Online Abortion Empowerment in Absence of Parental and Medical Support: A Thematic Analysis of a Reddit Community’s Contributions to Decision-Making and Access

Family planning decisions can be inuenced by several factors, including social and clinical support. Lack of support can hinder autonomous and informed pregnancy choices and healthcare access. Adolescents commonly use the internet as a communication platform and information source. This study sought to identify online reports of parental paternalism’s inuence abortion knowledge and access, and how virtual a community responded to paternalistic determinants. We explored on an that houses virtual We identied relevant posts within the community using collection methods. Relevant posts included those that discussed parents, and (n=93); Of these, 58 t the research question. We analyzed initial posts and responses using theory-driven thematic analysis through collaborative deductive codes and thematic maps.

information and resources to overcome physical, nancial, and privacy barriers to abortion. With appropriate moderation from r/abortion administrators, r/abortion proved to be a safe space for users to share empowering messages, accurate information, and helpful resources. Policymakers and health providers can use these identi ed experiences to improve informed decision-making and abortion access, and may join r/abortion community to share reliable abortion information.

Background
Paternalistic mechanisms exist at policy and interpersonal levels, exerting power over autonomous decisions. Though paternalism seeks to employ structures protecting the welfare of individuals within a society, subjectivity interferes with beliefs of what is and is not harmful to an individual [1]. Since paternalism illustrates a process of those with power making decisions for the less powerful, it is no surprise that healthcare's paternalistic policies and mechanisms greatly impact patients with marginalized identities. This paper focuses on paternalism's impact on young females' abortion access and decision-making from both healthcare structure and parental involvement.
Anti-abortion policies create barriers to abortion information and services, resulting in inequitable access based on physical and nancial factors [2,3]. Beneath governmental regulations restricting Ob-gyn providers' ability to integrate abortion services, institutional culture and protocols further impede comprehensive family planning approaches [4,5]. These combined constructs contribute to abortion care's uncertain future in the United States, with the number of accessible abortion facilities uctuating over time, and disparities between county and state lines [6].
Though patients report desiring more autonomy in their family planning care compared to general health decisions (p<.001) [7], abortion decisions are in uenced by combined individual, interpersonal, and sociocultural concerns [8,9]. A previous study found that parental and medical paternalism played a role in adolescent reproductive health navigation, even when patients exceeded the age of majority [10].
Relatedly, younger and single women commonly con de in their mothers about abortion contemplation [11,12], and lack of support from parental gures, which often comes from cultural and religious values, can hinder psychological-wellbeing after terminating a pregnancy [13,14]. Despite these potential impacts of parental disclosure, a majority of states in the US require parental consent for minors' abortion procedures [15]. Moreover, medical paternalism is well documented in abortion care through power dynamics, coercion and directive counseling, and covert mechanisms of provider biases [16][17][18].
Women often use the internet as a source of reproductive health and health service information [19], and US regions with less comprehensive reproductive health access show more frequent Google searches on the topic of abortion, suggesting an unmet need from family planning services in these areas [20]. Since individuals may use the internet as an information source to overcome such barriers, online reports are opportune in identifying abortion barriers.
This study explored the interaction of parental and medical paternalism in anonymous online "Reddit" abortion discussions. Reddit is a social discussion website composed of online communities sub-divided by themes or topics (i.e. "subreddits") in which users can have anonymous discussions [21]. The "r/abortion" subreddit provides virtual space for discussing pregnancy options, abortion experiences, and emotional support relating to family planning issues [22]. R/abortion has over 12,000 members and is moderated by volunteer abortion professionals that set and enforce community rules to provide a safe environment (see https://www.onlineabortionresources.org/ for more information). Conducting research on this platform allowed our research team to observe natural conversations about parents' paternalistic abortion decision and access barriers, and analyze how virtual community responded to these barriers.

Methods
This research was exempt from review by a University of Waterloo ethics committee. Reddit customer support clari ed that this study was appropriate for their public use standards. We adopted Arksey and O'Malley's scoping review methodology to identify and select posts about parental paternalistic abortion determinants, chart, and collate data [23]. We searched through the "r/abortion subreddit" posts made between December 13 th , 2019 and March 1 st , 2020 (n=1222).
Each post was initially scanned for the following search terms: "mom", "mother", "parents", "family", "social support", *young age*, and *religious and/or conservative upbringing*. The study team agreed on these terms after a literature review of parental power in adolescent health decision-making and chosen based on previously mentioned literature proximate to family planning services navigation [8][9][10]14]. We monitored posts for ten days after the initial submission to incorporate user responses, as responses to original posts stopped or became scarce after about a week. We identi ed 93 posts that t the search terms. These posts and their respective responses were downloaded as PDF documents, read, and sorted into "include" (n=58) and "exclude" (n= 35) folders based on the research question "What are r/abortion users' responses to reports of paternalistic barriers?". These theory-driven data collection steps are outlined in gure 1.
We used theoretical thematic analysis to actively identify patterns of interest within the data and ceased data collection when saturation occurred [24]. We declared saturation at the point in time where no new information about paternalism's role in abortion was being shared. This method allowed exibility in the co-construction of ndings [25] within a non-traditional "data set". Theory-driven analysis included underpinnings of paternalism in the research question, post inclusion, deductive coding, and theme development. Moreover, our theory-driven analysis was appropriate to explore a narrowed research question applied to these abundant pre-existing data [24]. Thus, we were able to uncover individuals' surface level realities within the social world and delve deeper into paternalism's latent role in abortion autonomy barriers.
Two trained qualitative researchers analyzed posts in NVivo (v. 12). Trained female researchers (PhD candidate, BSc student) used deduction to separately identify, de ne, and code initial patterns. We then discussed how the two sets of initial patterns were related, resulting in an agreed codebook that guided us in re exive and iterative data examination. Researchers compared coded excerpts to con rm reliability and wrote memos throughout to document perceived emerging concepts. We used codes and memos to identify latent themes through thematic maps and tables which were modi ed, de ned, and approved by the study team. Analyses steps were rigorously documented through an audit trail of the analysis process including preliminary maps and gures, memos, team discussions, and stakeholder feedback.

Results
Reddit users identi ed crucial factors in family planning access and outlined the impact of paternalistic forces [26]. Parents often played a role in Reddit users' values and knowledge, family planning service navigation, and resulting abortion options and decisions. Healthcare systems were an agent of paternalism through law and policy, institutional protocols, and provider communication. Overall, parents and the health system were inherent in adolescents' ability to exercise bodily autonomy.

Reddit users' reports of intertwined medical and parental paternalism
Reddit users reported feeling manipulated by their parents and feared consequences of familial abandonment. Parents were frequently authoritative over their child's pregnancy and coerced abortion decisions. Most often, parental coercion occurred through shame, misinformation, and negative consequences.
Those that were able to access the clinical setting sometimes felt stigmatized and coerced by their provider. These individuals reported instances of provider bias and insensitivity, inadequate information about their options, and pressure to make uninformed decisions (e.g., lack of patient education about abortion procedure and side effects).
Though health systems and parents satis ed these needs in some cases, we found that medical paternalism often reinforced barriers imposed by parental paternalism. That is, existing healthcare policies and practices required parental authority and involvement or lacked provisions that empowered patients to act independently. In addition to the impact on wellbeing, the lack of parental and medical support extended into structural abortion access issues, including intersecting physical, nancial, and privacy barriers. Figure 2 outlines examples and relationships between these barriers. In absence of positive medical and parental in uence, Reddit users assumed supportive roles by providing advice and resources to those needing help navigating abortion care.

Physical Barriers
Paternalistic Issues The number of facilities offering abortion services were limited in many areas, with some regions not having a clinic. Therefore, abortion locations were often physically distant and lacked appointment availability. Other reasons for travel included abortion cost and gestational law variance between states. Facilities also varied in services, some only offering medical abortion which limited access to those at 8-10 weeks gestation. Some users reported that their parents helped overcome these physical barriers.
However, most individuals lacked the parental support that would typically provide health appointment transportation. Combined, abortion policies and unsupportive parents created panic, as pregnancy was often discovered just prior to gestational limitations which decreased time for decision-making and accessing services: "The only appointment they had available for an in-clinic abortion is somewhere really far away, and I don't have a car. The next available appointment in my area would be too late for me to do anything about it." -Adolescent r/abortion user R/abortion Support Reddit users replied to paternalistic physical barriers with information about how to access clinical services, and alternatives to clinic-based counseling and procedures and transportation options ( Table 1). Those struggling with clinic access were often referred to online information sources and medical teams that mail abortion pills to patients. R/abortion users provided website links that assisted with informed decision-making, transportation, and nding an abortion clinic. In addition to overcoming physical barriers, "internet" or "at-home" abortion addressed nancial obstacles through subsidized or free medication. At-home abortions raised con dentiality concerns for those living with parents. Therefore, users were encouraged to nd a private and comfortable space to undergo the procedure.

Paternalistic Issues
Finances played a large part in pregnancy decisions. Users considered the affordability of both abortion and supporting a child, and came to r/abortion for nancial advice. In some health systems, abortion was not adequately covered by health insurance. US residents had disparate experiences with how much of the abortion costs their insurance company paid, if any. They reported variation of costs between facilities, insurances, and states ($200 -$1000). In addition to differences by location and coverage, the type of procedure and gestational age were discussed as impacting the cost. As one individual recounted, "The farther along you are the more expensive it is. Planned Parenthood can't do it because I'm past 16 weeks". Some parents would not provide nancial help because they disagreed with abortion; this disclosure often strained the parent-child relationship. Young individuals covered under their parents' insurance were especially frustrated with balancing payment and con dentiality. There were several accounts of questions related to billing statement con dentiality and reports of billing exacerbating nancial abortion barriers, "I could not afford the pill before 10 weeks and still only have $300 to offer. I'm over 15 weeks and I cannot have this child. Not only will it force me to quit college but also lose my family, etc. I cannot use my insurance as my parent will find out and will be furious."-Adolescent r/abortion user R/abortion Support In response to nancial barriers, r/abortion users offered information about different health insurances, payment options, and coverage alternatives. In addition to internet-based abortion services, members guided enrollment in public health insurances that covered family planning and discussed which organizations subsidized or provided low-cost abortions (Table 1).

Privacy Barriers
Paternalistic Issues As shown above, nancial and privacy abortion barriers overlapped for those insured by a family plan. Though some had heard about programs that provided abortion funding, these alternatives added barriers of understanding and navigating the complexity of coverage and payment options, information that some did not have the tools to interpret. Patients were unclear about how to avoid documentation that would disclose abortion services to their parents even when they asked their provider about the billing process. The individual below explains their di culty in applying for a health insurance plan separate from her parents: "I applied for Medi-Cal [California Medicaid Insurance], it said I'm eligible?? I don't know how the fuck it works. They're supposed to send a card, but my mom takes all my mail and doesn't give it to me. If I don't have the card, I don't know how to use it. I don't even know if it will work." Private abortion procedures were further complicated by laws in different regions which required parental consent prior to abortion. While judicial bypass was an option, users found the process di cult and added steps to an already sensitive timeline. Therefore, it was sometimes easier to travel to a near-by state to terminate a pregnancy. Though some had the means to travel, others did not. Thus, privacy and physical barriers proved to be interconnected. Adjacent to clinical privacy concerns, it was di cult for individuals to conceal pregnancies and abortions from their parents. Those that lived with their parents were afraid they would recognize pregnancy changes (e.g., "morning" sickness) or abortion side effects (e.g., at-home medical abortion).

R/abortion Support
The r/abortion community gave unique advice on preserving con dentiality inside and outside of the clinical setting (Table 1). Users helped with the judicial bypass process, giving information on who to contact, how it works, and what information they need. Responses also frequently prepared others' expectations of pregnancy and abortion and how to keep both conditions private. Users gave descriptions of each abortion option to help determine which method would better maintain privacy. Others discussed how to avoid accidental parental disclosure through insurance billing statements.
Reddit as a valued community R/abortion users and administrators provided the support individuals lacked from their families and health systems. The r/abortion subreddit allowed easy access to multiple abortion resources, networks, and organizations. In addition, community members played a valuable role in providing emotional support and sharing advice. R/abortion was instrumental in helping individuals overcome paternalistic barriers and become more informed and comfortable with their decision.
Members helped others make informed decisions through personal family planning navigation experience and knowledge, and helped empower individuals considering, undergoing, and after having an abortion. Members collectively valued and encouraged bodily autonomy, as evidenced by the selected excerpts below: "You have the final say. Your body. Your choice. You're the one that will deal with the physical impact of either carrying to term, or abortion." "Do you want to be pregnant right now? The only reason 'needed' to want an abortion is that you no longer wish to be pregnant." "We support you no matter what you choose. Remember not to let anyone tell you how you should/do feel. Only you know that." One key tenet of this community was its designation as a judgement-free space. This eliminated stigma and allowed users to safely engage in a di cult discussion. The community re ected a variety of perspectives without the coercion they experienced from parents and the health system. Many expressed their appreciation for this virtual environment: "Reading through these threads has helped me feel not alone...Thank you so much." "Thank you everyone for your helpful and informative comments…thank you for providing me with judgement free zone." "It's bittersweet knowing that hundreds of people on this Reddit community can relate to me."

Discussion
Overall, paternalistic barriers t within a larger framework of abortion-seeking determinants, including barriers at the health system, socio-cultural, health institution, and personal knowledge levels [27].
Paternal actors can play a positive role in informed shared decision-making but can also hinder family planning decisions through misinformation and power dynamics [10]. This study shows negative aspects of paternalism, as experiences with paternalistic access barriers often brought individuals to participate in r/abortion conversations. This space alleviated concerns for many users considering, undergoing, or re ecting on abortion. Multiple users continued conversations to share the conclusion of their story and emphasize how the community's role in knowledge, encouragement, and validation. These follow-up posts illustrated how r/abortion helped offset abortion decision and access barriers.
A major impact of paternalism for r/abortion users resulted from policy variation between states, causing inequity and travel barriers. State Targeted Regulations of Abortion Providers (TRAP) impose clinical restrictions without directly criminalizing abortion [28]. Our analysis found that these factors were major barriers to r/abortion users, as they often discussed ways to mitigate restrictions through interstate travel. Likewise, a Texas-based study found that a gestational TRAP law was responsible for an 88% decrease in state abortions while the number of out-of-state abortions quadrupled [29]. However, according to our ndings, traveling to abortion services was most di cult for minors and those surrounded by networks with conservative political values.
Most US states require minors to obtain parental consent to terminate pregnancy [15]. Parental consent laws are structured with the assumption that adolescents are incapable of making an abortion decision. However, research shows minors are capable of making informed health choices, including abortion decisions, through health resources and consultations [9,30,31]. In addition, adolescents' risk of negative responses to parental abortion disclosure (e.g. abuse, withholding nancial and housing support) suggests that mandating parental involvement may cause more harm than the alleged consequences of abortion [9]. This research builds upon the argument to eliminate parental consent, as r/abortion users facing consent barriers feared or experienced negative parental consequences, and reported di culty navigating the judicial bypass in a timely manner.
Many individuals that sought support from the r/abortion community recommended telemedicine abortion as a solution to overcome physical and nancial abortion barriers. Abortion telemedicine refers to self-sourced medical abortion outside of the formal healthcare system that can be accessed over-thecounter or online [33,34]. Though only available up to ten weeks gestation, this abortion method has shown to be as effective and low-risk as clinical procedures.
Peer support can promote informed decision-making and increase abortion access through information that is otherwise di cult to attain. Virtual community anonymity facilitated candid abortion discussions and provided a reassuring, informative environment for those lacking familial and medical support. Primarily, Reddit users improved others' health literacy, allowing individuals to understand abortion procedures and health systems, and dispel misinformation. The variety of individual experiences coupled with the knowledge diversity ensured a dearth of informative content. This learning process could improve positive reproductive health outcomes through mechanisms of health care navigation, patientprovider communication, and informed decision-making [19,35].
This online platform provided a unique opportunity to observe candid conversations about abortion barriers. Our theory-driven analysis limited our scope to paternalistic barriers but identi ed ways parents and health systems could support autonomous abortion decisions. This study sought to explore subjective realities of abortion from 'patient' experiences which may be divergent to actual abortion policies that impact accessibility. To mitigate undue in uence on ndings, researchers worked closely with theory, documented memos throughout analysis, and reached consensus on interpretations as they related to paternalism in health access. Though we did not identify misinformation or negative correspondence in this community, these situations do occur and are removed by r/abortion moderators. Additionally, moderators mentioned that they are unable to prevent harmful private messages that may be sent to users.

Conclusion
While reproductive autonomy advocates continue to work toward abortion access as a long-term policy goal, stakeholders can also learn and address individuals' urgent barriers through platforms like r/abortion. The complexity of abortion access determinants results in variant individual needs. Therefore, experts can use virtual communities as a tool to directly engage in person-centered efforts outside of traditional health systems. Meeting patients outside of the clinical setting is especially important during the COVID-19 crisis as patients face added barriers to accessing clinics [36]. Relatedly, r/abortion users' endorsement of at-home medical abortion con rms patient desire and appropriateness of telehealth abortion services.

Declarations
Ethics approval and consent to participate: This research was exempt from review by a University of Waterloo research ethics committee. Reddit customer support con rmed that this study was appropriate for their public use standards.
Consent for Publication: Not applicable, public use standards do not require individual consent from anonymous users for publication.
Availability of data and materials: The data that support the ndings of this study are available from https://www.reddit.com/r/abortion/ but these data are sometimes archived, and so are not publicly available. Data are however available from the authors upon reasonable request.
Competing Interests: The authors declare that they have no competing interests.
Funding: Student researcher pay, and research dissemination fees were funded by an institutional HeForShe Equity Grant. The funder did not have a role in the study design, implementation, or manuscript preparation.
Author's Contributions: 1 developed the study design, assisted with data collection, co-coded and interpreted data, and contributed to manuscript development. 2 collected data, co-coded and analyzed data, and edited manuscript. 3 supervised study design and data collection, interpreted data, and contributed to manuscript development. All authors approved the submitted manuscript and are personally accountable for their own contributions. "In California, you should be eligible for temporary (or permanent) insurance through the state that will cover an abortion."

Judicial Bypass
Privacy "If you live in one of those states and cannot tell your parents, there's another option called Judicial bypass. This is when a judge gives you permission to get an abortion without telling your parents. There is an organization called Jane's Due Process that has a call and text line that can help you through the process and give you more information. [weblink]" Advice for proceduretype Privacy Transportation "I HIGHLY recommend a hotel. If hers is anything like mine she… won't be able to talk or say much from the pain… My parents would have 100% called an ambulance if I was at their house." "I would recommend an in-clinic ("surgical") abortion if you are trying to hide this from your parents. That way the entire process is done during the appointment.
Do you have someone to drive you there? You will need someone to drive home." Intersecting paternalistic abortion barriers

Supplementary Files
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