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‘Abortion’ or ‘termination of pregnancy’? Views from abortion care providers in Scotland, UK
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  1. Aine Kavanagh1,
  2. Sally Wielding2,
  3. Rosemary Cochrane2,
  4. Judith Sim1,
  5. Anne Johnstone2,3,
  6. Sharon Cameron2,3
  1. 1 Deanery of Biomedical Sciences, University of Edinburgh, Edinburgh, UK
  2. 2 Chalmers Centre, Edinburgh, UK
  3. 3 Royal Infirmary of Edinburgh, Edinburgh, UK
  1. Correspondence to Aine Kavanagh, Deanery of Biomedical Sciences, University of Edinburgh, Edinburgh EH8 9YL, UK; aine.kavanagh{at}ed.ac.uk

Abstract

Background The phrase ‘termination of pregnancy’ has recently been adopted by a number of British medical institutions as a preferred descriptor of induced abortion. How it is used by abortion care providers is unclear, although the ongoing stigmatisation of abortion may play a role.

Methods A mixed methods study of the views of abortion care providers in Scotland, UK. Self-administered anonymous questionnaires were distributed to abortion care providers at a national conference (Scottish Abortion Care Providers). The main outcomes measured were the proportion of respondents reporting that they found the terms ‘abortion’ and ‘termination of pregnancy’ to be distressing, and their preferred terminology for use in consultations with women. In-depth interviews were conducted with 19 providers from a single clinic in Scotland to contextualise use of the terminology.

Results The questionnaire was completed by 90/118 delegates (76%). More respondents indicated they found the term ‘abortion’ distressing (28%), compared with those who found ‘termination of pregnancy’ distressing (6%; P<0.0001). Interview participants reported that ‘termination of pregnancy’ was the default phrase used in consultations. Some respondents stated that they occasionally purposely used ‘abortion’ in consultations to emphasise the seriousness of the procedure (morally, physically and/or emotionally).

Conclusions ‘Termination of pregnancy’ is the most commonly used term to describe induced abortion in patient consultations in Scotland. This and the term ‘abortion’ appear to play different roles, with the former being used euphemistically, and the latter as a more emphatic term. Further research is warranted to investigate how this interacts with patient care, service provision, and abortion stigma.

  • termination of pregnancy
  • induced abortion
  • terminology
  • organization and administration
  • stigma

https://doi.org/10.1136/bmjsrh-2017-101925

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    Key messages

    • Abortion terminology preference and use is variable across abortion care providers, although most seem to prefer to use the expression ’termination of pregnancy’ over ‘abortion.’

    • Abortion care providers appear to base their terminology preferences primarily on effective management of abortion stigma, as well as perceived specificity of the terms.

    • Further research is warranted to determine how abortion terminology use interacts with patient care, service provision, and abortion stigma.

    Introduction

    The term ‘abortion’ has historically been used in Scotland in all written clinical policies and guidelines, and it remains the phrase used in all legal documentation including the 1967 Abortion Act, reflecting international consensus.1 2 Recent expressions of preference for the synonym ‘termination of pregnancy,’ however, by a number of British medical institutions such as the NHS Scotland Information Services Division and some medical journal submission guidelines, have indicated a cultural change in how abortion is referred to, both in professional literature and discussion, and in consultations with women.3 4

    In other areas of obstetrics and gynaecology there have been concerns, both recently and historically, over use of inconsistent terminology by healthcare providers.5–9 Like the adoption of the term ‘miscarriage’ over ‘spontaneous abortion,’ a preference for using ‘termination of pregnancy’ over ‘abortion’ is thought to be driven by a desire to minimise stigmatisation or additional distress to women seeking abortion.8 9 A recent study of women attending for an abortion in the UK, however, found that the majority of respondents did not actually find either term distressing, but when given a choice still preferred ‘termination of pregnancy’.10

    There is little evidence to date as to the opinions of abortion care providers on the matter of abortion terminology, either in discussion with women or with other professionals.

    Methods

    All professionals working in abortion care provision in Scotland are invited to attend the annual Scottish Abortion Care Providers (SACP) conference. A wide range of healthcare professionals is usually represented: doctors, nurses, midwives, clinical support workers, policymakers, data analysts, administrators and clerical staff. As a wide-ranging multidisciplinary group together in one location, the SACP conference has previously provided valuable opportunities to rapidly garner views of abortion care providers on aspects of abortion care.11

    A paper, self-completion, anonymous questionnaire was given to all SACP conference delegates (n=118) in Edinburgh in December 2015. It consisted of a multiple-choice questionnaire with a combination of tick boxes, Likert scale responses to statements, and free-text options for comments.

    Respondents were asked for information on healthcare profession, age, geographical region of work, moral stance on abortion, and views on abortion terminology in common use: ‘abortion’, ‘termination of pregnancy’ and ‘voluntary interruption of pregnancy'.

    Respondents were asked if they or their patients found any of these terms distressing, which terminology patients preferred to use, and which they themselves preferred to use with patients and other healthcare practitioners.

    Responses were coded and data entered onto a Microsoft Office 2004 Excel Database for descriptive statistics analysis. Comparisons between groups were performed using a Fisher’s exact test.

    To explore the questionnaire findings in greater depth, from March to April 2017, in-depth one-off interviews of between 15 and 40 min were held with 19 abortion care providers from a single clinic in the Lothian region of Scotland caring for approximately 2000 women requesting abortion annually.12 Although the number of potential participants was limited, it was felt that their varied range of roles and experience in the field justified their inclusion in this part of the study. Potential participants were contacted via email, and interviews were conducted by a researcher on site.

    Interview questions (online supplementary table 1) were designed to repeat the SACP conference questionnaire, and also to expand the data on abortion terminology use, allowing development of a general (‘grounded’) theory to explain the trends in terminology use. Grounded theory qualitative research methodology was used as a basis for the interviews and data analysis.13

    Supplementary file 1–

    Interviews were transcribed and annotated (‘coded’) using NVivo Pro software (QSR International Pty Ltd).14 Constant-comparative data analysis methods were used, whereby transcripts were analysed while interviewing was still ongoing, and the interview schedule modified to allow for emerging themes in the data and retiring of unproductive questions or ones for which there was data saturation.13

    Sociological theories of stigma and emotional labour found in the published literature were used towards the end of the analysis to further develop the grounded theory to explain reported abortion terminology use.15 16

    The project proposals, questionnaire and interview schedules were reviewed by the ethical officer for NHS Lothian who confirmed that formal ethical approval was not required.

    Results

    Questionnaire of abortion care providers

    A total of 118 questionnaires were distributed to conference delegates, with 90 responses received (a 76.3% response rate). The majority (91%, n=81) of respondents were female. The median age of respondents was 46 (range 18 to >65) years. Some 45.6% (n=41) of respondents were nurses/midwives, 34.4% were doctors (senior grade doctors, i.e. consultant/sub-consultants (n=29), and junior grade doctors (n=2)), 6.7% (n=6) were managers and  2.2% (n=2) were counsellors. The remaining respondents (n=10) were pharmaceutical representatives, administration staff, medical students, or unspecified. Ten of the 14 Scottish regions were represented, with most delegates working in either Edinburgh and surrounding area (n=37), or Glasgow and surrounding area (n=17).

    Of the respondents, 92.2% (n=83) described their moral position on abortion as broadly ‘pro-choice,’ 2.2% (n=2) as ‘anti-choice’ and 3.3% (n=3) as undecided; 1.1% (n=1) preferred not to answer and 1.1% (n=1) did not respond to the question.

    Significantly more respondents indicated they personally found the term ‘abortion’ distressing (28%; n=25), than those who found ‘termination of pregnancy’ distressing (6%; n=5, P<0.0001).

    Additionally, significantly more respondents were of the opinion that women find the term ‘abortion’ distressing (51%; n=46), than those who thought the same for ‘termination of pregnancy’ (11%; n=10, P<0.0001). Responses are shown in online supplementary table 2.

    Supplementary file 2

    Consultations with women

    Significantly more respondents preferred to use ‘termination of pregnancy’ (59.6%, n=53) rather than ‘abortion’ (15.7%, n=14) in discussions with women (P<0.0001). Some 14.6% (n=13) would use either term, 9.0% (n=8) preferred to use ‘voluntary interruption of pregnancy’, while 1.1% (n=1) were happy using any of the suggested terminology. For each age group of respondents, ‘termination of pregnancy’ was the preferred term except for respondents aged 65 years and over (n=3) who preferred using ‘abortion’ during a consultation with women (figure 1).

    Figure 1
    Figure 1

    Preferred terminology to use with women, by age range of respondents. Any, any of the three terms; Either, ’TOP' or ’abortion'; TOP, ’termination of pregnancy'; VIP, ’voluntary interruption of pregnancy'.

    The preferred term among all professional groups in consultations with women was ‘termination of pregnancy’. Nurses and counsellors were least in favour of the term ‘abortion', with none stating a preference for using the term ‘abortion’ during consultations. The majority of nurses (73%, n=30) preferred instead to use ‘termination of pregnancy’, and 14.1% (n=5) preferred to use either term (figure 2).

    Figure 2
    Figure 2

    Preferred terminology to use with women, by percentage of professional group. Any, any of the three terms; Either, ’TOP' or ’abortion'; MW,  midwife; TOP, ’termination of pregnancy'; VIP, ’voluntary interruption of pregnancy'.

    Discussions with professionals

    Significantly more respondents preferred to use ‘termination of pregnancy’ (58.4%, n=52) than ‘abortion’ (18%, n=16) in discussions with other professionals (P<0.0001). Some 16.9% (n=15) preferred either ‘termination of pregnancy’ or ‘abortion’, 4.5% (n=4) preferred to use ‘voluntary interruption of pregnancy’, while 2.2% (n=2) were happy using any of the suggested terms. ‘Termination of pregnancy’ was the preferred term for each age group of respondents except for one respondent aged under 25 years who was content with either term, and those aged 65 years or over (n=3) who preferred to use ‘abortion’ with other professionals (figure 3).

    Figure 3
    Figure 3

    Preferred terminology to use in discussions with other medical professionals, by age range of respondents. Any, any of the three terms; Either, ’TOP' or ’abortion'; TOP, ’termination of pregnancy'; VIP, ’voluntary interruption of pregnancy'.

    Among doctors, nurses and clinic managers, the preferred term for consultations with other medical professionals was ‘termination of pregnancy’, while counsellors and other professional groups reported more openness and preference, respectively, towards the term ‘abortion’ (figure 4).

    Figure 4
    Figure 4

    Preferred terminology to use with other medical professionals, by percentage of professional group. Any, any of the three terms; Either, ’TOP' or ’abortion'; MW, midwife; TOP, ’termination of pregnancy'; VIP, ’voluntary interruption of pregnancy'.

    Interviews with abortion care providers

    Nineteen participants came forward for interview after approximately 30 were contacted by email, comprising nurses (n=9), doctors (n=8) and clinical support workers (n=2).

    Impressions of the terminology

    Participants consistently described ‘abortion’ as ‘harsh’ and/or ‘stigmatising’ for patients. These descriptors were generally spoken of interchangeably, with ‘harsh’ usually qualified to mean harshly judgemental or stigmatising. ‘Termination of pregnancy’ was almost always described as ‘gentler [than ‘abortion’]’.

    [I prefer using ‘termination of pregnancy’] just because abortion seems like a harsh word. It just feels like a harsh word just because it’s not normalised and because there’s certain stigma around [it]. [Participant 17]

    I think there are some women who don’t like the term abortion, termination of pregnancy seems like a slightly gentler term to use. [Participant 10]

    A secondary value mentioned of the terminology was specificity. Despite general consensus that ‘termination of pregnancy’ was a ‘gentler’ term than ‘abortion,’ opinions diverged on which term was more specific.

    I think [the phrase ‘termination of pregnancy’] is more obvious – you’re terminating the pregnancy as opposed to abortion, as spontaneous abortion or a, you know, a complete abortion, a complete miscarriage, if it’s completely passed, or medical abortion, so I think the word termination it gives the best idea of what’s happening. [Participant 2]

    I don’t know whether using termination of pregnancy is kind of trying to disguise it, do you know, whereas abortion, people talk about abortion - everyone knows what it is. [Participant 16]

    Usage

    Although many participants expressed preference for ‘termination of pregnancy’, in terms of actual usage some said they simply reflected the terminology the patient uses.

    I pretty much take my shots from what the patient says first of all. [Participant 9]

    Personally I don’t use the word abortion. I use the word termination of pregnancy. I don’t like the word abortion. I don’t know why and it’s not something like… I know it’s an abortion, but I just don’t like the word. But if a woman says it to me and it’s her frame of reference then I’ll use it. [Participant 14]

    Most participants asserted that patients rarely actually use the term ‘termination of pregnancy’, more commonly using the term ‘abortion’ or just the phrase ‘I don’t want [the pregnancy]’.

    ‘Termination [of pregnancy]’ is maybe more a medical term, I feel? Medical practitioners would use that, whereas I think… patients might use ‘abortion.’ [Participant 5]

    Culture change

    For both patient and interprofessional interactions, participants who had entered the field in the 1960s uniquely had a strong preference and usage of the term ‘abortion’. Other participants perceived that ‘abortion’ was more commonly used in the field at least prior to the 1990s.

    I got the impression that ’termination of pregnancy' has come in, actually in the last 10, 15, 20 years. [Participant 1]

    In my experience, it’s all now ‘termination [of pregnancy]’ and even with miscarriage it’s ‘miscarriage’, you know it’s not even ‘complete ‘or ‘incomplete abortion’ anymore. [Participant 18]

    Emphatic use of term ‘abortion’

    A small number of participants reported occasionally using the term ‘abortion’ deliberately to emphasise the seriousness of the procedure where they felt it was necessary, for instance to patients presenting who had previously had an abortion. These participants emphasised their regard for remaining non-judgemental, and their descriptions were all framed in a hesitant, hypothetical manner, perhaps reflecting the mostly subconscious nature of language choice echoed by many of the participants at the beginning of the interviews, for example: "I probably only use ‘termination’ actually, and I’ve no idea why. I don’t know, I’ve really no idea." [Participant 17]

    To be honest, if somebody was really really casual about [having an abortion], or had had it done lots of times, maybe I would use ‘abortion’ more? Maybe I’d – which is not necessarily the right thing to do but you’re maybe trying to em, make – if, if you felt you were trying to make somebody take [having an abortion] more seriously? [Participant 3]

    I would certainly use termination of pregnancy to begin with, but sometimes later in the consultation I might use the word abortion, and I don’t quite know why that is actually, maybe depends on how upset the woman is? How… ‘Cos I would say some of our clients are very cut-off from their feelings, especially people from very deprived areas who have maybe had several abortions, second terminations of pregnancy. [Participant 7]

    I did a feel a bit judgemental going in to that consultation, but I thought "No, it’s I consciously felt I can’t [judge], I’m just going to see what’s going on in this woman’s life". [Participant 7]

    Discussion

    This study indicates that among abortion care providers in Scotland, ‘termination of pregnancy’ is the preferred terminology across most age groups and professions, preferred both for interprofessional discussions and consultations with women. Views that patients find the term ‘abortion’ distressing, and that it could impart stigma, may play a role in this terminology preference. Suggested change from preference for the term ‘abortion’ in the 1960s may reflect evolution, since abortion legalisation in 1967, of language to fit the cultural context of legal abortion care provision in Scotland, and experienced stigma therein.17 18 It may also reflect differing attitudes towards the patient–doctor relationship, towards greater regard for the patient experience.19

    Abortion care provider impressions of what patients use and want to use appeared to diverge. The questionnaire reported that more providers conclude that patients find ‘abortion’ distressing than ‘termination of pregnancy’, while the interviews found that providers understand that patients themselves use ‘abortion’ more than ‘termination of pregnancy’. The recently published UK survey of women attending for a termination concluded that 45% of women preferred providers to use the term ‘termination of pregnancy’.10 This raises the possibility that providers may have misinterpreted what terminology patients would prefer to be used. Furthermore, the abortion terminology that patients want providers to use may differ from what patients want to use themselves.

    Abortion care providers appear to use the term ‘termination of pregnancy’ as a euphemistic tool; it’s ‘gentler’ than the ‘harsh’ term ‘abortion’. Euphemistic clinical language has had limited study and theorisation.20 21 It has been observed in managing patient fears during diagnosis for conditions usually stigmatised or sensationalised by mass media.22 In obesity and heart failure care, the conditions were observed being described as ‘unhealthy BMI’ and ‘heart isn’t pumping enough’, respectively.23 24

    Dysphemism (as opposed to ‘euphemism’) is the purposeful use of a harsher word over an available gentler synonym.25 Despite common participant perceptions of ‘abortion’ as a ‘harsh’, judgemental or ‘distressing’ term, ‘abortion’ was reported by some study participants to be occasionally used instead of ‘termination of pregnancy’, to emphasise to certain patients the ‘seriousness’ of the procedure. This may reflect cultural ideas and judgement of ‘good’ and ‘bad’ abortions, and ‘good’ and ‘bad’ abortion patients, a theme explored in abortion stigma literature.26

    The mixed-methods nature of this study provides power in both quantifying abortion terminology used by providers in Scotland and adding further detail to supplement those statistics; however, the scope of application of these findings is limited by the localised nature of the sample. Although respondents to the survey practised all over Scotland, the majority were based in the cities of Glasgow and Edinburgh. Providers from just one Edinburgh clinic were then interviewed. Data from Glasgow and Edinburgh are therefore overrepresented; caution must be exercised when extrapolating to rural areas of Scotland and further afield, where language and abortion stigma may be experienced differently.

    Conclusions

    Abortion care providers in Scotland appear to prefer using the term’ termination of pregnancy’ in patient consultations. This may arise from its perceived euphemistic value in minimising patient distress and stigma, and may have emerged after abortion legalisation in Britain. With some providers reporting use of the term ‘abortion’ where they felt a need to emphasise the ‘seriousness’ of the procedure to patients, further research on how terminology use interacts with patient care, service provision, and abortion stigma is warranted. 

    Acknowledgments

    The authors are grateful to the delegates of the 2015 Scottish Abortion Care Providers Conference for their questionnaire responses.

    We would also like to acknowledge the valuable contribution of the NHS Lothian abortion services staff.

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    Footnotes

    • Contributors SC planned the study and designed the survey with AJ and RC. SC and JS supervised AK who conducted and analysed the interviews. SW conducted the survey and analysed the results. All the authors reviewed and approved the manuscript.

    • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Additional unpublished data from this study are unavailable, as this may identify participants.

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      BMJ Sexual & Reproductive Health 2018; 44 75-76 Published Online First: 12 Apr 2018. doi: 10.1136/bmjsrh-2018-200108