Table 1. Characteristics of 760 individuals who completed the list experiment in the quantitative, state-wide survey
|
(%)*
|
Age, years
|
|
18-29
|
37
|
30-39
|
48
|
40-49
|
15
|
Race/ethnicity
|
|
Black, non-Hispanic
|
12
|
White, non-Hispanic
|
36
|
Hispanic
|
44
|
Other, non-Hispanic
|
7
|
Marital Status
|
|
Married
|
50
|
Living with partner
|
12
|
Not married
|
38
|
Educational attainment
|
|
High school or less
|
39
|
Some college
|
34
|
College degree
|
26
|
Language of survey
|
|
English
|
78
|
Spanish
|
22
|
Prior induced abortion
|
12
|
Prior self-managed abortion attempt (direct question)
|
1.7
|
* weighted percentages
|
|
List experiment results
We found no evidence for a design effect in either list set (List set A: p=0.99; List set B: p=0.94). The weighted results estimate that 8.6% (95% CI: 4-14%) of the population had ever attempted to end an unwanted pregnancy on their own. When restricted to individuals who reported ever having had intercourse with a man, the list experiment estimated that 8.2% (95%CI: 3-13%) had ever attempted to end an unwanted pregnancy on their own (Table 2).
Table 2. List experiment estimates of abortion self-induction attempts. All numbers are percentages.
Unweighted Results
|
List 1 Estimate
|
List 2 Estimate
|
Final List Estimate
|
95% CI
|
Overall
|
13.9
|
6.0
|
9.9
|
4-15
|
Ever had sex
|
15.2
|
7.7
|
11.5
|
5-17
|
Weighted Results
|
List 1 Estimate
|
List 2 Estimate
|
Final List Estimate
|
95% CI
|
Overall
|
11.8
|
5.5
|
8.6
|
4-14
|
Ever had sex
|
10.7
|
5.6
|
8.2
|
3-13
|
Cognitive interview sample
Twenty-six individuals participated in the cognitive interview portion of the study: four in Birmingham, Alabama, four from the Dallas, Texas area, four from El Paso, Texas, six in the Lower Rio Grande Valley of Texas, four in Bloomington, Indiana, and four in San Francisco, California. On average, participants were 26 years old (range: 20-44 years), 13 identified as Hispanic, six as non-Hispanic White, and four as non-Hispanic Black, 10 disclosed a prior abortion, and 5 disclosed a prior attempt to end an unwanted pregnancy on their own (Table 3). Of the five reported prior experiences with self-managed abortion, one was not known to the research team at the time of recruitment.
Table 3. Characteristics of 26 cognitive interview participants
|
|
n
|
Age, years
|
|
|
18-29
|
|
18
|
30-39
|
|
6
|
40-49
|
|
2
|
Race/ethnicity
|
|
|
Black, non-Hispanic
|
|
4
|
White, non-Hispanic
|
|
6
|
Hispanic
|
|
13
|
Other, non-Hispanic
|
|
3
|
Marital Status
|
|
|
Married
|
|
7
|
Living with partner
|
|
6
|
Not married
|
|
13
|
Educational attainment
|
|
|
High school or less
|
|
8
|
Some college
|
|
9
|
College degree
|
|
9
|
Language of interview
|
|
|
English
|
|
19
|
Spanish
|
|
7
|
Prior induced abortion
|
|
10
|
Prior self-managed abortion attempt (direct question)
|
|
5
|
List item phrasing
All participants were asked to provide interpretations of four variants of the list experiment item asking about experience with self-management of abortion. One of the variants, “Have you ever taken or done something to try and end an unwanted pregnancy on your own?”, was the text used in the list experiment fielded in Texas in 2015. The most common interpretation of this text was having an abortion outside of a clinic setting, without medical assistance or supervision (n=11/26).
“To me, it means have I done something, like, outside of a doctor’s office or in a health setting myself at home to try to end an unwanted pregnancy (…) Without the, you know, without the benefit of a health care provider. That’s what that means to me.” -Indiana, age 39
Four other women mentioned self-induction of abortion on their own, but without explicitly mentioning the lack of medical involvement. Other interpretations included having an abortion secretively or without the support or knowledge of friends, partners or family members, regardless of location (n=4/26):
"On my own" to me means literally on my own, like independently, in private, probably, by myself." – Texas, age 24.
For others, this item could include an in-clinic abortion where pills were dispensed at the clinic and the abortion completes at home.
“Yeah. I think of at-home abortions when I read that. And then "taken," I think of, don't you have - don't they have, some medicine that you can take? Even, like, the doctor can give it to you and send you home with it and it'll, like, make you have an abortion. So, that would be on my own, too, because I didn't do it at the hospital.” – Alabama, age 36
Similarly, others might include an in-clinic abortion under this item so long as the person made the decision to have the abortion independently, or paid for the procedure without any help (n=3/26).
"Like, on my own, my own decision--not necessarily with your money or something like that" – Texas, age 25, Spanish speaker
Of the four item variants, the most preferred phrasing read: “Have you ever taken or done something to try and end an unwanted pregnancy on your own, without medical assistance?” The main difference between this question and the prior phrasing was that adding “without medical assistance” seemed to change the abortion experiences that could be included in this category. For instance, a number of participants felt that this language allowed the respondent to include abortions done with social support from peers, partners, or family; whereas, in the previous question, these abortions were excluded because they were not thought to be done truly “on one’s own”.
“The previous question with that aspect of on your own was a little unclear as to whether it meant truly alone in doing these things to yourself or having somebody there to help you who just may not me a medical professional, but may still be knowledgeable about what they are doing or they are ready to help you (…) For example, if this had been my experience I would be more likely to explain a situation where a friend had helped me do something like this than I would have in the other one because it wouldn’t have truly been on my own.” – Indiana, age 20
Few respondents preferred the other two phrasing options tested in the cognitive interviews (“Ever taken anything on your own to try to bring back your period or end a pregnancy”; and “Ever taken or done anything on your own to try to self-induce an abortion”). Many participants commented that “bring back your period” was too vague and that it did not resonate with the language they used to talk about abortion. One participant captured this viewpoint as follows:
“Bring back your period or end a pregnancy? That seems like two very different questions. […]
I think I understand what it's trying to get at, which might be that using "bring back your period" as another way to say end a pregnancy or not be pregnant? I mean, I think I feel like that's what you're trying to ask. But I think that there are other contexts that "bring back your period" would work in. And, I don't think anyone uses that terminology. I've never, ever heard, you know, hey, have you seen my - have you heard about Jessica? She brought back her period. It's, you know, she had a miscarriage. She had an abortion. She, you know, took the day after pill.” – Alabama, age 36
While a number of participants appreciated the clarity and precision of the “self-induce an abortion” language, they also felt that the word “abortion” might carry too much stigma and “scare people away” and thus cause respondents to under-report abortion experiences as a result.
Methods of self-managed abortion
For each of the four phrasing options, participants were asked about the methods of abortion that the wording brought to mind. Participants provided varied responses, including abortion pills, contraceptives, Plan B, tea, herbs, home remedies, and other methods such as falling down the stairs, hitting oneself in the stomach, or abusing alcohol or other substances. When asked about “on your own,” participants mentioned medications and contraceptive methods more often, as compared to when asked about “on your own without medical assistance,” when slightly more participants mentioned dangerous methods of abortion self-induction such as using a hanger, punching one’s stomach, or falling down the stairs. All methods mentioned by participants for each of the phrasing options are presented in Table 4.
Table 4. Self-managed abortion methods brought to mind for participants by different phrasings of the self-managed abortion list item.
|
|
Phrasings
|
|
Total*
|
"on your own"
|
"on your own without medical assistance"
|
"bring back your period"
|
"self-induce an abortion"
|
Drugs or alcohol
|
12
|
4
|
3
|
2
|
3
|
Teas or herbs
|
19
|
4
|
4
|
5
|
6
|
Hitting oneself/causing oneself physical harm
|
21
|
5
|
7
|
1
|
8
|
Hanger
|
10
|
3
|
4
|
1
|
2
|
Medication/pill
|
34
|
10
|
10
|
7
|
7
|
Plan B
|
10
|
3
|
1
|
4
|
2
|
Contraceptives
|
11
|
4
|
1
|
4
|
2
|
Home remedies/toxic substances
|
15
|
2
|
3
|
6
|
4
|
Suction/In clinic
|
7
|
3
|
0
|
3
|
1
|
*Participants often mentioned the same methods for more than one phrasing, and thus, total numbers add to more than the total sample size of n=26
List experiment format
The majority of interviewees (n=20) understood the list experiment instructions, provided answers in the correct format, and felt confident in their responses. Participants who understood the list experiment questions correctly gave numbers as their answers to indicate how many of the listed experiences they had experienced, rather than specifying which items they had experienced. Despite accurate responses to the question format, not all participants understood why the question was being asked. One participant provided a succinct description of this viewpoint:
“I feel like it’s noninvasive because someone doesn’t have to check all that apply. But I’m not sure if it gets you the answer you’re looking for. But on the responder end, I would feel comfortable with putting a number because you’re not going to be able to [know which I’ve done] – or maybe you can. But when I first think, I’m like, oh, yes, I’ll just say what it is.” – California, age 29
Several respondents hypothesized that the question was structured to measure individual’s access to the listed sexual and reproductive health services, rather than any individual item:
Interviewer: “What do you think these series of these two questions next to each other, what do you think they are trying to ask? What are they trying to understand?”
Respondent: “Probably access. That’s kind of my interpretation of that, is you’re probably trying to understand what kind of health care you have received and what you’ve had access to. That’s basically what I get from it.” – Indiana, age 31
Most felt confident that the interviewer could not know if they had experienced any particular item on the list: “Yeah, so it’s kind of trying to protect us from personal information too.”- Texas, age 22. Some, however, felt that the interviewer might be able to tell which specific items on the list they had done, although this did not seem to deter them from answering honestly.
Interviewer: Do you feel like I know, well, yes, she maybe had a pap smear, and yes, she's used birth control? Or, do you think there's no way for me to know which items you have done?
Respondent: I'm pretty sure there's a way. Between asking both questions, there has to be some sort of pattern.
Interviewer: Okay. So, did that - did your feeling that way make you want to change the way you answered?
Respondent: Oh, no. I would still answer. I would feel comfortable. – California, age 29
Among participants who did not find the list experiment instructions clear, some wanted to provide a yes/no response for each list item, while others provided a numeric response, but were not confident that this was the correct way to answer the question. Beyond the format of the list experiment, we found that a number of respondents were not familiar with some of the individual list items, specifically “pap smear” (n=4) and “tubal/ectopic pregnancy” (n=9), and as a result, some felt that they did not know how to answer the question.