‘Risk’ perceptions among abortion seekers in Canada: A qualitative sub-analysis of interviews from the CART-Access Project

Abstract

Introduction: In this thesis, I sought to address the knowledge gap regarding how abortion seekers from equity-deserving populations in Canada define and navigate risks related to abortion care. While abortion access and safety have often been studied through legal, clinical, and policy perspectives, less is known about how abortion seekers themselves conceptualize risk and safety. In this study, risk refers to perceived or experienced threats that shape decision-making, trust, autonomy, and experiences of safety throughout abortion care. Methods and Analysis: This thesis is a qualitative sub-analysis of interviews from the CART Access Project, an integrated knowledge translation program of research on abortion access in Canada led by the Contraception and Abortion Research Team at the University of British Columbia in collaboration with Action Canada for Sexual Health and Rights. The dataset included in-depth, one-on-one, vignette-based interviews with 17 adults in Canada who had a uterus, were able to communicate in English, and were from equity-deserving populations. Equity-deserving population refers to abortion seekers who face intersecting structures of oppression to abortion care equitably including racialized, stigmatizing, cultural, social, informational, and health system barriers. I use this term to emphasize that inequitable access is not caused by individual identities themselves, but by the systems and structures that make it harder for some communities to access to high-quality, de-stigmatized, contextually appropriate abortion care. In the study, individuals were not required to have personal experience with abortion care, rather, in interviews they responded to fictional but realistic scenarios about “Jade,” a person seeking medication abortion from a primary care provider. I conducted a reflexive thematic analysis of the interview data using Braun and Clare’s approach and organized the findings using a socioecological framework. Results: Participants described abortion-related risk operating across multiple levels of the social-ecological model. The main types of risk identified in this analysis included legal and policy risk, such as uncertainty about abortion laws, provider obligations referral pathways, and whether care would be available. Clinical and health system risk, such as provider judgement, refusal of care, repeated disclosure, lack of trauma-informed or gender-affirming care, and uncertainty about where to access safe services. Social and relational risk, such as stigma, family judgment, community shame, loss of belonging, and fear of disclosure. Visibility and surveillance risk, such as being seen, recognized, overheard, monitored, or exposed in family community, healthcare, public or online settings. Information risk, such as misinformation, unclear care pathways, and difficulty identifying trustworthy resources. Physical or embodied risk, such as fear of pain bleeding, medication effects, recovery, and future fertility. Safety was described as the reduction of these risks through legal clarity, privacy, confidentiality, trustworthy information, supportive relationships, affirming and trauma-informed care, and care pathways that minimized unnecessary exposure or repeated disclosure. These concerns were shape by participants’ identities, social environments, care settings, stigma, trust, information reliability, and community relationships. Participants’ multiple and interesting identities could heighten vulnerability to stigma, exclusion, misgendering, or unwanted visibility, while also connecting them to supportive communities, alternative knowledge, and affirming forms of care. Conclusion: Abortion-related risks and safety are produced across individual, interpersonal, community, legal/policy, organizational, and environmental contexts. This thesis will provide a more detailed understanding how abortion seekers from equity-deserving populations in Canada define and navigate risks. The findings can inform abortion providers, public health practitioners, navigators, community organizations, and health systems working to create abortion to be more equitable, culturally safe, and responsive to the needs of diverse populations.