Key Words: Abortion, knowledge, attitude, risk Competing Interests: None declared .
Received on July 25, 2013 Accepted on September 11, 2013
Misperceptions About the Risks of
Abortion in Women Presenting for Abortion
Ellen R. Wiebe, MD,1 Lisa Littman, MD, MPH,2 Janusz Kaczorowski, PhD,3 Erin L. Moshier, MS2
1 Department of Family Practice, University of British Columbia, Vancouver BC
2 Adjunct Assistant Professor, Department of Preventive Medicine, Icahn School of Medicine at Mount Sinai, New York NY 3 Département de médecine de famille et de médecine d’urgence, Université de Montréal and CRCHUM, Montreal QC
J Obstet Gynaecol Can 2014;36(3):223–230 Abstract
Objective: Misinformation about the risks and sequelae of abortion is widespread . The purpose of this study was to examine whether women having an abortion who believe that there should be restrictions to abortion (i .e ., that some other women should not be allowed to have an abortion) also believe this misinformation about the health risks associated with abortion .
Methods: We carried out a cross-sectional survey of women presenting consecutively for an abortion at an urban abortion clinic in Vancouver, British Columbia, between February and September 2012 .
Results: Of 1008 women presenting for abortion, 978 completed questionnaires (97% response rate), and 333 of these (34%) favoured abortion restrictions . More women who favoured restrictions believed that the health risk of an abortion was the same as or greater than the health risk of childbirth (84 .2% vs . 65 .6%, P < 0 .001), that abortion caused mental health problems (39 .1% vs . 28 .3%, P < 0 .001), and that abortion caused infertility (41 .7% vs . 21 .9%, P < 0 .001) . Using multivariate logistic regression analyses, believing that abortion should not be
restricted was found to be a significantly correlated with correct
answers about health risks, mental health problems, and infertility .
Conclusion: Misinformed beliefs about the risks of abortion are common among women having an abortion . Women presenting for abortion who favoured restrictions to abortion have more misperceptions about abortion risks than women who favour no restrictions .
Résumé
Objectif : La désinformation au sujet des risques et des séquelles de l’avortement est généralisée . Cette étude avait pour objectif de tenter de déterminer si les femmes subissant un avortement qui estiment que des restrictions devraient être imposées en matière d’avortement (c .-à-d . qui estiment que certaines autres femmes ne devraient pas avoir le droit de subir un avortement) sont susceptibles de croire cette désinformation au sujet des risques pour la santé qui sont associés à l’avortement .
Méthodes : Nous avons mené un sondage transversal auprès des femmes s’étant consécutivement présentées à une clinique urbaine d’avortement de Vancouver, en Colombie-Britannique, entre février et septembre 2012, en vue d’y obtenir un avortement .
Résultats : Des 1 008 femmes s’étant présentées à cette clinique en vue d’y obtenir un avortement, 978 ont rempli le questionnaire (taux de réponse de 97 %) et 333 d’entre elles (34 %) favorisaient l’imposition de restrictions en matière d’avortement . Un nombre supérieur de femmes favorisant l’imposition de restrictions estimaient que les risques pour la santé associés à l’avortement étaient égaux ou supérieurs aux risques pour la santé associés à l’accouchement (84,2 % vs 65,6 %, P< 0,001), que l’avortement causait des problèmes de santé mentale (39,1 % vs 28,3 %, P< 0,001) et que l’avortement causait l’infertilité (41,7 % vs 21,9%, P< 0,001) . En utilisant des analyses de régression logistique multivariées, nous avons constaté que le fait d’estimer que l’avortement ne devrait pas faire l’objet de restrictions était en
corrélation significative avec l’offre de réponses exactes au sujet
des risques pour la santé, des problèmes de santé mentale et de l’infertilité .
Conclusion : Les opinions erronées au sujet des risques de l’avortement sont courantes chez les femmes qui subissent un avortement . Les femmes cherchant à obtenir un avortement qui favorisent l’imposition de restrictions à l’avortement sont plus susceptibles d’avoir des perceptions erronées, au sujet des risques de l’avortement, que les femmes qui ne favorisent pas l’imposition de telles restrictions .
INTRODUCTION
M
isinformation about the risks and sequelae of abortion is common. In a study of 52 women having an abortion, 79% of participants overestimated the health risks of a first trimester abortion compared with the risks of continuing a pregnancy and giving birth; 46% of participants overestimated the risk of mental health problems, and 25% of participants believed abortions caused infertility.1 Sources of misinformation include crisis pregnancy centres (centres that counsel against abortion),2,3 abstinence-only education programs,4 and, in the United States, government websites2,5 and state-legislated, mandated physician scripts.6 Common topics of abortion misinformation include the mental health risks, impaired fertility, and increased risk of breast cancer associated with abortion.2,7,8 There is strong evidence that abortion is a safe procedure, with a mortality rate of less than 1 per 100 000, and that it does not increase the risk of mental illness or breast cancer and does not reduce fecundity.9–15 An online survey of the general public (men and women) in 2012 found “respondents who believe that abortion should be allowed in at least some circumstances were more likely to be correct regarding the safety and consequences of contraception and abortion.”16Women favouring restrictions to abortion may have unresolved anxiety after the abortion procedure. In a study of 102 women having medical and surgical abortions, the women completed questionnaires (before and two to four weeks after the procedure) asking about anti-choice attitudes to abortion and anxiety levels.17 Attitude was assessed by the question “Under what circumstances do you feel a woman should not be allowed to have an abortion in the first trimester?,” followed by 10 possible responses. Anxiety was assessed by the question “How anxious do you feel on a scale of 0 to 10 about having the abortion?” Women who responded that women should be allowed to have an abortion for any of the given reasons had a mean anxiety score of 5.0 before and 2.7 after the abortion, while women who favoured restrictions to abortion had a mean score of 5.2 before and 4.4 after the abortion (P = 0.005). The two groups were similar with respect to age and religion, but women who favoured restrictions were more likely to be non-white (P = 0.02) and less educated (P = 0.03), and more likely to choose a medical rather than a surgical abortion (P = 0.03).17,18 In a questionnaire study of 52 Muslim women’s experiences with abortion, women who favoured restrictions to abortion had higher levels of anxiety (P = 0.01) and guilt (0.004) using a similar 0 to 10 scoring scale.19
The purpose of this study was to determine:
1. whether women having an abortion who believe that abortion should be restricted differ from women who do not with respect to their knowledge about health risks associated with abortion, and
2. the demographic characteristics associated with higher knowledge about abortion risk.
Because some women having an abortion who favour restrictions have been shown to have unresolved anxiety after abortions17 we wanted to examine the extent of beliefs that abortion has higher risks than the evidence shows. This would allow us to educate women about the true risks and perhaps reduce their anxiety.
METHODS
We conducted a questionnaire survey of women presenting for abortion between February and September 2012. Our questionnaire asked about women’s knowledge of abortion, attitude to abortion, and level of anxiety, and from what sources they had received their information. Attitude was assessed by two questions: “Under what circumstances do you feel a woman should not be allowed to have an abortion in the first trimester?,” followed by 10 possible responses; and “Which ONE of the opinions best represents your view?,” followed by four choices including “Abortion should be allowed for ANY reason, because no one should be forced to continue a pregnancy.”16–18 The knowledge questions covered four areas (general health risks, infertility, mental health [depression], and breast cancer) and were adapted from previous studies1,16 (Appendix).
We also collected sociodemographic data. The setting for the survey was an urban free-standing abortion clinic in Vancouver, British Columbia, offering medical and surgical abortions. The questionnaire was given consecutively to all women, while they were in the waiting room and before they saw a counsellor on their first abortion-related visit to the clinic. The questionnaire and cover sheet explaining the study were contained in a manila envelope. When women handed the envelope back to the staff, they were given the information sheet that addressed each of the misinformation points in the knowledge questions. The counsellors did not see the completed questionnaires but always discussed the known risks of abortion and asked about concerns. They could therefore address any of the issues raised in the questionnaires. The questionnaires were available in English, Punjabi, and Chinese. Our hypothesis was that, for women having an abortion, those favouring abortion restrictions are more likely than pro-choice women to believe that abortion has higher risks than the
evidence shows. From our earlier studies, we expected approximately 40% of our patients to favour abortion restrictions and approximately 50% to answer questions about the risks of abortion incorrectly.1,18 A sample of 1000 consecutive women would therefore provide us with approximately 400 respondents who favoured abortion restrictions and 600 who did not. A sample of this size would allow us to detect differences of 10% or more between these two groups of respondents using two-sided alpha of 0.05 and 80% power.
The women were divided into those who favoured abortion restrictions and those who did not, on the basis of their answers to the two attitude questions.16–18 If a woman stated that there was any reason for another woman to be denied an abortion, she was classified as favouring restrictions. Descriptive statistics were calculated for demographic data. A two sample chi-square test was used to compare the distributions of demographic variables, including education, ethnicity, religious attendance, religious importance, prior delivery, and being born in Canada, between women favouring and not favouring abortion restrictions. Multiple log binomial regression models were used to estimate probability ratios (PR) and corresponding 95% confidence intervals comparing the proportions of women correctly answering questions about general health risks, mental health risks, infertility, and breast cancer risk among different categories of demographic variables (education, ethnicity, religious attendance, religious importance, prior delivery, being born in Canada, and attitude). All statistical analyses were performed using SAS Version 9.2 (SAS Institute Inc., Cary, NC). For all estimates, the threshold for statistical significance was set at 5%. Ethics approval for the study was provided by the University of British Columbia Behavioural Ethics Board. RESULTS
Between February and September 2012, 1008 consecutive women presenting for abortion received the manila envelopes containing the questionnaires; 30 did not complete the questionnaire, leaving 978 responses for analysis (a 97% participation rate). Less than one half of the women (44.8%) self-identified as white/Caucasian and 42.7% as East or South Asian (Table 1). There were 333 respondents (34.0%) who favoured restrictions to abortion (i.e., believed that there were reasons why women should not be allowed to have an abortion or did not agree with the statement that “no one should be forced to continue a pregnancy”). We compared responses to the first and second attitude questions and found similar results (33.8%
vs. 34.2%), and therefore we assigned to the group “favour restrictions to abortion” those who answered either question in that way.
Women favouring abortion restrictions were more likely to be immigrants, to be non-white, and to state that religion was important to them, and they were less likely to have attended or graduated from college (Table 1). Many women had misperceptions about the risks of abortion: 638 (69.3%) stated that the health risks were the same as or higher than those of childbirth, 304 (32.0%) stated that the risk of depression was higher than after childbirth, 271 (28.6%) stated that there was an increased risk of infertility, and 88 (9.5%) stated that there was a higher risk of breast cancer after abortion. There were no significant differences in the number of correct answers to the knowledge questions with respect to age, history of a previous abortion, or whether respondents had received information from a doctor. In multiple regression models, having attended or graduated from college was significantly associated with correct answers about general health risks (PR 1.44; 95% CI 1.09 to 1.91, P = 0.012) and mental health (PR 1.16; 95% CI 1.03 to 1.31, P = 0.013), but not infertility or breast cancer. Favouring no restrictions to abortion was significantly associated with correct answers about health risks (PR 1.70; 95% CI 1.25 to 2.31, P = 0.001), mental health problems (PR 1.17; 95% CI 1.05 to 1.31, P = 0.007), and infertility (PR 1.26; 95% CI 1.13 to 1.42, P < 0.001) (Table 2). Having been born in Canada was significantly
Table 1. Demographics of women presenting for abortion n = 978 Favour restrictions to abortion (n = 333 ) Do not favour restrictions to abortion (n = 625) P Age, years 28 .7 ± 6 .7 27 .9 ± 6 .5 0 .07 Parity 0 .81± 0 .98 0 .60 ± 0 .93 0 .002 Total abortions 1 .6 ± 0 .98 1 .6 ± 1 .0 0 .55 Anxiety score 5 .4 ± 2 .9 5 .0 ± 2 .8 0 .05 Immigrant 233 (72 .1) 217 (34 .5) < 0 .001 Ethnicity < 0 .001 White/Caucasian 63 (19 .9) 358 (57 .5) East Asian 117 (36 .9) 101 (16 .2) South Asian 91 (28 .7) 92 (14 .8) Other 46 (14 .5) 72 (11 .5) Married 125 (38 .9) 152 (24 .2) < 0 .001 Attended/graduated college 231 (72 .2) 492 (78 .1) 0 .04 Religion important 192 (60 .8) 221 (36 .1) < 0 .001
correlated with correct answers about health risks (PR 1.58; 95% CI 1.15 to 2.15, P = 0.004) and infertility (PR 1.22; 95% CI 1.09 to 1.37, P < 0.001). Having had a child was significantly associated with incorrect answers about general health risks (PR 0.77; 95% CI 0.60 to 0.98,
P = 0.032) and correct answers about infertility (PR 1.10; 95% CI 1.01 to 1.20, P = 0.026). Caucasian ethnicity correlated significantly only with correct answers about cancer risk (PR 1.06; 95% CI 1.01 to 1.12, P = 0.034). Forty-two women stated that they had contacted anti-choice crisis pregnancy centres; 30 stated that the centres were helpful, and six stated that they were upset by them. Women favouring no restrictions had received information from more sources than women who favoured restrictions (Table 3). DISCUSSION
Women presenting for abortion have often been misinformed about the risks of abortion. Those women who responded that some other women should not be allowed to have an abortion were more likely than pro-choice women to believe that abortion has higher risks than the evidence shows. This may explain some of the unresolved anxiety after abortion we found in a previous study.17 If a woman has an abortion but believes that the abortion has caused her permanent harm, such as infertility, this might
explain higher anxiety after an uncomplicated successful procedure. It is unknown whether women who favour abortion restrictions are exposed to more misinformation about the harms of abortion because of their association with other individuals who are against abortion, or whether having more anti-choice beliefs might make women who are presented with conflicting information more likely to believe negative information. Additional qualitative studies are needed to determine how women obtain knowledge about abortion and how they decide which information to believe when their sources conflict.
In a previous study carried out in New York, women presenting for abortion had a higher proportion of misperceptions than the women in this study; for example, 78.9% believed that abortion had risks that were greater than or the same as childbirth, compared with 67.8% in our study group.1 Our patients had high levels of education; 42.4% had finished college, compared with 19.2% in the New York study. Since women with college degrees were more likely to answer the knowledge questions about general health risks and depression correctly, this may explain some of the difference. Many of our subjects were immigrants, and 40% were from Asia. It is possible that immigrants may find it more difficult to access information or assess the accuracy of information.20 These factors might make our findings less applicable in other settings.
Table 2. Predictors of correct knowledge about abortion risks in women presenting for abortion n = 978
Question Correct, n (%) PR (95% CI)Univariable Multivariable* PR (95% CI)
P for Multivariable
PR = 1 Which do you think has the HIGHEST health risks?
Correct answer “giving birth to baby”(instead of “having an
abortion in the first three months of pregnancy”)
57 (5 .8%) did not answer Favour restriction
Favour no restrictions 208 (34)50 (16) (1 .65 to 2 .88)2 .18 (1 .25 to 2 .31)1 .70
< 0 .001
Do you think that having an abortion increases your risk of breast cancer? Correct answer “no”
52 (5 .3%) did not answer Favour restriction
Favour no restrictions 264 (86) 574 (93) (1 .03 to 1 .13)1 .08 (0 .99 to 1 .11)1 .05
0 .09
Do you think that a woman is more likely to have mental health problems (like depression) if she has an abortion? Correct answer “no”
27 (2 .8%) did not answer Favour restriction
Favour no restrictions 196 (61) 451 (72) (1 .07 to 1 .30)1 .18 (1 .05 to 1 .31)1 .17
0 .007
Does having an abortion make it more difficult to get pregnant
in the future? Correct answer “no” 30 (3 .1%) did not answer Favour restriction
Favour no restrictions 187 (58) 490 (78) (1 .21 to 1 .49)1 .34 (1 .13 to 1 .42)1 .26
< 0 .001
It is surprising that almost one half of respondents stated that they had acquired their information from a doctor and yet their level of knowledge remained unchanged. When a woman receives information about abortion from multiple sources, there may be sources that she trusts more than her doctor. It is also possible that current counselling from doctors may not be effective in transmitting information about abortion risk, that doctors may be transmitting some inaccurate information, or that women may state that they received their information from a doctor (whether or not they did) because they believe it is the desired answer for a survey in a medical facility. It would be useful to determine the level of knowledge of abortion risks among primary care physicians.
The limitations of this study include using an arbitrary cut-off to code women as favouring or not favouring abortion restrictions when there are many gradations to beliefs about abortion. Another limitation is that our population was unusual in its high level of education, high level of immigrants, and disproportionately large population of Asian women; these differences would make our results less generalizable. Additionally, we identified multiple sources for women to obtain information about abortion, but we do not have information about the extent of information received from each source, or which sources were considered primary, most useful, or most trustworthy to women. It is possible that a sensitivity analysis using a different scoring method would have enhanced our findings. Finally, this was a cross-sectional study; therefore conclusions can be made only about associations, and not about causality.
Misinformation about the general health risks and the risks of depression, infertility, and breast cancer associated with abortion is believed by so many women, regardless of their attitude to abortion, that it is important to address each of these in all women presenting for abortion. In our clinic,
we now give an information sheet addressing these issues to all women. It is possible that correct information about the low risks of abortion will not change firmly held beliefs in some, but it is likely to help many women. Most women having an abortion who favour restrictions to abortion do not openly express their attitude while in an abortion clinic, so counsellors may not know that this is an issue. CONCLUSION
Misperceptions about risks of abortion are common among women having an abortion. Women presenting for an abortion who favoured restrictions to abortion were found to have more misperceptions about abortion risks than women who favoured no restrictions.
ACKNOWLEDGEMENTS
We are grateful to the staff and patients of Willow Women’s Clinic and Everywoman’s Health Centre for participating in this study.
REFERENCES
1. Littman L, Jacobs A, Negron R, Gold M, Cremer M, Zarcadoolas C.
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6. Lazzarini Z. South Dakota’s abortion script—threatening the physician-patient relationship. N Eng J Med 2008;359(21):2189–91.
Table 3. Sources of information about abortion
Favour restrictions to abortion
(n = 333 )
Do not favour restrictions to abortion
(n = 625) P
Crisis pregnancy centre (anti-choice), n (%) 13 (3 .9) 34 (5 .3) 0 .35
Church/temple/etc ., n (%) 4 (1 .2) 19 (3 .0) 0 .09 Family, n (%) 53 (16 .0) 146 (22 .7) 0 .01 Internet, n (%) 177 (53 .3) 425 (66 .1) < 0 .001 Doctor, n (%) 174 (52 .4) 318 (49 .5) 0 .38 Friends, n (%) 126 (38 .0) 321 (49 .9) < 0 .001 School, n (%) 59 (17 .8) 151 (23 .5) 0 .04
Mean no . of sources of information (SD) 2 .0 (1 .37) 2 .4 (1 .58) < 0 .001
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Representatives; July 2006. Available at: http://www.chsourcebook.com/ articles/waxman2.pdf. Accessed November 4, 2013.
9. Grimes DA. Estimation of pregnancy-related mortality risk by pregnancy outcome, United States, 1991 to 1999. Am J Obstet Gynecol 2006;194:92–4.
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during labor and delivery: United States, 1993–1997. Am J Public Health 2003;93:631–4.
11. Hakim-Elahi E, Tovell HM, Burnhill MS. Complications of first trimester abortion: a report of 170,000 cases. Obstet Gynecol 1990;76:129–35.
12. American College of Obstetrics and Gynecology Induced abortion and
breast cancer risk. ACOG Committee Opinion No. 434, June 2009. Obstet Gynecol 2009;113(6):1417–8.
13. Beral V, Bull D, Doll R, Peto R, Reeves G; Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and abortion:
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APPENDIX. KNOWLEDGE AND BELIEFS ABOUT ABORTION: ANSWERS AND INFORMATION SHEET 1 . Which do you think has the HIGHEST health risks? (check one)
Having an abortion in the first 3 months of pregnancy Giving birth to a baby
They have the same risk .
Answer: continuing a pregnancy and going through childbirth has higher health risks than having a first trimester abortion.
● Paul M & Stewart F (2007) Abortion. In: Hatcher RA et al. Contraceptive Technology, 19th revised edition . Ardent Media, Inc,
New York, NY, p664
● Grimes DA (2006) Estimation of pregnancy-related mortality risk by pregnancy outcome, United States, 1991to 1999. Am J Obstet
Gynecol,194, 92–94
● Danel I, Berg C, Johnson CH, Atrash H (2003) Magnitude of maternal morbidity during labor and delivery: United States, 1993-1997.
Am J Public Health, 93, 631–634
● Hakim-Elahi E, Tovell HM, Burnhill MS (1990) Complications of first trimester abortion: a report of 170,000 cases. Obstet Gynecol,
76, 129–135
2 . Do you think that having an abortion (check one) increases your risk of breast cancer? decreases your risk of breast cancer? does NOT change your risk of breast cancer?
Answer: Abortion does NOT change your breast cancer risk.
● American College of Obstetrics and Gynecology (2009) ACOG (American College of Obstetrics and Gynecology) Committee Opinion:
Induced Abortion and Breast Cancer Risk . Obstet Gynecol 113 (6): pp 1417–1418
● Beral V, Bull D, Doll R, Peto R, Reeves G, & Collaborative Group on Hormonal Factors in Breast Cancer (2004) Breast cancer and
abortion: Collaborative reanalysis of data from 53 epidemiological studies, including 83,000 women with breast cancer from 16 countries . Lancet, 363(9414), 1007–1016
● National Cancer Institute. (2005) Summary report: Early reproductive events and breast cancer workshop. Issues in Law & Medicine,
21(2), 161–165
3. Do you think that a woman is more likely to have mental health problems (like depression) if she has an abortion (in the first 3 months)
instead of continuing an unplanned pregnancy? Yes No
Answer: No. The American Psychological Association (APA) Task Force on Mental Health and Abortion recently completed a comprehensive review of the best research about mental health and abortion . The Task Force found that the best evidence shows that among women with an unplanned pregnancy, women who have a single, first-trimester abortion are not at greater risk for mental health problems than if they deliver that pregnancy.
What that means is that for all the women who have an unplanned pregnancy: some will continue that pregnancy and have
a baby; others will have an abortion. From the women choosing to continue that pregnancy—most of them will be fine, some may have difficulty, and some may have depression. Of the women choosing to have a single first trimester abortion for that pregnancy—most of them will be fine, some may have difficulty and some may have depression. The rate of women having
depression in the abortion group is not any higher than the rate of women having an abortion in the continuing the pregnancy group .
The evidence about second trimester abortions or multiple abortions are less clear . Late terminations for fetal abnormality can have more negative outcomes . Women’s individual experiences surrounding abortion are unique and vary depending on individual life circumstances, the circumstances surrounding the pregnancy, relationships, and the social and political culture in which the abortion takes place . The best predictor of how well a woman will do after abortion is how well she was doing before abortion .
● Major B, Appelbaum M, Beckman L, Dutton M, Russo, NF, West C (2008) Report of the APA Task Force on Mental Health and Abortion.
08/13/08 . http://www .apa .org/releases/abortion-report .pdf . Accessed 8 July 2009 .
● Charles VE, Polis CB, Sridhara, SK, Blum RW (2008) Abortion and long-term mental health outcomes: A systematic review of the
evidence . Contraception, 78(6), 436–450
However, if at any point you feel you are having difficulty coping after the abortion, or if you feel you would like to talk about
your feelings, contact Willow Women’s Clinic and we can refer you to a counselor .
4. Does having an abortion in the first 3 months of pregnancy make it more difficult to get pregnant in the future?
Yes No
Answer: No. A single first trimester abortion does not have a significant effect on future fertility.
● Paul M & Stewart F (2007) Abortion. In: Hatcher RA et al. Contraceptive Technology, 19th revised edition . Ardent Media, Inc,
New York, NY, p664 .
● Hogue, CJ (1986) Impact of abortion on subsequent fecundity. Clinics in Obstetrics and Gynaecology, 13(1), 95–103
5 . Do you know of any religious groups that support a woman’s decision to have an abortion? Yes No
Answer: There are several religions and religious groups that support women’s right to make decisions about birth control and abortion. The Religious Coalition for Reproductive Choice (RCRC) was founded in 1973 by pro-choice clergy and lay leaders from different faiths and traditions . For more information about religious groups that support women in their decisions, take a look at the RCRC website . http://www .rcrc .org/
