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Unwanted abortion disclosure and social support in the abortion decision and mental health symptoms: A cross-sectional survey

  • M. Antonia Biggs
    Correspondence
    Corresponding author.
    Affiliations
    Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States
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  • Matthew Driver
    Affiliations
    University of Washington, School of Public Health, Department of Epidemiology, Seattle, WA, United States
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  • Shelly Kaller
    Affiliations
    Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States
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  • Lauren J. Ralph
    Affiliations
    Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States
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Open AccessPublished:October 28, 2022DOI:https://doi.org/10.1016/j.contraception.2022.10.007

      ABSTRACT

      Objectives

      To assess the extent of unwanted abortion disclosure and levels of social support in the abortion decision and their association with depression, anxiety, and stress.

      Study design

      From January to June 2019, we surveyed people presenting for abortion at four clinics in California, New Mexico, and Illinois regarding their experiences accessing abortion. We used multivariable regression to examine associations between unwanted abortion disclosure and social support in the abortion decision, and symptoms of depression, anxiety and stress.

      Results

      Among 1092 people approached, 784 (72% response rate) eligible individuals initiated the survey, and 746 responded to the unwanted abortion disclosure item and were included in analyses. Over one-quarter (27%) told someone they would have preferred not to tell about their decision, mostly due to obstacles getting to the appointment—time to appointment (46%), travel distance (33%), and costs (32%). Three-quarters (74%, n=546) had at least one person in their life who supported the abortion decision “very much”; 20% had someone who supported the decision “not at all.” In adjusted analyses, unwanted abortion disclosure was associated with more symptoms of depression (B = 0.62, 95% confidence interval: 0.28, 0.95), anxiety (B = 1.79; 95% CI: 0.76, 2.82) and stress (B = 1.80, 95% CI: 0.64, 1.72). People also had more symptoms of depression and stress when one or more person (B = 0.64; 95% CI: 0.27, 1.02 and B = 0.75, 95% CI: 0.15, 1.35, respectively) or the man involved in the pregnancy (B = 0.67, 95% CI: 0.16, 1.18 and B = 0.96, 95% CI: 0.13, 1.78, respectively) supported their decision “not at all” (vs “very much” support).

      Conclusion

      Being forced to disclose the abortion decision due to logistical and cost constraints may be harmful to people's mental health.

      Implications

      Logistical burdens such as travel, time to access care, and costs needed to access abortion may force people seeking abortion to involve others who are unsupportive in the abortion decision having negative implications for their mental health.

      Keywords

      1. Introduction

      Social and emotional support—feeling cared about by members of one's social network—can help to reduce stress, anxiety and depression during the perinatal period [
      • Milner A
      • Krnjacki L
      • Butterworth P
      • LaMontagne AD.
      The role of social support in protecting mental health when employed and unemployed: a longitudinal fixed-effects analysis using 12 annual waves of the HILDA cohort.
      ,
      • Birtel MD
      • Wood L
      • Kempa NJ.
      Stigma and social support in substance abuse: implications for mental health and well-being.
      ,
      • Ozbay F
      • Johnson DC
      • Dimoulas E
      • Morgan CA
      • Charney D
      • Southwick S.
      Social support and resilience to stress.
      ,
      • Khan A
      • Husain A.
      Social support as a moderator of positive psychological strengths and subjective well-being.
      ,
      • Anderson FM
      • Hatch SL
      • Comacchio C
      • Howard LM.
      Prevalence and risk of mental disorders in the perinatal period among migrant women: a systematic review and meta-analysis.
      ,
      • Biaggi A
      • Conroy S
      • Pawlby S
      • Pariante CM.
      Identifying the women at risk of antenatal anxiety and depression: a systematic review.
      ,
      • Herbell K
      • Zauszniewski JA.
      Stress experiences and mental health of pregnant women: the mediating role of social support.
      ]. Although less studied, research among people seeking, obtaining, or being denied an abortion has examined the association of perceived emotional support from friends, family, and significant others and its association with abortion decision-making, post-abortion emotions and psychological outcomes. One U.S. study found that people who reported more social emotional support one week after seeking an abortion were more likely to report positive post-abortion emotions and less psychological distress years later [
      • Rocca CH
      • Kimport K
      • Roberts SCM
      • Gould H
      • Neuhaus J
      • Foster DG.
      Decision rightness and emotional responses to abortion in the United States: a longitudinal study.
      ,
      • Biggs MA
      • Brown K
      • Foster DG.
      Perceived abortion stigma and psychological well-being over five years after receiving or being denied an abortion.
      ]. However, this research only examined general social support and not social support specific to the abortion decision. Given the highly stigmatized nature of abortion, feeling supported more broadly by the people close to you does not necessarily equate with feeling supported in the abortion decision.
      Social support in the abortion decision may be particularly beneficial for people in need of financial, emotional, and tangible support to overcome barriers accessing abortion care. At the same time, given that abortion is highly stigmatized, being forced to disclose the abortion and to involve unsupportive individuals in the abortion decision could result in negative reactions from others [
      • Cowan SK.
      Enacted abortion stigma in the United States.
      ,
      • Kimport K
      • Foster K
      • Weitz TA.
      Social sources of women's emotional difficulty after abortion: lessons from women's abortion narratives.
      ]. About two-thirds of people seeking an abortion in the United States worry that people in their community would look down on them if they knew they sought an abortion [
      • Cowan SK.
      Enacted abortion stigma in the United States.
      ]. Concerns about other people's reactions, including fear of judgment can affect whether people disclose or conceal the abortion [
      • Astbury-Ward E
      • Parry O
      • Carnwell R.
      Stigma, abortion, and disclosure–findings from a qualitative study.
      ,
      • Major B
      • Richards C
      • Cooper ML
      • Cozzarelli C
      • Zubek J.
      Personal resilience, cognitive appraisals, and coping: an integrative model of adjustment to abortion.
      ,
      • Hanschmidt F
      • Linde K
      • Hilbert A
      • Riedel- Heller SG
      • Kersting A.
      Abortion stigma: a systematic review.
      ,
      • Rossier C
      • Marchin A
      • Kim C
      • Ganatra B.
      Disclosure to social network members among abortion-seeking women in low- and middle-income countries with restrictive access: a systematic review.
      ]. Research from the United States indicates that some young people conceal the abortion decision from parents due to concerns that disclosure might result in being shamed, kicked out of the house or emotional or physical abuse despite a desire for emotional support [
      • Coleman-Minahan K
      • Jean Stevenson A
      • Obront E
      • Hays S
      Adolescents obtaining abortion without parental consent: their reasons and experiences of social support.
      ], and that involving an unsupportive parent is associated with lower satisfaction with and confidence in the abortion decision [
      • Zabin LS
      • Hirsch MB
      • Emerson MR
      • Raymond E
      To whom do inner-city minors talk about their pregnancies? Adolescents’ communication with parents and parent surrogates.
      ,
      • Ralph L
      • Gould H
      • Baker A
      • Foster DG.
      The role of parents and partners in minors’ decisions to have an abortion and anticipated coping after abortion.
      ].
      The extent of unwanted abortion disclosure and social support in the abortion decision and their effects on people's mental health and wellbeing has not been quantitatively explored. The present study aims to fill this gap by evaluating the extent to which people unwantedly disclose the abortion to people in their social network as well as levels of social support in the abortion decision, and their association with symptoms of depression, anxiety, and stress in a large cohort of people seeking abortion services.

      2. Methods

      2.1 Study design and population

      The Burden Study is a cross-sectional survey of individuals seeking abortion services and is designed to assess the logistical and psychosocial barriers people encounter trying to access these services. Study details have been published elsewhere [
      • Biggs MA
      • Brown K
      • Foster DG.
      Perceived abortion stigma and psychological well-being over five years after receiving or being denied an abortion.
      ,
      • Ralph L
      • Ehrenreich K
      • Kaller S
      • Biggs MA.
      A cross-sectional study examining consideration of self-managed abortion among people seeking facility-based care in the United States.
      ]. From January to June 2019, we recruited people seeking abortion from waiting rooms in four clinics located in California, Illinois, and New Mexico. With the aim of capturing a broad range of experiences accessing abortion care, including out-of-state travel, we chose sites that offered abortion care beyond the first trimester and in states with more supportive abortion policies than neighboring states. Participant eligibility criteria included: seeking abortion, ages 15 and older, and able to speak and read in English or Spanish. Individuals were ineligible to participate if they were pre-medicated with narcotics or had completed their abortion. Research staff introduced the study to patients while they were waiting for their abortion appointment, handed interested patients a tablet device to complete and confirm their eligibility, and consented those eligible and interested to participate in the study. Participants self-administered an anonymous survey online, which they could choose to complete in either English or Spanish, with research staff available to assist as needed. Participants received a $30 gift card as remuneration. The survey items included questions related to the circumstances around their pregnancy and decision to seek abortion, barriers to accessing care, social support, mental health symptoms, and demographic characteristics. This study received ethical approval from the University of California, San Francisco Institutional Review Board.

      2.2 Exposure and dependent variables

      Unwanted disclosure about the abortion decision is our primary exposure of interest. Participants could respond “Yes” or “No” to the question, “In order to get to the clinic for your appointment today, did you have to tell anyone that you would have preferred not to tell, that you were considering ending this pregnancy?” Those who answered “yes” were asked who they had to tell and the reasons for the unwanted disclosure, according to a pre-defined list of categories.
      Perceived social support from individual sources regarding the abortion decision is our secondary exposure of interest. We asked respondents “To what extent do the following people in your life support you in ending this pregnancy?” followed by a list of these individuals: “Your mom(s),” “your dad(s),” “other family members,” “friends,” “the man involved in the pregnancy,” and “your current intimate partner,” the latter two of which could have been the same person. For each individual source of support, answer options included: “Not at all,” “A little bit,” “Somewhat,” “Very much,” “Mixed support,” “Don't know,” and “They are not in my life or they don't know I'm considering ending this pregnancy.” For multivariable analyses, we created a four-part categorical social support variable for each individual source of support grouping “a little bit,” “somewhat,” and “mixed support” into one category and “They are not in my life or they don't know I'm considering ending this pregnancy” and “Don't know” into one category. We created two additional aggregate dichotomous measures where the participant indicated that (1) one or more person “very much” supported their abortion decision (vs all other options) and (2) one or more person supported their decision “not at all” (vs all other options).
      Mental health symptoms served as our primary dependent variables of interest and included symptoms of depression, anxiety and stress at the time of seeking abortion services, using validated measures. We measured depressive symptoms using the Patient Health Questionnaire-2 [
      • Kroenke K
      • Spitzer RL
      • Williams JBW.
      The Patient Health Questionnaire-2: validity of a two-item depression screener.
      ], estimating the sum of two four-point, Likert-scaled items (α = .86, range 0−6). We measured anxiety symptoms using the Generalized Anxiety Disorder scale [
      • Spitzer RL
      • Kroenke K
      • Williams JBW
      • Löwe B.
      A brief measure for assessing generalized anxiety disorder: the GAD-7.
      ] which was based on the sum of seven Likert-scaled items (α = .94, range 0−21). For both the Patient Health Questionnaire-2 and Generalized Anxiety Disorder, we asked how often in the last two weeks they had been bothered by a list of problems and to indicate whether it was “not at all,” “several days,” “more than half the days,” or “nearly every day.” We used Cohen's Perceived Stress Scale [
      • Cohen S
      • Kamarck T
      • Mermelstein R.
      A global measure of perceived stress.
      ] to assess stress symptoms, which was based on the sum of four Likert-scaled items (ranging from never to very often) (α = .62, range 0−16).

      2.3 Statistical analysis and multiple imputation

      We used descriptive statistics to summarize sociodemographic characteristics, pregnancy characteristics, mental health history, sources of unwanted abortion disclosure, and social support in ending the pregnancy. We used multivariable logistic regression to model the relationship between involving someone who is “very much” supportive or “not at all” supportive in the decision and unwanted abortion disclosure and multivariable linear regression to model depression, anxiety and stress. We assessed statistical significance using an alpha level of 0.05.
      In our multivariable models, we included demographic, pregnancy, and mental health characteristics as covariates, based on a priori assumptions regarding their associations with social support and mental health in previous research [
      • Biggs MA
      • Upadhyay UD
      • McCulloch CE
      • Foster DG.
      Women's mental health and well-being 5 years after receiving or being denied an abortion: a prospective, longitudinal cohort study.
      ,
      • Harris LF
      • Roberts SCM
      • Biggs MA
      • Rocca CH
      • Foster DG.
      Perceived stress and emotional social support among women who are denied or receive abortions in the United States: a prospective cohort study.
      ]. Demographic covariates included age, race/ethnicity, marital status, and socioeconomic security which included confidence in being ability to come up $2000 if an unexpected need arose within the next month and receipt of any government assistance in the past year, where participants selected all that apply from a list of five options (i.e., Temporary Assistance to Needy Families, WIC, food stamps, social security/disability or other). Pregnancy characteristics included parity, retrospective pregnancy intentions (wanted to be pregnant sooner or later, pregnancy wanted, pregnancy not wanted and not sure what wanted), pregnancy duration calculated in weeks since date of last menstrual period and seeking abortion due to rape or because the fetus has a medical condition. Mental health characteristics included pre-pregnancy history of an anxiety or depression diagnosis, problem alcohol use, use of any illicit or street drugs or prescription drugs for recreational use, or history of adverse childhood experiences. To account for the clustering of our data we also adjusted for clinic site. In all multivariate regression analyses, we used multiple imputation with chained equations to address missingness for confounders, which ranged from 0% to 5% missingness [
      • von Hippel PT.
      Regression with missing Ys: an improved strategy for analyzing multiply imputed data.
      ]. Ten iterations were used to ensure model convergence. All statistical analyses were performed in Stata version 17.

      3. Results

      3.1 Sample characteristics

      Of the 1092 potential participants approached, 846 agreed to participate, of which 20 were ineligible, 784 (72% response rate) eligible individuals initiated the survey and 38 were excluded due to missing data on unwanted abortion disclosure, leaving 746 participants in our analytic sample. Sociodemographic, mental health, and pregnancy characteristics are reported in Table 1. Participant age, parity, and race/ethnicity distributions closely approximated those of abortion patients nationally [
      • Jones RK
      • Jerman J.
      Abortion incidence and service availability in the United States, 2014.
      ] (Table 1a and Table 1b) .
      Table 1aSociodemographic and pregnancy characteristics of people seeking abortion from four clinics in California, Illinois, and New Mexico, as part of the Burden study (N = 746)
      Characteristicn (%)
      Age group, y
      151734 (5)
      181956 (8)
      2024193 (26)
      2529218 (29)
      3039221 (30)
      404524 (3)
      Self-reported race/ethnicity
      Other race includes Native American, Middle Eastern or North African, and self-reported other race.
      Asian, Native Hawaiian or other Pacific Islander, non-Hispanic45 (6)
      Black, non-Hispanic208 (28)
      Hispanic/Latina/x178 (24)
      White, non-Hispanic208 (28)
      More than one race/other race86 (12)
      Missing21 (3)
      Highest level of education completed
      Less than high school diploma or equivalent83 (11)
      High school diploma or equivalent221 (30)
      Some college or Associate's degree287 (38)
      Bachelor's degree or higher131 (18)
      Missing24 (3)
      Marital status, n (%)
      Single or never married561 (75)
      Married84 (11)
      Separated, divorced, or widowed72 (10)
      Missing29 (4)
      Confidence in ability to come up with $2000 for unexpected needs in next month, n (%)
      Very confident79 (11)
      Somewhat confident121 (16)
      Only slightly confident155 (21)
      Not at all confident355 (48)
      Missing36 (5)
      Household received any government assistance, last year
      No394 (53)
      Yes330 (44)
      Missing22 (3)
      a Other race includes Native American, Middle Eastern or North African, and self-reported other race.
      Table 1bSociodemographic, pregnancy and mental health, characteristics of people seeking abortion in 2019 from four clinics in California, Illinois, and New Mexico, as part of the Burden study (N = 746) (continued)
      Characteristicn (%)
      Mental health history
      History of adverse childhood experiences264 (34)
      Lived with someone who had a drinking problem178 (24)
      Witnessed violence in the neighborhood173 (23)
      Lived with someone who was mentally ill or depressed125 (17)
      Lived with someone who served time in jail or prison126 (17)
      Felt unsupported, unloved or unprotected at home121 (16)
      Number of adverse childhood experiences (before age 18), mean (standard deviation)0.99 (1.46)
      Missing12 (2)
      History of depression or anxiety
      Yes195 (26)
      No525 (70)
      Missing26 (3)
      History of at least monthly illicit or street drug use in the past year (pre-pregnancy)99 (13)
      History of at least monthly problem alcohol use (Had four or more drinks on one occasion), past year (pre-pregnancy)233 (31)
      Current pregnancy and pregnancy history
      Number of live births
      None290 (40)
      One or more432 (60)
      Pregnancy duration of current pregnancy
      ≤12 wk521 (70)
      13-19 wk108 (14)
      ≥20 wk108 (14)
      Missing9 (1)
      Retrospective pregnancy intentions of current pregnancy
      Mistimed (wanted pregnancy sooner/later)254 (34)
      Pregnancy wanted28 (4)
      Wanted pregnancy never312 (42)
      Not sure what wanted149 (20)
      Missing3 (<1)
      Plans to pay for abortion using Medicaid or another state-run health insurance program372 (50)
      Seeking abortion due to fetal medical condition27 (4)
      Seeking abortion because pregnancy is result of rape or sexual assault13 (2)
      Recruitment site
      A230 (31)
      B203 (27)
      C207 (28)
      D106 (14)

      3.2 Unwanted abortion disclosure and level of support from individual sources

      Over one-quarter (27%) of participants reported unwanted abortion disclosure, most often to family members and because they had to take time away for the appointment (Table 2). About half of participants perceived “very much” support from the man involved in the pregnancy (52%) or current intimate partner (48%, Table 3); ten percent or less reported that each individual source supported their decision “not at all.” More than half of participants did not disclose or did not know the level of support from their dad(s) and other family members.
      Table 2Prevalence of unwanted disclosure of abortion decision and reasons for disclosure among people seeking abortion in 2019 from four clinics in California, Illinois, and New Mexico, as part of the Burden study
      In order to get to the appointment today, told someone they would have preferred not to tell, that they were considering ending the pregnancy (N = 746)N (%)
       No542 (73)
       Yes204 (27)
      Who did you tell that you would have preferred not to tell (n = 196)
       Your brother, sister, or other family member66 (32)
       Your friend61 (30)
       Someone you work with48 (24)
       The man you became pregnant with47 (23)
       Your mom45 (22)
       Your dad16 (8)
       Your childcare provider7 (3)
       Your teacher1 (0.5)
      Reasons for unwanted disclosure (n = 204)
       Had to take time away from home, work or school, for appointment(s)93 (46)
       Distance travelled to obtain care66 (32)
       Needed money to pay for procedure or other costs62 (30)
       Childcare needs43 (21)
       Was required to get permission from a parent or other adult2 (1)
      Other reasons, based on write in responses included:
       Physical safety or emotional support14 (7)
       Accidentally revealed3 (1)
      Table 3Distribution of social support regarding abortion decision among individual sources, among people seeking abortion in 2019 from four clinics in California, Illinois, and New Mexico, as part of the Burden study
      Extent that people in your life support you in ending this pregnancy
      Very muchSomewhat/a little bit/ mixed supportNot at allDon't knowNot in my life/have not disclosed
      Individual sourcen (%)n (%)n (%)n (%)n (%)
       Man involved in pregnancy369 (52)134 (19)74 (10)55 (8)83 (12)
       My current intimate partner340 (48)111 (16)72 (10)58 (8)125 (18)
       My mom(s)187 (26)69 (10)63 (9)136 (19)256 (36)
       My dad(s)84 (12)36 (5)71 (10)176 (25)341 (48)
       Other family members131 (19)89 (13)63 (9)169 (24)256 (36)
       My friends257 (37)120 (17)41 (6)114 (16)172 (24)
      Based on the question “To what extent do the following people in your life support you in ending this pregnancy?”

      3.3 Association between level of support and unwanted abortion disclosure

      Three-quarters (74%) reported that at least one person supported their abortion decision “very much” and 20% had at least one person who supported their decision “not at all” (Table 4). People who disclosed the decision unwantedly were significantly more likely to have someone who did not support their decision at all (31% vs 16%, p < 0.001) and less likely to have someone who supported their decision very much (65% vs 77%, p < 0.01).
      Table 4Associations of unwanted abortion disclosure and having someone in your life who is supportive or unsupportive of the abortion decision among people seeking abortion in 2019 from four clinics in California, Illinois, and New Mexico, as part of the Burden study
      TotalUnwanted abortion disclosureAdjusted odds ratio (95% CI)
      Column %NoYes
      n (%)n (%)n (%)
      Full sample746 (100)542 (73)204 (27)
      One or more person in your life supports you “very much” in ending the pregnancy
      No196 (26)125 (23)71 (35)
      Yes546 (74)413 (77)133 (65)0.57
      p < 0.01.
      (0.40, 0.82)
      One or more person in your life supports you “not at all” in ending the pregnancy
      No592 (80)451 (84)141 (69)
      Yes150 (20)87 (16)63 (31)2.42
      p < 0.001.
      (1.65, 3.56)
      a p < 0.01.
      b p < 0.001.

      3.4 Associations between unwanted abortion disclosure and levels of social support and symptoms of depression, anxiety, and stress

      Results of multivariable linear regression analyses with imputation are presented in Table 5. Unwanted abortion disclosure was associated with experiencing more symptoms of depression, anxiety, and stress; involving someone who supports the decision not at all was associated with more symptoms of depression and stress (Table 5). People had more symptoms of depression and stress when they perceived somewhat/a little bit/mixed support or “not at all” support (vs “very much” support) from the man involved in the pregnancy and more stress when other family members supported their decision less than “very much”. People also had more symptoms of depression and anxiety when they perceived that their current intimate partner supported their decision somewhat/a little bit/mixed (vs “very much” support). Levels of support from parents and friends were not significantly associated with any of the three mental health measures. Results of the multivariable models without multiple imputation were similar in direction and magnitude, having no impact on the conclusions of this study.
      Table 5Associations between individual sources of social support regarding abortion decision and mental health symptoms among people seeking abortion in 2019 from four clinics in California, Illinois, and New Mexico, as part of the Burden study
      Depressive symptomsAnxiety symptomsPerceived stress
      Adjusted B (95% CI)Adjusted B (95% CI)Adjusted B (95% CI)
      Unwanted abortion disclosure0.62
      p < 0.05.
      (0.28, 0.95)
      1.79
      p < 0.001.
      (0.76, 2.82)
      1.80
      p < 0.001.
      (0.64, 1.72)
      One or more people support decision “very much”-0.34 (-0.68, 0.01)-0.35 (-1.40, 0.71)-0.40 (-0.96, 0.15)
      One or more people support decision “not at all”0.64
      p < 0.05.
      (0.27, 1.01)
      0.91 (-0.23, 2.06)0.75
      p < 0.05.
      (0.15, 1.35)
      Social support by individual source.
       Man involved in pregnancy
      Very much supports decision (Reference)
      Somewhat/a little bit/mixed support0.51
      p < 0.05.
      (0.11, 0.92)
      0.98 (-0.26, 2.21)0.77
      p < 0.05.
      (0.13, 1.41)
      Supports decision not at all0.67
      p < 0.01.
      (0.16, 1.18)
      0.65 (-0.92, 2.22)0.96
      p < 0.05.
      (0.13, 1.78)
      Not in my life/have not disclosed/don't know0.02 (-0.39, 0.43)-0.39 (-1.65, 0.87)0.19 (-0.47, 0.85)
      My current intimate partner
      Very much supports decision (Reference)
      Somewhat/a little bit/mixed support0.46
      p < 0.05.
      (0.03, 0.89)
      1.37
      p < 0.05.
      (0.05, 2.70)
      0.63 (-0.07, 1.32)
      Supports decision not at all0.42 (-0.10, 0.95)0.51 (-2.12, 1.10)0.79 (-0.06, 1.64)
      Not in my life/have not disclosed/don't know0.01 (-0.36, 0.38)-0.31 (-1.45, 0.8)0.36 (-0.24, 0.95)
      My mom(s)
      Very much supports decision (Reference)
      Somewhat/a little bit/mixed support-0.07 (-0.62, 0.49)0.47 (-1.22, 2.17)0.67 (-0.23, 1.56)
      Supports decision not at all0.26 (-0.34, 0.84)-0.40 (-2.20, 1.39)0.39 (-0.56, 1.34)
      Not in my life/have not disclosed/don't know-0.18 (-0.54, 0.19)-0.65 (-1.77, 0.48)-0.22 (-0.81, 0.37)
      My dad(s)
      Very much supports decision (Reference)
      Somewhat/a little bit/mixed support0.02 (-0.77, 0.81)1.00 (-1.42, 3.42)0.88 (-0.40, 2.16)
      Supports decision not at all0.28 (-0.38, 0.93)0.00 (-2.00, 2.00)0.50 (-0.56, 1.56)
      Not in my life/have not disclosed/don't know-0.03 (-0.52, 0.45)-0.60 (-2.09, 0.89)0.12 (-0.66, 0.91)
      Other family members
      Very much supports decision (Reference)
      Somewhat/a little bit/mixed support0.28 (-0.26, 0.82)1.06 (-0.61, 2.72)1.22
      p < 0.01.
      (0.35, 2.10)
      Supports decision not at all0.45 (-0.16, 1.05)-0.10 (-1.97, 1.78)1.04
      p < 0.05.
      (0.06, 2.02)
      Not in my life/have not disclosed/don't know0.25 (-0.15, 0.65)0.66 (-0.57, 1.89)0.55 (-0.09, 1.20)
      My friends
      Very much supports decision (Reference)
      Somewhat/a little bit/mixed support0.40 (-0.04, 0.84)0.98 (-0.35, 2.32)0.69 (-0.01, 1.40)
      Supports decision not at all0.17 (-0.51, 0.84)0.07 (-2.01, 2.15)0.32 (-0.78, 1.42)
      Not in my life/have not disclosed/don't know0.23 (-0.11, 0.56)0.75 (-0.29, 1.79)0.09 (-0.46, 0.64)
      All analyses are multivariable linear regression models using multiple imputation and adjust for age, race/ethnicity, marital status, parity, pregnancy intentions, pregnancy duration, seeking abortion due to rape or fetal anomaly, confidence could come up with $2000 if unexpected need were to arise, receiving government assistance, history of anxiety, depression or childhood trauma, problem alcohol use, drug use, and recruitment site. B represents unstandardized regression coefficients.
      a p < 0.05.
      b p < 0.01.
      c p < 0.001.

      4. Discussion

      In this cross-sectional study of people seeking abortion services in three U.S. states, 20% indicated that someone in their life did not support the abortion decision at all, and one-quarter disclosed the decision to someone they would have preferred not to tell, mostly due to logistical constraints and cost burdens accessing care. Findings from a prospective study of people presenting for abortion in Utah found that 6% felt forced to disclose the abortion to make logistical arrangements to attend the information visit due the state's mandatory waiting period law, a somewhat smaller proportion than that found in the current study [
      • Roberts SCM
      • Turok DK
      • Belusa E
      • Combellick S
      • Upadhyay UD.
      Utah's 72-hour waiting period for abortion: experiences among a clinic-based sample of women.
      ], likely because the Utah study only asked about disclosure due to logistical arrangements. Even though the current study was conducted in states with Medicaid coverage for abortion, with half of the participants planning to use public funding to pay for their procedure, the strain of securing funds to pay for the procedure and other expenses led to disclosing the decision to someone they would have prefer not to tell, suggesting that cost barriers can compromise patients’ privacy needs, even when seeking care in protected access states. Our findings are consistent with other research suggested that paying for the abortion and other related expenses can be one of the most significant hurdles delaying or preventing access to care [
      • Jones RK
      • Upadhyay UD
      • Weitz TA.
      At what cost? Payment for abortion care by U.S. women.
      ,
      • Roberts SCM
      • Gould H
      • Kimport K
      • Weitz TA
      • Foster DG.
      Out-of-pocket costs and insurance coverage for abortion in the United States.
      ]. Experiences of unwanted disclosures may be even more pronounced for people living in or accessing care in states without Medicaid coverage of abortion given that they tend to experience more financial barriers and prolonged abortion seeking [
      • Upadhyay UD
      • McCook AA
      • Bennett AH
      • Cartwright AF
      • Roberts SCM.
      State abortion policies and Medicaid coverage of abortion are associated with pregnancy outcomes among individuals seeking abortion recruited using Google Ads: a national cohort study.
      ,
      • Roberts SCM
      • Johns NE
      • Williams V
      • Wingo E
      • Upadhyay UD.
      Estimating the proportion of Medicaid-eligible pregnant women in Louisiana who do not get abortions when Medicaid does not cover abortion.
      ].
      This study adds to the literature by presenting novel findings exploring this relationship between involving someone unsupportive, unwanted abortion disclosure and mental health symptoms. While most people involved at least one person who was supportive, involving someone, including a partner who was not at all supportive of the decision and unwanted abortion disclosure was associated with having more symptoms of depression, anxiety, and stress. This finding suggests that being forced to disclose the pregnancy decision due to forced travel or lack of funds may be harmful to people's psychological well-being.
      Social support for the abortion itself may be a key mediating factor in the relationship between disclosure and mental health symptoms; disclosing to a supportive source, particularly an intimate partner, may reduce the risk of adverse mental health outcomes while disclosing to an unsupportive source may increase this risk. People are likely selective in terms of who they involve in the abortion decision to protect their mental health and are less compelled to disclose the decision unwantedly if they have someone in their life who is supportive of the decision.
      This study has several strengths, including the novelty of its research question, its large sample size whose demographic characteristics with respect to race/ethnicity, educational attainment, marital status, age, and parity are largely consistent with the characteristics of patients seeking abortion nationally [
      • Jones RK
      • Jerman J.
      Abortion incidence and service availability in the United States, 2014.
      ]. Furthermore, our assessment of social support in the context of abortion-related decision-making, rather than general support, and measure of social support from a variety of individual sources adds new and important insight into the risk of depression and anxiety among people seeking abortion services.
      This study also has several limitations. First, its cross-sectional design precludes a temporal understanding of the observed relationship between unwanted abortion disclosure, social support, and mental health symptoms. Additionally, while our distinct findings for questions about the man involved in the pregnancy and the current intimate partner underscore the importance of evaluating both sources, we were unable to assess the extent of overlap between the two and should have used gender inclusive language (“person” instead of “man”) that did not make assumptions about the gender of the person involved. Furthermore, while the study was open to all genders, the sample of transgender and gender non-conforming participants was too small to evaluate potential differences in this group. We acknowledge that the need for abortion and other reproductive health services is not exclusive to cisgender women and that further research is necessary to understand the relationship between social support regarding the abortion decision and mental health symptoms in gender minority populations. Lastly, our study is limited in that it was conducted in states with protected access to abortion care, limiting the generalizability of our findings.
      These findings highlight how logistical burdens such as travel time, travel distance, and the costs needed to access abortion care can result in reduced privacy and autonomy in the decision-making process. Now that Roe v Wade has been overturned, many people will lose access to abortion care in their state of residence, forcing them to disclose the pregnancy to people who are unsupportive and to carry an unwanted pregnancy to term. This new policy context will also result in more people traveling for their abortion care, likely increasing the number of people who are forced to disclose the abortion decision to someone unsupportive, having negative implications for their mental health. Future research should explore the implications of this new post-Roe landscape on people's ability to choose with whom they disclose their pregnancy and pregnancy decision and the consequences to their mental health.

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