-related decision-making [32, 34, 37], for example, giving participants more confidence to advocate for themselves and their desires, and empowered to make well-informed decisions [34]. The process of learning about available legal services was often facilitated by an advocacy group or legitimate service provider [33].
Knowledge of methods and sources
Women’s knowledge of specific abortion methods and sources was a proximal factor that directly impacted their abortion-related decisions. Lacking awareness of methods and sources was common [30, 31, 33, 34, 39, 41,42,43,44,45,46,47,48] and was an obstacle to women using a medically safe method or source in one of two ways: either women would act upon the limited knowledge they had, which tended to lead them to obtain an unsafe abortion; [31, 39, 46] or their lack of knowledge led to delays, which in effect limited their options as a result of later gestational age [33, 34]. Regarding the latter experience, Seid et al. [39] summarized findings as such: Lack of information and knowledge about safe abortion services is the barrier. If they (women) do not have information, they hesitate to decide and as time goes, they do not have the chance to terminate their pregnancy. The only option they have may be giving birth.
Whether a woman had or could access information about safe abortion methods and sources was often related to her demographics. Rural, older, and less educated women, as well as those with less social capital (namely not having medical providers in their social network) were unlikely to have adequate information to make an informed decision and use a safe method [39, 47,48,49] While many women are aware of both safe and unsafe methods or sources, knowledge of misoprostol and mifepristone specifically appeared more common among younger women [48]. In one Kenyan study, information about abortions came from informal social networks from high school and from friends with a prior abortion experience [30, 50].
A lack of knowledge about methods and sources was not necessarily linked with a preference for a certain type of method; in fact, incomplete information led to significant misperceptions and heterogeneity in preferences [42]. It also resulted in incorrect use of medical abortifacients and concerns about product effectiveness. In some cases, this contributed to women preferring surgical abortion while for others, it led to a preference for medical abortion.
In societies where abortion is highly stigmatized, women tend to lack access to information about safe abortion methods or where they can be procured [51, 52]. As Kebede et al. [51] points out: ‘all [women in the study] struggled to access information about abortion possibilities and attributed this difficulty to the morally charged silence surrounding abortion and premarital sexual activity.’ Even in countries with more permissive laws, participants were often unaware of them because of the shroud of taboo [34].
The role of safety
In addition to women’s knowledge, their perceptions of medical, legal, and social safety were significant factors in their decision making regarding how and where to terminate their pregnancy [31, 33, 36,37,38,39,40,41,42, 44, 47, 48, 51,52,53,54,55,56,57,58,59,60,61]. While women strongly preferred their abortions to be medically safe, concerns about legal and social safety often prevailed, leading women to have a medically unsafe termination.
Perceptions of medical safety and quality
In the absence of other influencing factors, women strongly preferred medically safe abortion methods and services [37, 48, 52, 55, 56, 62]. Based on a study in Ghana, Esia et al. [55] summarized that ‘All the respondents indicated that they preferred to have abortion at recognized facilities and by recognized practitioners so as to make it safe’ However, there was significant variation in what methods women perceived as most safe. One study found that women perceived abortions induced by ingesting substances to be safer than surgical abortions because they associated surgical equipment with a greater risk of complications like infections [51]. In other cases, women stated preferences specifically for medical abortion due to the perception of lower health risks [48, 58, 63]. Regardless of preferred method or source, women’s preferences for medically safe abortions were often overridden by greater concerns about legal and social safety.
Women’s perceptions of the quality of care provided at facilities played a role in the decision-making process regarding where to seek abortion services [36, 37, 43, 44, 47, 51, 55,56,57, 59, 62] These perceptions included likelihood of respectful care and willingness of the provider to perform the requested procedure [33, 34, 57]. In Nigeria, perception of care had more to do with having a good reputation, i.e. not being a “quack [43, 62]”: “They noted that individuals who seek care from so-called “quacks” suffered from side effects and “regret it,” but for those who obtain services from a qualified provider “there won’t be any problem [62].”
Respectful care was generally identified as provider(s) having the interpersonal skills necessary to treat women with unwanted pregnancies – regardless of sociodemographic or marital status – with empathy and respect [33, 34]. Two studies found that women expected to experience disrespectful care (such as manipulating women to carry to full term or belittling a woman’s decision to abort) at public health facilities, leading them to instead choose facilities or providers recommended by friends [40, 57].
Perceptions of legal safety
Fear of legal repercussions often superseded women’s preferences for medically safe abortion methods and services, leading them to attempt to self-induce using unsafe methods and/or seek care from clandestine providers [31, 37, 38, 40, 49, 64]. In other instances this led women to withhold information from postabortion care (PAC) providers about their previous attempts to self-induce [40, 48, 58]. As Rominski, Lori, and Morhe [38] found: The legal status of abortion was mentioned by all groups of participants as a reason for why women self-induce rather than come to facilities for abortion services. Prosecution of women, or their providers, due to inducing an abortion is rare, but women are afraid of this potentiality.
As reported by Manriquez et al. [46]. women often lie to PAC providers about their attempts to self-induce for fear of legal consequences. This is in accordance with advice from harm reduction information handbooks, which enabled women to receive treatment while ‘reducing the risk of rejection and denunciation’ [48]. In interactions with providers, these investigators observed that ‘None of these women mentioned they had induced an abortion. They had all decided not to tell in advance. To ensure they succeeded in this they kept silent, denied it, lied, accepted rough treatment, did not express any pain, and did not ask for information.’ [48].
Even if providers had their suspicions, women’s fears of legal punishment often led them not to reveal prior attempts to self-induce or receipt of induced abortion care from clandestine providers [38, 46].
Perceptions of social safety
Of all three types of safety concerns—medical, legal, and social—concerns for social safety had the greatest influence on women’s decisions regarding how and where to terminate their pregnancy [33, 36, 38, 39, 41, 43, 44, 47, 48, 51, 53, 56, 58,59,60,61,62, 65]. Social safety encompasses abortion providers’ and others’ ability to maintain the secrecy of a woman’s abortion experience. Fear of stigma or social repercussions influenced women’s decisions about which method to use, but not consistently towards or away from any particular method [48, 53, 58, 59, 62, 66]. Women who preferred medical abortion cited the increased privacy possible through minimizing the number of hours spent in a hospital, as well as the risk of being recognized by or experiencing unwanted attention from others at or near the facility [38, 41, 44, 48, 58, 59, 64,65,66]. As one participant reported from Chile: “I am grateful that I was able to do this (abortion) quietly, alone in my home, and not with doctor [64].” However, the same motivation for privacy led other women to select other methods or sources [36, 38, 44, 56, 59]. Women who preferred surgical abortion appreciated a sense of privacy from fewer visits in comparison to medical abortion, which women believed may involve multiple visits in the case of excessive bleeding, which they perceived as a common side effect [44, 56, 59].
Fear of stigma or social repercussions caused many women—particularly young, unmarried women—to choose riskier methods or services in order to reduce the social risks [33, 38, 41, 47, 51]. Young women were likely to ingest harmful substances and/or avoid formal healthcare settings initially because of a desire to keep the abortion private and avoid involving their parents [47, 51, 53, 60] or social network [39, 47, 51, 53, 60, 61]. The perceived lack of confidentiality in high-profile health facilities led women to prefer to terminate elsewhere even when the high-profile facilities were thought to have the best equipment and providers [36, 51]. These concerns were particularly acute for young girls, who feared that these more legitimate facilities may contact their parents or guardians [41, 59].
Finally, fear of stigma or social repercussions led some women to choose services distant from their home [41, 42, 47, 48, 51, 52], and to choose discrete albeit unsafe methods and places to terminate the pregnancy [51, 53, 58, 60]. As Mohamed et al.[60] found: ‘In addition to strong religious and cultural beliefs preventing women from seeking out abortion services at healthcare facilities, many communities also use stigma, isolation and shame as tools to ensure that women do not break from tradition.’
Role of social networks and the internet
Social networks mainly influenced women’s decision regarding how and where to terminate a pregnancy through sharing of information and experiences [30,31,32,33, 35, 36, 38, 40, 41, 43, 45, 47, 50, 59, 61, 62, 64, 65, 67,68,69,70,71,72,73]. There was no uniform narrative about who a woman tells, gets information from, or involves in her decision-making process. Women most often involved their friends [32, 35,36,37, 40, 41, 43, 46,47,48, 50, 55, 58, 62, 65, 70, 71, 73], partners [30, 31, 34,35,36,37,38, 41, 46, 48, 54, 64, 67, 68, 70, 71, 74], and/or family [32, 35, 36, 48, 52, 61, 62, 70, 72, 74], in the decisions related to how, when, and where to abort. Health providers [32, 61, 68] and strangers or acquaintances [43], neighbors [32, 62], “feminist activists [64]” or other NGO staff [32] and abortion ‘brokers’ [45, 51] were also consulted, but with less frequency.
These articles suggested that social networks have significant influence over whether a woman ultimately has a safe or unsafe abortion by affecting her perceptions of methods and sources and their corresponding social and medical safety. In some cases, friends led women to have safe abortions [32, 33, 45, 47, 62], but in many cases they recommended unsafe options [31, 46, 47, 51, 70, 71]. The information and support that women received from friends was often related to her and her network’s social standing. Women of higher socioeconomic status and education, as well as those with connections to people in academic and health sectors, were more likely to experience safe abortion [33, 47, 54, 61, 62, 67], whereas women from social networks who lacked information or connections to knowledge or knowledgeable people tended to experience unsafe abortions [31, 36, 70, 71]. Regardless of the actual method or service they chose, women perceived that their choices were safer if they relied on information from trusted friends [32, 36, 37, 40, 41, 47, 48, 55, 57, 62, 70] or people who had previously successfully aborted [30, 38, 42, 48, 62, 64, 73]. In many cases, involving family members resulted in less safe abortions, especially when it involved unskilled family members as the providers of the abortion method [35, 36, 56, 61, 72]. In contrast, one article suggested that a lack of involvement of any friend or family member in the decision-making process, whether a result of preference or social isolation, led to less safe abortions [51].
When male partners were involved, they were typically most instrumental during the procurement phase—e.g. going as a surrogate to a chemist or pharmacy, identifying a facility-based provider, or financing the procedure [30, 31, 35, 36, 38, 41, 44, 46, 48, 52, 54, 67, 70, 74] In many of these instances, male partners also made the decisions about method and source on behalf of the woman; however, it was not always clear whether this was a situation preferred by the woman or whether she would have liked to be involved in the decision-making.
Women who sought an induced abortion sometimes (but not always) used the internet for abortion decision-making. In some cases, the internet was the main source of information for determining where and how to abort, especially for determining legality of abortion in different states and/or how to get pills [32, 64, 75]. In other cases, women with strong networks did not use the internet or support services to navigate the abortion-seeking process: “[In Chile], Most participants did not contact [Women Help Women] WHW during the abortion process because they did not need more information, or because they had support from other feminist organizations, acquaintances who had had abortions and trusted health professionals, with whom they could communicate via instant phone messaging [64].”
Cost, affordability and convenience
Evidence suggests that the perceived cost and affordability of specific services often influenced women’s decision-making related to abortion care seeking [30, 34, 36, 40, 41, 51,52,53, 55, 61, 65]. Some women’s knowledge of safe methods and sources was high, but barriers such as cost and affordability prevented utilization of those methods and sources [30, 36, 49, 51, 53], with perceptions of service affordability linked to women’s economic status and ability to pay [34, 59]. The most obvious way that cost and affordability impacted decision making was regarding whether to get services in public or private facilities. Women with more limited financial resources opted almost unanimously to patronize public clinics or other non-clinical providers in contrast to wealthier women who were more likely to seek services at private facilities [40, 53, 55, 65]. Further, women who were financially better off could procure pregnancy tests earlier following suspicion of pregnancy, which meant the gestational age at which they were making decisions regarding how, when, and where to terminate was earlier compared to women who were economically disadvantaged [54]. As such, because access to early care skewed towards wealthier women, less financially secure women were confronted with greater challenges and vulnerabilities as a consequence of delayed care seeking [51, 53].
Cost and affordability also impacted decision-making on which method—surgical or medical—women chose for their abortion. In general, if women could afford it, they wanted a method that they perceived as quick, efficient, and as painless as possible [44]. Some women viewed a surgical procedure conducted by a doctor as the best option, while others viewed going to a chemist for a medical procedure as best [30, 44, 49]. As reported by Loi et al.[30] Some women [i.e. participants] stated they knew about Marie Stopes, a reliable abortion provider; however, due to high transportation fees they opted for medical abortions using Misoprostol, which was provided by chemists.
Thus, poorer women were more likely to be constrained in their ability to operationalize their abortion preferences. In some situations, such as in Chile, affordability was a main reason for why women chose to use certain services, including abortion access organizations like Women Help Wome [64]. However, a few studies did not find that cost or affordability were predominant factors in women’s decisions related to when, where, and how they terminated [47, 56, 57, 66].
Finally, several studies showed that decisions about where and how to abort were related to convenience, including factors such as distance to the provider [32, 65], time spent waiting on medical abortion (i.e. pill) shipments [64], or simply a lack of other options: As one Nigerian participant stated, “The reason I came to [clinic name] is because I do not have any alternative” (Age 41, clinic) [62].
