Factors influencing abortion decision-making of adolescents and young women: A narrative scoping review

doi:10.21203/rs.3.rs-2074248/v1

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Factors influencing abortion decision-making of adolescents and young women: A narrative scoping review

https://doi.org/10.21203/rs.3.rs-2074248/v1

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Introduction: Globally, about half of all induced abortions have been estimated to be unsafe, and have resulted in maternal death. Of these, 41% unsafe abortions have been reported in young women who are dependent on their parents for livelihood. They are often left in a vulnerable position and may have difficulty in making a decision regarding abortion. This study aimed to (a) characterize and map factors that influence abortion decision-making of adolescents and young women, and (b) identify the care and support they need in their decision-making process.

Methods: We conducted a scoping review following the JBI method and PRISMA-ScR checklist. We comprehensively searched MEDLINE (PubMed), EMBASE, Cochrane Library, CINAHL, and PsycINFO, and hand searched publications in Google Scholar database between November 2021 and December 2021. The search included all English language qualitative and mixed-methods research articles published from 1976 to November 2021, and included participants aged 10-24 years. The CASP checklist was used as guide for the qualitative analysis. Nvivo was used to synthesize the findings. Results: There were 14 studies from 10 countries (N = 334 young women) that met the inclusion criteria. Three domains and 11 categories were included: Personal (Desire for self-realization and Unwanted pregnancy), Interpersonal (Parental impact, Reaction of partner, Roles of peers and friends, Existence of own child, and Lack of support), and Social circumstances (Sexual crime, Financial problem, Limitation of choice, and Underutilized healthcare services). Decision-making factors regarding abortions were also found across all three domains.

Conclusion: The abortion decision-making of young women is influenced by various external factors regardless of country. Parents are especially influential and tend to force their daughters to make a decision. Young women experienced suffering, frustration, and lack of autonomy in making decisions based on their preference. This emphasizes the importance of autonomous decision-making. In this regard, healthcare services should be used. However, there are barriers to access these services. To improve such access, the following are required: staff training to provide women-centered care, counseling based on women’s needs, counseling including parents or guardians that is confidential and ethical, promotion of decision aids, and affordable accessible care.

Adolescent pregnancy

Young women

Abortion

Decision-making

Factor

Qualitative research

Globally, there are approximately 73 million induced abortions each year [1]. In Africa, 97% of all abortions were reported to be unsafe [2]. Between 2010 and 2014, the World Health Organization (WHO) estimated that 45% of all abortions were unsafe [1]. Among these 45% unsafe abortions [1], 15% were from adolescents aged 15–19 years, and 41% were from young women aged 20–24 years [3]. Unfortunately, unsafe abortions result in 13% of maternal deaths yearly [4].

The WHO defines unsafe abortion as one that involves an unintended pregnancy and is performed by a person who lacks the appropriate skills or who carries out the abortion in an environment lacking sterility and medical asepsis, necessary equipment, evidenced-based interventions, and necessary after-care [4]. Grimes et al. [5] reported that unsafe abortions can include traditional methods such as (a) the use of oral medications (e.g., toxic solutions, teas and herbal remedies, drugs), (b) treatments placed in the vagina or cervix, (c) intramuscular injections (d), foreign bodies placed into the uterus through the cervix, (e) enemas, and (f) trauma. Several studies from developing countries similarly reported the use of traditional methods by unskilled providers for terminating unwanted pregnancies, resulting in unsafe abortions [6, 7, 8].

Even though 38 million adolescents reportedly nee

d contraceptives in developing countries to avoid unintended pregnancy, the majority (60%) do not use them because of complex underlying factors [9]. Yakubu et al. [10] described various factors influencing adolescent pregnancy in sub-Saharan Africa which include sociocultural, environmental, and economic factors (e.g., unequal gender power relations, coercive sexual relations, poverty, lack of knowledge, non-usage of contraceptives, early sexual behavior). Individual and health service-related factors have also been identified. However unintended pregnancy and abortion are common experiences shared by many women globally, regardless of country, income group, and legal status [11]. Pregnant adolescents not only face obstetric complications but also have greatly changed life prospects. This is because adolescent pregnancy and childbearing often lead to dropping out of school. Consequently, the resulting lack of education inhibits their ability to build self-esteem, improve their status in the family and community, and have a say in decisions that affect their lives [12] which include career loss and the subsequent financial distress. Thus, unintended adolescent pregnancy may lead to various adverse physical, social, and economic outcomes [9, 13].

Moreover, Adolescent pregnancy carries with it a high risk of obstetric complications [14, 15]. In fact, maternal factors are the second leading cause of death among adolescents aged 15–19 globally, with little change in the ranking since 2000 [16]. These environments surrounding adolescent girls put them at risk. Importantly, unintended pregnancies can lead adolescents to choose unsafe abortion.

Shah and Ahman [17] reported that the rates of abortions are about the same regardless of country or legal restrictions. One consideration for women in seeking unsafe abortion is whether abortion is legally permitted. Bearak et al. [11] found that the abortion rates from 2010–2014 did not substantially differ between countries where abortion was legally available compared with countries where abortion was restricted. The main difference was in safety. These social or legal barriers may influence women to seek unsafe abortion, or make them hesitant to seek urgent care for complications of unsafe abortion [4, 17].

Incidentally, adolescents are more likely to have access to unsafe abortions and delay seeking care for complications after unsafe abortion than adults [18, 19]. Adults and adolescents differ in terms of care-seeking behavior such that adolescents tend to (a) delay seeking abortion, (b) seek abortion from traditional providers or unskilled providers, (c) use dangerous methods, (d) have complications, (e) delay seeking help even after complications, (f) lack transportation, (g) lack of awareness of where to seek help, (h) disregard cost considerations and (i) have poor perception of health workers’ attitudes [20]. These circumstances will most likely endanger adolescents when seeking unsafe abortion.

The decision to have an abortion can be difficult, especially for adolescents and young women who are in a vulnerable position of having to depend on their parents or other people for their livelihood. Although there has been ongoing qualitative research about abortion decision-making of adolescents and young women, to our knowledge, the body of the research literature has not yet been characterized or mapped.

Research question

(a) What are the factors that influence the abortion decision-making process of adolescents and young women?

(b) What care and support do adolescents and young women need in their abortion decision-making process?

Objectives

This study aims to (a) characterize and map the factors that influence the abortion decision-making process of adolescents and young women, and to (b) identify the care and support they need in their decision-making process.

This study used the scoping review framework by Arksey and O'Malley [21]. A scoping review is a type of knowledge synthesis that engages a systematic approach to map evidence on a topic and identify main concepts, theories, sources, and knowledge gaps [22]. Moreover, scoping reviews may also be helpful precursors to systematic reviews [21, 23]. Hence, this study used a scoping review which should have great utility for synthesizing and mapping the extant research evidence.

This scoping review adhered to the JBI guideline and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist [22]. The Critical Appraisal Skills Programme (CASP) checklist was used for qualitative analysis of the study [24].

Inclusion criteria

iv class="gridtable">

Table 1
	Inclusion Criteria	Exclusion Criteria
Population	Adolescents aged 10–19 years Young women aged 10–24 years (Defined by WHO [64])	Women aged > 25 years Participants are all men
Concept	Research factor of decision-making abortion Influence their choice behavior of pregnancy outcome Research view of abortion Qualitative study, mixed method narrative story, interview, diary	Research examining miscarriage, abortion of fetus. Research examining abortion procedures Research examining adolescent sexual behaviors or activities, and contraception Research examining the effectiveness of interventions or pregnancy prevention programs
Context	Any institution, health facility, and country
Language	English	Non-English
Publication type	Original studies Primary research articles	Only Abstract Conference Trial registration Reviews (e.g., scoping review, systematic review)
Publication date	All articles published Articles published from 1976 to 2021-November	Articles published before the year 1976

Search strategy

We comprehensively searched MEDLINE (PubMed), EMBASE, Cochrane Library, CINAHL, and PsycINFO, and hand searched publications in Google Scholar database between November 2021 and December 2021. The search included all English language qualitative and mixed-methods research articles published from 1976 to November 2021, and included participants aged 10–24 years. The PCC framework guided the development of the key words. An additional hand search for reference lists searches identified other new articles. An example of the complete search strategy for MEDLINE (PubMed) is listed in Appendix A.

Study selection

There were 16,658 articles identified through database searching. Quantitative studies were removed leaving 882 articles from the databases and registers. There were 17 articles retrieved from the other searches. After duplicates were removed, 628 studies were retained. An additional 498 records were removed following the review of titles. Of those, 101 articles were excluded following review of the abstract screening based on the inclusion criteria. Then, 29 full-text articles were read and 15 articles were excluded (for exclusion reasons, see Appendix B). Six papers were excluded because the target population was over the age of 24 years; five papers did not meet the inclusion criteria for the aim of the study; three papers had no raw data and one paper was not in English. The process of selection is shown in the PRISMA Flowchart (Fig. 1). Two independent reviewers evaluated and discussed the qualifications of the articles for inclusion. If disagreements could not be resolved through discussion, a third reviewer made the decision regarding the selection. One study included 15-30-year-old individuals. We were able to identify data by age and thus excluded participants 25 years and older. Finally, 14 studies were included in the qualitative synthesis.

Data extraction

The articles were abstracted in terms of their publication details: Authors, Year, Title, Country, Aim, Study design, Population, Data collection methods, and Key findings. Thereafter, data were imported into Nvivo windows software, which extracted concepts by selecting, coding, and creating nodes (files) representing key concepts. This analysis allowed for the exploration of the data by identifying (a) different themes in the environment surrounding adolescents and young women, (b) factors influencing abortion decision-making, and (c) perspectives toward abortion. A code list was developed consisting of a broad domain, categories, and smaller analytical subcategories. Two reviewers read all the papers several times to grasp their main concepts.

Quality assessment

The two reviewers reviewed the quality of the articles using the CASP checklist [24]. The CASP checklist is a tool for systematically screening manuscripts through the enquiry and critique of the study’s validity, results, and research contributions. Quality assessment was undertaken and independently verified. There were no studies that were excluded (Table 2).

Fourteen studies meeting the inclusion criteria were included in this review and are summarized in Table 2. The research studies were conducted in the 10 countries: England (n = 3), South Africa (n = 2), Ghana (n = 2), Australia (n = 1), Brazil (n = 1), Malawi (n = 1), Mexico (n = 1), Mozambique (n = 1), Sweden (n = 1), and the United States of America (n = 1).

The studies were published from 2002 to 2020 and included 334 young women. There were 11 qualitative studies [26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38]. There were two qualitative studies involving secondary analyses, and there was one mixed method study [39]. There were 10 studies wherein all participants had abortion experiences and explored abortion decision-making [27, 28, 29, 30, 32, 33, 34, 35, 36, 37].

Three studies included mixed participants who continued their pregnancy or had abortion experiences or never had pregnancies, and stakeholders who explored their choice and decision-making process regarding pregnancy outcomes [31, 38, 39]. There was one study involving a young migrant and refugee people’s views on unintended pregnancy and abortion [26].

Categories from the data

Analysis of the included studies obtained three main domains of reasons for seeking an abortion: Personal, Interpersonal, and Social circumstances. Decision-making factors regarding abortions were also found across all three domains.

Data extraction yielded 11 categories nested within the three domains: Personal (Desire for self-realization and Unwanted pregnancy), Interpersonal (Parental impact, Reaction of partner, Roles of peers and friends, Existence of own child, and Lack of support), and Social circumstances (Sexual crime, Financial problem, Limitation of choice, and Underutilized healthcare services). Appendix C shows a summary of the findings according to the three domains of the framework (influence abortion decision-making of adolescents and young women) and their associated categories and subcategories.

Personal

Two categories were included under this domain. These are Desire for self- realization and Unwanted pregnancy. They are described below with their associated subcategories.

Desire for self-realization

Thirteen articles described Desire for self-realization, which had two subcategories: Actualized her intentions and Never give up education and career.

Young women who are dependent on their parents for their livelihood are often left in a vulnerable position. However, the desire to have autonomy and make decisions for themselves has been stated in many articles. These reasons can be summed up as follows: decision-making on having an abortion on one’s own will to live a life on one’s own terms.

Actualized her intentions

Twelve articles contained data regarding actualized young women intentions understood as a desire to be autonomous. Two articles found that young women had already made their abortion decision easily or had already decided by themselves. This indicates that they exercised their own will and were already certain about their decision [27, 39]

Other findings were reported in five articles wherein adolescents felt that the final decision was an individual one, emphasizing their autonomy and having no regrets about their decision. They sought to have autonomy and control over their reproductive lives [29, 31, 33, 34, 35].

Some adolescents view abortion positively as a solution to premarital pregnancies because men do not like women who have children [28]. Abortion is also possible for unintended pregnancies regardless of the circumstance or situation [26].

Four articles reported the decision of women to terminate their pregnancy to maintain their autonomy. They decided not to be influenced by others [30, 35, 36, 38]. Some young women wanted to avoid dependency on men, thereby worked toward their empowerment [30, 36]:

I don’t want to be dependent on somebody else.... I want stability…and I don’t want to live off a guy either, on his salary, in his apartment!

(Termination of Pregnancy [ToP], 17 years old, [30], P. 176)

Never give up education and career

Ten articles wrote the participants desire to “Never give up education and career” which is necessary for opening the future. Bell et al. [39] examined the differences in decision-making between the termination of pregnancy (ToP) group and the continuation of pregnancy antenatal (AN) group. There were more who mentioned ‘career plans’ as a factor in the ToP group than in the AN group. Furthermore, all those in the ToP group were unwilling to give up their plans:

“I am doing really well on the course at the minute, and I don’t want to give it up…” (ToP 16 years old, [39], P. 2508).

These findings are supported by other articles, indicating that the participants focused on their own future and own personal circumstances. Resorting to abortion helped actualize their dreams to secure a better future. Decision-making was influenced by the vision they had of their own future. In this context, it is important to understand how young women prioritize self-realization [27, 34, 36, 38].

Ramakuela et al. [37] found that pregnant learners opt for ToP because pregnancy at that age interferes with learning and teaching. Some schools did not allow pregnant learners to attend classes or required them to at least bring a parent to assist them in case of emergency. Being learners themselves, young women are concerned and aware of the lifelong effects of becoming pregnant. Additionally, five other articles described the desire to continue education as a reason for their abortion decision-making [27, 28, 29, 31, 35].

Unwanted pregnancy

Eleven articles reported on unwanted pregnancy which had three subcategories: Dilemma and justification, Not ready to be a mother, and Worry about physical health.

This category reported on a sudden life turning point wherein adolescents experienced feelings of confusion and conflict. This indicates young women’s attitude of ambivalence and their justification of abortion.

Dilemma and justification

Seven articles reported about Dilemma and justification. The decision to have an abortion is an emotional one. These women express a wide range of emotions because of their unexpected and unplanned pregnancies. Some young women are viewed negatively for what is often a mistake and can feel ‘attacked by everyone’. This emotion is related to their decision-making toward having an abortion [39].

Moreover, seven articles reported that pregnancy had been a shocking experience for most young women. They experienced emotional ambivalence when explaining their own decision-making [29, 30, 34, 35, 36, 38, 39]:

“It’s a horrible thing to do but I think it was the best thing” (ToP 19 years old, [34], P. 9)

Not ready to be a mother

Ten articles included the reason classified as Not ready to be a mother. For unwanted pregnancies, personal factors were mostly mentioned such as too young or wrong timing and not ready to be a mother.

Some adolescents were aware that getting pregnant as a teen in high school was not proper [37, 39]. The majority of these young women chose ToP and mentioned ‘stage of life’ as a reason for choosing abortion. These predicaments suggest that the teens were too young. The above-mentioned findings are supported by previous studies [27, 30, 33, 34, 36, 38].

Furthermore, most young women mentioned that they were not prepared to be mothers [30, 32, 34, 35, 36, 38, 39]. One of the young women stated that she is still immature:

"I didn't think I was going to be a good mother because even myself, I still need some care and still need someone's shoulder to cry on, especially may Mom." (ToP adolescent, [35], P. 78)

Worry about physical health

Interestingly, there are two articles reporting on aspects related to Worry about physical health. Bell et al. [39] indicated that an adolescent’s ‘own previous experience’ of pregnancy contributed to her resolution and decision not to go through another unplanned pregnancy:

“I had loads of problems with pregnancy before … Last time I was pregnant my body was telling me I could cope. This time it didn’t sink in. My body was saying I am not ready” (ToP 18 years old, [39], P .2509)

One of the young women who was 15 years old rationalized her abortion in terms of her body being immature, as well as the challenge of her young age in carrying through the demands of a growing child [36].

Another young woman was worried about the damage and effects of her rapid delivery on her body:

“If you give birth in quick succession, your body will soon become like an “abrewa” (old woman).” (ToP 21 years old, [36], P. 926)

Interpersonal

Five categories were included under this domain, namely, Parental impact, Reaction of partner, Roles of peers and friends, Existence of own child, and Lack of support. These categories are described below with their associated subcategories.

Parental impact

All fourteen studies included parental impact reasons for abortion. This category had three subcategories: Pressure on making a choice regardless of her desire, Fear of rejection and disappointment, and Mediate the decision.

Parental authority had a strong influence on young women, who were in a vulnerable position. The following reactions were identified: fear of being kicked out of the house; fear of being rejected; worry, anger, and violence; and the desire not to disappoint their parents. This category summarizes the influence and reactions of parents who have a significant impact on the decision-making of their young vulnerable adolescent child.

Pressure on making a choice regardless of her desire

Twelve articles indicated decision-making pressure from parents to have an abortion. Most of these cases were forced upon the young women regardless of their desire.

Some young women wanted to have an abortion but did not disclose this to their parents because they were concerned that their parents would disagree with their decision; others resorted to abortion because they were afraid of negative reactions such as being threatened, suffering violence, and experiencing anger from parents, and they wanted to avoid such reactions [28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38]. Botfield et al. [26] noted that views about adolescent abortion were not an acceptable topic or practice among the family and community if it involved pre-marital pregnancy. Young women are influenced by their parents’ reaction and attitude toward abortion.

Tatum et al. [38] reported two adolescents who experienced a traumatic event of being forced by their fathers to undergo abortion without their consent. There were also reports of cases where adolescents underwent secret unsafe abortions to avoid involving their parents:

“… wanted to do it quickly so that nothing [bad] happened and that [her] parents would not realize.” (ToP, 16 years old, [38], P. 49)

Conversely, five articles indicated that despite the desire of adolescents not to interrupt their pregnancy, they reported that they had no autonomy to make such a decision, and they were forced to comply with their parent’ decision. Despite their late involvement, parents had a strong influence on the final decisions of adolescents [29, 30, 31, 32, 38]:

“I had an abortion against my own will.” (ToP, 18-year-old, [30], P. 176)

Domingos et al. [29] reported on abortion imposed by mothers. The mothers forced their daughters to drink special teas and take abortive medication in their own homes:

“My mother gave me ‘buchinha do norte’, tea pot, [and] cachaça prepared with cinnamon. None of these worked and I ended up in the hospital. […] I got pretty sick […] almost died” and continue she said [...] It took a while for me to realize it. [...] I felt guilty [...]. Today, when I think about all I’ve done, I feel bad. [...] I feel angry with my mom and with myself. I should have fought harder.” (ToP, [29], P. 902).

Young women who experienced forced decision-making suffered and became frustrated for not having fought against their mothers’ decision, their lack of autonomy and power to decide about their preference, and the occasional guilt and regret as a result of an unsafe procedure [29, 31].

Fear of rejection and disappointment

Eight articles described fear of parental reactions, which was an important factor for making a decision to undergo abortion by the participants. Some studies indicated fear of being excluded from their family, damage to their relationships, and worry about losing support from their parents [26, 28, 32, 33, 34, 35].

One young woman worried about rejection:

“As I am an orphan, and I live with my uncle, they are going to kick me out. No one would assist me.” (ToP, 20 years old, [32], P. 7)

Interestingly, Bell et al. [39] noted that teenagers in the ToP group thought about the impact of abortion on their family more than in the AN group; no one in the AN group mentioned these factors. Similarly, three articles reported that young women considered the impact of abortion on their parents and they did not want to disappoint them. Abortion was also viewed as a potential solution to not disappointing their parent’s hopes [26, 35, 36]. Thus, some young women had to keep secrets from their parents including having to terminate their pregnancy [35, 36].

One adolescent did not want to disappoint her parents:

“My parents would be angry. I didn’t want to disappoint them and I did [it] for them.” (ToP, adolescent, [35], P. 78)

Mediate the decisions

Six articles reported on the parents’ attitude wherein they agreed with and assisted their young daughters in their choice. Young women sought emotional or decisional support from trusted parents or guardians in making a decision to undergo abortion [26, 27, 33, 34, 35, 38].

One adolescent experienced unexpected support from parents:

“I never thought they would understand, but they did and I am grateful to them.” (ToP, adolescent, [35], P. 75)

Additionally, young women needed and sought the assistance and accompaniment of an adult whom they trusted, someone including their parents to help them finalize and act on their decision [33, 38]:

“I know she can help me...in making a decision about what to do.” (ToP, adolescent, [33], P. 2209)

Reaction of partner

Thirteen articles showed the reactions of partners which explicate the influence of the partner’s reaction regarding abortion decision-making. The following three subcategories support this category: Unstable relationship, Negative and unhelpful, and Consulted him but ignored her preference.

Unstable relationship

Eight articles indicated the impact of a young woman’s unstable partner relationship on her abortion decision-making. It was common for young women to worry about being abandoned or finding themselves actually abandoned if their partners discovered that they were pregnant. Occasionally, a partner left or broke up before a decision about the pregnancy had been made [27, 28, 31, 32, 34, 35, 38].

One of the young women stated:

“As soon as I told him [that] I was pregnant, he didn’t want to know. Haven’t seen him since. “(ToP, 18 years old, [27], P. 10)

Tatum et al. [38] reported that in all the cases in which the partners were not involved, the respondents chose to terminate their pregnancy. This, however, may suggest that the absence of a partner may have encouraged the young woman’s autonomy. When one participant was asked whether she previously thought of herself as capable of making such an important decision by herself, she responded:

“No, I wanted my mother or [my boyfriend] to tell me what to do. When I saw that my cousin was supporting me in what I wanted [to do], when I saw [my boyfriend] with [another young woman], and when the doctor explained everything to me, then I was not afraid anymore.” (ToP, 16-year-old, [38], P. 48)

Ramakuela et al. [37] found that the majority of female teenagers with unplanned pregnancies did not live with their partners or have a committed relationship. These teenagers realized that they will be raising their child as single parents. Under such circumstance, most decided to have an abortion.

Negative and unhelpful

Eight articles contributed to this subcategory. Some articles reported that the partner’s denial and attitude of indifference can lead to ToP [28, 30, 32, 35, 36, 37, 38]. A young woman mentioned that the indifference shown to her by her partner influenced her decision to have an abortion:

“I took the final decision alone. When I told him about it, he wasn’t very happy and we quarreled. Though we are still together, he has not asked anything about it.” (ToP, 22 years old, [36], P. 929)

Two studies reported on an unreliable and unhelpful partner [27, 36]. For example, the partner was very young or was not involved as a partner for abortion decision-making. Oduro et al. [36] reported on a young woman who instead of informing and consulting her partner about her pregnancy asked a friend for advice and acted on it, because he would not have allowed the abortion:

“I did not tell the man who impregnated me, I know he would not have allowed the abortion.” (ToP, 19 years old, [36], P. 929)

Consulted him but ignored her preference

This subcategory included data from nine articles. In their study which examined the mindset of adolescents, Botfield et al. [26] mentioned the role of men as providing support to their female partners in their abortion decision-making process.

There were eight articles indicating that young women consulted with their partners when a pregnancy was suspected or confirmed [27, 29, 30, 32, 33, 35, 36, 38]. Although two of these articles reported that the male partners offered emotional support or commitment to help with raising the child, most of the articles reported that the male partners did not appear to support the preferences of the young women, and instead tried to convince them to abandon their initial preference to terminate their pregnancy. Thus, the male partners’ initial reaction was typically that young women should continue with their pregnancy, regardless of their preference. Nevertheless, several young women chose to have abortion despite their partners’ offer of support [36, 38]:

“[I asked him] what I should do. He told me, “Well, you should have it,” and I told him he was crazy.” (ToP, 15-year-old, [38], P. 49)

In contrast, the responses of some male partners have been overwhelmingly negative toward continuing the pregnancy, with almost all supporting abortion. Ekstrand et al. [30], Frederico et al. [32], and Tatum et al. [38] described how the participants’ partners made implicit but clear remarks in favor of termination:

“He said, ‘Regardless of what you choose, I’ll support you—but you know what I’d prefer you to do....’ And of course, I wanted to respect that.” (ToP, 18-year-old, [30], P. 177)

Roles of peers and friends

This section describes the roles of peers and friends. Nine papers reported the influence of peers and friends on abortion decision-making. This category has one subcategory: Supported decision making.

Supported decision-making

Most of the articles reported that peers and friends are present, often as sympathizers, supporters, and counselors, although not exerting as much influence as the parents and partners [27, 29, 30, 31, 33, 34, 36, 38]. Some young women initially shared the news with trusted peers or friends [29, 33, 36, 38]. When young women were in need, their peers and friends provided various forms of physical support such as buying pregnancy tests, teaching them about emergency contraceptives, and providing information about abortion methods [38].

Moreover, Tatum et al. [38] mentioned that once the pregnancy was confirmed, peers and friends continued to provide emotional support by exploring options and helping respondents determine how they wanted to proceed. Notably, two articles reported that the opinions of friends did not appear to influence the participants’ final decision. In several cases, a decision was made that was opposite of their peers’ opinion about whether the participant should have abortion or continue her pregnancy [31, 38]. One study reported that adolescents decided to have an abortion for fear of losing friendship [37].

Existence of own child

Young women who already have small children mentioned that the existence of their children was a major consideration in whether to keep their current pregnancy. This category has one subcategory: Could not cope with another child.

Could not cope with another child

Five articles indicated that an influencing factor for the decision to have an abortion was the existence of one’s own child. Many of the young women stated that they could not cope with another child such as not being able to take care of another child. They also resorted to abortion for birth-spacing considering the young ages of their children and they worry about the negative impact to their child [27, 32, 36, 37, 39]:

“I thought about my little girl. I don’t want to share my love with another baby.” (ToP, 18 years old, [39], P. 2509)

Lack of support

Lack of support has one subcategory: Desire emotional and physical support.

Desire emotional and physical support

Seven articles stated that the lack of support from their parents, partners, and others influenced their choice of abortion. They expressed anger, sadness, and disappointment related to the lack of support from others [30, 31, 32, 33, 35, 37, 39]. Moreover, they needed not only physical support but also emotional support [33, 35].

One adolescent girl sought emotional support from her mother:

“I am alone, that is the worst part. I didn’t have anyone to talk to except the people at the clinic and trusted that someone could help me, especially my mom.” (ToP, adolescent, [35], P. 74)

Social circumstances

Four categories were included under this domain: Sexual crime, Financial problem, Limitation of choice, and Underutilized healthcare services. These are described below along with their associated subcategories.

Sexual crime

This category has one subcategory: Rape and incest.

Rape and incest

Two articles indicated that rape and incest were related to abortion decision-making [32, 37]. Some participants felt that teenage pregnancy from rape and incest would bring a curse and cause disruptions to the family [37]. These teens would rather opt for ToP instead of giving birth to a potentially disabled child in the family as a result of rape and incest. One adolescent said:

“I did it because I was raped by my uncle and my parents advised me to terminate [my] pregnancy because they felt that the baby will be a curse to the family and can also be disabled.” (ToP, adolescent, [37], P. 4)

Financial problem

Financial problem has one subcategory: Lack of financial autonomy.

Lack of financial autonomy

Twelve articles found financial issues to be a major factor that influenced abortion decision-making. This included family financial status and the necessary financial stability.

Ramakuela et al. [37] reported poverty as a major factor in making teenagers opt for ToP as they would not be able to take care of themselves and the child would become a burden to them and their families:

“I see poverty as a cause of terminating pregnancy due to poor family background wherein you will find that they depend on social grants of the grandparents.” (ToP, adolescent, [37], P. 3)

Similar findings were reported in five other articles. Teenagers were concerned about adding another financial burden to their family, as most of them were financially dependent on their parents. Thus, a major factor influencing abortion decision-making was financial autonomy [28, 29, 31, 32, 38]. Additionally, six articles reported that participants attributed abortion decision-making to financial difficulty and the necessity for stable finances [27, 30, 33, 34, 36, 39]:

“I can’t give it anything, like I want to be able to have a kid when I’ve got money to bring it up.” (ToP, 18 years old, [27], P. 10)

Limitation of choice

Nine articles showed a limitation of choice. This category has three subcategories as stated and described below: Fear of stigma, Perspectives of religion, and Misconception and lack of knowledge.

Fear of stigma

Seven articles have pointed out the relevance of fear of pregnancy-related social impact and stigma in choosing ToP as a solution. Ramakuela et al. [37] stated that one of the main reasons teenage girls choose abortion is because they feared the stigma of being a pregnant teenager [28,30,31,36,37,39,].

Some studies found that pregnancy outside marriage was described as highly shameful [26, 28, 31]:

“I was worried, I feared that people would laugh at me and say bad things about me” (ToP, adolescent, [28], P. 32)

Additionally, Botfield et al. [26] reported that young migrants and refugees in Sydney were afraid of the embarrassment to the family name. Several young women believed that a woman would be ostracized from her family or community if she became pregnant outside marriage. Therefore, participants held the strong belief that families might view a ‘secret’ abortion as preferable to pregnancy outside marriage.

Furthermore, Bell et al. [39] reported ‘negative discourses’, in which adolescent participants expressed a negative image of an unwed teenage mother. For example, an adolescent girl who had ToP did not want to be seen as….

“a typical teenager who’s got pregnant and doesn’t care about anything” (ToP, 16 years old,[39], P. 2510).

Perspectives of religion

Four articles reported about the influence of religious perspectives on abortion decision-making. All articles showed that ToP was against the participants’ religious beliefs. Ekstrand et al. [30] reported the impact of the social network religion on participants. Some young women had encountered openly expressed attitudes against the forthcoming abortion, such as harsh remarks or remarks about God’s punishment.

One of the girls said about her parents:

“Since my parents are immigrants and Muslims, it was totally out of the question for me to tell them about the pregnancy.... They would have turned me away if they’d known. I felt I was forced to choose between my family and my unborn child.” (ToP, 18 years old, [30], P. 176)

Despite the prevailing religious beliefs, young women chose ToP [26, 30, 31, 35]. Mpshe et al. [35] reported guilt as a result of going against their religious norms.

These articles show that although they were religiously against abortion, this was not reflected in their decision to have an abortion, except to the extent that they felt guilty after having the abortion. This finding was also supported by Engelbert et al. [31], except that the situation about abortion was difficult to discuss openly.

Misconception and lack of knowledge

Eight articles touched on misconception and lack of knowledge regarding the law and abortion care.

Three articles reported a lack of awareness about the legal status governing abortions. Even though ToP on certain grounds was legal, abortion seekers stilled viewed abortion as illegal [31, 36, 38]:

“I don’t know that such a law existed in Ghana.” (ToP, 24 years old, [36], P. 925)

Nevertheless, Tatum et al. [38] mentioned that the legal status of abortion did not appear to be the main factor in deciding whether to continue the pregnancy or to seek termination services. Two young women who initially thought abortion was illegal, nonetheless, terminated their pregnancy [38]:

“I very much took that into account. I said, well, I do not think they can put me in jail.” (ToP, 17 years old, [38], P. 51)

However, Engelbert et al. [31] pointed out that lack of awareness on existing legislation was a barrier to accessing available safe abortion services.

Six articles reported that there was not enough correct information regarding ToP. In this case, there was usually no open discussion about abortion, thus young women had to make abortion decisions in the face of uncertain or insufficient information. Hence, they feared possible death or damage to some of their vital organs [26, 28, 30, 35, 37, 38].

Underutilized healthcare services

Nine articles reported on underutilized healthcare services, creating barriers to safe abortion procedures, and negatively affecting pregnancy outcomes. The importance of easy accessibility to abortion clinics was mentioned. This category has five subcategories: Level of need for counseling, Unaffordable, Confidentiality and privacy issues, Health care provider’s negative attitude, and Accessibility barriers.

Level of need for counseling

Four articles described counseling. Two of these four articles indicated that many young women do not feel the need for pre-abortion counseling because they had already decided to terminate their pregnancy. Notably, they had already discussed ToP with another trusted person because of unreliable healthcare providers [27, 38]:

“Because I didn’t feel I needed to, because I’ve talked a lot about it with my Mum, I talked about it with my boyfriend, I talked about it with my friend. (ToP, 18 years old, [27], P. 9)

However, the other two articles reported that counseling was effective. A few young women expressed appreciation for the neutral support of most healthcare providers and felt the need for professional counseling [30, 35].

Unaffordable

Two articles reported that healthcare services were unaffordable, keeping these services from being utilized. This affordability problem can hinder access to safe abortion care [31]. These findings were supported by those of Frederico et al. [32] who reported that participants visited a health facility, but could not avail of the services because of their lack of money to pay for an abortion:

“They charged us money that we did not have. The ladies did not want to negotiate anything. I think they wanted 1200 mt (17.1 euros) if I am not wrong. He [boyfriend] had a job, but he did not have that amount of money.” (ToP, 22 years old, [32], P. 8)

Confidentiality and privacy issues

Four articles reported on confidentiality and privacy issues [28, 30, 31, 32]. Most adolescents were afraid of healthcare providers’ disclosure to their relatives or community members [31]. In countries where abortion is illegal, there was worry that adolescents might be handed over to the police [28]. Chamanga et al. [28] indicated that this fear delayed the seeking of help by adolescents when they were in great pain and had developed complications following the unsafe induced abortion:

“I did not want to come to the hospital because I was worried, I was afraid

that the nurses would report me to the police, and the police would arrest me.” (ToP, adolescent, [28], P. 32)

Healthcare provider’s negative attitude

Four articles described the negative attitude of healthcare providers. For some participants, the healthcare providers’ attitude was a deciding factor in whether to seek an abortion. Three articles reported that young women were afraid of encountering negative attitudes of healthcare providers, and concluded that such fear also contributed to the underutilization of health facilities [28, 30, 38]. One article noted the judgmental, attitude of a physician specifically about age and the physician’s negative attitude [38]. Moreover, most participants were afraid to visit the hospital for unfounded fears of being shouted at or being hit by health workers [28]:

“I was worried because friends told me that people are beaten up when they go to the hospital. So, I was worried that they were going to slap me and add to the pain I was already feeling at the time. After coming here, I know these were lies, I was received and treated well here.” (ToP, [28], P. 32)

On the other hand, the choice of medical services was facilitated when knowing a specialist in the healthcare facility [32]:

“I already knew who could induce it (abortion). No, I knew that person. I went to the hospital, and I talked to her, (and) she helped me.” (ToP, 22 years old, [32], P. 8)

Accessibility barriers

Six articles reported several problems related to accessibility barriers of healthcare services. The first problem was the lack of information regarding abortions. Mpshe et al. [35] found that some of the pregnancies of the participants were almost outside the terms of legal termination when they sought the abortion. There was also a lack of awareness or access to information on services that could provide appropriate information and care in their local areas [26, 31, 32, 36, 38]:

“I think it’s just the fact that a lot of young people don’t know they have access to that kind of stuff.” (Nonpregnancy, 22 years old, [26], P. 204)

In addition, one article reported on a questionable health facility. Frederico et al. [32] described those treated at the hospital as saying that legal procedures were not followed and official receipts where not provided upon payment.

Owing to the lack of accessibility, Tatum et al. [38] reported that abortions were also performed outside of the health facility. Even with the involvement of an adult in the choice of place and method of pregnancy termination, this did not ensure the safety of the procedure [38].

This scoping review identified 14 qualitative studies from 10 countries and included 334 adolescents and young women participants. The findings were clustered into three domains: Personal, Interpersonal, and Social circumstances. These three domains were supported by 11 categories and 24 subcategories including narratives of adolescents and young women regarding abortion decision-making. Bain et al. [40] explained that the Social Ecological Model assumes that behaviors and decisions are shaped by individuals, relationships, communities, and social factors. Similar studies used domains, akin to this study, that affected abortion decision-making which included these main factors: individual, others, and environment [32, 36, 41, 42].

The first aim of this study was to characterize and map the factors that influence the abortion decision-making process of adolescents and young women. This narrative scoping review included all countries wherein all the three domains were found to be relevant determinants of abortion without bias. This is likely related to the fact that the women are not financially autonomous and are in a vulnerable position as young people. Adolescent pregnancy is not the result of an intended choice; besides, young women often have little say in the decisions that affect their lives [13]. Adolescent pregnancy is a global issue occurring in high-, middle-, and low-income countries [15].

Barriers To Autonomy Of Decision-making

In the present review, all the articles provided data supporting the category of parental impact toward abortion decision-making. There have been several articles on abortion decision-making factors for young women, primarily on parental influence [43, 44, 45]. Some articles compared adults to minors in terms of decision-making toward pregnancy outcomes. The articles reported that minors were more likely to consider the effect of their pregnancy on their parents, with external factors (e.g., family pressure) precluding pregnancy continuation [20, 45, 46, 47].

Regarding decision-making in dependent relationships (e.g., parent-child relationships), the feelings of guilt, shame, and loyalty appear to be more closely intertwined, and parental involvement in decision- making reflects dependence [48]. In this subcategory, the pressure of making a choice regardless of her desire comes with the fear of parental rejection and disappointment, as well as the need to mediate the decision. These findings indicate that complex emotions are intertwined in abortion decision-making, consistent with previous studies.

In addition, autonomous decision-making is made with a sense of freedom; forced decision-making would be contrary to and a violation of this free choice, especially when there is a sense of pressure, control, and coercion [48]. The present review found pressure from parents to be a major factor influencing autonomous decision-making. When the decisions of adolescents are controlled by external forces, they are likely to experience emotional distress manifested as guilt and regret about their abortion more than those who went through the process of personally justifying their abortion decisions [45, 46].

Some studies reported that unsafe abortion practices were a factor that made young women hide their pregnancies and abortion-decision making from their parents or guardians to avoid disappointment, resentment, and fear of stigma [20, 49]. Thus, negative attitudes, such as pressure and fear, can lead young women to have an abortion even if the procedure used is unsafe.

Within the personal domain, the identified factors influencing abortion decision-making were self-realization and unwanted pregnancy. Each of these indicates that the decision to have an abortion is a spontaneous choice to be autonomous using one’s own reason. Grootens et al. [50] concluded that adolescents 12 years of age have the capacity to make adequate decisions given favorable environmental factors. However, adolescents’ decision-making depends on their abilities that vary across situations, and they may be able to make autonomous decisions with the support of facilitative environmental factors, such as having the right information, at the right time, in the right place, by the right person, and in the right way [50, 51].

The present review found that adolescents needed, and sought assistance and accompaniment by adults whom they trusted including their parents to finalize and then act on their decision [33, 38]. Hoggart [34] indicated that if a person is confident that she made the right decision and had no doubts or regrets, then the decision is comfortable.

Considering these findings, it is ultimately important that individuals be able to arrive at a point where they can feel confident enough to make an autonomous decision. To achieve this, people around them should be both involved in a non-coercive attitude and be supportive. To have an abortion in a safe, secure, and appropriate environment, it is necessary to enhance abortion decision support, provide correct knowledge, and give accurate information for adolescents to make an informed choice.

Some studies of decision aids suggest that these aids improve patient decision-making compared with the usual care [52, 53]. At the same time, the reported decision aids were poorly used in daily practice [52]. Presently, research on abortion decision-making aids remains insufficient [54]. There is therefore an urgent need to promote the use of abortion decision-making aids.

The present review found that the identified role of the partner changed depending on the situation and relationship status. Some articles reported the influence of partners [55, 56]. However, in the present review, some articles reported that the partners did not influence the final decision-making [31, 38]. In a review of adolescent men’s attitudes and decision-making regarding pregnancy outcome, it was reported that the findings of studies can often be contradictory owing to their “…attitudes about unintended pregnancy, contraception, and abortion and can be contextual and contingent on the dominant or prevailing social norms and roles within a given time, space or social group” ([57], abstract, results section). Thus, the findings of this present research coincide with those of previous research.

Barriers To Accessibility Of Healthcare Services

The second aim of this study was to identify the care and support needed by adolescents in their decision-making process. The first need is to promote decision-making aids so that adolescents can make informed decisions, and the second need is to increase the use of healthcare services. However, the underutilized healthcare services was found to be an important category. Adding strength to this category are the subcategories Level of need for counseling, Unaffordable, Confidentiality and privacy issues, Healthcare provider’s negative attitude, and Accessibility barriers.

Because of personal issues, and the interpersonal and social pressures associated with ToP, the decision to have an abortion may involve conflict [58]. Nevertheless, adolescents may not use healthcare services because they were anxious, had fear of unfounded rumors, lacked knowledge, held the negative attitudes of healthcare providers, feared disclosure of secrets, and found abortion unaffordable [4, 7, 42]. The negative effects of this include unsafe abortion practice and delays in seeking medical attention in case of complications [19, 20, 49].

The present review clarified that most of the women had already discussed about seeking an abortion or viewed the issue as very private so that they carefully chose the person(s) they talked to. Therefore, pre-abortion counselling was helpful only for some women and it was viewed as unnecessary by most women. The abortion decision-making process varies with individual differences. Women who want to have an abortion are often already sure of their decision and do not need counseling, whereas women who are not yet sure of their decision likely need and should be offered the suitable counseling [59, 60]. As there was a lack of information about the induce abortion procedure [27, 38], it will be necessary to consider how to provide effective counseling that meets the needs of the target population regardless of their decision status.

Additionally, many studies have mentioned the negative attitudes of and the stigma from healthcare providers [20, 42, 56, 61]. These attitudes and stigma act as barriers to access healthcare services. Interestingly, the choice of medical services is strengthened by knowing someone in the health facility [32]. Thus, it is important for healthcare providers to be friendly and reliable [62]. This underscores the importance of training healthcare providers on how to provide women-centered care.

Tatum et al. [38] described the practice of abortion outside medical facilities. They stated that adult involvement in the choice of location and method of abortion does not guarantee the safety of the procedure. The lack of awareness of access to safe abortion occurs not only among adolescents and young women, but also among adults [20]. This situation indicates the need for counseling involving the parents or guardian(s) with proper consideration of confidentiality and ethics.

Finally, in the present review, some adolescents and young women experienced feelings of guilt and regret after having an abortion, indicating the need for post-abortion counseling [28, 35], particularly because the results of unsafe abortion may cause post-abortion complications [5, 20, 63]. In this way, healthcare services can be involved in both physical and mental care before, during, and after the abortion.

Limitations and strengths

In terms of limitations, this scoping review included only 14 articles as the study’s focus was on the examination of findings of qualitative studies. Furthermore, this scoping review was restricted to participants aged 10–24 years. Some studies included not only young women who had an abortion but also young women who were pregnant or not pregnant. Thus, some themes that are characteristic of each age group may have been missed, making the results non-generalizable to all settings.

In terms of strengths, this scoping review is, to the best of our knowledge, the first narrative scoping review which examined the abortion decision-making factors of adolescents and young women. This scoping review was also not limited to certain countries. Moreover, the findings showed that the abortion decision-making process of adolescents and young women is influenced by various personal, interpersonal, and social external factors regardless of the country status: high-, middle-, or low-income countries. Finally, the categories were robustly supported by subcategories, thus this scoping review could be used for mapping.

The abortion decision-making process of adolescents and young women is influenced by various personal, interpersonal, and social external factors. In particular, young women who are dependent on their parents for their livelihood are often left in a vulnerable position. This situation is the same in every country regardless of the country’s socioeconomic status (i.e., high-, middle-, or low-income status). Thus, parents are especially influential and tend to force their daughters to make a decision often against their will. Unwanted pregnancy causes a sudden life turning point, causing confusion and conflict among adolescents and young women. They often experience suffering and frustration for not standing up against their parent’s decision, as well as for their lack of autonomy and power to decide in accordance with their preference. Adolescents and young women usually desire autonomy in decision-making. Therefore, it is necessary for those around these still immature women to provide them support and to encourage their autonomous decision-making by providing appropriate and sufficient information.

Notably, healthcare services related to abortion decision-making remain underutilized. To improve access to these healthcare services, the following items must be implemented: (a) training of staff to provide women-centered care, (b) counseling of adolescents and young women based on their needs, and counseling involving their parents or guardians while ensuring confidentiality and ethical considerations, (c) promotion of decision aids, and (d) care that is affordable and accessible, so that pregnant adolescents and young women can take full advantage of healthcare services.

AN: Antenatal

CASP: Critical Appraisals kills Programme

JBI: Joanna Briggs Institute

PRISMA-ScR: Preferred Reporting Items for systematics reviews and Meta-Analyses extension for Scoping Reviews

ToP: Termination of Pregnancy

WHO: World health Organization

Conflicts of interest

The authors have no conflicts of interest related to this study.

Acknowledgements

I am very grateful to Dr. Shigeko Horiuchi, Professor of Midwifery at St. Luke’s International University, for her guidance and support in conducting this study.

I greatly appreciate Dr. Edward Barroga (https://orcid.org/0000-0002-8920-2607), Medical and Nursing Science Editor and Professor of Academic Writing at St. Luke’s International University, for reviewing and editing the manuscript.

I am also truly grateful for the Scholarship of Ogura Kazuharu International Nursing for Postgraduate Education (scholarship number O211001), as well as to The Japan Society for the Promotion of Science Core-to-Core Program, Asia-Africa Science Platforms (2021-2024) (PI: Shigeko Horiuchi) for the financial support of this research.
Ethics approval and consent to participate

Not applicable in reviews.

Consent for publication

Not applicable in reviews.

Availability of data and materials

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Competing interests

The authors declare that they have no conflicts of interest with respect to the research, authorship, and/or publication of this scoping review.

Funding

This study was funded by the Japan Society for the Promotion of Science (JSPS) Core-to-Core Program, Asia-Africa Science Platforms (2021-2024, PI: Shigeko Horiuchi).

Authors’ contributions

Conceptualization: YK

Funding acquisition: SH

Investigation: YK, ES, SH

Methodology: YK, SH

Project administration: YK, SH

Supervision: SH

Validation: YK, ES, SH

Visualization: YK

Writing - original draft: YK

Writing - review and editing: YK, ES, SH

Acknowledgements

We would like to express our gratitude to Dr. Edward Barroga (https://orcid.org/0000-0002-8920-2607), Medical/Nursing Science Editor and Professor of Academic Writing at St. Luke’s International University, Tokyo for his editorial review of the manuscript.

World Health Organization. Abortion. https://www.who.int/news-room/fact-sheets/detail/abortion . Accessed 25 November 2021.
Sedgh G, Singh S, Shah IH, Ahman E, Henshaw SK, Bankole A. Induced abortion: incidence and trends worldwide from 1995 to 2008. Lancet. 2012;379(9816):625-32.
Shah IH, Ahman E. Unsafe abortion differentials in 2008 by age and developing country region: high burden among young women. Reprod Health Matters. 2012;20(39):169-73.
Department of Reproductive Health and Research, World Health Organization. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008 Sixth edition. http://apps.who.int/iris/bitstream/handle/10665/44529/9789241501118_eng.pdf?sequence=1 Accessed 25 November 2021.
Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, et al. Unsafe abortion: the preventable pandemic. Lancet. 2006;368(9550):1908-19.
Atuhaire S. Abortion among adolescents in Africa: A review of practices, consequences, and control strategies. Int J Health Plann Manage. 2019;34(4):e1378-86.
Penfold S, Wendot S, Nafula I, Footman K. A qualitative study of safe abortion and post-abortion family planning service experiences of women attending private facilities in Kenya. Reprod Health. 2018;15(1):70-4.
Plummer ML, Wamoyi J, Nyalali K, Mshana G, Shigongo ZS, Ross DA, et al. Aborting and suspending pregnancy in rural Tanzania: An ethnography of young people’s beliefs and practices. Stud Family Plann. 2008;39(4):281-92.
Darroch JE, Woog V, Bankole A, Ashford LS. Costs and benefits of meeting the contraceptive needs of adolescents Key Points. 2016 -05. https://www.guttmacher.org/sites/default/files/report_pdf/adding-it-up-adolescents-report.pdf. Accessed 10 November 2021
Yakubu I, Salisu WJ. Determinants of adolescent pregnancy in sub-Saharan Africa: a systematic review. Reprod Health. 2018;15(1):15-4.
Bearak J, Popinchalk A, Ganatra B, Moller AB, Tunçalp Ö, Beavin C, et al. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990-2019. Lancet Glob Health. 2020;8(9):e1152-61.
UNFPA. Motherhood in Childhood: Facing the challenge of adolescent pregnancy. https://www.unfpa.org/sites/default/files/pub-pdf/EN-SWOP2013.pdf Accessed 01 December 2021.
United Nations Population Fund, UNFPA. Adolescent pregnancy. https://www.unfpa.org/adolescent-pregnancy Accessed 25 November 2021.
Ganchimeg T, Ota E, Morisaki N, Laopaiboon M, Lumbiganon P, Zhang J, et al. Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study. BJOG. 2014;121 Suppl 1:40-8.
World Health Organization. Adolescent pregnancy. https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy Accessed 6 December 2021.
World Health Organization (Mortality, morbidity and disability in adolescence, 2014. https://apps.who.int/adolescent/second-decade/section3/page2/mortality.html Accessed 6 December 2021.
Shah I, Ahman E. Unsafe abortion: global and regional incidence, trends, consequences, and challenges. J Obstet Gynaecol Can. 2009;31(12):1149-58.
Mutua MM, Maina BW, Achia TO, Izugbara CO. Factors associated with delays in seeking post abortion care among women in Kenya. BMC Pregnancy Childbirth. 2015;15:241-7.
Woog V, Singh S, Browne A, Philbin J. HIGHLIGHTS August 2015 Adolescent Women’s Need for and Use of Sexual and Reproductive Health Services in Developing Countries. https://www.guttmacher.org/report/adolescent-womens-need-and-use-sexual-and-reproductive-health-services-developing-countries. Accessed 10 November 2021.
Olukoya AA, Kaya A, Ferguson BJ, AbouZahr C. Unsafe abortion in adolescents. Int J Gynecol Obstet. 2001;75(2):137-47.
Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 2005;8(1):19-32.
Tricco AC, Lillie E, Zarin W, Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and explanation. Ann Intern Med. 2018;169(7):467-73.
Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18(1):143.
Critical Appraisal Skills Programme; CASP-Qualitative-Checklist-2018. Critical Appraisal Skills Programme; CASP-Qualitative-Checklist-2018. https://casp-uk.net/wp-content/uploads/2018/01/CASP-Qualitative-Checklist-2018.pdf. Accessed 22 Nov 2021.
Khalil H, Bennett M, Godfrey C, McInerney P, Munn Z, Peters M. Evaluation of the JBI scoping reviews methodology by current users. Int J Evid Based Healthc. 2020;18(1):95-100.
Botfield JR, Newman CE, Bateson D, Haire B, Estoesta J, Forster C, et al. Young migrant and refugee people’s views on unintended pregnancy and abortion in Sydney. Health Sociol Rev. 2020;29(2):195-210.
Brown S. Is counselling necessary? Making the decision to have an abortion. A qualitative interview study. Eur J Contracept Reprod Health Care. 2013;18(1):44-8.
Chamanga RP, Kazembe A, Maluwa A, Chirwa E, Chimango J. Psychological distress among adolescents before, during and after unsafe induced abortion in Malawi. Paediatr Int Child Health 2012;41(2):29-36.
Domingos SR, Merighi MA, de Jesus MC, de Oliveira DM. The experience of women with abortion during adolescence as demanded by their mothers. Rev Lat Am Enfermagem. 2013;21(4):899-905.
Ekstrand M, Tydén T, Darj E, Larsson M. An illusion of power: qualitative perspectives on abortion decision-making among teenage women in Sweden. Perspect Sex Reprod Health. 2009;41(3):173-80.
Engelbert Bain L, Zweekhorst MBM, Amoakoh-Coleman M, Muftugil-Yalcin S, Omolade AI, Becquet R, et al. To keep or not to keep? Decision making in adolescent pregnancies in Jamestown, Ghana. PLoS One. 2019;14(9):e0221789.
Frederico M, Michielsen K, Arnaldo C, Decat P. Factors influencing abortion decision-making processes among young women. Int J Environ Res Public Health. 2018;15(2):329. doi: 10.3390/ijerph15020329.
Hasselbacher LA, Dekleva A, Tristan S, Gilliam ML. Factors influencing parental involvement among minors seeking an abortion: a qualitative study. Am J Public Health. 2014;104(11):2207-11.
Hoggart L. Moral dilemmas and abortion decision-making: Lessons learnt from abortion research in England and Wales. Glob Public Health. 2019;14(1):1-8.
Mpshe WS, Gmeiner A, van Wyk S. Experiences of black adolescents who chose to terminate their pregnancies. Health SA Gesondheid: Journal of Interdisciplinary Health Sciences 2002;7(1):68-81.
Oduro GY, Otsin MN. “Abortion--it is my own body”: women’s narratives about influences on their abortion decisions in Ghana. Health Care Women Int. 2014;35(7-9):918-36.
Ramakuela NJ, Lebese TR, Maputle SM, Mulaudzi L. Views of teenagers on termination of pregnancy at Muyexe high school in Mopani District, Limpopo Province, South Africa. Afr J Prim Health Care Fam Med. 2016;8(2):1.
Tatum C, Rueda M, Bain J, Clyde J, Carino G. Decision-making regarding unwanted pregnancy among adolescents in Mexico City: a qualitative study. Stud Fam Plann. 2012;43(1):43-56.
Bell ER, Glover L, Alexander T. An exploration of pregnant teenagers’ views of the future and their decisions to continue or terminate their pregnancy: implications for nursing care. J Clin Nurs. 2014;23(17-18):2503-13.
Bain LE, Muftugil-Yalcin S, Amoakoh-Coleman M, Zweekhorst MBM, Becquet R, de Cock Buning T. Decision-making preferences and risk factors regarding early adolescent pregnancy in Ghana: stakeholders’ and adolescents’ perspectives from a vignette-based qualitative study. Reprod Health. 2020;17(1): https://doi.org/10.1186/s12978-020-00992-x.
Kirkman M, Rowe H, Hardiman A, Mallett S, Rosenthal D. Reasons women give for abortion: A review of the literature. Arch Women’s Ment Health. 2009;12(6):365-78.
Kyilleh JM, Tabong PT, Konlaan BB. Adolescents’ reproductive health knowledge, choices and factors affecting reproductive health choices: a qualitative study in the West Gonja District in Northern region, Ghana. BMC Int Health Hum Rights. 2018;18(1):6 https://doi.org/10.1186/s12914-018-0147-5.
Henshaw SK, Kost K. Parental involvement in minors’ abortion decisions. Fam Plann Perspect. 1992;24(5):196-207, 213.
Olsson P, Wijewardena K. Unmarried women’s decisions on pregnancy termination: Qualitative interviews in Colombo, Sri Lanka. Sex Reprod Healthc. 2010;1(4):135-41.
Ralph L, Gould H, Baker A, Foster DG. The role of parents and partners in minors’ decisions to have an abortion and anticipated coping after abortion. J Adolesc Health. 2014;54(4):428-34.
Lewis CC. A comparison of minors' and adults' pregnancy decisions. Am J Orthopsychiatry. 1980;50(3):446-53.
Pereira J, Pires R, Canavarro MC. Decision-making trajectories leading to termination of an unplanned pregnancy: specificities among adolescent and adult women. J Reprod Infant Psychol. 2019;37(3):242-55.
Van Petegem S, Beyers W, Vansteenkiste M, Soenens B. On the association between adolescent autonomy and psychosocial functioning: examining decisional independence from a self-determination theory perspective. Dev Psychol. 2012;48(1):76-88.
Atakro CA, Addo SB, Aboagye JS, Menlah A, Garti I, Amoa-Gyarteng KG, et al. Contributing factors to unsafe abortion practices among women of reproductive age at selected district hospitals in the Ashanti region of Ghana. BMC Womens Health. 2019;19(1):60-5.
Grootens-Wiegers P, Hein IM, van den Broek, J. M., de Vries MC. Medical decision-making in children and adolescents: developmental and neuroscientific aspects. BMC Pediatr. 2017;17(1): https://doi.org/10.1186/s12887-017-0869-x.
Bain LE. Understanding the meaning of autonomy in adolescent pregnancy decision-making: lessons from Ghana. Pan Afr Med J. 2021;40:34.
Vlemmix F, Warendorf JK, Rosman AN, Kok M, Mol BW, Morris JM, et al. Decision aids to improve informed decision-making in pregnancy care: a systematic review. BJOG. 2013;120(3):257-66.
Wong SS, Thornton JG, Gbolade B, Bekker HL. A randomised controlled trial of a decision-aid leaflet to facilitate women's choice between pregnancy termination methods. BJOG. 2006;113(6):688-94.
Donnelly KZ, Elwyn G, Thompson R. Quantity over quality-Findings from a systematic review and environmental scan of patient decision aids on early abortion methods. Health Expect. 2018;21(1):316-26.
Rehnström Loi U, Lindgren M, Faxelid E, Oguttu M, Klingberg-Allvin M. Decision-making preceding induced abortion: a qualitative study of women’s experiences in Kisumu, Kenya. Reprod Health. 2018;15(1):166-6.
Schwandt HM, Creanga AA, Adanu RM, Danso KA, Agbenyega T, Hindin MJ. Pathways to unsafe abortion in Ghana: the role of male partners, women and health care providers. Contraception. 2013;88(4):509-17.
Kane J, Lohan M, Kelly C. Adolescent men’s attitudes and decision making in relation to pregnancy and pregnancy outcomes: An integrative review of the literature from 2010 to 2017. J Adolesc. 2019;72:23-31.
Breitbart V. Counseling for medical abortion. Am J Obstet Gynecol. 2000;183(2 Suppl):26.
Cameron ST, Glasier A. Identifying women in need of further discussion about the decision to have an abortion and eventual outcome. Contraception. 2013;88(1):128-32.
Kumar U, Baraitser P, Morton S, Massil H. Decision making and referral prior to abortion: a qualitative study of women's experiences. J Fam Plann Reprod Health Care. 2004;30(1):51-4.
Espinoza C, Samandari G, Andersen K. Abortion knowledge, attitudes and experiences among adolescent girls: a review of the literature. Sex Reprod Health Matters. 2020;28(1):1744225.
Atuyambe LM, Kibira SP, Bukenya J, Muhumuza C, Apolot RR, Mulogo E. Understanding sexual and reproductive health needs of adolescents: evidence from a formative evaluation in Wakiso district, Uganda. Reprod Health. 2015;12:35-7.
Lim LM, Singh K. Termination of pregnancy and unsafe abortion. Best Pract Res Clin Obstet Gynaecol. 2014;28(6):859-69.
World Health Organization. Health for World’s Adolescents. https://apps.who.int/adolescent/second-decade/section2/page1/recognizing-adolescence.html Accessed 25 November 2021.

Table 2 is available in the Supplementary Files section.

No competing interests reported.

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Factors influencing abortion decision-making of adolescents and young women: A narrative scoping review

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Abstract

Figures

Background

Research question

Objectives

Methods

Inclusion criteria

Search strategy

Study selection

Data extraction

Quality assessment

Results

Categories from the data

Personal

Desire for self-realization

Actualized her intentions

(Termination of Pregnancy [ToP], 17 years old, [30], P. 176)

Never give up education and career

Unwanted pregnancy

Dilemma and justification

Not ready to be a mother

Worry about physical health

Interpersonal

Parental impact

Pressure on making a choice regardless of her desire

Fear of rejection and disappointment

One young woman worried about rejection:

Mediate the decisions

Reaction of partner

Unstable relationship

One of the young women stated:

Negative and unhelpful

Consulted him but ignored her preference

Roles of peers and friends

Supported decision-making

Existence of own child

Could not cope with another child

Lack of support

Desire emotional and physical support

Social circumstances

Sexual crime

Rape and incest

Financial problem

Lack of financial autonomy

Limitation of choice

Fear of stigma

Perspectives of religion

Misconception and lack of knowledge

Underutilized healthcare services

Level of need for counseling

Unaffordable

Confidentiality and privacy issues

Healthcare provider’s negative attitude

Accessibility barriers

Discussion

Barriers To Autonomy Of Decision-making

Barriers To Accessibility Of Healthcare Services

Limitations and strengths

Conclusion

Abbreviations

Declarations

Conflicts of interest

References

Table 2

Additional Declarations

Supplementary Files

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