Abstract
Background
Little is known about women's experiences with and reactions to protesters and how protesters affect women's emotional responses to abortion.
Study Design
We interviewed 956 women seeking abortion between 2008 and 2010 at 30 US abortion care facilities and informants from 27 of these facilities.
Results
Most facilities reported a regular protester presence; one third identified protesters as aggressive towards patients. Nearly half (46%) of women interviewed saw protesters; of those, 25% reported being ���a little��� upset, and 16% reported being ���quite a lot��� or ���extremely��� upset. Women who had difficulty deciding to abort had higher odds of reporting being upset by protesters. In multivariable models, exposure to protesters was not associated with differences in emotions 1 week after the abortion.
Conclusion
Protesters do upset some women seeking abortion services. However, exposure to protesters does not seem to have an effect on women's emotions about the abortion 1 week later.
Keywords
1. Introduction
Over the past decade, the provision of abortion has been increasingly centralized in stand-alone clinical facilities whose primary service is abortion care [
[1]
]. Such centralization allows for efficiency and specialization of care [2
, 3
] and also enables abortion rights opponents to concentrate their protest at these facilities. Protesters gather near abortion facilities both to voice their opposition to abortion, often through picketing, and to conduct sidewalk conversations aimed at dissuading women from their decision to have an abortion [[4]
].Empirical data on the breadth and frequency of protester presence and behavior have been collected largely at the level of the facility or the abortion provider. In 2008, the most recent year for which data are available, the National Abortion Federation reported 12,503 incidents of facility picketing [
[5]
]. Research cataloging trends in protester behavior finds that demonstrations have increased over the last decade: in a 2008 study, 89% of facilities (up from 80% in 2000 [[6]
]) reported picketing, and 37% (up from 28%) reported picketing with contact or attempts to block access [[1]
]. Data also suggest that some geographical areas ��� specifically the Midwest and the South ��� experience more protester presence than others [[1]
]. State-level analyses suggest that abortion protests have an effect on both the supply and demand for abortion services [[7]
]. However, while facilities experience frequent protester presence and those protests have an effect on abortion care in general, these data do not tell us how women interact with protesters and the psychological consequences of these interactions.The presence and behavior of abortion protesters have been intensely debated in the courts. These debates generally frame the issue as a contest between the first amendment rights of protesters to register their claim against abortion and the rights of providers or women not to be harassed and to feel safe [
8
, 9
, 10
, 11
, 12
]. Advocates of restrictions on protester activity often cite concerns for the safety of doctors and other workers at abortion facilities [[13]
], although there is no empirical evidence that the laws are effective in this aim [[14]
]. In these arguments, there is also an implicit, but untested, assumption that abortion protesters negatively affect women's experience of abortion.Research on women's emotional experience of abortion finds that the vast majority of women report positive emotional outcomes postabortion, with negative psychological outcomes associated with poor preabortion mental health [
15
, 16
, 17
, 18
]. Nonetheless, scholars studying women's experience of abortion have raised the possibility that abortion protesters increase women's distress in abortion [19
, 20
]. There is very little research on this question. A 1994 study of one facility suggested that abortion picketing could contribute to women's immediate postabortion depression [[21]
]. Research also shows that some women report protester interaction as traumatic and others as merely bothersome [22
, 23
]. Even when they do not interact with protesters, women report anticipating that protester presence will intensify their experience of emotional difficulty associated with abortion [[22]
].Only one study has empirically investigated the longer-term effects of protester activity on women's experience of abortion. This 2000 study by Cozzarelli and Major [
[24]
] of three clinical sites in Buffalo, NY, found that women experienced negative emotions upon interacting with abortion protesters at 1 h postinteraction, but these effects were not present during the follow-up data collection 2 years later. In other words, the negative effects of protester interaction did not extend beyond the short term [[24]
]. More contemporary research on this question is lacking. Given current data showing an increase in abortion protester activity outside abortion facilities nationwide and higher frequency in the Midwest and the South [[1]
], the question of how such activity affects women's emotional experience of abortion is of renewed importance.In the present study, we seek to understand who experiences and is upset by protesters and how protesters affect women's emotional responses to an abortion. In addition, our study supplements the early research by reporting on data from clinics in diverse geographical and sociocultural environments throughout the United States. These findings can better inform counseling practices around protester interaction.
2. Materials and methods
The Turnaway Study [] is a 5-year prospective longitudinal study which aims to understand the effect of abortion on women's lives. Women were recruited from 30 US abortion facilities where no facility nearby offered care at a later gestational age of pregnancy. Detailed information about recruitment is described elsewhere [
[26]
]. In summary, three groups of women were enrolled in the study: women denied an abortion because they were just over the pregnancy gestational age for the clinic, women who received an abortion who were just under the gestational age limit and women receiving a first-trimester procedure. The Turnaway Study was approved by the University of California, San Francisco Committee on Human Research.2.1 Site practice survey and study interviews
In 2011, a staff member from 27 of the 30 Turnaway Study recruitment sites participated in a confidential telephone interview about their facility's provision of abortion care [
[27]
]. Key informants (e.g., directors, managers, counselors) described their institution's characteristics (e.g., facility type, patient volume, pregnancy gestational limits), policies and practices (e.g., patient education and emotional support, pain control methods), and environment, including the presence and behaviors of protesters at the facility. Three recruitment sites (which recruited 5% of the women in the study) did not participate; one facility closed, and two declined to participate. We asked each facility representative four questions pertaining to protesters:- 1.Does your facility regularly have antiabortion protesters who are visible to abortion patients?
- 2.If yes, how often are these abortion protesters present on abortion clinic days? (always, very often, sometimes, rarely ever)
- 3.Would you describe the tactics used by the protesters at your clinic on an average day as passive (for example, praying quietly from a distance), aggressive (such as shouting at women or attempting to hand them literature) or mixed?
- 4.How frequently do staff comfort patients who are upset by protesters they encounter on the way into your facility? (regularly, occasionally, very rarely, never)
After the completion of participant recruitment into the study, we asked each key informant to answer some questions about the facility's practice as part of a survey of recruitment sites. Relevant to this paper, we asked, ���Approximately how many abortions (including aspiration and medication abortions) did your facility perform in 2010?��� and ���In 2010, about what percent of all patient visits at your facility were for abortion-related services?��� We construct one variable to describe the facility type and volume: high-volume facilities which include physician offices, clinics and ambulatory surgical centers which see over 3000 abortion patients per year and two types who saw fewer than 3000 patients per year: hospital-based practices and non-hospital-based facilities. Region is a variable indicating the location of the facility in the United States ��� West, Northeast, Midwest and South.
2.2 Interviews and measures regarding women's experiences
We enrolled 231 women who were denied an abortion because they presented for care 3 weeks above the facility's gestational limit, 452 women who presented for care 2 weeks below the facility's gestational limit who received an abortion and 273 women who received a first-trimester abortion. The first phone interview took place 1 week after either receiving or being denied an abortion. To assess the presence and effect of protesters, we asked women who had received their abortion about their experience with abortion protesters at the facility. Women were asked:
- 1.Did you see any antiabortion demonstrators outside the clinic when you entered?
- 2.Did any of the antiabortion demonstrators talk to you?
- 3.Did any of the antiabortion demonstrators try to stop you from entering the clinic?
- 4.To what extent did the protesters upset you, if at all? Would you say: not at all, a little bit, moderately, quite a bit or extremely?
We construct a variable, intensity of protesters, using the first three of these questions. We rank the intensity of interaction in the following order: saw no protesters, seeing a protester, hearing a protester and being stopped by a protester. Eight women did not answer the questions about experiencing protesters and are excluded from analyses.
In these analyses, we use responses to questions about difficulty deciding to have an abortion and emotions about the abortion 1 week later. To assess difficulty deciding whether to have an abortion, we asked women, ���How difficult was it for you to decide whether to have an abortion? Would you say it was very easy, somewhat easy, neither easy nor difficult, somewhat difficult or very difficult?��� We consider a woman to have had difficulty deciding if she said it was ���somewhat��� or ���very��� difficult. Women were asked about their emotions during the past week about having become pregnant and, separately, about having had an abortion. For each of six emotions (regret, relief, guilt, happiness, sadness and anger), women were asked to say whether they felt the emotion ���not at all, a little bit, moderately, quite a bit or extremely.��� We dichotomize these emotions so that the woman is said to experience each emotion if she reports feeling it ���quite a bit��� or ���extremely.���
2.3 Analytic methods
Using descriptive statistics, we first examined facility reports of protester presence and aggressiveness by facility region, type and patient volume. In a series of bivariable and multivariable analyses, we assessed the reported intensity of interaction with protesters, how upset women were by protesters and how these two outcomes vary by facility and women's characteristics, including region, facility type and volume, age, race/ethnicity, gestational age and difficulty deciding to have the abortion. For multivariable analyses, we treated Upset by protesters as a dichotomous variable defined as women answering that they were ���quite a bit��� or ���extremely��� upset by protesters. Finally, in a series of multivariable models considering each emotion separately, we assessed whether odds of experiencing each of six emotions varied based on exposure to protesters. Because we expect that individual women's experiences with protesters are affected by the specific site in which she sought an abortion, we employed models that deal appropriately with data that are clustered at the site level; bivariable and multivariable models were assessed with mixed-effects logistic, multinomial logistic and ordinal logistic regression models with random intercepts for facility. All analyses were conducted in STATA 12.0. Models of emotions about the abortion are limited to the women who received the procedure.
3. Results
3.1 Facility reports of abortion protesters
The 30 recruitment sites were located in 21 states ��� 7 in the West, 6 in the Northeast, 7 in the Midwest and 10 in the South. One representative at each of 27 sites reported on the presence of protesters at the facility. Twenty of these sites were stand-alone abortion clinics, 2 were physician offices, 2 were hospital-based practices, and 3 were ambulatory surgical centers. Six sites saw fewer than 1000 abortion patients per year, 10 saw between 1000 and 3000, and 11 saw 3000 or more. The gestational limits varied from 10 weeks to the end of the second trimester.
Most (85%) of the 27 clinics reported the presence of regular abortion protesters who are visible to patients always (70%), very often (22%) or sometimes (8%). The facilities that had abortion protesters reported that their protesters were aggressive (35%), passive (22%) or mixed (44%). The presence and aggressiveness of protesters appear to vary across facility, with providers in the Midwest and South reporting more frequent and more aggressive protesters than providers in other regions. The presence of protesters also differs by type and volume of provider, with higher-volume facilities reporting the most aggressive protesters and lower-volume clinics reporting less aggressive protesters. The two hospital-based practices both reported no protesters. Among the facilities that reported the presence of protesters, the great majority (83%) reported that their staff regularly comfort patients who are upset by protesters they encounter on the way into their facility; 17% reported doing so occasionally. One informant explained that an increase in protester presence has changed her facility's counseling practices: ���Before a couple of years ago we didn't have protesters much but now that they are out there all the time everything has changed ��� many patients come in upset ��� and their rides come in wanting to run people over ��� We spend a lot of time on that now.���
3.2 Exposure to protesters as reported by abortion patients
Just over half of the women in the study (54%) reported that there were no protesters at the abortion facility they visited (Table��1). Sixteen percent reported seeing protesters, 15% reported hearing and seeing protesters, and 16% reported that protesters tried to stop them from entering the clinic. Women's experiences with protesters varied by region. Almost three quarters (72%) of women in the Midwest, a little more than half of women in the Northeast (52%) and South (58%), and less than 10% of women in the West experienced protesters. In bivariable analyses, fewer women in the West than in the South reported hearing and being stopped by protesters. Exposure to protesters varies somewhat by race/ethnicity: African American women have lower odds of hearing protesters versus not being exposed to protesters than White women. There were no other racial/ethnic differences. There was a difference in exposure to protesters by the woman's pregnancy gestation, but this relationship does not show a clear pattern of later gestation and more or less intense protester presence. There were no differences in protester presence by women's age or women's reported difficulty deciding to have the abortion.
Table��1Who sees protesters, who is talked to, who is stopped and who is upset by abortion protesters
| Intensity of protesters, among all women | How upset, among those who saw, heard or were stopped by protesters | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Did not see | Saw but not heard | Heard but not stopped | Stopped | N | Not at all | A little bit | Moderately | Quite a bit | Extremely | N | |||
| % | % | % | % | % | % | % | % | % | |||||
| Total | 54 | 16 | 15 | 16 | 948 | 48 | 25 | 12 | 9 | 7 | 442 | ||
| Region | |||||||||||||
| West | 94 | 5 | <1 | 1 | 260 | 60 | 20 | 7 | 7 | 7 | 15 | ||
| Northeast | 48 | 21 | 15 | 16 | 143 | 58 | 27 | 8 | 3 | 4 | 74 | ||
| Midwest | 28 | 22 | 28 | 23 | 261 | 41 | 25 | 16 | 8 | 10 | 189 | ||
| South | 42 | 17 | 16 | 25 | ref | 284 | 49 | 24 | 10 | 12 | 4 | ref | 164 |
| Facility volume and type | |||||||||||||
| High volume (>3000 procedures) | 35 | 20 | 20 | 25 | ref | 405 | 52 | 22 | 8 | 10 | 7 | ref | 264 |
| Lower volume (<3000), non-hospital-based | 53 | 17 | 16 | 14 | 367 | 40 | 29 | 18 | 7 | 6 | 175 | ||
| Lower volume (<3000), hospital-based | 98 | 1 | 1 | - | 167 | 100 | 0 | 0 | 0 | 0 | 3 | ||
| Age, years | |||||||||||||
| 15���19 | 59 | 12 | 11 | 18 | 170 | 50 | 24 | 13 | 3 | 10 | 70 | ||
| 20���24 | 53 | 16 | 14 | 17 | 342 | 47 | 30 | 7 | 11 | 4 | 161 | ||
| 25���34 | 50 | 16 | 18 | 15 | 365 | 45 | 21 | 15 | 10 | 8 | 181 | ||
| 35-46 | 58 | 20 | 8 | 14 | ref | 71 | 60 | 20 | 13 | 7 | <1 | ref | 30 |
| Race/ethnicity | |||||||||||||
| White, non-Latina | 51 | 15 | 20 | 14 | ref | 352 | 44 | 20 | 18 | 11 | 6 | ref | 171 |
| African American, non-Latina | 50 | 20 | 10 | 20 | 279 | 56 | 24 | 6 | 8 | 7 | 140 | ||
| Latina | 57 | 11 | 12 | 20 | 197 | 45 | 31 | 11 | 8 | 6 | 85 | ||
| Other | 62 | 14 | 15 | 9 | 120 | 41 | 35 | 11 | 4 | 9 | 46 | ||
| Gestational age | |||||||||||||
| ���8 weeks | 52 | 12 | 17 | 19 | ref | 189 | 48 | 21 | 10 | 10 | 11 | ref | 91 |
| >8������13 weeks | 69 | 12 | 10 | 8 | 169 | 48 | 21 | 15 | 10 | 6 | 52 | ||
| >13������21 weeks | 33 | 18 | 24 | 25 | 219 | 47 | 28 | 14 | 7 | 4 | 146 | ||
| 21+ weeks | 59 | 18 | 10 | 13 | 371 | 48 | 25 | 10 | 10 | 7 | 153 | ||
| Difficulty deciding | |||||||||||||
| Very or somewhat easy, neither easy nor difficult | 52 | 18 | 15 | 15 | ref | 420 | 58 | 21 | 10 | 7 | 4 | ref | 202 |
| Somewhat or very difficult | 54 | 14 | 14 | 18 | 527 | 39 | 28 | 13 | 10 | 9 | 240 | ||
| Exposure to protestors | |||||||||||||
| Saw, but not heard | 64 | 18 | 9 | 7 | 3 | ref | 148 | ||||||
| Heard, but not stopped | 44 | 27 | 15 | 6 | 8 | 139 | |||||||
| Stopped | 36 | 30 | 12 | 12 | 9 | 155 | |||||||
��� Significant differences from reference group at p<.05.
������ Significant differences from reference group at p<.01.
��������� Significant differences from reference group at p<.001.
a Compares lower-volume nonhospital to high-volume facilities. There are too few women reporting seeing protesters at hospital-based facilities.
b This age category includes one participant aged 14 who was recruited early in the study before the minimum enrollment age was changed to 15.
c Bivariable multinomial logistic regression models were used to test for significance.
d Bivariable ordinal logistic regression models were used to test for significance.
In a mixed-effects multinomial logistic regression model (Table��2) where the reference category is no exposure to protesters, the only significant difference in exposure to protesters is by region. Women in the West had lower odds of hearing (0.02) and being stopped by (0.03) protesters than women in the reference group South. There are no differences by age, race/ethnicity, gestational age or difficulty deciding in intensity of exposure to protesters.
Table��2Predictors of different types of exposure to protesters relative to no exposure to protestors: results of a multivariable mixed-effects multinomial logistic regression in n=947 women seeking abortion
| Saw but not heard or stopped | Heard but not stopped | Stopped | |||||
|---|---|---|---|---|---|---|---|
| RRR | [95% CI] | RRR | [95% CI] | RRR | [95% CI] | ||
| Region | West | 0.21 | [0.02���1.83] | 0.02 | [0.00���0.41] | 0.03 | [0.00���0.37] |
| Northeast | 0.85 | [0.14���5.25] | 0.86 | [0.14���5.43] | 0.50 | [0.08���3.13] | |
| Midwest | 1.87 | [0.38���9.22] | 2.53 | [0.51���12.47] | 1.57 | [0.32���7.65] | |
| South | 1.00 | 1.00 | 1.00 | ||||
| Age, years | 15���19 | 0.44 | [0.17���1.16] | 1.23 | [0.38���4.00] | 1.07 | [0.39���2.94] |
| 20���24 | 0.68 | [0.29���1.61] | 1.60 | [0.55���4.71] | 1.14 | [0.45���2.90] | |
| 25���34 | 0.68 | [0.29���1.60] | 1.92 | [0.66���5.61] | 0.91 | [0.36���2.32] | |
| 35���46 | 1.00 | 1.00 | 1.00 | ||||
| Race/ethnicity | White, non-Latina | 1.00 | 1.00 | 1.00 | |||
| African American, non-Latina | 1.20 | [0.68���2.11] | 0.54 | [0.29���1.00] | 1.51 | [0.84���2.72] | |
| Latina | 0.67 | [0.32���1.37] | 0.65 | [0.32���1.34] | 1.33 | [0.67���2.64] | |
| Other | 0.85 | [0.40���1.80] | 0.69 | [0.32���1.48] | 0.69 | [0.29���1.62] | |
| Gestational age | ���8 weeks | 1.00 | 1.00 | 1.00 | |||
| >8���13 weeks | 2.03 | [0.89���4.64] | 1.45 | [0.62���3.39] | 0.95 | [0.40���2.25] | |
| >13���21 weeks | 1.80 | [0.85���3.81] | 1.70 | [0.84���3.45] | 1.26 | [0.64���2.50] | |
| 21+ weeks | 1.36 | [0.69���2.66] | 0.70 | [0.35���1.39] | 0.65 | [0.34���1.24] | |
| Difficulty deciding | Very easy to neither easy or difficult | 1.00 | 1.00 | 1.00 | |||
| Somewhat or very difficult | 0.80 | [0.51���1.26] | 0.93 | [0.58���1.48] | 1.35 | [0.86���2.14] | |
Note: Facility type is not included in the multivariable model because it is highly colinear with region. RRR=relative risk ratio.
Reference group is women who did not see any protesters.
3.3 Abortion patients��� reports of being upset by protesters
Among women who saw, heard or were stopped by protesters, 48% said that the protesters did not upset them at all, 25% said they were a little bit upset, 12% reported being moderately upset, 9% reported being quite a bit upset, and 7% were extremely upset. In bivariable analyses, there were no differences in who is upset by protesters by region, facility type, age, race/ethnicity or gestational age (Table��1). However, women who reported more difficulty making the decision to have the abortion reported being more upset than women reporting less difficulty (19% with more difficulty reported being quite a bit or extremely upset compared to 11% reporting less difficulty, p<.001). More women who were stopped and who heard protesters reported being quite a bit or extremely upset than women who only saw protesters (21%, 14% and 10%, respectively). In a mixed-effects multivariable logistic regression model of reporting being upset by protesters, difficulty making the decision continued to be positively associated with being upset; women who report difficulty deciding whether to have an abortion reported more than twice the odds of being upset by protesters [odds ratio (OR)=2.13, 95% confidence interval (CI 1.19��� 3.79)]. Compared to women who only saw protesters, women who reported being stopped by protesters reported more than twice the odds of being upset by protesters (OR=2.36, 95% CI 1.17���4.76). Women in the Northeast and women in the earlier part of the second trimester had lower odds of being upset by protesters than women in the South and women in the first 8 weeks of pregnancy, respectively (Table��3).
Table��3Predictors of being upset by protesters among women who saw, heard or were stopped by protesters: results of a multivariable mixed-effects logistic regression model in N=442 women seeking abortion and who were exposed to protesters
| OR | [95% CI] | ||
|---|---|---|---|
| Region | West | 1.05 | [0.22���5.55] |
| Northeast | 0.29 | [0.10���0.84] | |
| Midwest | 1.01 | [0.55���1.87] | |
| South | 1.00 | ||
| Race/ethnicity | White, non-Latina | 1.00 | |
| African American, non-Latina | 0.91 | [0.47���1.78] | |
| Latina | 0.77 | [0.35���1.69] | |
| Other | 0.86 | [0.32���2.35] | |
| Age, years | 15���19 | 1.90 | [0.36���9.98] |
| 20���24 | 2.46 | [0.53���11.45] | |
| 25���34 | 2.86 | [0.62���13.21] | |
| 35���46 | 1.00 | ||
| Gestational age | ���8 weeks | 1.00 | |
| >8������13 weeks | 0.75 | [0.28���1.99] | |
| >13������21 weeks | 0.39 | [0.18���0.84] | |
| 21+ weeks | 0.89 | [0.43���1.85] | |
| Difficulty deciding | Very easy to neither easy or difficult | 1.00 | |
| Somewhat or very difficult | 2.13 | [1.19���3.79] | |
| Exposure to protesters | Saw but did not hear | 1.00 | |
| Heard but was not stopped | 1.45 | [0.68���3.08] | |
| Stopped | 2.36 | [1.17���4.76] | |
3.4 Association between exposure to protesters and emotions about the abortion 1 week later
Among the 712 women in the study who received an abortion and replied to both the emotions and protester questions, we found no association between emotions about the abortion ��� regret, relief, guilt, happiness, sadness or anger ��� and the level of exposure to protesters. Compared to women who had no exposure to protesters, women who reported seeing, hearing or being stopped by protesters did not have higher or lower odds of feeling any of these six emotions (Table��4). Instead, difficulty deciding to have the abortion is significantly positively associated with experiencing the negative emotions (regret, guilt, sadness and anger) and significantly negatively associated with feeling the positive emotions (happiness and relief) (data not shown).
Table��4Predictors of six emotions 1 week after abortion by exposure to protesters: results of a multivariate mixed-effects logistic regression model in n=712 women who received an abortion
| Did not see or hear protesters | Saw but did not hear | Heard but was not stopped | Stopped | ||||
|---|---|---|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | OR | 95% CI | ||
| Regret | 1.00 | 0.69 | [0.29���1.65] | 0.58 | [0.24���1.40] | 1.00 | [0.47���2.12] |
| Relief | 1.00 | 1.08 | [0.67���1.74] | 1.49 | [0.89���2.47] | 1.16 | [0.71���1.90] |
| Guilt | 1.00 | 1.31 | [0.72���2.36] | 0.80 | [0.42���1.55] | 1.08 | [0.59���1.97] |
| Happiness | 1.00 | 1.14 | [0.61���2.13] | 1.42 | [0.75���2.68] | 1.03 | [0.53���2.03] |
| Sadness | 1.00 | 1.39 | [0.77���2.48] | 0.85 | [0.44���1.62] | 1.26 | [0.70���2.26] |
| Anger | 1.00 | 1.29 | [0.56���2.97] | 0.45 | [0.15���1.32] | 1.15 | [0.50���2.65] |
Controlling for region, race/ethnicity, age, gestational age and difficulty deciding.
4. Discussion
Although researchers and advocates have reason to believe that abortion protesters affect women's experience of abortion, little research has comprehensively documented women's experience of protester interactions. This study brings novel data to this literature. We find that women seeking abortions regularly interact with protesters and that a substantial minority report being upset by this interaction. In this study, while half of the women did not see a protester, the remaining half were evenly divided between seeing, hearing and being stopped by protesters. Among those who went to abortion facilities with protesters present, just under half said they were not at all upset by the protesters, while one in six reported that they were quite a bit or extremely upset by them. One of the strongest predictors of being upset by protesters is whether the woman had had difficulty deciding to have an abortion. Women who had more difficulty deciding were more likely to find the protesters upsetting. While being stopped by protesters does increase the odds of women being upset by protesters compared to seeing protesters only, the presence and intensity of the protester interaction had no effect on women's emotional response to their abortion (relief, regret, anger, happiness, sadness or guilt) 1 week after the abortion. In other words, women may be upset by protesters, but the protesters do not affect women's subsequent feelings about their abortions.
These results are the product of a secondary data analysis for a study that was not designed specifically to examine abortion protesters. The nature of the study recruitment may preclude our detection of the full effect of abortion protesters. If some protesters deterred women from entering the facility at all, the women would not be in the study. Women who found protesters extremely upsetting might have decided to carry the pregnancy to term or to go to another abortion facility and thus not be recruited into the present study. Further, we have found that protesters are most prevalent at large-volume abortion facilities and ambulatory surgical centers. Women who are deterred by the presence of protesters may be more likely to seek out lower-volume facilities where no protesters are present and thus not be recruited.
Protesters may have an effect on women's emotions. We find that most facilities reported that staff regularly comfort women who experienced the demonstrations of protesters, and staff at some facilities provided support specifically addressing these experiences. Although we cannot assess the effect of these interventions, it may be that the effect of protesters on women's emotions is dampened by support provided at the facilities. The vast majority of facilities report that staff regularly talk to women about the protesters. If facilities with more aggressive protesters directly address any issues the protesters raise, their practices may be mitigating the effect of protesters.
Additional limitations of this study include the absence of patients from lower-volume abortion facilities, which likely have fewer abortion protesters, and the disproportionate representation of women with pregnancies in the second trimester. Both are consequences of study design. We acknowledge that the facilities in this study may not represent facilities as a whole. And although only approximately 1 in 10 abortions nationally occurs in the second trimester, by study design, most of the women in our study were seeking abortions after the 13th week. However, we find no differences in women's experience of protesters by the gestational age of their pregnancy. Finally, we asked women whether they found the protesters upsetting, but we did not ask why ��� whether they were upset by the antiabortion message, the protesters��� intrusion on their personal decisions, the religious messages or other reasons.
Although our findings suggest that protesters do not cause women to have negative feelings about their abortions, we did find that interacting with protesters can be upsetting to women at the time of the visit and may prompt facility staff to provide extra support. Research is needed to assess other possible effects that protesters may have on women. These include reinforcing stigma, changing feelings about seeking reproductive health care and further polarizing political views on abortion rights.
Acknowledgments
The authors thank Rana Barar and Sandy Stonesifer for study coordination and management; Janine Carpenter, Undine Darney, Ivette Gomez, Selena Phipps, Claire Schreiber and Danielle Sinkford for conducting interviews; Michaela Ferrari and Elisette Weiss for project support; and Jay Fraser and John Neuhaus for statistical and database assistance and the participating providers for their assistance with recruitment.
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Article info
Publication history
Published online: October 12, 2012
Accepted:
September 6,
2012
Received in revised form:
August 29,
2012
Received:
May 18,
2012
Identification
Copyright
© 2013 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
