Abortion rights opponents increasingly claim that many, or even most, women who have an abortion eventually regret it,^1–4 despite empirical findings that the proportion of women who experience regret is small,^5–8 even among adolescent populations.⁹ Nonetheless, some women do experience negative emotions after abortion^5,6 and need emotional care.¹⁰ Research has shown that while most women experience relief following an abortion, some experience episodes of depression.^6,11

A woman’s mental health before an abortion is a strong predictor of her mental health afterward,^6,12–14 although it does not explain all variation: Some women without prior mental health problems experience postabortion distress.¹¹ It is important, therefore, to consider interpersonal and psychosocial factors.

The highly politicized nature of the abortion debate encourages the minimization or exaggeration of women’s emotional difficulties.¹⁵ Abortion rights advocates have avoided focusing on regret, concerned that it could weaken their political position.¹⁶ Meanwhile, abortion rights opponents have cited regret and other negative emotions to justify laws geared toward limiting women’s decision making about abortion.^17,18 These laws’ role in preventing abortion-related regret and emotional distress has not been investigated. Moreover, they focus narrowly on clinical interactions and practices.

In this study, we examine the relational, familial and social factors that make unintended pregnancy and abortion difficult for women. We conducted a qualitative analysis of abortion narratives to assess the needs and experiences of women who articulated emotional difficulty related to unintended pregnancy and abortion. In so doing, we aim to highlight the social experience of abortion and promote discussion about ways to recognize, validate and meet these needs.

METHODS

Despite consensus in the psychological literature about what constitutes regret,¹⁹ its sources and those of other negative emotions regarding abortion have not been thoroughly studied.¹¹ In this exploratory phase, qualitative research is the most appropriate method for investigation, as it allows respondents to communicate the salient aspects of their experience in their own words. The semistructured interview format allows respondents to introduce topics that closed-ended interviews and surveys may overlook.

In 2009, we conducted a study using open-ended, semistructured interviews with women who had had an abortion. We pretested an interview guide with four experienced talkline counselors, who assumed the role of a caller, and with one woman, recruited through personal networks, who qualified for the study and responded according to her own experience. These pretests prompted a redesign of the interview instrument, to begin with questions that would elicit information about women’s personal experiences and then explore interactions with others and the broader social context.

Given that most women do not experience negative emotions related to their abortion,⁶ sampling at a clinic or among the general population of postabortion women was unlikely to produce data that would answer our research questions. Sampling specific populations was also unlikely to yield useful data, as researchers have not identified particular demographic characteristics clearly associated with emotional difficulty.^6,11 Instead, we recruited respondents through two methods.

First, we partnered with two secular abortion support talklines. We surmised that women who call such a talkline need help working through their emotions after an abortion. We trained talkline staff to brief eligible callers about the study and invite them to call a designated cell phone if they wished to participate. Callers were eligible if they were older than 18 and had had an abortion. Recruitment took place between March and August of 2009.

Between the two talklines, 62 callers qualified for the study, and approximately half were referred. (Incomplete reporting from talkline counselors about referrals prevents us from reporting an exact referral rate.) Counselors failed to refer callers because they forgot, the caller hung up too quickly or the counselor did not feel enough rapport. Confirming our expectation that many women who call these talklines have had an emotionally difficult experience with abortion, talkline counselors judged nine callers too distraught to be referred to the study. (Callers were considered too distraught if they could not stop crying, hung up before speaking with the counselor or discussed harming themselves.) A member of the study team reviewed and verified the counselors’ evaluations.

Callers varied in age, race, geographic location, gestational age at abortion and time since the abortion, among other variables. Fourteen women contacted the study; all agreed to participate and completed an interview. Ten of these 14 respondents were within two years of their abortion, and seven were within three months of their abortion.

Our second source for recruiting respondents was a pilot sample generated for a separate research project on women’s experience of abortion. Since emotions associated with abortion may shift over time, particularly after at least two years,²⁰ in June 2009, we recruited women from this sample, who had had an abortion more than two years earlier. As with the talkline recruits, potential respondents were invited to call the designated cell phone if they were interested in participating. Of the 12 women contacted, seven agreed to participate.

The designated cell phone was monitored at all times, and interviews were conducted immediately when respondents called or were scheduled for a future time, according to their preference. Interviewees were assured confidentiality, per human subjects protections approved by the institutional review board at the researchers’ university. No identifying data were retained; all names used below are pseudonyms.

Interviews were conducted by carefully trained interviewers and lasted between 30 minutes and nearly three hours, averaging 75 minutes. Questions covered the reactions of family, friends, the partner involved in the pregnancy and the larger community to the respondent’s pregnancy and abortion; the involvement of others in the woman’s decision-making process; and her emotional experience of pregnancy and abortion. All questions were open-ended, allowing respondents to speak at length. When appropriate, the interviewer asked follow-up questions, encouraging respondents to expand on their responses. Interviews were semistructured; questions were asked in an order that made sense to the conversational flow of the interview. This allowed respondents to tell their story in whatever way made most sense to them and helped create rapport. At the end of the interview, researchers asked closed-ended demographic questions. Afterward, respondents were mailed a gift card to compensate them for their time. All interviews were taped and transcribed; transcripts were reviewed for quality of rapport and probing after the end of each interview, and resulting information was used to create guidelines for conducting future interviews.

In qualitative analyses, the number of interviews is less important than their quality; therefore, we stopped recruiting participants—and directed the talklines to stop referring callers to the study—when we reached saturation, the point at which new interviews from the existing recruitment pool did not yield additional insight into the experiences, meanings and practices under study. Because of the length and thoroughness of the interviews and the powerful social determinants of the abortion experience in the U.S. context, clear themes and patterns emerged fairly early, and saturation was reached with a relatively small sample.

Analysis

Data were examined using grounded theory analytic techniques.²¹ With this methodology, researchers seek conceptual categories in the data that explain social phenomena. Rather than beginning from a set of hypotheses, grounded theory builds inductively from the data. We coded interviews using Atlas.ti software in reference to needs, positive emotions and negative emotions related to respondents’ abortion experience. Analysis of patterns within the data yielded the two categories of needs explored here: decision making and support regarding abortion. Rereading the interviews confirmed our interpretation of the data and, further, helped us to identify themes within the two categories of needs. When no more themes emerged, analysis was complete.

RESULTS

Respondents ranged in age from 21 to 47. Eleven had experienced a single abortion, five had undergone two abortions, and the remaining five had had more than two. Four women had had medication abortions; the rest had had aspiration abortions. Ten respondents had children; of the 11 who did not, two were primary caregivers for their nieces and nephews. Three respondents identified themselves as Asian or Pacific Islander, four as black, three as Hispanic, one as of mixed racial background (Hispanic and white) and 10 as white. Interviews conducted by phone allowed respondents nationwide to participate; three lived on the East Coast, four in the Midwest and the remainder on the West Coast. Levels of religious observance varied: Eight respondents reported never attending religious services, five attended a handful of times a year, two attended monthly and six at least twice a month. While most respondents were romantically involved, only three were married, and two others had only a casual sexual relationship with the partner involved in their pregnancy.

Eighteen respondents reported emotional difficulty related to their abortion experience. Of the 14 respondents recruited from talklines, nine said they called a talkline because they were experiencing emotional difficulty (e.g., crying, anxiety, sadness, regret) stemming from their abortion; the remaining five said they called to have someone to talk to. Four of the seven respondents recruited from the pilot study sample described emotional difficulty related to their abortion; the others did not, suggesting that regret does not necessarily emerge in the years following an abortion.

For many respondents, having an unplanned pregnancy and abortion were emotionally complicated experiences, made particularly difficult by two social processes: the decision-making process before the abortion and the process of finding social support afterward.

Making the Decision

Deciding to have an abortion was easy for some and wrenchingly difficult for others. For some women, choosing abortion was the decision they wanted, both at a gut level and intellectually. For others, however, abortion was not their preferred decision; while logically they understood the reasons for this decision, part of them wished they could have chosen to carry the pregnancy to term. Either way the process unfolded, respondents consistently reported that they needed the decision to be fundamentally theirs, not their parents,’ their friends’ or even their sexual partner’s.

Respondents reported negative emotions when they felt the decision to have an abortion was not primarily their own, even if they would likely have made the same choice without any interference. Susan (a white 47-year-old) described resenting her husband for pushing abortion, despite their both feeling financially unprepared to have another child and her desire to have the abortion. She said:

"My husband was putting a lot of pressure on me to have one. He was like, ‘No, this [pregnancy] isn’t a good idea…. You need to have that done.’ Because it was his decision more than mine, I think I resented that a little bit, although now that I’m looking back at it, I know that it was the best thing I could’ve done."

Women who faced pressure from their parents to have an abortion conveyed similar feelings. For instance, Cynthia (a white 36-year-old) experienced her first abortion at age 15, largely because of her parents’ wishes. She continues to sort through feelings about this:

"I had a lot of unresolved feelings because it was decided for me by my parents …’cause, of course, at 15 they didn’t want me to have a child. So they took me for it, and they kind of controlled the whole thing. [But] I have to say I felt very relieved after I had it, you know. You get a lot of relief from it. And I was glad to be able to kind of resume my life."

Difficulties also emerged in these accounts when the partner involved in the pregnancy clearly was invested in a specific outcome, even if he ostensibly deferred to the woman’s decision. Julie (a white 40-year-old) described her abortion experience as very difficult and the source of significant regret, in part because her husband claimed to be "honoring my feelings" even as he made very clear "that he didn’t want the baby or didn’t think it was a wise choice." Her husband’s superficial support for her feelings belied his preference for abortion and interfered with her decision making. Although she enumerated several compelling reasons for having an abortion, the pressure she felt from him short-circuited her thinking about her own desires.

The importance to women of making their own decision is clearest in the case of Michelle (a white 39-year-old). Michelle explained that she had no hang-ups about her first abortion, in her early 20s, because "that was my decision, I guess I would say. It wasn’t coming from him or anybody else. It was definitely my decision." Nearly two decades later, however, her experience of her second abortion was dramatically different. Although her boyfriend said he would stand by her decision, he also made it clear that he did not want to be a parent. As Michelle recounted, "He kept saying, ‘I don’t want to be a parent. I don’t want to have a child.’" Part of Michelle wanted to contemplate having a child, but her boyfriend’s response foreclosed that possibility, which she resented:

"I was angry. I was angry at him for not being more supportive. I mean, I wish he had just said, ‘I’ll support your decision no matter what.’ Not ‘I’ll support your decision,’ with these constant trailers of ‘but I don’t want to have a child’ and ‘I don’t want to be a parent.’"

Michelle wanted the opportunity to decide to have the baby. Without that opportunity, having an abortion did not feel like a choice. Her relationship ended soon after the abortion, and Michelle continues to feel distressed by the experience.

A reverse mismatch of desires sparked similar negative emotions for Melinda (a white 29-year-old):

"My boyfriend really, really, really wanted a child, and that’s been one of the main problems in our relationship. I just didn’t feel ready. So he was really cool about it, though. You know, he was a lot more understanding than I thought he would be, and he just kind of said, you know, ‘It’s your body, it’s your decision, but I’ll be there for you if you decide to have it.’"

In response to a follow-up question, however, Melinda described the limits of her boyfriend’s promised support. He supported her, she said, "only if I decided to have [the baby]. So it’s kind of a catch there. He’s not there for me now."

Abandonment by their partners upon discovering their pregnancy left three women feeling that they had no choice but to have an abortion because they were unprepared, financially and emotionally, to raise a child alone. Lana (an Asian 28-year-old), the child of a single mother, explained, "I didn’t want a child to grow up without the father, because I knew how devastating that could be." In three other cases, although the partners did not literally abandon the respondents, they actively rejected any responsibility for the pregnancy or childrearing. One man in this category asserted that the pregnancy was not his and, by implication, any decision making about the pregnancy was not his responsibility. Alicia (a black 27-year-old) explained:

"It’s like, you know, that saying that, ‘Mama’s baby, Daddy’s maybe.’ He was like, ‘It’s not my baby.’ Or, no, he said, ‘It’s a possibility that it’s not my baby, and I’m not [going to help].’"

Nicole (a white 38-year-old) related that her boyfriend became suicidal at the prospect of having a child and refused to participate in any future childrearing. She believed she could not take care of another child alone (she had three children from her prior marriage) and had an abortion. Her boyfriend’s lack of support led her to end their relationship.

The behavior of their partners was not all that left respondents feeling that they had no other option. The perception that family members would not support their pregnancy and parenthood also led some women to elect abortion. For example, Alicia feared her family’s and friends’ response to the news that she was pregnant. She felt their judgments could jeopardize the child care support that her mother provided for her daughter. Although she strongly considered continuing the pregnancy, and she completed prenatal examinations while making appointments for termination, the reaction she anticipated from her family was critical. "Had my mom supported me, oh, we would’ve had this baby. There wouldn’t have been no ifs, ands or buts."

This emphasis on women’s preeminence in abortion decision making illustrates a gender gap in responsibility for pregnancy, abortion and childrearing. It also is tied to women’s physical experience as carriers of the pregnancy and to their (experientially and culturally confirmed) sense that they bear all responsibility for conceiving, rearing and supporting the child. Respondents told stories of mistakes they had made by forgetting birth control pills or neglecting to refill a prescription and, as a result, regarding their experiences with birth control as failures. Only one woman explicitly cited her partner’s failure to use contraceptives, but she resisted blaming him for the unintended pregnancy.

Women’s disproportionate responsibility for contraceptive use held in long-term as well as short-term relationships. For example, Julie and her husband of 16 years did not plan to have any more children, but their use of contraceptives was intermittent. According to Julie, they agreed that she would have an abortion in the event of an unplanned pregnancy because he was "too scared" to have a vasectomy, effectively making her solely responsible for birth control.

Respondents explicitly and implicitly acknowledged that the burden of raising a child would fall disproportionately on them and that they should therefore be able to make the decision about pregnancy. Lauren (a black 24-year-old) decided to have an abortion when she became pregnant for the third time by the same man. He provided no help or support for their two existing children, and she expected the same would be true if they had another. Although he believed she should carry the pregnancy to term, Lauren felt that he did not get any "say" in this pregnancy:

"I wasn’t considering nobody else but my’s and my two kids, ’cause when it all comes down to it, nobody has to sit up there and go through what I have to go through, you know? You’re just the person that got me pregnant."

The behavior of many of the partners reinforced this unequal division of responsibility. By abandoning women, these men saddled them with all responsibility for the pregnancy and subsequent child care. As Michelle, whose boyfriend was adamant about not wanting a child, explained:

"I was feeling kind of, I guess, backed into a corner…. I know I had a choice, but I was so overwhelmed with the idea of doing it all on my own that I felt like I was kind of in a no-win situation."

In other cases, men assigned full responsibility for the pregnancy to the women by accusing them of being sexually promiscuous (as reported by two women) or of intentionally trying to get pregnant (reported by one). By eschewing any role in the pregnancy, these men produced a double burden for women: making them feel that they had no choice about abortion but full responsibility for having one.

Positive emotional assessments of the decision-making process and positive outcomes for the relationship occurred when the respondent felt empowered to make the decision independently (as one woman discussed), or when the partner deferred to her decision, even if he partially wanted to continue the pregnancy (a situation described by three women). Katia (a mixed-race 25-year-old) explained that although her boyfriend expressed deep sadness when he learned she was going to have an abortion, he entirely supported her decision. Noting that his behavior had a positive effect on their relationship, she said: "He was really there for me. He really surprised me in [that] he really stepped up to everything. So I think it’s brought us closer."

A similar kind of unconditional support helped Katia and other women who were nervous about revealing their unplanned pregnancy to friends. Katia described feeling helped by a close friend’s emphasis that she make her own decision:

"I told my friend on the phone, and she just helped me calm down and said that whatever my decision is that [she and my other friend were] there. So it was scary, but at the same time, I’m really glad that I had them."

Overall, the women who experienced the decision to have an abortion as their own had fewer negative associations with the decision-making experience than others.

Social Support After Abortion

As did women studied elsewhere,^22–24 women in this sample emphasized the importance of having social support after their abortion; when women lack support, negative psychological outcomes can follow.²⁴ Several respondents reported that friends and family were not supportive when they disclosed their abortion. Allison (a white 29-year-old), for example, reported that her father challenged her decision to have an abortion after the fact, insisting that she should have given the child up for adoption. Allison felt that he was not being understanding of her needs, which weakened their relationship and made her feel that she had few people to talk to. Susan, who resented her husband’s pushing abortion but agreed that they were financially unprepared to have another child, characterized the habitual comments by extended family members about a long-ago abortion as "mean"; yet, she felt unable to withdraw from interactions with them because they are family.

Lack of support took a significant toll. Melinda’s decision to not raise a child with her boyfriend led to the end of their relationship and her abortion cost her "a handful of friendships." She explained:

"I was not prepared for how archaic and old-fashioned people’s beliefs are about abortion, and I have a couple of friends who have a really strong Christian background, who said some things that actually really, really hurt my feelings. So I felt really pressured and overwhelmed."

Melinda was not the only respondent to lose relationships because of abortion. Two others detailed how their decision to have an abortion elicited negative judgment from friends who, in turn, ended their friendship. This sequence of events was particularly traumatic for Alicia, who feared the reactions of others to her unplanned pregnancy and was abandoned by her best friend after disclosing her abortion. Alicia’s voice broke as she explained, "She was supposed to be my best friend, and now she turned into like this distant, you know, like we broke up. Oh, gosh, it’s too much."

Few respondents told family and friends about their abortions after the fact, however. Most kept their abortions secret because they feared an unsupportive response, consistent with other findings regarding secrecy surrounding abortion.²⁵ Recalling conversations about other hot-button issues, Tamara (a white 35-year-old) said, "I did not feel safe talking about abortion with a family member." Early on, Julie reached out to a friend, who told her she had made a bad decision. Afraid of similar reactions, she avoided telling others.

Other respondents were not as sure that their family and friends would be unsupportive, but their uncertainty dissuaded them from sharing. They felt that the risk of an unsupportive response or the fallout from one was too great. Even though Katia received unconditional support from her boyfriend, she pragmatically explained, "I just haven’t told other people ’cause I’m still not comfortable with … being told something negative, especially by someone I’m close with." Respondents wanted to talk to someone who they believed would not judge them. Without such an assurance, they opted to conceal their experience and all the complex emotions it engendered.

Although not telling anyone about their abortion may have saved some respondents from expected negative responses, it exacerbated feelings of secrecy and stigma. Women described insomnia, panic attacks and anxiety that stemmed from their effort to hide their abortion.

Social support following an abortion was critical to respondents’ emotional state regardless of whether they felt supported in their initial decision to terminate their pregnancy. A lack of social support compounded an already difficult experience for women who felt that the decision to abort had not been entirely their own. The secrecy, judgment and stigma surrounding abortion can augment feelings of distress already plaguing women who do not have support in the decision-making process about their pregnancy. Indeed, women whose boyfriends had abandoned them and who concealed the abortion for fear of unsupportive responses described the experience as doubly difficult.

In contrast, supportive responses sometimes strengthened relationships. Lauren, the single mother of two, turned to her family after she had an abortion, and they supported her. "[Now]," she explained, "I’m a lot closer to my family. Me and my mom was always close, but now I’m closer to my sisters, and I’m closer to my dad, and everything just pretty much fell in place for me. And I’m very happy about that."

Generally, women expressed a desire for immediate support, but also expressed appreciation for support later in life. Tamara explained that she found the support she needed with her current boyfriend, nearly 15 years after her abortion:

"You know, there is no TMI [too much information] with my boyfriend, and that I think is part of what has made it possible [for me] to talk about [my abortion] with other people. So, in some ways, my current boyfriend … is the first person with whom I felt comfortable enough to really have as much conversation as I wanted about it."

DISCUSSION

Overall, women in our sample expressed a need to control their decision making regarding abortion. When they felt that the decision to have an abortion was not primarily their own or was made under duress, they reported emotional difficulties. Furthermore, women wanted their partner, family and close friends to validate and support their decision making. Fear of an unsupportive reaction by friends and family prompted many respondents to hide their abortions, which often had negative emotional consequences.

The women in this study are not broadly representative of those who have had abortions; we purposefully recruited women who experienced emotional difficulty afterward. Thus, we cannot generalize from this sample to all women, especially given findings from other research that abortion reduces depression.⁶ We also note the generally low level of religiosity among our respondents as a potential limitation. Women who identify strongly with religions that have denounced abortion may experience different emotions and have different needs related to their abortion. This potential limitation also points to the important finding that women’s emotional difficulty regarding abortion is not inherently about religion; since some women who suffered emotionally did not have strong religious affiliations, other social sources must be considered.

To the extent that the negative experiences articulated in this analysis broadly reflect social reactions to abortion, they likewise apply to women’s social experience of abortion and point to ways clinicians, counselors and loved ones can mitigate negative social aspects of the abortion experience.

Women’s narratives suggest that they feel most supported by listeners who affirm their decisional authority while also recognizing the many factors they must weigh to make a decision. The need for decisional authority, however, is not a wish for decisional isolation, and does not exempt partners, friends and family from engaging with women during this time. We found a range of decision-making scenarios: Partners, family and friends sometimes deferred to women’s decisions, sometimes only ostensibly deferred and sometimes opted out of the decision-making process altogether. But in all scenarios, women expressed a desire to think through the decision for themselves and to have important people in their lives be nonjudgmental sounding boards. Counselors in the clinical setting may wish to acknowledge the range and complexity of factors that women must consider in their decision making, recognizing that the decision is not always clear-cut and, in fact, may involve multiple assessments (e.g., whether a woman has adequate social support and resources to be a parent). Women who acknowledge that their decision is influenced primarily by others, even as they recognize their own desire for an abortion, may need to be referred for additional support afterward.

Many respondents’ accounts emphasized the status of their relationship to the partner involved in the pregnancy, which was often explicitly tied to their emotional experience of abortion. This finding is consistent with those of prior research, which has found that perceived conflict with the partner can increase women’s distress about abortion.²² The field of family planning has increased its attention to men’s involvement, largely focusing on engaging men in efforts to avoid unintended pregnancy.²⁶ Our data point to a need for abortion care and support services specifically addressing associated relationship issues.

At a theoretical level, these findings also tell us about gendered imbalances in responsibility for pregnancy prevention, abortion and childrearing. Women in this study felt the bulk of responsibility for pregnancy and abortion, often recognizing how childrearing duties would fall on their shoulders, while many of their partners felt no responsibility for the pregnancy. Several respondents attributed their negative emotional experience with abortion to the lack of support from their sexual partners. Our data show that men’s refusal to use contraceptives led to some of the pregnancies respondents terminated. They also suggest that making women fully responsible for pregnancy prevention, abortion and childrearing can have negative outcomes; as a society, we need to find better ways of allocating these responsibilities.

According to our findings, conveying negative opinions about abortion to women who have had or are considering having one can have long-term emotional consequences. Friends and family should realize that their words matter and may have lasting impact. Loved ones should also realize that female friends and relatives may conceal abortion to avoid their judgment. This silence has tangible consequences for some women. Given the high number of American women who have an abortion at some point,²⁷ public education campaigns are needed to teach people how to respond to such a disclosure supportively.

While some women experience regret or other negative emotions after abortion, further restrictions on the procedure is not the solution. Rather, loved ones, as well as abortion rights opponents and supporters, funders and policymakers, must find and develop new ways to meet women’s short- and long-term emotional needs. As our data demonstrate, the social processes associated with abortion can be the sources of women’s emotional difficulty. Thus, the solution lies in changing social behaviors, rather than clearing procedural hurdles. We need to provide relationship counseling services at the community level, learn to talk to women who have had abortions in ways that affirm rather than criticize their decision making and take a critical look at women and men’s division of responsibility for reproduction.