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Abstract
Background An animated film has been created to provide information to women requesting early medical abortion (EMA). The 9 min film, Lara’s Story, was created using one woman’s personal account of her experience. This study evaluated the views of women who had recently undergone EMA on the film and its potential usefulness in providing experiential information to women requesting EMA.
Method Women who had undergone EMA within the past month were recruited. They were shown the film and interviewed in a semi-structured style. Interviews were recorded and transcribed verbatim. They were analysed using cross-sectional indexing and thematic analysis with an inductive approach.
Results 13 women were interviewed. All reported that the film gave a realistic account of EMA and most agreed that they would have wanted to watch it before EMA had it been available. Some said that it might help women who were struggling with decision-making with regard to EMA and all said that there should be unrestricted access to the film from the website of the abortion service. The women commented that the animated style of the film allowed all groups of women to relate to the story. Some commented that Lara’s experience of pain, bleeding and side effects such as nausea differed from their own and therefore felt that it would be useful to make more than one woman’s account available.
Conclusion The availability of animated audiovisual films recounting women’s experiences of EMA might be a valuable adjunct to clinical information for women seeking EMA.
- abortion
- termination of pregnancy
- patient stories
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Key message points
The women interviewed supported the development and use of animated films about experiences of early medical abortion (EMA) for others seeking a termination.
Experiential information on EMA could provide a valuable adjunct to clinical information for women seeking EMA.
Abortion services should consider developing animated films based on real women’s experiences for their own clients.
Introduction
Increasing proportions of women undergoing abortions in Great Britain are having them before 9 weeks’ gestation and choosing to have them performed medically using the drugs mifepristone and misoprostol—early medical abortion (EMA).1 2 In Scotland 72.5% of abortions in 2015 were before 9 weeks,1 of which 88% were EMAs.1 In England and Wales 80% of abortions were before 10 weeks, of which 55% were medical.2
In NHS Lothian, the National Health Service region providing services to the city of Edinburgh and the surrounding area, women requesting EMA are given detailed information on the procedure, its benefits and risks, and on future contraception. This evidence-based information is given verbally during the consultation, supported by leaflets and by a film on the abortion service website. Previous research has shown that women find such audiovisual information about the clinical aspects of abortion acceptable and informative.3
In many areas of medicine, patients provide support and information to others through sharing their personal experiences. Websites and support groups are available online, offering films featuring patient stories.4 5 However, provision of objective information based on women’s own experiences of abortion is rare, probably complicated by the sensitive nature of the procedure and the continuing stigma surrounding it. In addition to receiving quality clinical information about what to expect, women requesting abortion may value information based on other women’s experiences and this can be difficult for staff to provide. An animated film giving experiential information on EMA was therefore developed. This film, Lara’s Story, was based on one woman’s experience of EMA at home. It was created from the transcript of an interview conducted as part of previous qualitative research, with the participant’s permission. The present study was conducted to evaluate the opinions on the film of women who had undergone EMA.
Methods
Lara’s Story was created by one of the authors (DC) using GoAnimate software (GoAnimate, Inc, San Mateo, CA, USA).6 It describes the experiences of ‘Lara’, a woman who underwent EMA at 5 to 6 weeks’ gestation. Pseudonyms were used to preserve anonymity. Animations and pictures, including a photo representing Lara’s home and GP surgery, support the 9 min narrative.
A convenience sample of 12–20 women, a typical sample size for qualitative research, was deemed likely to be sufficient to generate breadth of views. To participate in the study, women had to have undergone EMA within the previous 4 weeks. We excluded women aged under 16 years as well as those who did not speak English as it was not feasible to provide a translator due to the short time frame of the study and the qualitative methodology. Between 15 February and 11 March 2016, clinic reception staff gave information sheets detailing the study to women attending NHS Lothian termination clinics for EMA (approximately 56 women). Eleven women returned the contact sheet indicating interest in participating. The researcher (SS) telephoned them a week later to confirm participation and arrange an interview. Of the 11 women, five agreed to interview. Additionally, women attending for intrauterine contraception within a month of EMA were provided with the same information by a research nurse and invited to participate. Eight women were recruited in this way; 13 interviews were conducted in total.
Data collection
Women were shown Lara’s Story in a private room. Semi-structured interviews were then conducted by SS. A topic guide developed by SS, STC and JH, based on previous qualitative research with women who had had EMA, was used. Topics covered included: women’s opinion of the film and its usefulness, accuracy of the description of the experience, and technical aspects of the film such as length, narration and animations. Women gave consent before interview. The interviews, lasting an average of 16 min, were audio-recorded and transcribed verbatim, removing all personal identifiers. Transcripts were kept on a password-protected computer.
Analysis
Analysis of the interview content was iterative with interviews analysed as soon as they were transcribed. Interview transcripts were organised using cross-sectional indexing. They were then analysed by SS following Braun and Clarke’s six phase process of thematic analysis.7 Initial codes were generated and collated into data-driven themes, which were refined and reviewed by JH and STC. The final themes were defined and named; they are described in the Results section. Saturation of results was reached when no new themes emerged. At this point study recruitment ceased.
Ethics
The Scientific Officer for South East Scotland Research Ethics Service reviewed the project protocol, as did the responsible person for reviewing projects conducted by medical students at the University of Edinburgh, and confirmed that NHS ethical committee approval was not required. The Quality Improvement Team for abortion in NHS Lothian approved the project.
Results
Common themes from the interviews were as follows; see Appendix 1 for additional quotes from women.
1 The film as a realistic experience
Women commented on how natural and realistic the story was and how well it reflected their own experiences of EMA. They all reported that the process and medical procedure were accurately and clearly explained and found that Lara’s positive experiences with clinic staff were similar to their own. They described the film as straightforward and honest:
“It just sort of said everything and how I felt and what I went through. That’s what I said, it was just pretty weird watching it because it covered pretty much everything - how I was feeling and what I was thinking really.” I-8
2 Would women have watched the film if it had been available?
The majority would have watched the film had it been available before their EMA. Many of the women had tried to inform and ‘mentally prepare’ themselves before their appointment and said that they would have found the film useful. They described their emotional ‘state of turmoil’ surrounding the abortion and would have liked to know exactly what the process would be like. Some were worried that they would come across anti-abortion material or ‘horror stories’ while researching abortion and felt that it would have been reassuring to know that there was information available from a trustworthy source.
Three women felt that the description of pain would have made them more nervous. A further three women said that they would not have watched the film before their EMA as they had made their decision and didn’t feel they needed any more information. One woman believed that the film would be more useful to women who were ‘struggling with their decision’. Another explained that she didn’t want anything to ‘sway her decision’ and would have found it difficult to watch the film before her EMA because Lara seemed ‘happy to have an abortion’:
“It wasn’t such an easy decision for me, that might have frustrated me a bit, like how did she know, it was so easy for her.” I-12
3 Usefulness of the film
All women agreed that the film would be useful to others and supported its availability on the abortion service website. Women reported that the film could allay any fears about the EMA process. It was suggested that it would be useful for women to watch the film at home before their clinic appointment so that they knew what to expect and that the service would benefit from this as women would be better informed.
“Yeah it would definitely help, like I said, certain people. It wouldn’t be for everybody of course but it would help them with their decision and just to understand what they are going to go through from somebody else who’d been through it.” I-1
4 Pain
The topic of pain was raised in 11 of the 13 interviews. Six women felt that the pain described in the film was more extreme than they had experienced, while five women said that the film accurately reflected their experiences. They felt that pain was a very important factor of EMA that should not be underplayed.
“It does explain exactly what’s going to happen but the pain bit would scare me definitely…I just wouldn’t have liked to watch it because the pain thing would have scared me.” I-3
“For me it wasn’t very bad so maybe it’s better to say don’t expect really really bad pains. It can happen but for some people it doesn’t.” I-4
5 Bleeding
Women also reported differing experiences of bleeding during their EMA and felt that this required more emphasis. Some experienced lighter bleeding than expected while others found that it was the worst aspect of their EMA. They felt that the film should detail the extent and duration of bleeding to expect.
“For me it wasn’t the pain that was the problem, it was the amount of bleeding was more than I expected. I wasn’t really prepared for that.” I-10
6 Multiple films featuring different experiences
A recurring theme was the individuality of the women’s experiences. Many appreciated the film as Lara’s experience but felt that it wasn’t representative of their own experience. They suggested featuring different stories so that a wider range of women could relate to them. Some found it more difficult than Lara to make the decision to have the EMA and suggested making a film with a woman struggling with her decision.
“Because it’s only one person’s response, maybe some people who weren’t happy getting an abortion might find it harder to connect with that…I think if there were others and there were ones that said actually it’s ok to be really upset afterwards, I think that probably would have been better.” I-6
A number of the women experienced sickness and pain after taking mifepristone, which is not described in the film. They felt that it would be useful if this were addressed in another woman’s story.
One woman felt that there was such diversity of experiences that it would be difficult to address every one. In her opinion, it was the responsibility of the viewer to recognise that their experience may not be exactly the same as Lara’s.
Women also supported making similar films for surgical abortion and late medical abortion. Two women suggested making a film specifically for men. One clarified that her partner would have liked information on how to support someone through an EMA and felt that a film to help men understand the process would be helpful.
7 Length of the film
The majority of the women felt that the film’s length (9 min) allowed adequate detail without it becoming boring. Three stated that the film was too long although they felt that removing sections risked compromising the quality of the film.
One woman suggested cutting the film into chapters, an idea supported by Interviewee-9 who felt that women might not watch the whole film.
“I’m not sure if you would watch it all, I think if you were really deliberating over a decision but normally I don’t know, people tend to watch quite short things don’t they?” I-9
8 Animations
Many of the women preferred the use of animation and images to an actress playing Lara as it enabled them to imagine Lara as real. She could be any age and from any background, making it easier to relate to her. Women also felt that animation enabled them to imagine Lara’s story as their own and that it demonstrated confidentiality.
“I think I preferred that because obviously you’d probably get too bogged down with what they look like, ‘oh they look quite professional they’re not being judged’.” I-2
One woman would have preferred an actress telling the story but explained that too much acting could be distracting.
9 Timescale
The majority felt that it was important that the film begins with Lara missing a period and finding out that she’s pregnant as this reflected their experiences.
Some felt that the story ended prematurely as expelling the pregnancy was not the end of the process. They experienced bleeding for up to 3 weeks following EMA and some returned for scans following positive pregnancy tests. Two women thought that discussion of contraception should be included.
“The end bit is not the end point, it’s going for that pregnancy test in 2 weeks time and finding out from that point that you may be going for a scan and also what kind of contraception are you going back to?” I-12
10 Narrator
All of the women found the film clear and easy to understand. The majority did not have any strong opinions of the narration. Although one woman felt that Lara sounded young, others thought that younger women might not be able to relate to her, as Lara’s voice was of an ‘older woman’.
Discussion
To our knowledge, this is the first evaluation of an animated film on personal experience of EMA. Qualitative research allowed the collection of data with enough depth to gain a full understanding of women’s views of the film within the context of their own EMA experiences. Semi-structured interviews allowed flexibility while ensuring discussion of relevant areas.
All the women interviewed for this study felt that the film would be useful for women seeking abortion and supported the availability of the film on the abortion service website. Most would have watched the film had it been available before their EMA; those that would not explained that they had not wanted or needed more information. Women felt that the film was a good, honest representation of the EMA process and that it was presented clearly. Opinion was divided over the depiction of pain: some women felt that the pain described was too severe and others thought that the pain was not described in enough detail. Some women felt that bleeding and side effects such as nausea were not described in enough detail. The women’s responses show the variety in experiences of EMA, suggesting that a ‘one story fits all’ approach may not be possible.
One of the 13 women interviewed commented that she would have found the film difficult to watch before her EMA because Lara seemed ‘happy to have an abortion’. Lara’s decision was included in the film to give the full story. However, this is only one woman’s experience. Abortion is a very sensitive issue and everyone’s experiences are different. This highlights the need for more stories with more women’s experiences. Indeed, all the women interviewed felt that more stories should be made available for comparison.
The film was made to inform women who have already taken the decision to undergo EMA and for those considering it. Although women were not asked during interview how they thought seeing the film would affect the decision-making process, one woman did imply that it would be useful in decision-making. This was not explored further in the interviews but may reflect how information, both clinical and experiential, may be valued by women.
A limitation of this study is that Lara’s Story was developed for women to watch before undergoing EMA, but the study was conducted retrospectively with women participating following their EMA. A lot of information is given during the first EMA appointment and it can be a stressful time, so this would not have been a practical time for women to watch the film and to be interviewed. Although the timing of the interviews meant that women could not comment on the impact that seeing the film might have had on their EMA experience, women were able to comment on the accuracy of EMA representation in the film.
A second limitation is that a convenience self-selected sample of women was used in this study which therefore may not be representative of all women who attend the clinic for EMA. Only one of the 13 women lived in an area with a Scottish Index of Multiple Deprivation (SIMD)8 score of 1 (ranking it as ‘most deprived’). Seven had postcodes consistent with relative affluence. There is a strong association between deprivation and termination rates,1 with proportionally higher rates of termination in women with lower SIMD scores in both Lothian and in Scotland as a whole. Our research sample may also not be representative of women undergoing EMA in other parts of the UK or in other countries.
The International Planned Parenthood Foundation (IPFF) has made four short films featuring personal accounts of women from Uruguay,9 Cameroon,10 India11 and France12 who have undergone abortions. These films are available on their website and have been created not only to inform and educate patients but to reduce the stigma surrounding abortion. However, to our knowledge nothing like this is available for women seeking EMA in the UK.
Delivering high quality information to patients about medical procedures that they are considering is key to effective counselling. Provision of ‘quality’ experiential information is also considered an adjunct to clinical information provision. The information collected in this study suggests that the development and availability of ‘experiential’ information on EMA might be of value to women requesting this procedure. Furthermore the women sampled supported the modification and use of this particular film on our service’s website and the development of other films. Following this study, Lara’s Story has therefore been made available on the NHS Lothian Sexual Health website.13 As the modifications recommended by the women interviewed were minimal, the film has been uploaded in its original form. We suggest making more films based on other experiences, which can then be evaluated and made available. Similar films for use in other areas of the UK could be produced centrally as their development requires funding and resources that may not be available to smaller sexual health services. However, research14 has shown that women in remote and rural parts of the UK might have concerns specific to their geographical area of residence, suggesting that there would also be merit in services providing films based on the experiences of local women.
Acknowledgments
We gratefully acknowledge the assistance of Anne Johnstone, clinical research nurse,with distributing and collecting questionnaires. We are grateful to Eric Chen,qualitative researcher, University of Edinburgh, for his advice and guidance on qualitative analysis. Carrie Purcell is gratefully acknowledged for conducting the original qualitative research that generated the transcript used to make Lara’s Story.
Footnotes
Contributors STC conceived the idea for this study. JH, SS, DC developed the idea. DC undertook animation and voiceover of Lara’s Story. SS conducted interviews. SS and JH conducted analysis. All contributors have reviewed and approved the paper.
Funding This study received funding from Lothian Sexual Health Strategy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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