Barriers and facilitators of access tofirst-trimester abortion services forwomen in the developed world:a systematic review

Frances Doran,1 Susan Nancarrow2

▸ Additional material ispublished online only. To viewplease visit the journal online(http://dx.doi.org/10.1136/jfprhc-2013-100862).

1Senior Lecturer, School ofHealth and Human Sciences,Southern Cross University,Lismore, New South Wales,Australia2Professor of Health Sciences,School of Health and HumanSciences, Southern CrossUniversity, Lismore, New SouthWales, Australia

Correspondence toDr Frances Doran, School ofHealth and Human Sciences,Southern Cross University,PO Box 157, Lismore,NSW 2480, Australia;frances.doran@scu.edu.au

Received 16 December 2013Revised 13 January 2015Accepted 14 April 2015

To cite: Doran F,Nancarrow S. J Fam PlannReprod Health Care2015;41:170–180.

ABSTRACTObjectives To identify the barriers andfacilitators to accessing first-trimester abortionservices for women in the developed world.Methods Systematic review of publishedliterature. CINAHL, PubMed, Proquest, MEDLINE,InformIT, Scopus, PsycINFO and Academic SearchPremier were searched for papers written in theEnglish language, from the developed world,including quantitative and qualitative articlespublished between 1993 and 2014.Results The search initially yielded 2511 articles.After screening of title, abstract and removingduplicates, 38 articles were reviewed. From theprovider perspective, barriers included moralopposition to abortion, lack of training, too fewphysicians, staff harassment, and insufficienthospital resources, particularly in rural areas.From the women’s perspective, barriers includedlack of access to services (including distance andlack of service availability), negative attitudes ofstaff, and the associated costs of the abortionprocedure. Service access could be enhanced byincreasing training, particularly for mid-levelpractitioners; by increasing the range of serviceoptions, including the use of telehealth; and bycreating clear guidelines and referral proceduresto alternative providers when staff have a moralopposition to abortion.Conclusion Despite fewer legal barriers toaccessing abortion services, the evidence fromthis review suggests that women in developedcountries still face significant inequities in termsof the level of quality and access to services asrecommended by the World HealthOrganization.

BACKGROUNDInduced abortion is a relatively commonexperience for women. Globally, one infive pregnancies is estimated to end inabortion.1 2 In 2008, more than 43million abortions were performed

worldwide, an abortion rate of 28 per1000 women aged 15–44 years.3

Induced abortion can be medical or sur-gical.4 The World Health Organization’s(WHO) recommended regime for earlymedical abortion involves a combinationof mifepristone with misoprostol.4 Mostabortions are performed surgically and inthe first trimester of pregnancy.5–7

Despite the abortifacient medicationmifepristone being listed as an essentialmedicine by the WHO since 2005,8 accessto medical abortion is still subject tointernational variations. Where medicalabortion is more readily available it iswidely used. For example in France,Scotland, Sweden and Switzerland, morethan half of all abortions are performedusing mifepristone.9 10 Conversely, restric-tions on providers and on availability ofmedical abortion affects provision.11 12 Forexample, in Canada, where mifepristone isnot licensed, medical abortion accounted

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Key message points

▸ Despite fewer legal constraints than inthe developing world, women andservice providers in developed countriesface barriers in relation to provision ofabortion services and their access tothem.

▸ Lack of local services, especially inrural areas, the need to travel, negativeattitudes and lack of training opportun-ities constrain access to abortion.

▸ Increasing the range of service options,including the use of telemedicine andcorrect referral processes when staffhave a moral opposition to abortionservices, would enhance access.

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for 4% of abortions in hospitals in 2009,12 althoughsome abortions are performed using methotrexate.When performed legally and in a regulated environ-

ment, abortion is one of the safest elective medicalinterventions,1 4 yet access to abortion services isproblematic. Even when abortion is legal and avail-able, women in developed countries are restrictedfrom accessing abortion services in many ways.13

Where abortion is located in the criminal code14 15 itcreates a lack of confidence for both women and theirdoctors.16 17 It also hinders coordinated policy devel-opment, service delivery and equitable access to safe,legal and affordable abortion services.18

National variations around the availability andaccessibility of abortion reflect the culture, economicstatus and religious beliefs of each country.19 In theNetherlands, France and Slovenia, abortion is rela-tively accessible in terms of facilities, fees and healthinsurance coverage. In Ireland, the Protection of Lifeduring Pregnancy Act 2013 permits abortion only tosave a woman’s life. No abortion services are availablein Ireland, so Irish women must travel abroad.The provision of abortion services is an important

clinical, public health and political issue for womenworldwide. Around 60% of women live in countriesthat support women’s decision to have an abortionwithout restriction.4 Abortion is prohibited, orallowed only to save a woman’s life, in 72 countries.4

Countries with liberal abortion laws have low abor-tion rates1 4 but access to abortion is still constrainedby social, economic and health system barriers, stigmaand negative social attitudes.20 Despite the well-known obstacles to access to and provision of abortionservices, there is a significant gap in the literature sur-rounding accessibility of abortion services.This paper draws on a systematic literature review

to identify the factors that facilitate and hinderaccess to abortion services for women in developedcountries in relation to first-trimester abortions, fromthe perspective of both the woman and the serviceprovider.

METHODSWe searched CINAHL, PubMed, Proquest, MEDLINE,InformIT, Scopus, PsycINFO and Academic SearchPremier databases. Citation searches of the bibliograph-ies of relevant articles were also undertaken usingGoogle Scholar. Searches were restricted to the Englishlanguage, the developed world, quantitative, qualitativeand studies synthesising diverse evidence between 1993and 2014. See online-only Supplementary MaterialAppendix 1 for a sample search strategy.Quality assessment of the literature was undertaken

by both authors, using the “Standard QualityAssessment Criteria”21 (see online-only SupplementaryMaterial Appendix 2). Each article was independentlyreviewed and quality assessed by both authors. Eachitem was scored according to the degree that the

specific criteria were met. Papers are reported as highquality (all or most of the criteria fulfilled), goodquality (many of the criteria fulfilled) or poor quality(few of the criteria fulfilled).First-trimester abortions are examined specifically as

abortion beyond the first trimester has more legal con-straints that specifically influence access. The reviewexcludes women’s reasons for abortion,22 23 abortionin adolescence,24 25 late-stage abortion,5 access issuesin relation to safe abortion,20 women in developingcountries3 26 or countries where abortion is legallyrestricted27 28 as the contextual social and legal accessissues were likely to vary too much between settings.

ANALYSISWe drew on the principles of thematic analysis29 toidentify barriers and facilitators to access to abortionservices from the woman’s and provider’s perspec-tives. Through a collaborative process the authorsidentified key factors which are discussed under separ-ate headings below. This method integrates the find-ings from all of the included papers.24

RESULTSThe initial search yielded 2251 articles. After screen-ing title, abstract and removing duplicates, 58 articleswere deemed eligible for full-text screening. Bothauthors independently reviewed all papers against theinclusion criteria. Both authors discussed theirdecision-making and any discrepancies of studies eli-gible for inclusion. Of the 58 full text articles, 18were excluded because they did not focus on accessissues from either a woman’s or provider’s perspec-tive. See Figure 1 for a modified Preferred ReportingItems for Systematic Reviews and Meta-Analysis(PRISMA) flow diagram.30

Of the 38 included papers, one was mixedmethods, six were qualitative, five were review of sec-ondary data and 26 were quantitative articles. Thequalitative studies involved focus groups and inter-views. The quantitative studies were primarily surveybased and only four randomised survey participants.There were no experimental studies.Included papers were from the USA (22), Canada

(5), Australia (2), New Zealand (1), France (1),Norway (2), Sweden (1), Northern Ireland/Norway(1) and the UK (3). The results of the quality assess-ment and characteristics of the primary papersincluded in this review are outlined in Table 1.Chapter 3 in the WHO guidelines for Safe

Abortion: Technical and Policy Guidance for HealthSystems1 establishes a series of principles that supportsafe abortion services, and for guidelines that facilitateaccess to safe abortion services to the full extent ofthe law. The guidance specifies that to optimise accessto safe abortion services, health services and systemsneed to: establish national standards and guidelines tofacilitate access to safe abortion care to the full

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extent of the law; ensure appropriate training andmonitoring of health providers, including mid-level(non-physician) practitioners; financing of abortionservices; timely access to services for women at theappropriate stage of their pregnancy; and access toappropriate equipment and medication. The results ofthis review are structured to reflect these broadprinciples.

Appropriate training and monitoring of health providers,including mid-level (non-physician) practitionersAttitudes of current health care providersThe quality and accessibility of abortion servicesare influenced by health care provider attitudes toabortion. Not surprisingly, there are international,regional and professional variations in attitudes toabortion. Comparisons need to be treated cau-tiously because of different approaches to surveyadministration.Reported rates of opposition to abortion ranged

from a high of 35% in rural physicians in Idaho, USA,who opposed abortion because of religious beliefs andcommunity opposition,31 compared to the majority ofpractising midwives and gynaecologists in Swedensupporting abortion.32 Around 20% of practisinggeneral practitioners (GPs) surveyed in the UK wereanti-abortion,33 although 60% of supporters believedthe law should be liberalised to give women the rightto choose an abortion without restriction or reason.33

Moral opposition to abortionSeveral studies explored provider attitudes towardsabortion and abortion law.31–33 Of British GPs sur-veyed, 20% with anti-abortion beliefs felt theyshould not have to declare this to a woman seekingaccess to abortion services.33 Similarly, over 35% ofrural physicians surveyed from Idaho, USA reporteda moral opposition to abortion and unwillingness to

refer to another provider.31 As only 2/114 familyphysicians surveyed perform surgical abortions it wasnot surprising that 80% of physicians in this studyhad moral objections to abortion. Reasons for notproviding abortion services were religious and com-munity opposition.31

Negative attitudes of non-physician staff restrictedaccess to abortion.34 35 One study reported an unwill-ingness of nurses to deliver abortion services.34

Another identified staff conflicts and service deliverybarriers amongst operating theatre nurses or anaesthe-tists unwilling to provide abortion services in ruralhospitals in the USA.35 Additionally, staff attitudesimpacted negatively on the women’s experiences ofabortion services.36 37 More than 10% of Canadianwomen said that staff at abortion clinics were rude,37

and almost half of women surveyed reported a lack ofsupport from the physician and clinical team.36

Conscientious objection was specifically explored inthree studies of health professionals.38–40 Some GPsin Norway reported ambivalence towards their ownrefusal practices related to a non-absolutist conscien-tious objection stance illustrated by willingness tomake certain compromises to refer women.39

Although most physicians surveyed in the USA did notreport an objection to abortion in general, abortionfor gender selection was not supported by 75% ofparticipants.38 Obstetricians and gynaecologists in theUSA asked to comment on a vignette of a physician’srefusal of a requested medical abortion found thatwhilst almost half the participants supported the con-scientious refusal by the vignette doctor, supportdecreased when the doctor disclosed objections topatients, particularly for male participants.40

Future health care providersEight studies explored the attitudes of future serviceproviders towards abortion.38 41–47 Attitudes were

Figure 1 Modified Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram.31

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Table 1 Characteristics of the primary papers included in this review

Reference/country QualityData collectionmethod Sample size Participants Focus of study Perspective

Mixed method articleWeiebe and Sandhu53

CanadaGood Survey and

interviewsn=402Interviews n=39Convenience

Women accessing abortionclinics

Barriers to access abortion W

Qualitative articlesHarvey et al.62

USAGood Focus groups n=73

3 groupsWomen from familyplanning clinics

Medical abortion knowledge W

Bessett et al.55

USALow Interviews n=39 Women eligible for

subsidised insuranceBarriers to obtaining funds;impact on timely abortion

W

Dennis and Blanchard54

USAHigh Interviews n=68 Providers from 15 states

with restrictive Medicaidfunding

Evaluate Medicaid abortionpolicies

P

Dressler et al.35

CanadaGood Interviews n=20 Rural and urban physician

abortion providersExperiences of rural andurban physician abortionproviders

P

Grindlay et al.59

USAHigh Interviews n=25 Staff and users of Planned

Parenthood clinicsAcceptability of telemedicinefor medical abortion

W and P

Nordberg et al.39

NorwayLow Interviews n=7 Christian GPs Conscientious objection to

abortion referralsP

Quantitative articlesHenshaw56

USAHigh Survey n=1525 Non-hospital abortion

providersFactors hindering access toabortion service

P

Rosenblatt et al.31

USAPoor Survey n=138 Physicians, specialists Attitudes and practices P

Ferris et al.65

CanadaGood Survey n=301 Health professionals from

provider and non-providerhospitals

Variations in availability anddistribution of abortionservices

P

Hammarstedt et al.32

SwedenGood Survey n=444 Midwives and

gynaecologistsViews on legal abortion P

Rosenblattt et al.42

USAPoor Survey n=219 University medical students Attitudes towards abortion PP

Francome andFreeman33

UK

High Survey n=702 GPs from British MedicalAssociation

Attitudes towards abortion P

Henshaw and Finer2

USAHigh Survey n=1819 facilities Non-hospital abortion

providersDelivery of services andnumber performed

P

Moreau et al.36

FranceHigh Interviews n=480 Population based Patterns of care W

Shotorbani et al.41

USAGood Survey n=312 Health science students Intention to provide abortion

servicesPP

Kade et al.34

USAPoor Survey and

interviewsn=20 Physicians and nurse

managersNurse attitudes to abortion P

Hwang et al.43

USAHigh Survey n=1176 Licensed advanced

practitionersIntention to provide abortionservices

PP

Schwarz et al.44

USALow Survey n=212 Medical residents in

trainingWillingness to providemedical abortion

PP

Nickson et al.50

AustraliaGood Survey n=1244 Women from 8 major

abortion providersExtent and cost of travel W

Sethna and Doull37

CanadaGood Survey n=1022 Women who accessed

private clinicCost, distance, experiences W

Gleeson et al.46

UKLow Survey n=300 Medical students Attitudes towards abortion PP

Shochet and Trussell58

USAHigh Interviews n=208 Women who accessed

private clinicsMethod selection, providerpreference

W

Steele45

Northern Ireland andNorway

Low Survey n=145 Medical students Comparison of attitudes PP

Continued

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generally positive, with pro-choice attitudes, willing-ness to provide abortion services, for the service to beexpanded to non-physicians and to attend trainingprogrammes reported.38 41–46

In California, around a quarter of licensed advancedpractice clinicians wanted training to be able toprovide medical abortion.43 Almost half the traineemedical residents surveyed from the San FranciscoBay area indicated willingness to provide medicalabortion but 35% of trainee gynaecologists, 74% offamily practitioners and 84% of internists were con-cerned about inadequate backup access to vacuumaspiration services. Predictors of positive attitudesincluded a belief that mifepristone was very safe andthat women needed the service.44

In one study over 60% of medical students surveyedin the UK were pro-choice. Their beliefs correlatedpositively with willingness to be involved in abortionprocedures.46 Two studies on medical students’attitudes in the UK found that most supported theright to conscientious objection which was higher inMuslim students compared to other religious

groups,48 and despite an objection to abortion fewwere unwilling to perform the procedure.38

Abortion on demand was acceptable to almost 90%of Norwegian medical students surveyed. Morefavourable attitudes were apparent in the final yearsof training compared to first-year students, when 27%wanted to exercise their right to conscientiousobjection.48

A comparison of the abortion attitudes of medicalstudents in Northern Ireland and Norway foundsignificant differences. Almost 80% of Norwegian stu-dents were pro-abortion compared to less than 15%in Northern Ireland, reflecting differences in religious,legal and educational experiences.45

Financing of abortion servicesCosts of travelThe direct and indirect costs of travel – including timeaway from work or studies; extended arrangements forchild care; transport, accommodation and cost of meals;poor continuity of care and significant time away fromhome – were identified in four studies.37 49–51

Table 1 Continued

Reference/country QualityData collectionmethod Sample size Participants Focus of study Perspective

Jones and Kooistra52

USAHigh Survey n=2344 facilities Current and potential

providers facilitiesIncidence and access toservice

P

Godfrey et al.57

USAGood Survey n=299 Women attending 2

abortion clinicsFactors influencing women’schoice

W

Frank38

USAPoor Survey n=154 Family medicine, physician

residents, facultyConscientious refusal P

Grossman et al.61

USAHigh Survey n=578 Women seeking medical

abortion from 6 clinicsAcceptability of telemedicinecompared with face-to-faceservice provision

W

Hagen et al.48

NorwayLow Survey n=514 Medical students Attitudes towards abortion PP

Page et al.11

USAGood Survey n=102 Women attending

community health clinicAttitudes to medical abortion W

Rasinski et al.40

USAGood Survey n=1154 Obstetricians,

gynaecologists, physiciansConscientious refusal P

Strickland47

UKPoor Survey n=733 Medical students Conscientious objection PP

Norman et al.63

CanadaGood Surveys and

interviewsn=39 Rural and urban abortion

providersDistribution, practice andexperiences

P

Review of secondary data sourcesDobie et al.64

USAHigh Population data

and abortionreports

Compareddecade

NA Comparison of availabilityand outcomes of abortionservices

W and P

Nickson et al.51

AustraliaGood Health data Women who

claimedMedicare

NA Use of interstate abortionservice

W

Silva and McNeill49

New ZealandGood Population data

and abortionservice

Regional councilsn=16

NA Geographic access W

Yunzal-Butler et al.67

USAHigh Population health

datan=667 633procedures

NA Trends in medical abortion W and P

Grossman et al.60

USAHigh Abortion clinic

datan=17 956encounters

NA Compared telemedicinemodel to service delivery inclinics

W and P

GP, general practitioner; NA, not applicable; P, provider, PP, potential provider; W, woman.

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Cost of abortion procedureThe cost of abortion procedures was identified as abarrier in four studies.2 37 52 53 Almost 20% ofCanadian women who accessed an abortion clinicreported that the fees were too high.37 One study spe-cifically explored the experiences of Medicaid abortioncoverage and the impact on low-income abortionclients54 and another study explored women’s experi-ences of accessing subsidised insurance funds for abor-tion.55 In the USA, hospital-based abortions costaround six times that of non-hospital abortions andincrease sharply beyond a gestational age of 12 weeks.Almost 75% of women self-fund their abortions.2

Research undertaken in 15 USA states revealed that inonly two states were 97% of submitted claims funded,and women with low incomes experienced significantchallenges to access affordable and timely care.54

Women who qualify for Medicaid have delays in reim-bursement, which sometimes prohibits them fromaccessing abortion.56 Delays in accessing resulted in aninability to access an abortion; later abortions for somewomen; and inability to access a medical abortion.55

In the USA in 2008, medical abortion at 10 weekswas reported to be more expensive than surgical abor-tion except in facilities with smaller caseloads thatpossibly specialised in medical abortion and chargedmore for surgical abortion because of training andequipment.52 Conversely, possible reasons for higherfees for medical abortion were linked to the ‘newertechnology’ and high cost of the drugs.52

Timely access to services for women at the appropriatestage of their pregnancyAccess to abortion services was influenced by a rangeof factors, including service and appointment avail-ability and proximity, gestational limits on service pro-vision, and choice and type of facility.

Appointment availabilityLack of appointment availability for abortion serviceswas reported in three Canadian studies37 53 56 andnumber of abortion centres contacted was reported inone French study.36 More than 35% of Canadianwomen reported that no appointments were availablewhen they first contacted the abortion service, whichcaused critical inconvenience.37 However, a 1992study of non-hospital abortion providers found thatthe time between first contact with the service and thereceipt of the abortion was quite short, 50% within4 days.56 A Canadian study reported that waitingtimes for an abortion are significantly shorter inprivate clinics than for government-funded services,and 85% of women said that they would be willing topay for an earlier abortion.53

Choice of facility or settingFive studies explored women’s preferences for differ-ent models of abortion services.11 36 56–58 Women inChicago and New York, USA were asked to specify

their service location preference for a first-trimesterabortion. The majority (60%) preferred to see a doctorat a primary care clinic because they were comfortablewith their known provider and the doctor was familiarwith their medical history. Women who expressed apreference for an abortion at a dedicated clinic listedreasons such as “specialisation”, “privacy and anonym-ity” when the procedure is “separate” from the usualsource of care.57 In a survey of a clinical sample ofwomen in New York, the majority (87%) expressed apreference for receiving a medication abortion fromtheir primary care doctor.11 Another study found somewomen choose to travel for anonymity, lower fees orto access a surgical abortion which might not be avail-able locally.56 One study compared women’s providerpreferences (GP or obstetrician/gynaecologist) andabortion methods.58 Most women expressed a prefer-ence for an obstetrician/gynaecologist; however, thechoice of abortion method was the main predictor ofservice preference.59

Provision of medical termination via telemedicineA study in Iowa, USA explored provider acceptabilityof the provision of telemedicine for medical abor-tion.59 Staff cited benefits such as greater reach ofphysicians, greater efficiency of resources, reducedtravel, fewer cancellations due to travel and weather,greater appointment availability and location, and theability to better meet time deadlines with narrowtimeframes. A follow-up study comparing servicedelivery patterns before and after the introduction oftelemedicine provision of medical abortion found anoverall decrease in the abortion rate but an increase inthe number of medical abortions and abortions before13 weeks’ gestation for women who lived more than50 miles from the clinic.60

One study compared the effectiveness and accept-ability of medical abortion via telemedicine withstandard, face-to-face care.61 Both models were com-parable in relation to clinical outcomes and satisfac-tion. Factors that influenced women’s decisions tohave a medical abortion via telemedicine included adesire for a medical termination (71%), as early aspossible (94%) and closer to home (69%). A qualita-tive analysis of the same telemedicine setting foundthat telemedicine was generally acceptable for medicaltermination as it reduced the need to travel, therebyreducing costs and enabling earlier access to the abor-tion.59 Over 80% of women interviewed in New Yorkat an internal medicine practice stated the importanceof the availability of medical abortions, and if it wasan option over 87% would consider having a medicalabortion at the clinic.62

Availability and acceptability of medical abortionThree studies explored the acceptability of medicalabortion.4 59 62 In a study of acceptability of mifepris-tone before it was approved for general usage, morethan a third of women said they would choose

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mifepristone if it was available.62 Women perceived itcould increase anonymity of abortion as it can bebetween the provider and the woman.62 Despite fewphysicians providing abortion services in Iowa, USA,around one-quarter said they would prescribe mife-pristone if it became available.31 Some 25% oflicensed advanced clinicians in the USA were inter-ested in receiving medical abortion training.44

Gestational limitsThis review focused on women’s access to first-trimester abortion, up to 12 weeks’ gestation. Most ofthe studies identified gestational limits only withregard to early- or late-stage abortion with minimalbarriers to first-trimester abortion reported in fourstudies.2 37 41 52 In the USA, although 98% of thefacilities provided services to women up to andincluding 8 weeks’ gestation, fewer than half provideservices at 13 weeks and many set limits between 11and 12 weeks.2 In Canada limits are more stringent,and only 36% of provider hospitals perform abortionsup to a maximum gestational age of 12 weeks.37

Lack of services in rural areasNine studies explored geographical obstacles to careand travel undertaken by women to access abortionproviders.37 49–51 56 59 63 64 Women travel between 1and 12 hours to access services. More than 15% ofwomen in Canada travelled between 101 and 1000kilometres to access an abortion provider.37 Youngwomen,37 50 indigenous women49 and women on lowincomes are disproportionately affected.37 Womenwho travel are more likely to have an abortion laterthan 12 weeks’ gestation compared to those who donot travel.64 However, the introduction of medicalabortion via telemedicine was found to increase ratesof medical abortion among women living more than50 miles from the nearest clinic offering surgicalabortion.60

The reasons that women in rural areas travelinclude: insufficient services in their local area; lack ofdoctors willing to perform abortions; confidential-ity;49–51 to access a provider who charges lower fees;or to access surgical abortion.56

Provider experienceThe initial service contact was also found to influencewomen’s subsequent access to abortion.36 53 Womenwho first contacted a private gynaecologist, the mostcommon situation in France, were more likely to bereferred directly to the abortion service and experi-enced fewer time delays compared to women who firstaccessed their GP.36 Less educated women who firstaccessed a GP had lengthier delays before accessing anabortion.36 Although most Canadian women werereferred to an abortion service by a physician, theresults of qualitative interviews revealed that this wasdistressing for some women and caused interference toaccess for self-referral.53 Ninety percent of French

women contacted only one abortion service wherethey subsequently had their abortion.36

Harassment of women and providersHarassment of staff and women is a well-knownbarrier to providing and accessing abortion ser-vices.2 43 52 63 65 66 Of all the abortion providers sur-veyed in the USA, 57% of non-hospital providersexperienced anti-abortion harassment in 2008.52

Harassment was much higher in conservative ruralareas such as the mid-West and Southern states.2 52

Actual or potential harassment influences hospitaland provider willingness to provide abortions.65 One infive advanced clinicians identified fear of anti-abortionharassment as a perceived barrier to offering medicalabortion.65 In rural Canada, harassment and stigmawere the main reason for the resignation of doctors andnurses providing abortion services.35 Of the 163 pro-vider and non-provider hospitals in Ontario, Canadaalmost half the provider hospitals reported experiencingharassment and 15% of physicians stated that harass-ment directly contributed to staff unwillingness toperform abortions.65 Rural providers reported having to“fly under the radar” in small communities.63

While harassment rates have generally declinedsince 2000,2 the majority of abortion clinics (88%)and providers (61%) reported some harassment in2008.52 The most common form of harassment waspicketing.2 52

Only one Canadian study reported harassment ofwomen seeking access to an abortion clinic. Womenwho accessed an abortion provider were concernedfor their safety because of anti-abortion protestors.37

Access to appropriate equipment and medicationLack of availability of, and barriers to, delivery of medical abortionFive studies identify lack of availability of medicalabortion in the USA, Canada and NewZealand35 49 52 63 67 and one explored barriers to theprovision of medical abortion in the USA.43

In the USA between 2001 and 2008, only 13% offacilities offered medical abortion in 2008 and mostwere offered at free-standing clinics (82%).67 Rates ofmedical termination were lower in black and Hispanicpopulations.67 In the USA, from 2001 to 2008 thenumber of hospitals and physician offices providingmedical abortions decreased by 9% and 13%, respect-ively, whilst the number of non-specialised clinicsincreased by 23%.52

In Canada, medical abortions accounted for 15% ofall abortions in 2011.63 In New Zealand, althoughmedical termination was approved in 2001, only fourclinics within 16 council regions offered this option in2006.49

One study reported barriers identified by nursepractitioners, physicians’ assistants and certified nurse-midwives that would potentially influence the provi-sion of medical abortion, if they were able to offer

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this as part of their role.43 Barriers included lack oftraining opportunities, uncertainty around legalrestrictions, abortion not permitted by the facility,lack of physician backup and the increased cost ofmalpractice insurance.43

Insufficient resources: lack of training, too few physicians, lack ofhospital facilitiesSix studies examined the resource issues influencingthe delivery of abortion services;37 52 64 65 twofocused specifically on rural issues.35 63 Lack of train-ing, too few physicians and lack of hospital facilitieswere identified as factors limiting provision of abor-tion services.Ferris et al.65 found only half the hospitals had phy-

sicians who performed abortions in Ontario, Canadaand almost one-third of physicians from these pro-vider hospitals identified barriers to service deliveryincluding limited operating room time, lack of avail-ability of beds and too few physicians. Since theresearch was undertaken, hospital restructuring inOntario has reduced the number of provider hospi-tals, further reducing abortion services.65 Ageing pro-viders combined with lack of training opportunitiescontribute to a lack of providers in Canada.37

Jones and Kooistra52 point out that in the USA,one-third of women of reproductive age live in 87%of counties that lack providers.53 Dobie et al.64 reporta decade-long decline in the number of abortion pro-viders in Washington State.65

Two Canadian studies highlight the lack of abortionservice provision in rural areas and obstacles for ruralproviders: lack of staff, high demand for services,professional isolation and lack of replacementoptions.35 63

DISCUSSIONThe WHO estimates that around four unsafe abor-tions are performed for every 100 live births in devel-oped countries,4 placing an avoidable burden ofillness on women and society. Despite the safety andfrequency with which legal, regulated abortions areperformed, this review identifies several avoidablefactors that limit the provision of, and access to, abor-tion services.The most appropriate method of termination depends

on the stage of the pregnancy, the woman’s preference,the clinical judgement and technical ability of the practi-tioner, and local availability of resources and infrastruc-ture.68 However, variations around each of these factorshave the potential to limit access to abortion for women.In addition, there is a complex interplay betweenwomen’s preferences, service availability and the contextin which the services are provided.Medical termination has the potential to increase

access to abortion; however, this option is not widelyavailable, and may be more expensive thansurgery.6 67 69 Expanding the range of abortion

providers to different settings, including telemedicine,may reduce obstacles for women accessing an abortionservice. The provision of medical abortion via telemedi-cine had clear benefits for the woman and the providerwith excellent clinical outcomes.61 Furthermore, ifwomen could procure safe medical abortifacients fromnon-physician providers13 outside their local commu-nity, or in an outpatient medical setting, terminationthen becomes a private decision between the doctor andthe patient,62 which is less susceptible to the outsidescrutiny of external conservative anti-abortion attitudesand pressures.59 If abortions were integrated into othermainstream health services for women, several of thedifficulties in obtaining and providing access may bereduced.2

Women living in rural areas, who travel long dis-tances to services, who are on low incomes or fromminority groups experience particular inequities whenthey seek access to abortion care. In this review, traveland waiting for appointments were the main impedi-ments for women to accessing timely abortion.37 50

Silva and McNeill49 note an international trend whereabortion services are concentrated in metropolitanareas, with fewer doctors.Abortion services are hindered by lack of opportun-

ities for training and lack of providers. Those willingto provide services may experience harassment, pro-fessional isolation, lack of support from their commu-nity and staff within the hospital system who impactnegatively on service delivery. Expanding clinicaltraining opportunities for physicians and non-medicalpractitioners could help to ameliorate the abortionprovider shortage. However, whilst health andmedical students report a positive attitude towardsabortion, intentions may not translate into the provi-sion of abortion services, particularly for practitionersin rural areas who work in conservative communities.Negative attitudes and beliefs of health professionals

towards abortion create obstacles for women seekingaccess to abortion. The WHO guidance specificallyaddresses the issue of conscientious objection byhealth care providers. Whilst acknowledging theirright to not conduct the abortion, that right “does notentitle them to impede or deny access to lawful abor-tion services because it delays care for women, puttingtheir health and life at risk” (p. 69).1 The providermust refer women to an appropriately trained andaccessible provider. If that is not possible and thewoman’s life is in danger, the health care providermust provide the woman with a safe abortion.Harassment is a significant factor that hinders deliv-

ery of abortion services and women’s access to a pro-vider. Whilst Ferris et al.65 suggest that earlytermination, either medical or surgical, performed innon-hospital settings may lessen physician harassment,results from this review indicate that harassmentremains a common obstacle to the provision of abor-tion services in all settings. To overcome this, laws

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need to be enforced that prohibit the most overt anddamaging harassment and allow access to abortionservices.52

For most women, an unplanned pregnancy and thedecision to have an abortion constitutes a stressful situ-ation, yet contrary to public perception, abortion is notsignificantly associated with short- or long-term psy-chological distress.70 71 However, it is essential thatwomen making these decisions should not be subjectto unnecessary hardship as a result of their choice.72

A large Australian study of women’s experiences ofunplanned pregnancy and abortion highlighted thecomplex personal and social contexts within whichreproductive events must be understood, and the needfor increased ease of access to coordinated services thatreduce inequalities, are sensitive and responsive towomen’s needs, and reduce stigma and shame.73

Limitations of the reviewAbortion services sit within a complex social, legaland ethical framework, therefore this review hasdeliberately taken a narrow focus to identify barriersand facilitators to abortion services that are relevant inthe more homogenous context of developed countriesfor women of legal age in the first trimester of preg-nancy. In establishing this scope, we have ignored agreat deal of literature that may have established amore detailed picture of the issues faced by women incomplex settings who try to access abortion services.There are challenges in providing an overview fromheterogeneous countries with different social andlegal contexts. Findings may have been different ifarticles published in languages other than Englishwere included. It is interesting that well-known bar-riers such as stigma, difficulties in importing andlicensing mifepristone/misoprostol, complex referralsystems that prevent self-referral, doctors’ signatureand committee decision requirements were not identi-fied in the research examined.Although the majority of research was from the

USA, the perspectives of the provider and the womanare fairly equally represented. The quantitative studiesdid not include any interventions or experimentalstudies; they were mainly descriptive surveys and onlyone randomised survey of participants. There wereminimal qualitative studies. The challenging contextof abortion services also means that there is limitedhigh-quality research evidence informing issues ofaccess.The findings of this review suggest that there is rela-

tively limited research about barriers to access to abor-tion services in developed countries.

CONCLUSIONBased on the findings from this study, seven mechan-isms that would enhance access to abortion serviceshave been elucidated as follows: (1) Providing abor-tion services early, closer to the woman’s home, which

could include the provision of telemedicine or alterna-tive (mid-level) providers with appropriate training;increased availability of willing providers; access tomifepristone; and developing networked models ofcare to provide tertiary or secondary support ifrequired. (2) Making services free or affordable at thepoint of service to the woman, and these beingprimary contact services, so they do not require areferral from another provider. (3) Ensuring servicesare provided safely and confidentially, in a non-judgmental way. (4) Providing services as part of amultidisciplinary clinic so they are less stigmatisedand better integrated with a mainstream service. (5)Developing clinical protocols to support advancedpractitioners in their roles. (6) Providing appropriateservice provider training. Regardless of practitionervalues, they should be trained to refer appropriately,and provide services that are in the best interests ofthe woman. (7) Enabling access to appropriate facil-ities (hospital or clinic), and reducing barriers toaccessing services.

Twitter Follow Susan Nancarrow at @Susan.Nancarrow

Competing interests None declared.

Provenance and peer review Not commissioned; externallypeer reviewed.

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