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Abstract
Background Controversy exists as to whether ‘abortion or ‘termination of pregnancy’ should be used by health professionals during interactions with women and in published works.
Methods Self-administered anonymous questionnaires were distributed to women attending 54 abortion clinics in Scotland, England and Wales during a 4-month period in 2015. Responses were coded and analysed using SPSS. Descriptive statistics were generated and responses compared by demographic characteristics. The main outcome measures were the proportion of respondents reporting that they found the terms ‘abortion’ and ‘termination of pregnancy’ to be distressing, and women’s preferred terminology for referring to induced abortion.
Results Surveys were completed by 2259 women. The mean age of the respondents was 27(range 13–51) years; 82% identified as white, 51% had children and 36% had previously undergone abortion. Thirty-five percent indicated that they found the word ‘abortion’ distressing compared with 18% who reported that ‘termination of pregnancy’ was distressing (p< 0.001). Forty-five percent of respondents expressed a preference for ‘termination of pregnancy’ and 12% for ‘abortion’. Sixteen percent would choose either term. This pattern of results did not vary statistically by age, reproductive history, country of residence, ethnicity or level of deprivation.
Conclusions Most women seeking abortion did not find the terms ‘abortion’ or termination of pregnancy’ distressing. When given a choice of terms, more women who expressed a preference chose ‘termination of pregnancy’. Healthcare professionals should be sensitive to preferences for terminology when communicating with women seeking abortion.
- abortion
- terminology
- termination of pregnancy
- voluntary interruption of pregnancy
Statistics from Altmetric.com
Key message points
Most women seeking abortion did not find the terms ‘abortion’ or termination of pregnancy’ distressing.
When given a choice of terms, more women who expressed a preference chose ‘termination of pregnancy’.
Healthcare professionals should be sensitive to womens’s preferences for abortion terminology when communicating with them at this time.
Introduction
There has been some controversy in recent years over the terminology that healthcare professionals should use for induced abortion.1 2 ‘Abortion’ is an internationally recognised term in the World Health Organization’s International Classification of Disease3 and in English language legal documentation, including the 1967 Abortion Act.4 Abortion is also the term used by the Royal College of Obstetricians and Gynaecologists5 and in the Department of Health in England official reports of annual statistics. However, some medical journals now require that ‘termination of pregnancy’ is used in preference to ‘abortion’ in submitted manuscripts.6 In addition, since 2015, the Scottish Information Services Division has changed their terminology and now reports on ‘terminations of pregnancy’.7 This change in terminology might imply that ‘termination of pregnancy’ is considered more appropriate than ‘abortion’. It could also imply that the word ‘abortion’ is perceived to be insensitive. In the UK, the term ‘miscarriage’ has been advocated as preferential to ‘spontaneous abortion’ on the basis that it is considered more sensitive.8 Conversely, it has been argued that ‘termination of pregnancy’ should not be adopted by the medical profession on the grounds that it is imprecise since all pregnancies are eventually terminated, either by birth, abortion or miscarriage.1 An alternative term to abortion that is in use in French-speaking countries is ‘voluntary interruption of pregnancy’ (translation from interruption volontaire de grossesse), but its acceptability in English-speaking countries is unknown. Moreover, this term has been criticised for raising the spectre of ‘involuntary’ abortion.1 Healthcare professionals may be concerned about using appropriate and sensitive language when discussing a woman’s request to end an unintended or unwanted pregnancy. However, there is an absence of evidence to provide guidance on what women prefer. The aim of this study was to ascertain the views of women seeking induced abortion and to determine whether or not they find the terminology in use (abortion and termination of pregnancy) to be distressing and what their preferred term would be.
Methods
A one-page, self-administered anonymous questionnaire containing nine questions was developed to ascertain whether women seeking abortion found common terminology used to describe termination of pregnancy distressing (‘abortion’ and ‘termination of pregnancy), whether they had preferences for terminology, and to collect basic demographic information including age, ethnicity and reproductive history. In addition, partial postcodes were obtained. These were used to provide a non-identifying measure of deprivation in Scotland (Carstairs index) based on area of residence,9 and for England and Wales partial postcodes were matched against deprivation indices and the resultant distribution was split into quintiles to create an index of relative deprivation.10
From May to July 2015, five Scottish NHS abortion services (Lothian, Greater Glasgow and Clyde, Grampian, Ayrshire and Arran, Highland) distributed the surveys to all women attending dedicated clinics requesting a termination of pregnancy. Women presenting for termination in the case of fetal anomaly were excluded. These five services provided 64% of all abortions in Scotland in 2015.7 Completed forms were placed in an opaque envelope in a sealed collection box in the clinic waiting room. Surveys were similarly distributed and collected at 49 BPAS (British Pregnancy Advisory Service) clinics in England and Wales from August to September 2015. Approximately 60 000 abortions are performed by BPAS each year, which represents about one-third of the abortions conducted in England and Wales.
Completed forms were coded, data were cleaned and entered into a database and analysed using SPSS V22. Descriptive statistics were generated and responses were compared across age category, country of residence, history of having children, prior abortion and area of deprivation using Chi-square tests. A p value of <0.05 was considered statistically significant.
The NHS Lothian Sexual Health Service Patient Public Involvement Group approved the project as being of importance for patient benefit and reviewed the final questionnaire for language and sense. The project and questionnaire were reviewed by the ethical officer for NHS Lothian and the BPAS Research and Ethics Committee who confirmed that formal ethical approval was not required for an anonymous survey.
Results
A total of 3013 surveys were distributed and 2259 surveys were completed by women requesting abortion at the 54 participating clinics. This represented an overall coverage rate of 75%; 775 completed surveys out of 1111 women presenting for abortion at participating services in Scotland (70%) and 1484 out of 1902 during the study periods, in England and Wales (79%).
The characteristics of participants are shown in Table 1. The mean age of respondents was 27 range 13–51) years, 36% (n=823) had previously had an abortion and 51% (n=1156) had previously given birth. The majority (82%) self-identified as white.
Characteristics of the study participants (n=2259)
Do women find the terms ’abortion' or ’termination of pregnancy' distressing?
Table 2 shows the numbers and proportions of respondents who indicated that they found the terms ‘abortion’ and ‘termination of pregnancy’ distressing. Thirty five percent (n=783) of respondents indicated that they found ‘abortion’ to be distressing, with 21% (n=476) being ‘unsure’. Eighteen percent (n=399) of women indicated that they found ‘termination of pregnancy’ to be distressing, with 19% (n=438) being unsure. There were no statistically significant differences in responses between countries, nor between age groups, history of abortion, having children, or deprivation (based on area of residence) (Supplementary Table 1). Over the whole sample, 13% reported finding both terms distressing, 39% reported finding neither term distressing, with 15% reporting ‘abortion’ to be distressing but not ‘termination of pregnancy’ and 3% reporting ‘termination of pregnancy’, but not ‘abortion’, to be distressing; the remaining answers involved one or more ‘unsure responses’. The variation in the distribution of these responses was statistically significant (Chi-square 857.7, df=4, p<0.001).
Responses to the questions ‘Do you find the term ‘abortion’ distressing?’ and ‘Do you find the term ‘termination of pregnancy’ distressing?’ (n=2225)
What term would women prefer?
When asked which term respondents preferred, 45% (n=1009) indicated ‘termination of pregnancy’, followed by 12% (n=263) who selected ‘abortion’ and 9% (n=203) who selected ‘voluntary interruption of pregnancy’ (Table 3). There was no statistically significant association between preference for a particular term and any of the demographic characteristics, reproductive history or country of residence (data not shown).
Responses to the question 'Which ONE of the following word(s)/terms would you prefer us to use?' (Please tick one only) (n=2240)
In the free text section of this question, there were 16 suggestions for alternative terminology; termination (n=5), induced miscarriage (n=2), early intervention/cessation of pregnancy (n=2) and miscarriage (n=2) and one each suggesting voluntary ending of pregnancy, end of pregnancy, late contraception, pregnancy not followed through, and procedure. A further five commented that there was “no nice word for it”.
Discussion
The survey showed that most women seeking abortion did not find either ‘abortion’ or ‘termination of pregnancy’ to be distressing terms. Although a higher proportion did indicate that they found ‘abortion’ rather than ‘termination of pregnancy’ distressing, this was still a relative minority of all women (one-third of respondents). As regards preference, ‘termination of pregnancy’ was the preferred term for just under half of all respondents, and there was no significant association with any of the demographic characteristics recorded. ‘Voluntary interruption of pregnancy’, despite not being a term believed to be widely used by healthcare providers in Great Britain, was preferred by almost one in ten women. Few women suggested an alternative, and a small number of women commented that there was no good term. The women in our study were of similar demographic characteristics to the larger population of women undergoing abortion at that time in Britain.7 11 We believe that the findings of our survey are likely to be representative of the views of women seeking abortion in Britain.
Grimes and Stuart, in an article about the significance of terminology in this area of medicine, cogently argue that ‘termination of pregnancy’ should not be used “… because of its ambiguity. All pregnancies terminate, but not all abort”.1 However, they do not refer to women’s feelings about the terminology nor to what a healthcare professional should do when the views of those women who do express a preference do lean towards using ‘termination’ rather than ‘abortion’.
A strength of this study is that it is a large cross-sectional survey of the views of women presenting for abortion in Great Britain. In 2015, approximately 2 20 000 women had an induced abortion in Great Britain;7 11 based on these figures, we estimate that our sample might have captured the views of 7% of women presenting for abortion in Britain over the 8-week period during which the study ran in each of the two locations. Further, our sampling frame included clinics that served women from remote and rural communities, in addition to large urban areas, and was endorsed by patient public involvement as being a question of importance to women seeking abortion in Britain.
Coverage of 75% is very respectable for studies of this nature; this was presumably helped by keeping the survey as short as possible, although this does mean that some potentially interesting topics could not be included.
Of course, the findings cannot be assumed to reflect those of women in other English-speaking parts of the world; similar surveys of women’s views in other countries will be important. A further limitation is that the estimate of deprivation for England and Wales is based on partial postcodes, a process that entails averaging the small area estimates over a number of localities. This approach loses refinement but is necessary if anonymity is to be guaranteed.
This study is unique as it is the only one to determine women’s views on terminology used for abortion. The possible reasons for a greater proportion of respondents preferring the term ‘termination of pregnancy’ to ‘abortion’ are purely speculative. It could be related to antagonistic discourse in the British media12 and/or the stigmatisation of abortion,12–15 meaning that the word ‘abortion’ itself has become so stigmatised that some women find the word to be relatively distressing. As with all quantitative studies, the survey can tell us what the responses of women were but not the justifications for those responses. The study survey was simple and yet the subject matter is almost certainly more complex. Further qualitative research with women on their reasons for preferred terminology will be instructive to the healthcare community in determining whether changes to the abortion terminology in use is required.
However, despite the stated preferences, it is still a relative minority of women who find the term ‘abortion’ distressing. Nevertheless, given the relative preference for ‘termination of pregnancy’ among women seeking abortion, providers in Great Britain should consider identifying women’s preference for terminology at the beginning of a consultation and modify the language used accordingly, if they do not already do so.
Conclusions
The majority of women seeking abortion do not find either of the terms ‘abortion’ or ‘termination of pregnancy’ distressing, but a substantial minority do so. Healthcare providers should be sensitive to this in their communication with women. Similar studies on the views of women in other countries on abortion terminology should also be sought, in tandem with qualitative research in the UK and elsewhere on reasons for preference of term.
Acknowledgments
This study was conducted using the Scottish Abortion Care Providers Network and BPAS. The authors are grateful to clinical staff at the participating NHS clinics in Scotland and BPAS clinics in England and Wales. The assistance of Anne Johnstone (Clinical Research Nurse, Edinburgh) and Jeanette Taylor (Senior Research Nurse, BPAS) with study data collection and entry is gratefully acknowledged. The support of the Chalmers Centre Patient Public Involvement (PPI) group is also gratefully acknowledged.
Footnotes
Contributors STC conceived the idea and co designed with PL and RI. RI conducted all analyses. All authors contributed to writing the article and approve the final draft.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Results from all available data collected is presented in the paper.
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