Experiences of abortion care in Australia during the COVID-19 pandemic: examining multiple dimensions of access

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Yet barriers to abortion access remain, including legal restrictions, cost, stigma, and limited availability of services and information. The COVID-19 pandemic exacerbated barriers to abortion care. The aim was to identify barriers to and facilitators of abortion by examining experiences of access during the COVID-19 pandemic. Methods This qualitative phenomenological study examined abortion access during the pandemic in Australia, where abortion is decriminalised. We used social media and flyers in clinics to recruit adults who sought abortion care since March 2020, then conducted in-depth interviews. We mapped participant experiences to five dimensions of access identified by Levesque et al.’s patient-centred access to healthcare framework: approachability, acceptability, availability and accommodation, affordability, and appropriateness. Results The 24 participants lived across Australia and sought abortion in a range of pandemic-related restrictions. Approachability : Most lacked information about abortion and where to seek it. Acceptability : Many were uncomfortable disclosing their abortion to family, friends, and healthcare providers, and providers demonstrated varying levels of support. Availability and accommodation : Regional participants travelled far and faced long wait-times, exacerbated by pandemic restrictions. Affordability : Participants described financial stress paying for the service, travel, and related expenses. Appropriateness : Most participants expected judgement in care. Providers commonly assumed they wanted to remain pregnant, and some provided unempathetic and rushed care. Some participants reported non-judgmental and supportive services with appropriate emotional support and time spent with providers. Discussion Abortion seekers experienced varying obstacles when seeking care, exacerbated by the COVID-19 pandemic. Challenges during the pandemic illustrated the importance of ensuring social support during care and choice between abortion modalities and service types. The findings illustrate the need for population- and system-level initiatives such as: providing accurate information about and normalising abortion; implementing system-level efforts to reduce wait times, travel, and costs, especially for rural populations; and developing regulatory and quality improvement initiatives to increase the workforce and its readiness to provide high-quality, non-judgemental abortion care. Consumer voices can help understand the diverse pathways to abortion care and inform solutions to overcome the multidimensional barriers to access. Abortion healthcare access Australia COVID-19 qualitative research Introduction To achieve the Sustainable Development Goals target of universal access to sexual and reproductive health services( 1 ), the obstacles to abortion information and services must be understood and overcome. The World Health Organization (WHO) defines access as the “continual and organised” delivery of healthcare services in a “geographically, financially, culturally and functionally”( 2 ) appropriate way. The WHO’s conceptual framework for abortion care (2022) describes the four main components of an enabling environment for access to high-quality care. These are, respect for human rights, legal and policy frameworks that support abortion, available and accessible information about abortion, and supportive and appropriately-resourced health systems.( 1 ) When these components are absent, access to safe abortion care can be hindered by barriers such as legal restrictions to abortion provision, high costs, abortion stigma, and the limited availability of abortion methods, services and related information.( 1 ) Various frameworks have been developed to illustrate the multidimensional factors influencing access to healthcare. The 2013 Conceptual Framework of Access to Healthcare by Levesque et al. draws comprehensively on previous definitions and frameworks for individual and community health to identify five dimensions that encompass the most common and crucial aspects of access. These are approachability, acceptability, availability and accommodation, affordability, and appropriateness of service delivery.( 3 ) Two qualitative studies have previously utilised this framework to explore access to telemedicine abortion care in rural Australia and in the United States, demonstrating applicability to a stigmatised service such as abortion.( 4 , 5 ) However, stigma is not explicitly mentioned in Levesque’s framework. Abortion stigma, drawing on Goffman’s widely-used definition, is an attribute that works to discredit a person due to their choice to obtain or provide abortions.( 6 , 7 , 8 ) Abortion stigma contributes to secrecy about abortion among abortion seekers and providers,( 9 ) and exacerbates the lack of information( 10 ) or misinformation about abortion.( 6 ) Health stigmas can lead to social isolation, maladaptive coping behaviours, and stress, and are a cause of health inequalities.( 11 ) Stigma is a barrier to accessing high-quality sexual and reproductive health services across contexts.( 12 ) Another factor limiting access to abortion in recent years is the COVID-19 pandemic. The pandemic has been associated with increased domestic violence( 13 ) and with shifting fertility intentions, with some people delaying their childbearing as a result of the pandemic.( 14 ) These circumstances can increase the demand for abortion care. Travel restrictions, supply chain challenges, and provider shortages, among other barriers, have limited timely access to healthcare during the pandemic, particularly impacting sexual and reproductive health services.( 15 , 16 , 17 ) Delays to care are disproportionately burdensome for abortion, which is a time-sensitive health service with growing complexity and costs and reduced service options as gestational age increases.( 18 ) Telehealth services for medication abortion( 19 ) were introduced or expanded in some settings to counteract health system limitations during the pandemic,( 17 ) with particular benefits for rural populations.( 4 ) Telehealth is a safe, acceptable, and effective strategy to bolster access to medication abortion.( 19 , 20 , 21 ) The pandemic also exacerbated the pre-existing health and social inequities that limit access to sexual and reproductive health services.( 16 ) Examining abortion care during COVID-19 “may serve as a lens through which systemic barriers to access may be illuminated.”( 15 ) The aim of this study was to elucidate barriers to and facilitators of abortion care during the COVID-19 pandemic in Australia.( 15 ) Methods Setting Australia is a federation with national, state, and local tiers of government. The Federal Government subsidises the cost of healthcare services for citizens, permanent residents, and some visa holders through the Medicare Benefits Scheme.( 22 ) Some people also pay for private health insurance, which covers the cost of some private hospital services and some hospital services not paid for by Medicare.( 22 ) Abortion was gradually decriminalised in Australian states and territories between 1998 and 2022.( 23 , 24 ) Regulations differ between states and territories,( 25 ) with gestational age limits for surgical abortion ranging from 14 weeks in the Northern Territory to 24 weeks in Victoria without any restrictions; some jurisdictions require medical provider approval or consultation of additional providers after set gestational limits (for example beyond 22 weeks in New South Wales).( 26 , 27 , 28 ) Medical practitioners, including pharmacists, have a right to conscientious objection that obligates them to refer clients to an appropriate provider if they do not wish to provide abortion care on religious, moral or personal grounds.( 29 , 30 ) According to recent estimates, 13.7% of Australian obstetrics and gynaecology physicians and those undergoing specialist training were completely opposed to the delivery of abortions based on conscientious or religious grounds.( 15 , 31 ) Medication abortion has been available nationwide since 2012 until 63 days of gestation, requiring the prescription of Mifepristone and Misoprostol (branded as MS-2 Step) by a registered medical practitioner.( 32 ) General practitioners (GPs) can refer women for abortion care and can register to prescribe medication abortion.( 33 ) As of 2021, however, only around 7% of Australian GPs were registered to do so.( 34 ) Most abortions are provided privately, either by GPs (medication abortion) or in abortion clinics or hospitals (surgical or medication).( 33 , 35 , 36 ) The provision of abortion care in public hospitals is mainly limited to foetal conditions.( 25 , 37 ) Out-of-pocket costs are commonly incurred by abortion seekers,( 36 ) and abortion costs vary by abortion type, the presiding jurisdiction, gestational age, insurance scheme,( 38 ) and between private and public facilities.( 36 , 37 ) In efforts to facilitate access in the context of pandemic-related public health restrictions, Australia provided abortions as essential medical care during the COVID-19 pandemic ( 15 ) and the Federal Government expanded Medicare-covered telehealth to include abortion services.( 39 ) Despite this, policy and health system analyses have shown that the pandemic exacerbated existing barriers to abortion access in Australia and contributed to delays to care.( 15 , 19 , 33 , 40 , 41 ) Abortion seeker perspectives of the barriers to and facilitators of abortion during the pandemic have been insufficiently examined, and are needed to inform efforts to improve access. Study design This qualitative phenomenological study examined experiences of abortion care in Australia since the start of the COVID-19 pandemic. We used the 2013 patient-centred access to healthcare framework (hereafter referred to as ‘Levesque’s framework’)( 3 ) as a theoretical framework to inform data analysis and interpretation. It is a general healthcare framework with a patient-centred lens, and is well-suited to “comprehensively assess the complex and dynamic process” ( 42 ) that is common in abortion seeking. Levesque’s framework evaluates the ways people seek information and care, their experiences with the multiple steps of care-seeking, and the interconnectedness of the dimensions of access( 3 ). Drawing on global literature about abortion access, we have adapted each dimension from Levesque’s framework to abortion (detailed in Supplementary Table 1 and summarised in Tables 2 to 6 ). Participants and recruitment Any person who attempted to access abortion services in Australia since March 2020, was at least 18 years of age, and was able to communicate in English for an interview was eligible to participate. Recruitment took place from November 2021 until October 2022 through social media posts (Twitter, Instagram, and Facebook). After April 2022, once COVID-19 restrictions had lifted, flyers were distributed by sexual health clinics. Eligible participants were directed through a QR code or URL to submit an expression of interest through Qualtrics, answering brief questions about their location, age, how the pandemic influenced their experience seeking abortion care, whether they had obtained an abortion and if so, when and what type. We reviewed each expression of interest and selected participants to ensure a diversity of characteristics and experiences in terms of state or territory, type of abortion (medication vs. surgical), regional/metropolitan residence, age, and extent of pandemic-related restrictions at the time of their abortion. Data collection We adapted a semi-structured interview guide from instruments used in similar studies in other countries,( 10 , 43 ) and added questions relevant to abortion-seeking during the pandemic. Questions explored participants’ experiences, from finding out they were pregnant, through seeking and obtaining care (or not), and any influence of the COVID-19 pandemic on their experience. The semi-structured interview approach allowed for a flexible interview, with elaboration, probing, and modification of questions based on participant responses.( 44 ) All interviews were audio-recorded and documented with field notes. Each invited participant was emailed to schedule an interview, with information about the study attached. Interviews were conducted over Zoom by an experienced abortion researcher (SM). After reviewing the Explanatory Statement and answering any questions, the interviewer audio-recorded verbal consent. Each participant chose between video and audio calls to maximise their comfort. We provided each participant with a AUD40 gift card in respectful recognition of their time. The study was approved by the Monash University Human Research Ethics Committee (Project 30926). Data management Automatic transcription was generated by Zoom software, and then quality checked and edited. Edited transcripts were imported into NVIVO 12 ( 45 ) for analysis. De-identified audio recordings, field notes, and sociodemographic information were stored electronically on a password protected Monash University server. Analysis Two researchers (SM and SW) familiarised themselves with the data by reading transcripts, listening to audio recordings, and writing reflective memos about each interview. We conducted thematic analysis based on a codebook,( 46 ) using the five dimensions of access in Levesque’s framework as the main codes, and developing sub-codes reflecting barriers and facilitators of access. We coded two transcripts, compared coding, and adjusted the codebook to ensure the definitions were clear. All remaining transcripts were then coded by one researcher (SW), with input throughout the process through researcher meetings. The team documented their process through field notes and memo writing to practice reflexivity.( 47 ) Results Participant characteristics A total of 24 participants were interviewed from 55 total expressions of interest, of which 14 were lost to follow-up and 17 excluded due to ineligibility or in efforts to balance the sample across states and territories and between rural and urban participants. The interviews lasted 30 to 105 minutes. All participants identified as cis women and sought abortion services between April 2020 and November 2022. They ranged from 20 to 40 years old (mean: 29.6 years old) and lived in seven of the eight Australian states and territories. Ten lived in rural areas and 14 in urban ones, according to the Australian Institute of Health and Welfare rural and remote classification system.( 48 ) Twenty-one participants had one abortion during the study period, two participants had two abortions each, and one had a miscarriage and did not obtain an abortion, with a total of 24 people and 25 abortion services included in the analysis. Of these, 14 were medication abortions within the 63-day gestational age limit, nine were surgical abortions, and two were hospital-based medical inductions beyond 20 weeks. Six participants used both telehealth and in-person consultations, while the remainder only had in-person consultations. COVID-19 restrictions at the time of the abortion services ranged from severe (no travel beyond 5 km from home) to negligible (screening questions for symptoms before the service). Most participants who obtained care in 2020 and 2021 were not permitted to bring an accompanying person to their service due to public health measures. [Table 1 about here] Table 1 Participant characteristics Participant characteristic (n = 24) Age (mean: 29.6) n (%) 20–24 5 (21%) 25–29 6 (25%) 30–34 9 (38%) 35+ 4 (17%) Identifies as n Caucasian 20 (83%) Aboriginal 1 (4%) Asian 1 (4%) Hispanic 1 (4%) Multiracial 1 (4%) Location n Victoria 10 (42%) Queensland 6 (25%) New South Wales 3 (13%) South Australia 2 (8%) Australian Capital Territory 1 (4%) Western Australia 1 (4%) Northern Territory 1 (4%) Tasmania 0 Rurality 1 n Urban 14 (58%) Regional 10 (42%) Abortion characteristics (n = 25) 2 Abortion type n Medication abortion 14 (56%) Surgical abortion 9 (36%) Hospital-based medical induction 2 (8%) Modality n In-person only 19 (76%) Combination telehealth and in-person 6 (24%) 1 Per AIHW rural and remote classification system 2 Twenty-one participants had one abortion during the study period, two participants had two abortions, and one had a miscarriage and did not ultimately obtain an abortion Experiences of abortion seekers for each dimension of Levesque’s framework For each dimension of access identified in Levesque’s framework, we present an adapted definition specific to abortion, describe key aspects of how the sample experienced that dimension, and present illustrative quotes (Tables 2 to 6 ). i. Approachability We found that participants had limited prior understanding about the availability, legality, and provision of abortion care. Some participants said they were not taught about abortion when they were younger, for example due to a lack of sexuality education in school or reflecting the religious beliefs of their family. Many sought information outside of the healthcare system – primarily online and from family and friends. Most of the ten participants located in Victoria were unaware of the presence of the state-funded telephone hotline providing comprehensive contraceptive, pregnancy options, and sexual health information called 1800MyOptions. The main findings and quotes to illustrate these experiences are shown in Table 2 . [Table 2 about here] Table 2 Abortion seekers’ experiences of abortion care relative to the approachability dimension of Levesque’s framework A Approachable abortion care includes availability of accurate abortion information to all people about abortion options, legalities, gestational limits, and where to access abortion. Participants had some prior understanding of the availability of abortion care, though the information they had was not comprehensive. They described having limited knowledge and uncertainty about: The types of abortions available • “I knew what options were available like […] medication, or like a surgical. […] I didn't know, like the specifics, but I knew enough.” (ID020, Miscarriage, QLD, Regional) The legalities and gestational limits of abortions • “I didn’t even know […] if it was illegal or legal.” (ID013, Surgical, WA, Urban) • “I knew that there were time limits on when I could make a decision by […] and […] [that there were] different limits with both procedures.” (ID012, Medication (x2), VIC, Urban) Who provided abortion and where to go • “I didn't know which places offered abortion.” (ID006, Surgical, VIC, Urban) • “I just had no idea where to go, I didn’t necessarily know that […] my GP could do it.” (ID008, Medication, VIC, Urban) Many participants chose to seek information on abortion care independently of the healthcare system. The main methods of information-seeking included: Searching online • “I was completely isolated from my usual mechanisms of reaching information and […] at the mercy of Google, which ranks its first couple of pages based on how much you pay.” (ID016, Medication, VIC, Urban) Family and friends • “I didn’t know what I was in for and so finding out from other people [...] and listening to what they had to say about it […] was helpful.” (ID003, Medication, SA, Urban) B Approachable abortion care includes ensuring that tailored information is available to all people of reproductive ages. Some participants said they were not taught about abortion at a young age through credible sources, making the process of sourcing information independently difficult. • “I didn’t really have much of a sexual health education. I grew up in a religious family, quite conservative, […] so I didn’t know anyone who’d had an abortion before.” (ID008, Medication, VIC, Urban) ii. Acceptability Participants expressed different levels of (dis)comfort speaking to friends and family about their abortion. Most did not feel comfortable speaking to their colleagues about having an abortion, though some told their supervisors to explain an absence from work. Some participants said their medical provider emphasised their free choice to obtain an abortion. However, others felt their provider did not support their decision, or even tried to dissuade them from having an abortion. The main findings and related quotes are shown in Table 3 . [Table 3 about here] Table 3 Abortion seekers’ experiences of abortion care relative to the acceptability dimension of Levesque’s framework A Acceptable care includes accounting for social and cultural factors that can impact a person’s decision and ability to access an abortion. There was varying comfortability amongst participants about speaking to friends and family about their abortion. • “My family is extremely religious. So […] I can never talk to them about it because I’ll pretty much be disowned. […] I think the stigma around [abortion], […] it's extremely hard […]. You don't want to even tell […] [your] friends about it.” (ID018, Medication, QLD, Urban) • “It's a bit taboo, yeah, and initially I wasn't going to tell anyone. I told my housemate and […] my mum and I just wanted to keep it at that. But I’ve actually […] been telling people, and I think it's great to talk about it, and normalise it.” (ID005, Surgical, VIC, Urban) • “We didn't want anyone to watch our kids because we didn't want anyone to know what we were doing.” (ID013, Surgical, WA, Urban) Most participants did not feel comfortable speaking to their colleagues about having an abortion, though some did tell their direct supervisor. • “I was in like a really sort of pressurised work situation, and so I actually never got any time [off]. […] I think that speaks to a whole range of issues, particularly about gender relations in the workplace, and what is taboo, and what is acceptable personal leave.” (ID008, Medication, VIC, 27, 2021, Urban) • “I'm full time ongoing. […] It's [a] really small organisation and they're incredibly supportive so I never had to justify anything. […] It's just honestly so rare to not be questioned on needing time or needing space. And [it was made easier] because of the support of my boss as well.” (ID001, Medication, VIC, Urban) B Acceptable care includes abortion providers supporting abortion seekers in the decision making process. Many participants valued being reminded by a medical practitioner that the choice to obtain an abortion was theirs and that this decision was not in question. However, some healthcare staff and providers were not supportive of the participant’s decision to have an abortion. Supportive staff • “[The abortion provider] just said, ‘this is your choice. […] You know what you need, you know your life, you know what you're capable of, and what you're doing isn't wrong. You're just making a decision.’” (ID013, Surgical, WA, Urban) Unsupportive staff • “When I said I want to know what my options are to get an abortion […] [the GP] said, ‘I don’t recommend it because […] you’ll regret it if you’re 30.’”(ID002, Surgical, VIC, Regional) • “The receptionist on the phone, just said ‘no, we don't do that’. But she was very short and very abrupt, and […] that was really the end of the conversation.” (ID019, Medication, QLD, Urban) iii. Availability and accommodation All ten participants living in non-metropolitan areas described barriers when accessing abortion care. Some participants travelled significant distances to access care and faced long wait times before securing an appointment due to a lack of abortion providers in their area. Barriers to abortion care were exacerbated by the COVID-19 pandemic, and participants described reduced service availability, prioritisation of telehealth over in-person care, and pandemic-related travel restrictions. Key findings and related quotes to illustrate these experiences are shown in Table 4 . [Table 4 about here] Table 4 Abortion seekers’ experiences of abortion care relative to the availability dimension of Levesque’s framework A Available and accommodating care includes having both medication and surgical abortion options in all regions of the country through public and private services. Many participants in regional areas experienced barriers accessing local abortion care. • “The [only provider in my local area] was only [providing] medical, they didn't do surgery […]. You could do like a rural medical one, where […] everything's like via post or something. But that was going to be too time consuming. Because I was rural at the time, […] I can't even really […] access a post office and a doctor to go get all these tests and everything done.” (ID015, Medication, QLD, Regional B Available and accommodating care includes a reasonable distance to abortion care and sufficient availability in all areas in proportion to demand. Some participants, especially those from regional areas, had to travel significant distances to access abortion. • “The GP is in town, which is about 45 minutes from my place. And the ultrasound clinic was an hour and a half from our house at the next major city. And then I did have to travel two-and-a-half hours to the abortion clinic.” (ID025, Medication, NSW, Regional) • “Distance is a barrier, but [in the Northern Territory, where abortion is free], you know you can access it if you can get there.” (ID021, Medication + Surgical, NT, Regional) C Available and accommodating care includes the presence of sufficient abortion providers throughout the country. Some participants faced long wait times due to a lack of abortion providers in their area. • “I had to be flown down to Brisbane in order to have [the abortion]. But due to the high demand of abortions now, it was a month wait for me. […] Mentally, I wasn't able to tolerate or handle a month.” (ID024, Hospital-based induction, QLD, Regional) • “I had to wait a while [and] […] [it was hard] finding out the date [of the abortion service] was a couple of weeks away. […] I still had to deal with knowing that it was coming up […] and then knowing I had to go and do it all alone.” (ID003, Medication, SA, Urban) D Available and accommodating care includes the ability of abortion services to meet increases in service demand. The pandemic influenced the ability of abortion services to meet service demand, with many participants experiencing delays. Experiences of access were impacted by pandemic restrictions, including rules about how far they could travel for care and restrictions on being accompanied to the service. Some participants were offered telehealth services when they would have preferred in person care. Reductions in service availability • “[At the abortion clinic] they were understaffed. [...] I definitely think it was pandemic related as to why it was so busy, and people weren’t getting seen quick enough.” (ID012, Medication (x2), VIC, Urban) Prioritisation of telehealth services • “They were very strongly pushing for phone appointments because of wanting to have less people in the clinic. And I was already quite emotional about the decision that we were making [to have an abortion]. [...] So I was very reluctant to have a conversation over the phone with a stranger.” (ID011, Medication, VIC, Urban) • “It [telehealth] was definitely impersonal. Because you want to meet the people that you're seeing, and you know, be able to talk to them face-to-face. […] You think that these medical professionals are there for you, but I suppose doing it via telehealth it doesn't feel that way.” (ID007, Hospital-based induction, VIC, Regional) Travel restrictions • “I don’t know what the exact rules [for travel over 5km] were, [or] whether you could [legally] access healthcare [at the time].” (ID009, Surgical, VIC, Urban) No accompanying person allowed • “[Pandemic] restrictions […] still made it quite difficult, because my partner was never allowed to come with me to any of the appointments. [… ] Not having that support was quite difficult.” (ID018) iv. Affordability Most participants paid for their abortion, and some experienced significant financial stress in doing so. A small number received fee-free services because their state or territory of residence guaranteed free or low-cost abortion care. Additional expenses reported by participants included out-of-pocket costs for healthcare appointments, prescription medication, contraception, and sanitary items; child-minding; travel and accommodation; and counselling services. Some abortion seekers and their partners lost income or had to take leave from work when accessing abortion care, especially those casually employed or needing to travel for care. Some participants mentioned that the Medicare rebate was insufficient, and those ineligible for reimbursement from health insurance often had high out-of-pocket costs. Quotes to illustrate these experiences are shown in Table 5 . [Table 5 about here] Table 5 Abortion seekers’ experiences of abortion care relative to the affordability dimension of Levesque’s framework A Affordable care includes the ability to pay for abortion services regardless of procedure types, jurisdictions, and private and public service provision. While most participants paid for their abortion, some struggled to do so. A small number received free services. • “The doctor asked, ‘Do you want to travel to the sexual clinic for a low-cost service or do you want to be seen locally in a private practice?’ So, I went with the sexual health clinic.” (ID023, Medication, QLD, Regional) • “We're very lucky here in South Australia in that the services actually don't charge [for abortion care]. The only thing that I had to pay for was the medication.” (ID014, Medication, SA, Urban) • “[The clinic] told me [the price] over the phone and I had a heart attack, because it was, it was $500. And with a health care card too, which is just, it's so much money. [...] I had to pay for that, on my own.” (ID005, Surgical, VIC, Urban) B Affordable care includes eliminating the additional financial burden for those without Medicare to pay for abortion. Additional costs incurred when accessing abortion care included : Out-of-pocked appointment costs GP appointments • “It was just so expensive. […] [I went to a private clinic] because I just wanted to get in and out pretty quickly.” (ID004, Surgical, QLD, Urban) Prescribed medication, birth control, or sanitary items. • “We went to the chemist, and yeah, I think I spent about $150 just on medication. And then I also bought some Nurofen and Panadol and some pads as well.” (ID017, Surgical, NSW, Regional) Child-minding • “I can't like, drive myself. [...] I need to bring my husband and then […] I can't bring four kids with me. So, I was like, someone's got to look after them at home.” (ID020, Miscarriage, QLD, Regional) Travel and accommodation • “Petrol to get there was quite expensive. […] Parking, I think that was about $40 for the day.” (ID017, Surgical, NSW, Regional) Loss of income • “I actually ended up paying it all, and [my partner] paid me back. [...] He had a really hard time paying that, [...] because he just had to take so much work off [unpaid to come to the appointments with me].” (ID004, Surgical, QLD, Urban) Counselling services • "I am really keen to actually, probably do an appointment with the counsellor soon [to process my abortion experience]. […] I can't afford it at the moment.” (ID012, Medication (x2), VIC, Urban) C Affordable care includes removing the additional financial burden of all facets of seeking abortion care for those without Medicare and others struggling to pay for abortion. Participants without access to Medicare often had high out-of-pocket costs to access abortion care. • “[In addition to the cost of the abortion medication and transport costs], I had to pay […] the first GP I saw [around] 60 or 80 [dollars]. […] I didn’t have any [Medicare] at that point.” (ID023, Medication, QLD, Regional) Some participants mentioned the that the Medicare rebate was insufficient. • “I think they did [give a rebate] but I can't remember what that was in the end. [...] I can't remember it [the rebate] making much difference.” (ID004, Surgical, QLD, Urban) v. Appropriateness Most participants reported apprehension about judgement from healthcare providers or anticipated needing to justify their decision to their provider. Many said that providers along the care pathway, including laboratory staff, ultra-sonographers, and their general practitioner, assumed they wanted to remain pregnant. Those who did experience non-judgmental and supportive care valued this experience. Several participants said they experienced a lack of empathy during the appointment. Those who received empathetic care appreciated that the provider was patient and attentive to their emotions. Several participants felt that their appointments were rushed, while those who had sufficient time with providers said they valued this interaction. Some participants said their healthcare provider proactively facilitated access by referring to additional abortion services or helping them find a timely appointment, whereas a few participants would have liked to receive more appropriate referrals. Some participants told us their providers listened to their preferences and engaged in a joint decision-making process to best meet their needs. In contrast, many providers did not spend adequate time with them, leaving the client feeling unsupported in choosing a service that best met their needs. The main findings and quotes to illustrate them are shown in Table 6 . [Table 6 about here] Table 6 Abortion seekers’ experiences of abortion care relative to the appropriateness dimension of Levesque’s framework A Appropriate care includes the provision of non-judgmental abortion care. Nearly all participants mentioned experiences of judgement or apprehension of judgement from care providers. Examples include : Expecting to have to justify their decision to their provider • “I felt like I would possibly need to justify my decision [to the provider], which I was worried would be my undoing.” (ID011, Medication, VIC, Urban) Different types of providers along the care pathway assumed the client wanted to remain pregnant • “[The GP] was talking to me as though I was gonna continue with the pregnancy. […] I knew in myself, that this [having a baby] wasn't something that I could cope with.” (ID009, Surgical, VIC, Urban) • “I went in for a blood test and the nurse knew that I was getting tested for pregnancy. […] She also said to me like • ‘Oh, is it your first one? Congratulations.’ And I was […] like, ‘Oh thanks, but I'm not keeping it.’” (ID002, Surgical, VIC, Regional) • “I said [to the receptionist], ‘I think I’m about five weeks’, and she said, […] ‘There's no point doing an ultrasound because you won't be able to see [the embryo], you’re better off coming back later.’ […] Then I had to tell her in a very crowded room that I was terminating. […] [The receptionist was] not sensitive to the situation, and just assumed that I was, you know, an expectant mom.” (ID022, Surgical, NSW, Regional) Participants said they valued any experience of non-judgmental, supportive care. • “They [clinic staff] were fantastic. [I] spoke to somebody on the phone […] and you’re thinking, oh God, they’re judging me […]. But you know, [they were] […] just very non-judgmental, […] supportive and helpful.” (ID009, Surgical, VIC, Urban) B Appropriate care includes the provision of empathetic abortion care. Participants who experienced empathetic care said their providers were patient and attentive to their emotions. • “[On the phone I said,] ‘I don’t understand how this all works. […] I’ve never done this before. I don’t want to be pregnant.’ […] [The abortion clinic staff] were just really calm, and […] [said] ‘It’s okay, just take a deep breath, […] Should I give you a call back in 10 minutes? Are you feeling safe? Do you want to lie down? Like, do you want to put me on speakerphone whilst you make yourself a cup of tea?’” (ID004, Surgical, QLD, Urban) • “[I experienced] just this extraordinary level of care checking [from my GP] [...]. I felt like [it] was the first time somebody [...] actually understood […] what was going on.” (ID016, Medication, VIC, Urban) • “I really didn’t want [to] get an ultrasound […] by myself. […] They were like, ‘someone will come in with you, you don’t have to, like, look at anything.’ […] They were […] good at calming all the things that I was bringing up.” (ID008, Medication, VIC, Urban) However, several participants said they experienced a lack of empathy and patience during the appointment. • “When she [the nurse] was going through the forms, she was just sort of like glossing over parts of it. You know, and I just remember thinking like, this is really important to me, […] [but] I wasn't really in the position to be like, ‘Oh, sorry, you know, go back through that’ […]. I know that that's something that they do routine all the time, so I don't know whether they're a little bit desensitized to us.” (ID021, Medication + Surgical, NT, Regional) • “It was the only clinic that I could get into on a public holiday, everywhere else was closed. […] I went to see a random male doctor who referred me to get my bloods done. […] He also referred me to a women's health clinic. He wasn't very nice to me. It wasn't no sympathy, nothing. […] I was in there for about two minutes. […] There was just no conversation at all.” (ID005, Surgical, VIC, Urban) C Appropriate care includes providers allocating adequate time during abortion provision. Participants valued when their provider took time during their appointments “[The] emotional support in terms of my GP [was great]. I hope everyone gets access to a GP […] who will take the time to sit with you and go through all the options. Like, we were certainly extending beyond standard appointments. In my time with her, we were really going through things and understanding what was going to happen.” (ID001, Medication, VIC, Urban) Several participants felt that their appointments were rushed. • “The anaesthetist came in and spoke to me just about the drugs that they would use and then, […] I just went straight in [to surgery]. […] I didn't really have a lot of contact with anyone there. […] It was very rushed, and […] I felt very vulnerable at the time.” (ID017, Surgical, NSW, Regional) • “Everyone was just rushing around like they were overbooked, but the whole vibe wasn't… [it] wasn't great. (ID005, Surgical, VIC, Urban) • “[The doctor] was just very dismissive about the whole thing. […] I was literally on the phone with him, for I think three minutes in total. […] I left more confused I think than anything. […] [It felt like] he was like, well you know, this is the too hard basket. I don't want to deal with this.” (ID018, Medication, QLD, Urban) D Appropriate care includes abortion providers giving appropriate referrals to additional abortion services. Many participants appreciated their healthcare provider proactively facilitating access by referring to additional abortion services. • “[The sonographer] made a call to my GP’s office, […] and they got [me] booked in […]. That was like, really efficient and a relief. It meant that I came away from the appointment with a clear plan […], the sense of agency, and some sort of picture of what was about to happen.” (ID008, Medication, VIC, Urban) A few participants felt that they were referred to a place that was not vetted by their providers and therefore was not appropriate. • “There’s no [alternative] services, there's nothing. So, you know, anything would be better than nothing. […] I don't know if [my GP is] aware [how bad this clinic was], or if she has a relationship with this clinic, or if she knows these people. But no, I wouldn't send anybody there. It was appalling.” (ID022, Surgical, NSW, Regional) E Appropriate care includes the provision of tailored and continuous care that is centred around the patient’s needs whilst fully informing them of their options. Some abortion providers listened to abortion seekers concerns and preferences and engaged in a joint decision-making process to best meet the client’s needs. • “[The GP] gave me the options. We weighed them up together and then made the decision together. I sort of already knew what I wanted to go towards, but he was really good in giving me, like, in talking to me about both [types of abortion].” (ID025, Medication, NSW, Regional) • “I spoke to both a nurse, the doctor who did the scan, and the anaesthetist. [...] I went in and spoke to each of them separately, which […] gave a lot of opportunity for asking questions.” (ID019, Medication, QLD, Urban) • “[The doctor] asked me just, like, if I was thinking of keeping it or not.” (ID004, Surgical, QLD, Urban) In contrast, some providers did not spend adequate time, leaving the client feeling unsupported in making a decision that best meet their needs. • “I probably would have definitely liked to have a longer appointment with the psychologist at the start and […] to have a bit more time with the doctor […]. I just feel like that would have comforted me a little bit more, to have a proper conversation with the doctor or the person performing the procedure about what was going to happen and what they were going to do.” (ID017, Surgical, NSW, Regional) • “I had told the doctor that I didn't [want to see the ultrasound screen] […] and he left the ultrasound, like, face up [and visible to me], instead of down, which I didn't like.” (ID004, Surgical, QLD, Urban) Discussion This analysis adapted Levesque et al’s influential framework of patient-centred access to healthcare( 3 ) to abortion access during the COVID-19 pandemic. We found that the framework facilitated a nuanced examination of the multifaceted and intersecting factors that influence access to abortion – a historically criminalised and still stigmatised service ( 15 , 49 ). This adaption of Levesque’s framework can be applied in different contexts to understand experiences of access to stigmatised health services and examine healthcare access in pandemic or other disaster conditions. The findings identify important facets of abortion access from the client perspective, with implications for how to enhance access in all its dimensions. We found that abortion seekers had relatively poor experiences in the dimension of approachability , with most having insufficient information about how to obtain abortions. These findings align with other studies in Australia( 4 , 50 , 51 , 52 , 53 ) and globally,( 10 , 54 , 55 , 56 ) highlighting that abortion seekers are often unsure where to seek care, unaware of the laws governing abortion and gestational age limits, and commonly use sources outside of the health system to learn about abortion – with potential risks in terms of accuracy of information. This is important in light of WHO guidelines identifying available and accessible information as a key component of an enabling environment for abortion.( 1 ) Abortion seekers described mixed experiences in the dimension of acceptability , expressing different levels of (dis)comfort talking about their abortion/s. For some, this reflected their religious upbringing or living in a small community. A systematic review of abortion stigma highlights that secrecy is a common form of abortion stigma management, with implications including social isolation and distress, which in turn can have negative mental health consequences.( 9 ) It is noteworthy that some participants, who hesitated to disclose their abortion, received a supportive response from family, friends, or colleagues and described the process as positive and normalising. Research in other settings examines strategies to reduce the secrecy around abortion as a pathway to de-stigmatisation.( 57 , 58 , 59 ) Experiences in the dimension of availability and accommodation varied by place of residence, with those living outside metropolitan areas describing challenges including long wait times and large distances to obtain care. This is consistent with the notion of “abortion deserts” coined in the United states, in reference to places with no abortion care available nearby.( 60 ) As elsewhere,( 61 ) there is a shortage of abortion providers in Australia( 62 ), particularly in rural areas.( 33 , 63 ) Provider shortages can limit the choices of abortion seekers between abortion types and between private and public care, and may result in significant travel to obtain care.( 64 ) Many private abortion clinics are in metropolitan regions,( 15 , 33 ) with limited surgical abortion availability elsewhere. Pharmacies dispensing abortion medication are also limited in rural areas, often compelling travel.( 33 ) Additionally, rural GPs commonly have limited appointment availability, creating challenges for those seeking time-sensitive services like abortion.( 33 ) Our findings align with evidence that the COVID-19 pandemic limited health system capacity to delivery timely and high-quality abortion care, thereby disproportionately affecting rural abortion seekers.( 15 , 17 ) Telehealth abortion was increased in Australia and globally to reduce the need to travel for care during the pandemic; telehealth can enhance access in the context of health system pressure and travel restrictions.( 19 , 20 , 21 ) However, telehealth is neither acceptable nor appropriate for all abortion seekers.( 15 , 65 ) For example, some individuals from migrant or refugee-like backgrounds or those experiencing family violence may have difficulty accessing telehealth services, as their personal safety may be compromised by an unsafe home environment or being around people who do not support their abortion decision.( 15 ) Our findings show that telehealth can evoke negative feelings for some abortion seekers due to the impersonal interaction, which lacks the interpersonal support of an in-person consultation. Additionally, some participants in this study described the restriction on bringing an accompanying person to their service as one of the most challenging aspects of seeking abortion care in the pandemic. Taken together, these findings identify interpersonal contact and social support as important facets of accommodating abortion care. The results highlight inequities in the affordability of abortion care based on location, income, employment type, and insurance status. Abortion care can entail additional expenses such as transport, accommodation, or childcare, disproportionately affecting people experiencing financial disadvantage( 50 ) and those having to travel for care, largely in rural and remote areas.( 15 , 33 , 50 ) The affordability of abortion care remains a problem in Australia, where a 2017 study of more than 2,300 participants recruited at abortion clinics found that more than 20% were concerned about their ability to pay for abortion care.( 36 ) Financial barriers to abortion care globally should be addressed to create an enabling environment for the service.( 1 ) Our findings demonstrate a diversity of experiences in the dimension of appropriateness . Some participants described very positive treatment, some very negative treatment, and some experienced both at different points in their service. Inappropriate interactions with healthcare staff and providers were reported by abortion seekers across states and territories, in urban and rural areas, and in different settings including GP clinics, at ultrasound, during bloodwork, and in dedicated abortion clinics. Overall, abortion seekers in the study expressed a desire for adequate time to ask questions and have their concerns addressed in a supportive, non-judgemental environment. Yet this can be challenging in the limited time allocated to reimbursable healthcare appointments,( 63 ) which may be insufficient to support dialectical decision-making between abortion seekers and providers. Implications To improve approachability , these data suggest the need for community-wide dissemination of information about abortion( 54 ), acknowledging that friends and family are an important source of information and support for abortion seekers. Accurate information about abortion and where to seek care can be provided through smartphone applications( 66 ) or telephone services. For example, the 1800MyOptions hotline in Victoria( 67 ) was identified as a useful model to deliver abortion information, with potential for national scale-up.( 63 ) However, most Victorian participants in this study were unaware of this resource, signalling the challenges of dissemination even when comprehensive funded models exist. The lack of public information about abortion in part relates to stigma, which can limit information availability and hinder public listings of abortion providers.( 68 ) For example, studies in Victoria have found that providers fear being negatively perceived for providing abortion care ( 67 ) and may exercise their right to conscientious objection to preserve their reputations.( 29 ) Stigma can also prevent people from discussing abortion with friends and family( 50 ), contributing to an environment in which abortion seekers do not know where to seek, and have limited options for obtaining, information and care – even where abortion is decriminalised. Interventions to reduce community-level abortion stigma can increase the acceptability of abortion. Comprehensive sexuality education programs can normalise open discourse about sexual and reproductive health( 69 ), including abortion, while also equipping young people with information about accessing healthcare services. This approach would address a gap in knowledge about abortion, as information on this topic is generally lacking in schools( 70 ); however, it is challenging to garner support to broach this topic with young people due to the stigma associated with abortion and with sexual activity among adolescents( 10 ). The COVID-19 pandemic limited the capacity of individual providers and the health system to make timely services available and accommodate the needs of abortion seekers, particularly in rural areas. Availability could be enhanced by reducing the ‘exceptional’ regulation of abortion provision seen around the world.( 71 ) Regulatory changes such as task-sharing, recommended by the WHO,( 72 ) can increase the availability of abortion providers relative to demand, and in doing so, reduce wait times. In Australia, the Therapeutic Goods Administration (the national regulation body for therapeutic goods such as the abortion medication licensed as MS-2Step) made changes in 2023 to reduce exceptional regulation of abortion; it now permits nurse practitioners to prescribe MS-2Step when certified, and unnecessarily stringent requirements for retraining and registration for GPs and pharmacists providing medication abortion have been removed.( 32 , 63 , 73 ) Further measures can be made to expand task-sharing to nurses and midwives. In addition, medication abortion is safe and effective up to 70 days gestation,( 74 ) suggesting that current limits in many jurisdictions around the world, including Australia, could be safely extended. Doing so would provide abortion seekers more time to make informed decisions about abortion care and obtain medication abortion.( 19 ) These findings align with calls in the United Kingdom to ensure choice for clients between modalities of care and types of abortion.( 75 , 76 ) Even in pandemic conditions, efforts to accommodate abortion seeker needs and preferences could be prioritised, for example by ensuring social support during the service. The dimension of affordability could be improved through publicly-funded initiatives to eliminate or reduce out-of-pocket expenses for abortion seekers.( 38 ) For example, the Netherlands offers free abortions to those living or working in the country under their Long Term Care Act,( 55 ) and universal access to free abortion has been introduced in the Australian Capital Territory, a federal territory of Australia containing the capital city.( 77 ) Financial barriers can be further reduced by initiatives to fund travel for abortion care. In some places, including the United States and Europe, support for those who can’t afford to travel is provided by civil society organisations.( 78 ) A model of publicly-funded abortion travel is found in Australia through the Northern Territory’s Patient Assistance Travel Scheme funded by the Department of Health( 79 ). Such policies can help address the inequities of the ‘post-code lottery’ – that where someone lives dictates the accessibility and affordability of public abortion care.( 80 , 81 ) To ensure appropriate services, different models of information provision can be explored to create more productive consultation time with providers. For example, a Scottish study found that disseminating an informational video about abortion care before seeing the provider gave clients more time to ask questions during the appointment as they could formulate questions beforehand.( 56 ) Additionally, equipping practising and prospective healthcare providers with the skills to deliver sensitive, tailored, judgement-free, and empathic abortion care can facilitate appropriate care. Evidence-based strategies are needed to reduce stigma experienced by abortion seekers,( 12 , 82 ) particularly stigma enacted by healthcare providers,( 83 ) including conscientious objectors.( 29 ) Strengths and Limitations: This study contributes to gaps in the literature by centring the lived experiences of abortion seekers during the COVID-19 pandemic. The findings have particular relevance in Australia, where despite a National Women’s Health Strategy( 84 ) supporting universal abortion access, a 2023 Senate inquiry identified numerous barriers to equitable access, particularly in rural Australia.( 63 ) This analysis complements prior Australian studies that primarily drew on provider perspectives( 51 , 68 , 85 ), focused on one state or territory, and took place before broad decriminalisation. Further, this study elucidates all facets of abortion access during the pandemic, rather than focusing only on telehealth provision( 86 ). Examining abortion seekers’ experiences to identify barriers and facilitators of access is important even in relatively favourable policy environments. The study also has limitations. Social media was our primary recruitment method. Stigma may have limited the public sharing of our recruitment materials, possibly limiting their reach. However, social media recruitment is not uncommon, with other Australian abortion research utilising this approach.( 87 ) Research on social media recruitment during the pandemic suggests that platforms such as Facebook are appropriate for reaching diverse communities.( 88 ) Additionally, a systematic review found that social media recruitment has benefits for stigmatised topics such as sexual health.( 89 ) The study sample was diverse in terms of participant age and location, gestational age at time of the abortion, and type of abortion procedure. However, there is an overrepresentation of participants from Victoria, the second most populous state in the country and the research team’s location. All participants were able to pay for care, so our data may exclude individuals who are unable to afford care. Additionally, most participants were white, highlighting the need for further research with more diverse populations to address barriers uniquely faced by racial minorities accessing abortions. Conclusion This study examined lived experiences of five domains of abortion access: approachability, acceptability, availability and accommodation, affordability, and appropriateness. Even in a context with supportive legal and policy frameworks, abortion seekers in Australia experienced challenges when seeking services and information. Addressing obstacles to abortion care around the world is a priority under the Sustainable Development Goals( 1 ) focus on universal access to reproductive healthcare. Barriers to care, already worsened by the COVID-19 pandemic, are likely to be even more burdensome in more legally restrictive settings.( 1 ) Initiatives to improve access could focus on creating an enabling environment for abortion, taking into account general health system limitations and the ongoing stigma around abortion in many parts of the world. Regardless of context, an enabling environment for universal abortion access requires effective mechanisms to educate the population about abortion and provide abortion seekers with accurate and credible information . An enabling environment is also premised on supportive and appropriately-resourced health systems . To achieve this, investments are needed to reduce wait times, costs, and travel, especially for rural populations. Regulatory and workforce strategies to increase the types and number of abortion providers, improve the patient-centredness of healthcare providers, and reduce stigma in healthcare settings can improve experiences of those who are accessing care. Consumer voices can help understand the diverse pathways to and through abortion care and play an important role in informing solutions to overcome the multidimensional barriers to access. Declarations Ethics approval and consent to participate Ethics approval for this study were obtained from the Monash University Human Research Ethics Committee (ID 30926), with all methodology completed in accordance with the Declaration of Helsinki. All methods were performed in accordance with the Declaration of Helsinki. All interviews with participants were audio-recorded following informed verbal consent, in compliance with the Monash University Human Research Ethics Committee. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available for privacy reasons but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was not funded. Authors’ contributions SM, AT and JF conceptualised the study. SM recruited participants and conducted interviews. SW developed the analysis strategy, codebook, and analysis with supervision from SM. SW drafted the paper with substantive redrafting and revisions by SM. All authors reviewed drafts, provided significant revisions and feedback, and approved the submitted version. Acknowledgements We acknowledge the participants in this study who took the time to share their personal experiences to support this research. We thank the SPHERE community for providing feedback on this study at various points in time. References Kim CR, Lavelanet A, Ganatra B. 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Attitudes towards abortion in male and female adolescents with diverse sexual and pregnancy experiences: a cross-sectional study. Sex Health. 2020;17(1):77–86. Joffe C, Schroeder R. COVID-19, health care, and abortion exceptionalism in the United States. Perspect Sex Reprod Health. 2021;53(1–2):5–12. Sorhaindo AM. Creativity, serendipity, and collaboration: Cross-cutting features of successful task-sharing in comprehensive safe abortion care. Int J Gynecol Obstet. 2020;150:49–54. Department of Health and Aged Care, Therapeutic Goods Administration. : Amendments to restrictions for prescribing of MS-2 Step (Mifepristone and Misoprostol). Australian Government. Accessed 11 July 2023. Medication Abortion Up to 70 Days of Gestation. Contraception. Medication Abortion Up to 70 Days of Gestation. Contraception. 2020;102(4):225–36. Footman K. Revolution in abortion care? Perspectives of key informants on the importance of abortion method choice in the era of telemedicine. Sex Reprod Health Matters. 2023;31(1):2149379. Blaylock R, Makleff S, Whitehouse KC, Lohr PA. Client perspectives on choice of abortion method in England and Wales. BMJ Sex Reprod Health. 2021;48:246–51. ACT Government. Abortion Access. https://www.health.act.gov.au/services-and-programs/sexual-health/abortion-access (2023) Accessed 24 May 2023. Ely GE, Hales T, Jackson DL, Maguin E, Hamilton G. The undue burden of paying for abortion: An exploration of abortion fund cases. Soc Work Health Care. 2017;56(2):99–114. Murdoch J, Thompson K, Belton S. Rapid uptake of early medical abortions in the Northern Territory: A family planning-based model. Aust N Z J Obstet Gynaecol. 2020;60(6):970–5. Tait-Orr T, Isster R. Girlie does a deep policy dive. Altern Law J. 2023;48(1):74. de Costa C, Douglas H, Hamblin J, Ramsay P, Shircore M. Abortion law across Australia–a review of nine jurisdictions. Aust N Z J Obstet Gynaecol. 2015;55(2):105–11. Sorhaindo A, Rehnstrom Loi U. Interventions to reduce stigma related to contraception and abortion: a scoping review. BMJ Open. 2022;12(11):e063870. Makleff S, Belfrage M, Wickramasinghe S, Fisher J, Bateson D, Black KI. The intersection of stigma, quality of care, and structural barriers. a qualitative study of interactions between abortion seekers and healthcare workers in Australia; 2023. Department of Health and Aged Care. National Women’s Health Strategy 2020–2030. Australian Government, Department of Health and Aged Care. 2019. https://www.health.gov.au/resources/publications/national-womens-health-strategy-2020-2030 Accessed 10 May 2023. Dawson AJ, Nicolls R, Bateson D, Doab A, Estoesta J, Brassil A, et al. Medical termination of pregnancy in general practice in Australia: a descriptive-interpretive qualitative study. Reprod Health. 2017;14(1):39. Cheng Y, Boerma C, Peck L, Botfield JR, Estoesta J, McGeechan K. Telehealth sexual and reproductive health care during the COVID-19 pandemic. Med J Aust. 2021;215(8):371–2. Vallury KD, Baird B, Miller E, Ward P. Going viral: researching safely on social media. J Med Internet Res. 2021;23(12):e29737. Green H, Fernandez R, MacPhail C. Social media as a platform for recruitment to a national survey during the COVID-19 pandemic: feasibility and cost analysis. JMIR Form Res. 2021;5(7):e28656. Capurro D, Cole K, Echavarría MI, Joe J, Neogi T, Turner AM. The use of social networking sites for public health practice and research: a systematic review. J Med Internet Res. 2014;16(3):e2679. Levesque J-F, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12(1):1–9. Additional Declarations No competing interests reported. Supplementary Files AbortionaccessSupplementaryTable1final.docx Cite Share Download PDF Status: Published Journal Publication published 07 Oct, 2024 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 13 Oct, 2023 Editorial decision: Major revision 13 Oct, 2023 Reviews received at journal 23 Sep, 2023 Reviewers agreed at journal 16 Sep, 2023 Reviewers agreed at journal 03 Sep, 2023 Reviewers invited by journal 28 Aug, 2023 Editor assigned by journal 23 Aug, 2023 Editor invited by journal 17 Aug, 2023 Submission checks completed at journal 17 Aug, 2023 First submitted to journal 27 Jul, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3209353","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":227010800,"identity":"cb25381e-f1d0-417b-a530-36d7a164479d","order_by":0,"name":"Sethini Wickramasinghe","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sethini","middleName":"","lastName":"Wickramasinghe","suffix":""},{"id":227010801,"identity":"d67c4bf7-935c-4d41-8061-bfdb5453f8f2","order_by":1,"name":"Jane Fisher","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jane","middleName":"","lastName":"Fisher","suffix":""},{"id":227010802,"identity":"ad34e726-9527-4ce2-aa7f-3b787ab265de","order_by":2,"name":"Angela Taft","email":"","orcid":"","institution":"La Trobe University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Angela","middleName":"","lastName":"Taft","suffix":""},{"id":227010803,"identity":"86fface8-369b-4555-92b9-c6cb1cdfbeda","order_by":3,"name":"Shelly Makleff","email":"data:image/png;base64,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","orcid":"","institution":"Monash University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Shelly","middleName":"","lastName":"Makleff","suffix":""}],"badges":[],"createdAt":"2023-07-27 10:29:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3209353/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3209353/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-024-06758-8","type":"published","date":"2024-10-07T15:57:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66597112,"identity":"9c3bcf4f-29a0-478a-8d86-0ee00b54b404","added_by":"auto","created_at":"2024-10-14 16:07:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1022085,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3209353/v1/90676468-1324-412d-84a8-c50233593a64.pdf"},{"id":41914912,"identity":"788cb265-3b38-48c3-ad5c-6532be47aacf","added_by":"auto","created_at":"2023-08-22 06:23:05","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18632,"visible":true,"origin":"","legend":"","description":"","filename":"AbortionaccessSupplementaryTable1final.docx","url":"https://assets-eu.researchsquare.com/files/rs-3209353/v1/6e8bb70bd78db4b7834892b5.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Experiences of abortion care in Australia during the COVID-19 pandemic: examining multiple dimensions of access","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTo achieve the Sustainable Development Goals target of universal access to sexual and reproductive health services(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), the obstacles to abortion information and services must be understood and overcome. The World Health Organization (WHO) defines access as the \u0026ldquo;continual and organised\u0026rdquo; delivery of healthcare services in a \u0026ldquo;geographically, financially, culturally and functionally\u0026rdquo;(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) appropriate way. The WHO\u0026rsquo;s conceptual framework for abortion care (2022) describes the four main components of an enabling environment for access to high-quality care. These are, respect for human rights, legal and policy frameworks that support abortion, available and accessible information about abortion, and supportive and appropriately-resourced health systems.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) When these components are absent, access to safe abortion care can be hindered by barriers such as legal restrictions to abortion provision, high costs, abortion stigma, and the limited availability of abortion methods, services and related information.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eVarious frameworks have been developed to illustrate the multidimensional factors influencing access to healthcare. The 2013 Conceptual Framework of Access to Healthcare by Levesque et al. draws comprehensively on previous definitions and frameworks for individual and community health to identify five dimensions that encompass the most common and crucial aspects of access. These are approachability, acceptability, availability and accommodation, affordability, and appropriateness of service delivery.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Two qualitative studies have previously utilised this framework to explore access to telemedicine abortion care in rural Australia and in the United States, demonstrating applicability to a stigmatised service such as abortion.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) However, stigma is not explicitly mentioned in Levesque\u0026rsquo;s framework.\u003c/p\u003e \u003cp\u003eAbortion stigma, drawing on Goffman\u0026rsquo;s widely-used definition, is an attribute that works to discredit a person due to their choice to obtain or provide abortions.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) Abortion stigma contributes to secrecy about abortion among abortion seekers and providers,(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and exacerbates the lack of information(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) or misinformation about abortion.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Health stigmas can lead to social isolation, maladaptive coping behaviours, and stress, and are a cause of health inequalities.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) Stigma is a barrier to accessing high-quality sexual and reproductive health services across contexts.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAnother factor limiting access to abortion in recent years is the COVID-19 pandemic. The pandemic has been associated with increased domestic violence(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) and with shifting fertility intentions, with some people delaying their childbearing as a result of the pandemic.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) These circumstances can increase the demand for abortion care. Travel restrictions, supply chain challenges, and provider shortages, among other barriers, have limited timely access to healthcare during the pandemic, particularly impacting sexual and reproductive health services.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) Delays to care are disproportionately burdensome for abortion, which is a time-sensitive health service with growing complexity and costs and reduced service options as gestational age increases.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) Telehealth services for medication abortion(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) were introduced or expanded in some settings to counteract health system limitations during the pandemic,(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) with particular benefits for rural populations.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Telehealth is a safe, acceptable, and effective strategy to bolster access to medication abortion.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe pandemic also exacerbated the pre-existing health and social inequities that limit access to sexual and reproductive health services.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) Examining abortion care during COVID-19 \u0026ldquo;may serve as a lens through which systemic barriers to access may be illuminated.\u0026rdquo;(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) The aim of this study was to elucidate barriers to and facilitators of abortion care during the COVID-19 pandemic in Australia.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eSetting\u003c/h2\u003e\n \u003cp\u003eAustralia is a federation with national, state, and local tiers of government. The Federal Government subsidises the cost of healthcare services for citizens, permanent residents, and some visa holders through the Medicare Benefits Scheme.(\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e) Some people also pay for private health insurance, which covers the cost of some private hospital services and some hospital services not paid for by Medicare.(\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e\n \u003cp\u003eAbortion was gradually decriminalised in Australian states and territories between 1998 and 2022.(\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e) Regulations differ between states and territories,(\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e) with gestational age limits for surgical abortion ranging from 14 weeks in the Northern Territory to 24 weeks in Victoria without any restrictions; some jurisdictions require medical provider approval or consultation of additional providers after set gestational limits (for example beyond 22 weeks in New South Wales).(\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e\n \u003cp\u003eMedical practitioners, including pharmacists, have a right to conscientious objection that obligates them to refer clients to an appropriate provider if they do not wish to provide abortion care on religious, moral or personal grounds.(\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e) According to recent estimates, 13.7% of Australian obstetrics and gynaecology physicians and those undergoing specialist training were completely opposed to the delivery of abortions based on conscientious or religious grounds.(\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e\n \u003cp\u003eMedication abortion has been available nationwide since 2012 until 63 days of gestation, requiring the prescription of Mifepristone and Misoprostol (branded as MS-2 Step) by a registered medical practitioner.(\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e) General practitioners (GPs) can refer women for abortion care and can register to prescribe medication abortion.(\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e) As of 2021, however, only around 7% of Australian GPs were registered to do so.(\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e\n \u003cp\u003eMost abortions are provided privately, either by GPs (medication abortion) or in abortion clinics or hospitals (surgical or medication).(\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e) The provision of abortion care in public hospitals is mainly limited to foetal conditions.(\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e) Out-of-pocket costs are commonly incurred by abortion seekers,(\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e) and abortion costs vary by abortion type, the presiding jurisdiction, gestational age, insurance scheme,(\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e) and between private and public facilities.(\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e\n \u003cp\u003eIn efforts to facilitate access in the context of pandemic-related public health restrictions, Australia provided abortions as essential medical care during the COVID-19 pandemic (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e) and the Federal Government expanded Medicare-covered telehealth to include abortion services.(\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e) Despite this, policy and health system analyses have shown that the pandemic exacerbated existing barriers to abortion access in Australia and contributed to delays to care.(\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e) Abortion seeker perspectives of the barriers to and facilitators of abortion during the pandemic have been insufficiently examined, and are needed to inform efforts to improve access.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy design\u003c/h2\u003e\n \u003cp\u003eThis qualitative phenomenological study examined experiences of abortion care in Australia since the start of the COVID-19 pandemic. We used the 2013 patient-centred access to healthcare framework (hereafter referred to as \u0026lsquo;Levesque\u0026rsquo;s framework\u0026rsquo;)(\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) as a theoretical framework to inform data analysis and interpretation. It is a general healthcare framework with a patient-centred lens, and is well-suited to \u0026ldquo;comprehensively assess the complex and dynamic process\u0026rdquo; (\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e) that is common in abortion seeking. Levesque\u0026rsquo;s framework evaluates the ways people seek information and care, their experiences with the multiple steps of care-seeking, and the interconnectedness of the dimensions of access(\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e). Drawing on global literature about abortion access, we have adapted each dimension from Levesque\u0026rsquo;s framework to abortion (detailed in Supplementary Table 1 and summarised in Tables \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e to \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipants and recruitment\u003c/h2\u003e\n \u003cp\u003eAny person who attempted to access abortion services in Australia since March 2020, was at least 18 years of age, and was able to communicate in English for an interview was eligible to participate. Recruitment took place from November 2021 until October 2022 through social media posts (Twitter, Instagram, and Facebook). After April 2022, once COVID-19 restrictions had lifted, flyers were distributed by sexual health clinics. Eligible participants were directed through a QR code or URL to submit an expression of interest through Qualtrics, answering brief questions about their location, age, how the pandemic influenced their experience seeking abortion care, whether they had obtained an abortion and if so, when and what type. We reviewed each expression of interest and selected participants to ensure a diversity of characteristics and experiences in terms of state or territory, type of abortion (medication vs. surgical), regional/metropolitan residence, age, and extent of pandemic-related restrictions at the time of their abortion.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eData collection\u003c/h2\u003e\n \u003cp\u003eWe adapted a semi-structured interview guide from instruments used in similar studies in other countries,(\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e) and added questions relevant to abortion-seeking during the pandemic. Questions explored participants\u0026rsquo; experiences, from finding out they were pregnant, through seeking and obtaining care (or not), and any influence of the COVID-19 pandemic on their experience. The semi-structured interview approach allowed for a flexible interview, with elaboration, probing, and modification of questions based on participant responses.(\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e) All interviews were audio-recorded and documented with field notes.\u003c/p\u003e\n \u003cp\u003eEach invited participant was emailed to schedule an interview, with information about the study attached. Interviews were conducted over Zoom by an experienced abortion researcher (SM). After reviewing the Explanatory Statement and answering any questions, the interviewer audio-recorded verbal consent. Each participant chose between video and audio calls to maximise their comfort. We provided each participant with a AUD40 gift card in respectful recognition of their time. The study was approved by the Monash University Human Research Ethics Committee (Project 30926).\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eData management\u003c/h2\u003e\n \u003cp\u003eAutomatic transcription was generated by Zoom software, and then quality checked and edited. Edited transcripts were imported into NVIVO 12 (\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e) for analysis. De-identified audio recordings, field notes, and sociodemographic information were stored electronically on a password protected Monash University server.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eAnalysis\u003c/h2\u003e\n \u003cp\u003eTwo researchers (SM and SW) familiarised themselves with the data by reading transcripts, listening to audio recordings, and writing reflective memos about each interview. We conducted thematic analysis based on a codebook,(\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e) using the five dimensions of access in Levesque\u0026rsquo;s framework as the main codes, and developing sub-codes reflecting barriers and facilitators of access. We coded two transcripts, compared coding, and adjusted the codebook to ensure the definitions were clear. All remaining transcripts were then coded by one researcher (SW), with input throughout the process through researcher meetings. The team documented their process through field notes and memo writing to practice reflexivity.(\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e)\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipant characteristics\u003c/h2\u003e\n \u003cp\u003eA total of 24 participants were interviewed from 55 total expressions of interest, of which 14 were lost to follow-up and 17 excluded due to ineligibility or in efforts to balance the sample across states and territories and between rural and urban participants. The interviews lasted 30 to 105 minutes. All participants identified as cis women and sought abortion services between April 2020 and November 2022. They ranged from 20 to 40 years old (mean: 29.6 years old) and lived in seven of the eight Australian states and territories. Ten lived in rural areas and 14 in urban ones, according to the Australian Institute of Health and Welfare rural and remote classification system.(\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e) Twenty-one participants had one abortion during the study period, two participants had two abortions each, and one had a miscarriage and did not obtain an abortion, with a total of 24 people and 25 abortion services included in the analysis. Of these, 14 were medication abortions within the 63-day gestational age limit, nine were surgical abortions, and two were hospital-based medical inductions beyond 20 weeks. Six participants used both telehealth and in-person consultations, while the remainder only had in-person consultations. COVID-19 restrictions at the time of the abortion services ranged from severe (no travel beyond 5 km from home) to negligible (screening questions for symptoms before the service). Most participants who obtained care in 2020 and 2021 were not permitted to bring an accompanying person to their service due to public health measures.\u003c/p\u003e\n \u003cp\u003e[Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e about here]\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eParticipant characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eParticipant characteristic (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge (mean: 29.6)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u0026ndash;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u0026ndash;29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u0026ndash;34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIdentifies as\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCaucasian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAboriginal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHispanic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMultiracial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVictoria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQueensland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNew South Wales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSouth Australia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAustralian Capital Territory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWestern Australia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNorthern Territory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTasmania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRurality\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRegional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbortion characteristics (n\u0026thinsp;=\u0026thinsp;25)\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbortion type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedication abortion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurgical abortion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHospital-based medical induction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eModality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn-person only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCombination telehealth and in-person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\u003csup\u003e1\u003c/sup\u003e Per AIHW rural and remote classification system\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\u003csup\u003e2\u003c/sup\u003eTwenty-one participants had one abortion during the study period, two participants had two abortions, and one had a miscarriage and did not ultimately obtain an abortion\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eExperiences of abortion seekers for each dimension of Levesque\u0026rsquo;s framework\u003c/h2\u003e\n \u003cp\u003eFor each dimension of access identified in Levesque\u0026rsquo;s framework, we present an adapted definition specific to abortion, describe key aspects of how the sample experienced that dimension, and present illustrative quotes (Tables\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e to \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003ei. Approachability\u003c/h2\u003e\n \u003cp\u003eWe found that participants had limited prior understanding about the availability, legality, and provision of abortion care. Some participants said they were not taught about abortion when they were younger, for example due to a lack of sexuality education in school or reflecting the religious beliefs of their family. Many sought information outside of the healthcare system \u0026ndash; primarily online and from family and friends. Most of the ten participants located in Victoria were unaware of the presence of the state-funded telephone hotline providing comprehensive contraceptive, pregnancy options, and sexual health information called 1800MyOptions. The main findings and quotes to illustrate these experiences are shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003e[Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e about here]\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAbortion seekers\u0026rsquo; experiences of abortion care relative to the approachability dimension of Levesque\u0026rsquo;s framework\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eApproachable abortion care includes availability of accurate abortion information to all people about abortion options, legalities, gestational limits, and where to access abortion.\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eParticipants had some prior understanding of the availability of abortion care, though the information they had was not comprehensive. They described having limited knowledge and uncertainty about:\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eThe types of abortions available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I knew what options were available like [\u0026hellip;] medication, or like a surgical. [\u0026hellip;] I didn\u0026apos;t know, like the specifics, but I knew enough.\u0026rdquo; (ID020, Miscarriage, QLD, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eThe legalities and gestational limits of abortions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I didn\u0026rsquo;t even know [\u0026hellip;] if it was illegal or legal.\u0026rdquo; (ID013, Surgical, WA, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I knew that there were time limits on when I could make a decision by [\u0026hellip;] and [\u0026hellip;] [that there were] different limits with both procedures.\u0026rdquo; (ID012, Medication (x2), VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eWho provided abortion and where to go\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I didn\u0026apos;t know which places offered abortion.\u0026rdquo; (ID006, Surgical, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I just had no idea where to go, I didn\u0026rsquo;t necessarily know that [\u0026hellip;] my GP could do it.\u0026rdquo; (ID008, Medication, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eMany participants chose to seek information on abortion care independently of the healthcare system. The main methods of information-seeking included:\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSearching online\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I was completely isolated from my usual mechanisms of reaching information and [\u0026hellip;] at the mercy of Google, which ranks its first couple of pages based on how much you pay.\u0026rdquo; (ID016, Medication, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eFamily and friends\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I didn\u0026rsquo;t know what I was in for and so finding out from other people [...] and listening to what they had to say about it [\u0026hellip;] was helpful.\u0026rdquo; (ID003, Medication, SA, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eApproachable\u003c/strong\u003e abortion care includes ensuring that tailored information is available to all people of reproductive ages.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eSome participants said they were not taught about abortion at a young age through credible sources, making the process of sourcing information independently difficult.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I didn\u0026rsquo;t really have much of a sexual health education. I grew up in a religious family, quite conservative, [\u0026hellip;] so I didn\u0026rsquo;t know anyone who\u0026rsquo;d had an abortion before.\u0026rdquo; (ID008, Medication, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eii. Acceptability\u003c/h2\u003e\n \u003cp\u003eParticipants expressed different levels of (dis)comfort speaking to friends and family about their abortion. Most did not feel comfortable speaking to their colleagues about having an abortion, though some told their supervisors to explain an absence from work. Some participants said their medical provider emphasised their free choice to obtain an abortion. However, others felt their provider did not support their decision, or even tried to dissuade them from having an abortion. The main findings and related quotes are shown in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003e[Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e about here]\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eAbortion seekers\u0026rsquo; experiences of abortion care relative to the acceptability dimension of Levesque\u0026rsquo;s framework\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAcceptable care includes accounting for social and cultural factors that can impact a person\u0026rsquo;s decision and ability to access an abortion.\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eThere was varying comfortability amongst participants about speaking to friends and family about their abortion.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;My family is extremely religious. So [\u0026hellip;] I can never talk to them about it because I\u0026rsquo;ll pretty much be disowned. [\u0026hellip;] I think the stigma around [abortion], [\u0026hellip;] it\u0026apos;s extremely hard [\u0026hellip;]. You don\u0026apos;t want to even tell [\u0026hellip;] [your] friends about it.\u0026rdquo; (ID018, Medication, QLD, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;It\u0026apos;s a bit taboo, yeah, and initially I wasn\u0026apos;t going to tell anyone. I told my housemate and [\u0026hellip;] my mum and I just wanted to keep it at that. But I\u0026rsquo;ve actually [\u0026hellip;] been telling people, and I think it\u0026apos;s great to talk about it, and normalise it.\u0026rdquo; (ID005, Surgical, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;We didn\u0026apos;t want anyone to watch our kids because we didn\u0026apos;t want anyone to know what we were doing.\u0026rdquo; (ID013, Surgical, WA, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMost participants did not feel comfortable speaking to their colleagues about having an abortion, though some did tell their direct supervisor.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I was in like a really sort of pressurised work situation, and so I actually never got any time [off]. [\u0026hellip;] I think that speaks to a whole range of issues, particularly about gender relations in the workplace, and what is taboo, and what is acceptable personal leave.\u0026rdquo; (ID008, Medication, VIC, 27, 2021, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I\u0026apos;m full time ongoing. [\u0026hellip;] It\u0026apos;s [a] really small organisation and they\u0026apos;re incredibly supportive so I never had to justify anything. [\u0026hellip;] It\u0026apos;s just honestly so rare to not be questioned on needing time or needing space. And [it was made easier] because of the support of my boss as well.\u0026rdquo; (ID001, Medication, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAcceptable\u003c/strong\u003e care includes abortion providers supporting abortion seekers in the decision making process.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMany participants valued being reminded by a medical practitioner that the choice to obtain an abortion was theirs and that this decision was not in question. However, some healthcare staff and providers were not supportive of the participant\u0026rsquo;s decision to have an abortion.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSupportive staff\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;[The abortion provider] just said, \u0026lsquo;this is your choice. [\u0026hellip;] You know what you need, you know your life, you know what you\u0026apos;re capable of, and what you\u0026apos;re doing isn\u0026apos;t wrong. You\u0026apos;re just making a decision.\u0026rsquo;\u0026rdquo; (ID013, Surgical, WA, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eUnsupportive staff\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;When I said I want to know what my options are to get an abortion [\u0026hellip;] [the GP] said, \u0026lsquo;I don\u0026rsquo;t recommend it because [\u0026hellip;] you\u0026rsquo;ll regret it if you\u0026rsquo;re 30.\u0026rsquo;\u0026rdquo;(ID002, Surgical, VIC, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;The receptionist on the phone, just said \u0026lsquo;no, we don\u0026apos;t do that\u0026rsquo;. But she was very short and very abrupt, and [\u0026hellip;] that was really the end of the conversation.\u0026rdquo; (ID019, Medication, QLD, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eiii. Availability and accommodation\u003c/h2\u003e\n \u003cp\u003eAll ten participants living in non-metropolitan areas described barriers when accessing abortion care. Some participants travelled significant distances to access care and faced long wait times before securing an appointment due to a lack of abortion providers in their area. Barriers to abortion care were exacerbated by the COVID-19 pandemic, and participants described reduced service availability, prioritisation of telehealth over in-person care, and pandemic-related travel restrictions. Key findings and related quotes to illustrate these experiences are shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003e[Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e about here]\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eAbortion seekers\u0026rsquo; experiences of abortion care relative to the availability dimension of Levesque\u0026rsquo;s framework\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAvailable and accommodating care includes having both medication and surgical abortion options in all regions of the country through public and private services.\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eMany participants in regional areas experienced barriers accessing local abortion care.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;The [only provider in my local area] was only [providing] medical, they didn\u0026apos;t do surgery [\u0026hellip;]. You could do like a rural medical one, where [\u0026hellip;] everything\u0026apos;s like via post or something. But that was going to be too time consuming. Because I was rural at the time, [\u0026hellip;] I can\u0026apos;t even really [\u0026hellip;] access a post office and a doctor to go get all these tests and everything done.\u0026rdquo; (ID015, Medication, QLD, Regional\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAvailable and accommodating\u003c/strong\u003e care includes a reasonable distance to abortion care and sufficient availability in all areas in proportion to demand.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eSome participants, especially those from regional areas, had to travel significant distances to access abortion.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;The GP is in town, which is about 45 minutes from my place. And the ultrasound clinic was an hour and a half from our house at the next major city. And then I did have to travel two-and-a-half hours to the abortion clinic.\u0026rdquo; (ID025, Medication, NSW, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;Distance is a barrier, but [in the Northern Territory, where abortion is free], you know you can access it if you can get there.\u0026rdquo; (ID021, Medication\u0026thinsp;+\u0026thinsp;Surgical, NT, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAvailable and accommodating\u003c/strong\u003e care includes the presence of sufficient abortion providers throughout the country.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eSome participants faced long wait times due to a lack of abortion providers in their area.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I had to be flown down to Brisbane in order to have [the abortion]. But due to the high demand of abortions now, it was a month wait for me. [\u0026hellip;] Mentally, I wasn\u0026apos;t able to tolerate or handle a month.\u0026rdquo; (ID024, Hospital-based induction, QLD, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I had to wait a while [and] [\u0026hellip;] [it was hard] finding out the date [of the abortion service] was a couple of weeks away. [\u0026hellip;] I still had to deal with knowing that it was coming up [\u0026hellip;] and then knowing I had to go and do it all alone.\u0026rdquo; (ID003, Medication, SA, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAvailable and accommodating\u003c/strong\u003e care includes the ability of abortion services to meet increases in service demand.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eThe pandemic influenced the ability of abortion services to meet service demand, with many participants experiencing delays. Experiences of access were impacted by pandemic restrictions, including rules about how far they could travel for care and restrictions on being accompanied to the service. Some participants were offered telehealth services when they would have preferred in person care.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eReductions in service availability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;[At the abortion clinic] they were understaffed. [...] I definitely think it was pandemic related as to why it was so busy, and people weren\u0026rsquo;t getting seen quick enough.\u0026rdquo; (ID012, Medication (x2), VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePrioritisation of telehealth services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;They were very strongly pushing for phone appointments because of wanting to have less people in the clinic. And I was already quite emotional about the decision that we were making [to have an abortion]. [...] So I was very reluctant to have a conversation over the phone with a stranger.\u0026rdquo; (ID011, Medication, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;It [telehealth] was definitely impersonal. Because you want to meet the people that you\u0026apos;re seeing, and you know, be able to talk to them face-to-face. [\u0026hellip;] You think that these medical professionals are there for you, but I suppose doing it via telehealth it doesn\u0026apos;t feel that way.\u0026rdquo; (ID007, Hospital-based induction, VIC, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTravel restrictions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t know what the exact rules [for travel over 5km] were, [or] whether you could [legally] access healthcare [at the time].\u0026rdquo; (ID009, Surgical, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eNo accompanying person allowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;[Pandemic] restrictions [\u0026hellip;] still made it quite difficult, because my partner was never allowed to come with me to any of the appointments. [\u0026hellip; ] Not having that support was quite difficult.\u0026rdquo; (ID018)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv\u003e\n \u003cdiv align=\"left\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eiv. Affordability\u003c/h2\u003e\n \u003cp\u003eMost participants paid for their abortion, and some experienced significant financial stress in doing so. A small number received fee-free services because their state or territory of residence guaranteed free or low-cost abortion care. Additional expenses reported by participants included out-of-pocket costs for healthcare appointments, prescription medication, contraception, and sanitary items; child-minding; travel and accommodation; and counselling services. Some abortion seekers and their partners lost income or had to take leave from work when accessing abortion care, especially those casually employed or needing to travel for care. Some participants mentioned that the Medicare rebate was insufficient, and those ineligible for reimbursement from health insurance often had high out-of-pocket costs. Quotes to illustrate these experiences are shown in Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003e[Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e about here]\u003c/p\u003e\n \u003ctable border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 5\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eAbortion seekers\u0026rsquo; experiences of abortion care relative to the affordability dimension of Levesque\u0026rsquo;s framework\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAffordable care includes the ability to pay for abortion services regardless of procedure types, jurisdictions, and private and public service provision.\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eWhile most participants paid for their abortion, some struggled to do so. A small number received free services.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;The doctor asked, \u0026lsquo;Do you want to travel to the sexual clinic for a low-cost service or do you want to be seen locally in a private practice?\u0026rsquo; So, I went with the sexual health clinic.\u0026rdquo; (ID023, Medication, QLD, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;We\u0026apos;re very lucky here in South Australia in that the services actually don\u0026apos;t charge [for abortion care]. The only thing that I had to pay for was the medication.\u0026rdquo; (ID014, Medication, SA, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;[The clinic] told me [the price] over the phone and I had a heart attack, because it was, it was $500. And with a health care card too, which is just, it\u0026apos;s so much money. [...] I had to pay for that, on my own.\u0026rdquo; (ID005, Surgical, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAffordable\u003c/strong\u003e care includes eliminating the additional financial burden for those without Medicare to pay for abortion.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cem\u003eAdditional costs incurred when accessing abortion care included\u003c/em\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eOut-of-pocked appointment costs GP appointments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;It was just so expensive. [\u0026hellip;] [I went to a private clinic] because I just wanted to get in and out pretty quickly.\u0026rdquo; (ID004, Surgical, QLD, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePrescribed medication, birth control, or sanitary items.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;We went to the chemist, and yeah, I think I spent about $150 just on medication. And then I also bought some Nurofen and Panadol and some pads as well.\u0026rdquo; (ID017, Surgical, NSW, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eChild-minding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I can\u0026apos;t like, drive myself. [...] I need to bring my husband and then [\u0026hellip;] I can\u0026apos;t bring four kids with me. So, I was like, someone\u0026apos;s got to look after them at home.\u0026rdquo; (ID020, Miscarriage, QLD, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTravel and accommodation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;Petrol to get there was quite expensive. [\u0026hellip;] Parking, I think that was about $40 for the day.\u0026rdquo; (ID017, Surgical, NSW, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eLoss of income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I actually ended up paying it all, and [my partner] paid me back. [...] He had a really hard time paying that, [...] because he just had to take so much work off [unpaid to come to the appointments with me].\u0026rdquo; (ID004, Surgical, QLD, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eCounselling services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026quot;I am really keen to actually, probably do an appointment with the counsellor soon [to process my abortion experience]. [\u0026hellip;] I can\u0026apos;t afford it at the moment.\u0026rdquo; (ID012, Medication (x2), VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAffordable\u003c/strong\u003e care includes removing the additional financial burden of all facets of seeking abortion care for those without Medicare and others struggling to pay for abortion.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eParticipants without access to Medicare often had high out-of-pocket costs to access abortion care.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;[In addition to the cost of the abortion medication and transport costs], I had to pay [\u0026hellip;] the first GP I saw [around] 60 or 80 [dollars]. [\u0026hellip;] I didn\u0026rsquo;t have any [Medicare] at that point.\u0026rdquo; (ID023, Medication, QLD, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eSome participants mentioned the that the Medicare rebate was insufficient.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I think they did [give a rebate] but I can\u0026apos;t remember what that was in the end. [...] I can\u0026apos;t remember it [the rebate] making much difference.\u0026rdquo; (ID004, Surgical, QLD, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003ev. Appropriateness\u003c/h2\u003e\n \u003cp\u003eMost participants reported apprehension about judgement from healthcare providers or anticipated needing to justify their decision to their provider. Many said that providers along the care pathway, including laboratory staff, ultra-sonographers, and their general practitioner, assumed they wanted to remain pregnant. Those who did experience non-judgmental and supportive care valued this experience. Several participants said they experienced a lack of empathy during the appointment. Those who received empathetic care appreciated that the provider was patient and attentive to their emotions. Several participants felt that their appointments were rushed, while those who had sufficient time with providers said they valued this interaction. Some participants said their healthcare provider proactively facilitated access by referring to additional abortion services or helping them find a timely appointment, whereas a few participants would have liked to receive more appropriate referrals. Some participants told us their providers listened to their preferences and engaged in a joint decision-making process to best meet their needs. In contrast, many providers did not spend adequate time with them, leaving the client feeling unsupported in choosing a service that best met their needs. The main findings and quotes to illustrate them are shown in Table \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003e[Table \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e about here]\u003c/p\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAbortion seekers\u0026rsquo; experiences of abortion care relative to the appropriateness dimension of Levesque\u0026rsquo;s framework\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAppropriate care includes the provision of non-judgmental abortion care.\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cem\u003eNearly all participants mentioned experiences of judgement or apprehension of judgement from care providers. Examples include\u003c/em\u003e:\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eExpecting to have to justify their decision to their provider\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I felt like I would possibly need to justify my decision [to the provider], which I was worried would be my undoing.\u0026rdquo; (ID011, Medication, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eDifferent types of providers along the care pathway assumed the client wanted to remain pregnant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;[The GP] was talking to me as though I was gonna continue with the pregnancy. [\u0026hellip;] I knew in myself, that this [having a baby] wasn\u0026apos;t something that I could cope with.\u0026rdquo; (ID009, Surgical, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I went in for a blood test and the nurse knew that I was getting tested for pregnancy. [\u0026hellip;] She also said to me like\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026lsquo;Oh, is it your first one? Congratulations.\u0026rsquo; And I was [\u0026hellip;] like, \u0026lsquo;Oh thanks, but I\u0026apos;m not keeping it.\u0026rsquo;\u0026rdquo; (ID002, Surgical, VIC, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I said [to the receptionist], \u0026lsquo;I think I\u0026rsquo;m about five weeks\u0026rsquo;, and she said, [\u0026hellip;] \u0026lsquo;There\u0026apos;s no point doing an ultrasound because you won\u0026apos;t be able to see [the embryo], you\u0026rsquo;re better off coming back later.\u0026rsquo; [\u0026hellip;] Then I had to tell her in a very crowded room that I was terminating. [\u0026hellip;] [The receptionist was] not sensitive to the situation, and just assumed that I was, you know, an expectant mom.\u0026rdquo; (ID022, Surgical, NSW, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cem\u003eParticipants said they valued any experience of non-judgmental, supportive care.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;They [clinic staff] were fantastic. [I] spoke to somebody on the phone [\u0026hellip;] and you\u0026rsquo;re thinking, oh God, they\u0026rsquo;re judging me [\u0026hellip;]. But you know, [they were] [\u0026hellip;] just very non-judgmental, [\u0026hellip;] supportive and helpful.\u0026rdquo; (ID009, Surgical, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAppropriate\u003c/strong\u003e care includes the provision of empathetic abortion care.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eParticipants who experienced empathetic care said their providers were patient and attentive to their emotions.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;[On the phone I said,] \u0026lsquo;I don\u0026rsquo;t understand how this all works. [\u0026hellip;] I\u0026rsquo;ve never done this before. I don\u0026rsquo;t want to be pregnant.\u0026rsquo; [\u0026hellip;] [The abortion clinic staff] were just really calm, and [\u0026hellip;] [said] \u0026lsquo;It\u0026rsquo;s okay, just take a deep breath, [\u0026hellip;] Should I give you a call back in 10 minutes? Are you feeling safe? Do you want to lie down? Like, do you want to put me on speakerphone whilst you make yourself a cup of tea?\u0026rsquo;\u0026rdquo; (ID004, Surgical, QLD, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;[I experienced] just this extraordinary level of care checking [from my GP] [...]. I felt like [it] was the first time somebody [...] actually understood [\u0026hellip;] what was going on.\u0026rdquo; (ID016, Medication, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I really didn\u0026rsquo;t want [to] get an ultrasound [\u0026hellip;] by myself. [\u0026hellip;] They were like, \u0026lsquo;someone will come in with you, you don\u0026rsquo;t have to, like, look at anything.\u0026rsquo; [\u0026hellip;] They were [\u0026hellip;] good at calming all the things that I was bringing up.\u0026rdquo; (ID008, Medication, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eHowever, several participants said they experienced a lack of empathy and patience during the appointment.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;When she [the nurse] was going through the forms, she was just sort of like glossing over parts of it. You know, and I just remember thinking like, this is really important to me, [\u0026hellip;] [but] I wasn\u0026apos;t really in the position to be like, \u0026lsquo;Oh, sorry, you know, go back through that\u0026rsquo; [\u0026hellip;]. I know that that\u0026apos;s something that they do routine all the time, so I don\u0026apos;t know whether they\u0026apos;re a little bit desensitized to us.\u0026rdquo; (ID021, Medication\u0026thinsp;+\u0026thinsp;Surgical, NT, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;It was the only clinic that I could get into on a public holiday, everywhere else was closed. [\u0026hellip;] I went to see a random male doctor who referred me to get my bloods done. [\u0026hellip;] He also referred me to a women\u0026apos;s health clinic. He wasn\u0026apos;t very nice to me. It wasn\u0026apos;t no sympathy, nothing. [\u0026hellip;] I was in there for about two minutes. [\u0026hellip;] There was just no conversation at all.\u0026rdquo; (ID005, Surgical, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAppropriate\u003c/strong\u003e care includes providers allocating \u003cstrong\u003eadequate time\u003c/strong\u003e during abortion provision.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eParticipants valued when their provider took time during their appointments\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;[The] emotional support in terms of my GP [was great]. I hope everyone gets access to a GP [\u0026hellip;] who will take the time to sit with you and go through all the options. Like, we were certainly extending beyond standard appointments. In my time with her, we were really going through things and understanding what was going to happen.\u0026rdquo; (ID001, Medication, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eSeveral participants felt that their appointments were rushed.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;The anaesthetist came in and spoke to me just about the drugs that they would use and then, [\u0026hellip;] I just went straight in [to surgery]. [\u0026hellip;] I didn\u0026apos;t really have a lot of contact with anyone there. [\u0026hellip;] It was very rushed, and [\u0026hellip;] I felt very vulnerable at the time.\u0026rdquo; (ID017, Surgical, NSW, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;Everyone was just rushing around like they were overbooked, but the whole vibe wasn\u0026apos;t\u0026hellip; [it] wasn\u0026apos;t great. (ID005, Surgical, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;[The doctor] was just very dismissive about the whole thing. [\u0026hellip;] I was literally on the phone with him, for I think three minutes in total. [\u0026hellip;] I left more confused I think than anything. [\u0026hellip;] [It felt like] he was like, well you know, this is the too hard basket. I don\u0026apos;t want to deal with this.\u0026rdquo; (ID018, Medication, QLD, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAppropriate\u003c/strong\u003e care includes abortion providers giving \u003cstrong\u003eappropriate referrals\u003c/strong\u003e to additional abortion services.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eMany participants appreciated their healthcare provider proactively facilitating access by referring to additional abortion services.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;[The sonographer] made a call to my GP\u0026rsquo;s office, [\u0026hellip;] and they got [me] booked in [\u0026hellip;]. That was like, really efficient and a relief. It meant that I came away from the appointment with a clear plan [\u0026hellip;], the sense of agency, and some sort of picture of what was about to happen.\u0026rdquo; (ID008, Medication, VIC, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eA few participants felt that they were referred to a place that was not vetted by their providers and therefore was not appropriate.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;There\u0026rsquo;s no [alternative] services, there\u0026apos;s nothing. So, you know, anything would be better than nothing. [\u0026hellip;] I don\u0026apos;t know if [my GP is] aware [how bad this clinic was], or if she has a relationship with this clinic, or if she knows these people. But no, I wouldn\u0026apos;t send anybody there. It was appalling.\u0026rdquo; (ID022, Surgical, NSW, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAppropriate\u003c/strong\u003e care includes the provision of tailored and continuous care that is centred around the patient\u0026rsquo;s needs whilst fully informing them of their options.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eSome abortion providers listened to abortion seekers concerns and preferences and engaged in a joint decision-making process to best meet the client\u0026rsquo;s needs.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;[The GP] gave me the options. We weighed them up together and then made the decision together. I sort of already knew what I wanted to go towards, but he was really good in giving me, like, in talking to me about both [types of abortion].\u0026rdquo; (ID025, Medication, NSW, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I spoke to both a nurse, the doctor who did the scan, and the anaesthetist. [...] I went in and spoke to each of them separately, which [\u0026hellip;] gave a lot of opportunity for asking questions.\u0026rdquo; (ID019, Medication, QLD, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;[The doctor] asked me just, like, if I was thinking of keeping it or not.\u0026rdquo; (ID004, Surgical, QLD, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eIn contrast, some providers did not spend adequate time, leaving the client feeling unsupported in making a decision that best meet their needs.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I probably would have definitely liked to have a longer appointment with the psychologist at the start and [\u0026hellip;] to have a bit more time with the doctor [\u0026hellip;]. I just feel like that would have comforted me a little bit more, to have a proper conversation with the doctor or the person performing the procedure about what was going to happen and what they were going to do.\u0026rdquo; (ID017, Surgical, NSW, Regional)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; \u003cem\u003e\u0026ldquo;I had told the doctor that I didn\u0026apos;t [want to see the ultrasound screen] [\u0026hellip;] and he left the ultrasound, like, face up [and visible to me], instead of down, which I didn\u0026apos;t like.\u0026rdquo; (ID004, Surgical, QLD, Urban)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis analysis adapted Levesque et al\u0026rsquo;s influential framework of patient-centred access to healthcare(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) to abortion access during the COVID-19 pandemic. We found that the framework facilitated a nuanced examination of the multifaceted and intersecting factors that influence access to abortion \u0026ndash; a historically criminalised and still stigmatised service (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). This adaption of Levesque\u0026rsquo;s framework can be applied in different contexts to understand experiences of access to stigmatised health services and examine healthcare access in pandemic or other disaster conditions.\u003c/p\u003e \u003cp\u003eThe findings identify important facets of abortion access from the client perspective, with implications for how to enhance access in all its dimensions.\u003c/p\u003e \u003cp\u003eWe found that abortion seekers had relatively poor experiences in the dimension of \u003cb\u003eapproachability\u003c/b\u003e, with most having insufficient information about how to obtain abortions. These findings align with other studies in Australia(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e) and globally,(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e) highlighting that abortion seekers are often unsure where to seek care, unaware of the laws governing abortion and gestational age limits, and commonly use sources outside of the health system to learn about abortion \u0026ndash; with potential risks in terms of accuracy of information. This is important in light of WHO guidelines identifying available and accessible information as a key component of an enabling environment for abortion.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAbortion seekers described mixed experiences in the dimension of \u003cb\u003eacceptability\u003c/b\u003e, expressing different levels of (dis)comfort talking about their abortion/s. For some, this reflected their religious upbringing or living in a small community. A systematic review of abortion stigma highlights that secrecy is a common form of abortion stigma management, with implications including social isolation and distress, which in turn can have negative mental health consequences.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) It is noteworthy that some participants, who hesitated to disclose their abortion, received a supportive response from family, friends, or colleagues and described the process as positive and normalising. Research in other settings examines strategies to reduce the secrecy around abortion as a pathway to de-stigmatisation.(\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eExperiences in the dimension of \u003cb\u003eavailability and accommodation\u003c/b\u003e varied by place of residence, with those living outside metropolitan areas describing challenges including long wait times and large distances to obtain care. This is consistent with the notion of \u0026ldquo;abortion deserts\u0026rdquo; coined in the United states, in reference to places with no abortion care available nearby.(\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e) As elsewhere,(\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e) there is a shortage of abortion providers in Australia(\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e), particularly in rural areas.(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e) Provider shortages can limit the choices of abortion seekers between abortion types and between private and public care, and may result in significant travel to obtain care.(\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e) Many private abortion clinics are in metropolitan regions,(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) with limited surgical abortion availability elsewhere. Pharmacies dispensing abortion medication are also limited in rural areas, often compelling travel.(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) Additionally, rural GPs commonly have limited appointment availability, creating challenges for those seeking time-sensitive services like abortion.(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOur findings align with evidence that the COVID-19 pandemic limited health system capacity to delivery timely and high-quality abortion care, thereby disproportionately affecting rural abortion seekers.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) Telehealth abortion was increased in Australia and globally to reduce the need to travel for care during the pandemic; telehealth can enhance access in the context of health system pressure and travel restrictions.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) However, telehealth is neither acceptable nor appropriate for all abortion seekers.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e) For example, some individuals from migrant or refugee-like backgrounds or those experiencing family violence may have difficulty accessing telehealth services, as their personal safety may be compromised by an unsafe home environment or being around people who do not support their abortion decision.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) Our findings show that telehealth can evoke negative feelings for some abortion seekers due to the impersonal interaction, which lacks the interpersonal support of an in-person consultation. Additionally, some participants in this study described the restriction on bringing an accompanying person to their service as one of the most challenging aspects of seeking abortion care in the pandemic. Taken together, these findings identify interpersonal contact and social support as important facets of accommodating abortion care.\u003c/p\u003e \u003cp\u003eThe results highlight inequities in the \u003cb\u003eaffordability\u003c/b\u003e of abortion care based on location, income, employment type, and insurance status. Abortion care can entail additional expenses such as transport, accommodation, or childcare, disproportionately affecting people experiencing financial disadvantage(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e) and those having to travel for care, largely in rural and remote areas.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e) The affordability of abortion care remains a problem in Australia, where a 2017 study of more than 2,300 participants recruited at abortion clinics found that more than 20% were concerned about their ability to pay for abortion care.(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) Financial barriers to abortion care globally should be addressed to create an enabling environment for the service.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOur findings demonstrate a diversity of experiences in the dimension of \u003cb\u003eappropriateness\u003c/b\u003e. Some participants described very positive treatment, some very negative treatment, and some experienced both at different points in their service. Inappropriate interactions with healthcare staff and providers were reported by abortion seekers across states and territories, in urban and rural areas, and in different settings including GP clinics, at ultrasound, during bloodwork, and in dedicated abortion clinics. Overall, abortion seekers in the study expressed a desire for adequate time to ask questions and have their concerns addressed in a supportive, non-judgemental environment. Yet this can be challenging in the limited time allocated to reimbursable healthcare appointments,(\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e) which may be insufficient to support dialectical decision-making between abortion seekers and providers.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eTo improve \u003cb\u003eapproachability\u003c/b\u003e, these data suggest the need for community-wide dissemination of information about abortion(\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e), acknowledging that friends and family are an important source of information and support for abortion seekers. Accurate information about abortion and where to seek care can be provided through smartphone applications(\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e) or telephone services. For example, the 1800MyOptions hotline in Victoria(\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e) was identified as a useful model to deliver abortion information, with potential for national scale-up.(\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e) However, most Victorian participants in this study were unaware of this resource, signalling the challenges of dissemination even when comprehensive funded models exist. The lack of public information about abortion in part relates to stigma, which can limit information availability and hinder public listings of abortion providers.(\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e) For example, studies in Victoria have found that providers fear being negatively perceived for providing abortion care (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e) and may exercise their right to conscientious objection to preserve their reputations.(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) Stigma can also prevent people from discussing abortion with friends and family(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), contributing to an environment in which abortion seekers do not know where to seek, and have limited options for obtaining, information and care \u0026ndash; even where abortion is decriminalised.\u003c/p\u003e \u003cp\u003eInterventions to reduce community-level abortion stigma can increase the \u003cb\u003eacceptability\u003c/b\u003e of abortion. Comprehensive sexuality education programs can normalise open discourse about sexual and reproductive health(\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e), including abortion, while also equipping young people with information about accessing healthcare services. This approach would address a gap in knowledge about abortion, as information on this topic is generally lacking in schools(\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e); however, it is challenging to garner support to broach this topic with young people due to the stigma associated with abortion and with sexual activity among adolescents(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic limited the capacity of individual providers and the health system to make timely services \u003cb\u003eavailable\u003c/b\u003e and \u003cb\u003eaccommodate\u003c/b\u003e the needs of abortion seekers, particularly in rural areas. Availability could be enhanced by reducing the \u0026lsquo;exceptional\u0026rsquo; regulation of abortion provision seen around the world.(\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e) Regulatory changes such as task-sharing, recommended by the WHO,(\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e) can increase the availability of abortion providers relative to demand, and in doing so, reduce wait times. In Australia, the Therapeutic Goods Administration (the national regulation body for therapeutic goods such as the abortion medication licensed as MS-2Step) made changes in 2023 to reduce exceptional regulation of abortion; it now permits nurse practitioners to prescribe MS-2Step when certified, and unnecessarily stringent requirements for retraining and registration for GPs and pharmacists providing medication abortion have been removed.(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e) Further measures can be made to expand task-sharing to nurses and midwives. In addition, medication abortion is safe and effective up to 70 days gestation,(\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e) suggesting that current limits in many jurisdictions around the world, including Australia, could be safely extended. Doing so would provide abortion seekers more time to make informed decisions about abortion care and obtain medication abortion.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) These findings align with calls in the United Kingdom to ensure choice for clients between modalities of care and types of abortion.(\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e) Even in pandemic conditions, efforts to accommodate abortion seeker needs and preferences could be prioritised, for example by ensuring social support during the service.\u003c/p\u003e \u003cp\u003eThe dimension of \u003cb\u003eaffordability\u003c/b\u003e could be improved through publicly-funded initiatives to eliminate or reduce out-of-pocket expenses for abortion seekers.(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) For example, the Netherlands offers free abortions to those living or working in the country under their Long Term Care Act,(\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e) and universal access to free abortion has been introduced in the Australian Capital Territory, a federal territory of Australia containing the capital city.(\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e) Financial barriers can be further reduced by initiatives to fund travel for abortion care. In some places, including the United States and Europe, support for those who can\u0026rsquo;t afford to travel is provided by civil society organisations.(\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e) A model of publicly-funded abortion travel is found in Australia through the Northern Territory\u0026rsquo;s Patient Assistance Travel Scheme funded by the Department of Health(\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e). Such policies can help address the inequities of the \u0026lsquo;post-code lottery\u0026rsquo; \u0026ndash; that where someone lives dictates the accessibility and affordability of public abortion care.(\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTo ensure \u003cb\u003eappropriate\u003c/b\u003e services, different models of information provision can be explored to create more productive consultation time with providers. For example, a Scottish study found that disseminating an informational video about abortion care before seeing the provider gave clients more time to ask questions during the appointment as they could formulate questions beforehand.(\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e) Additionally, equipping practising and prospective healthcare providers with the skills to deliver sensitive, tailored, judgement-free, and empathic abortion care can facilitate appropriate care. Evidence-based strategies are needed to reduce stigma experienced by abortion seekers,(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e) particularly stigma enacted by healthcare providers,(\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e) including conscientious objectors.(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations:\u003c/h2\u003e \u003cp\u003eThis study contributes to gaps in the literature by centring the lived experiences of abortion seekers during the COVID-19 pandemic. The findings have particular relevance in Australia, where despite a National Women\u0026rsquo;s Health Strategy(\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e) supporting universal abortion access, a 2023 Senate inquiry identified numerous barriers to equitable access, particularly in rural Australia.(\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e) This analysis complements prior Australian studies that primarily drew on provider perspectives(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e), focused on one state or territory, and took place before broad decriminalisation. Further, this study elucidates all facets of abortion access during the pandemic, rather than focusing only on telehealth provision(\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e). Examining abortion seekers\u0026rsquo; experiences to identify barriers and facilitators of access is important even in relatively favourable policy environments.\u003c/p\u003e \u003cp\u003eThe study also has limitations. Social media was our primary recruitment method. Stigma may have limited the public sharing of our recruitment materials, possibly limiting their reach. However, social media recruitment is not uncommon, with other Australian abortion research utilising this approach.(\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e) Research on social media recruitment during the pandemic suggests that platforms such as Facebook are appropriate for reaching diverse communities.(\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e) Additionally, a systematic review found that social media recruitment has benefits for stigmatised topics such as sexual health.(\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe study sample was diverse in terms of participant age and location, gestational age at time of the abortion, and type of abortion procedure. However, there is an overrepresentation of participants from Victoria, the second most populous state in the country and the research team\u0026rsquo;s location. All participants were able to pay for care, so our data may exclude individuals who are unable to afford care. Additionally, most participants were white, highlighting the need for further research with more diverse populations to address barriers uniquely faced by racial minorities accessing abortions.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study examined lived experiences of five domains of abortion access: approachability, acceptability, availability and accommodation, affordability, and appropriateness. Even in a context with supportive legal and policy frameworks, abortion seekers in Australia experienced challenges when seeking services and information. Addressing obstacles to abortion care around the world is a priority under the Sustainable Development Goals(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) focus on universal access to reproductive healthcare. Barriers to care, already worsened by the COVID-19 pandemic, are likely to be even more burdensome in more legally restrictive settings.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eInitiatives to improve access could focus on creating an enabling environment for abortion, taking into account general health system limitations and the ongoing stigma around abortion in many parts of the world. Regardless of context, an enabling environment for universal abortion access requires effective mechanisms to educate the population about abortion and provide abortion seekers with \u003cem\u003eaccurate and credible information\u003c/em\u003e. An enabling environment is also premised on \u003cem\u003esupportive and appropriately-resourced health systems\u003c/em\u003e. To achieve this, investments are needed to reduce wait times, costs, and travel, especially for rural populations. Regulatory and workforce strategies to increase the types and number of abortion providers, improve the patient-centredness of healthcare providers, and reduce stigma in healthcare settings can improve experiences of those who are accessing care. Consumer voices can help understand the diverse pathways to and through abortion care and play an important role in informing solutions to overcome the multidimensional barriers to access.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval for this study were obtained from the Monash University\u0026nbsp;Human Research Ethics\u0026nbsp;Committee (ID 30926), with all methodology completed in accordance with the Declaration of Helsinki. All methods were performed in accordance with the Declaration of Helsinki. All interviews with participants were audio-recorded following informed verbal consent, in compliance with the Monash University\u0026nbsp;Human Research Ethics\u0026nbsp;Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available for privacy reasons but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not funded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSM, AT and JF conceptualised the study. SM recruited participants and conducted interviews. SW developed the analysis strategy, codebook, and analysis with supervision from SM. SW drafted the paper with substantive redrafting and revisions by SM. All authors reviewed drafts, provided significant revisions and feedback, and approved the submitted version.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the participants in this study who took the time to share their personal experiences to support this research. We thank the SPHERE community for providing feedback on this study at various points in time. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKim CR, Lavelanet A, Ganatra B. Enabling access to quality abortion care: WHO's Abortion Care guideline. Lancet Glob Health. 2022;10(4):e467\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization \u0026amp; United Nations Children's Fund (\u0026lrm;UNICEF).\u0026lrm; Report of the International Conference on Primary Health Care. Alma-Ata, USSR, 6\u0026ndash;12 September 1978. 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J Med Internet Res. 2018;20(5):e186.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorman WV, Soon JA, Maughn N, Dressler J. Barriers to Rural Induced Abortion Services in Canada: Findings of the British Columbia Abortion Providers Survey (BCAPS). PLoS ONE. 2013;8(6):e67023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMelville C. Abortion care in Australasia: A matter of health, not politics or religion. Aust N Z J Obstet Gynaecol. 2022;62(2):187\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSenate Community Affairs References Committee. Ending the postcode lottery: addressing barriers to sexual, maternity and reproductive healthcare in Australia. 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Women's Health Victoria. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://womenshealthvic.com.au/resources/WHV_Publications/1800MyOptions_2021.03.01_1800-My-Options-evaluation-summary-report_(\u003c/span\u003e\u003cspan address=\"https://womenshealthvic.com.au/resources/WHV_Publications/1800MyOptions_2021.03.01_1800-My-Options-evaluation-summary-report_(\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eFulltext-PDF).pdf Accessed: 05 Apr 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHulme-Chambers A, Clune S, Tomnay J. Medical termination of pregnancy service delivery in the context of decentralization: social and structural influences. Int J Equity Health. 2018;17(1):1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakleff S, Gardu\u0026ntilde;o J, Zavala RI, Barindelli F, Valades J, Billowitz M, et al. 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Int J Gynecol Obstet. 2020;150:49\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDepartment of Health and Aged Care, Therapeutic Goods Administration. : Amendments to restrictions for prescribing of MS-2 Step (Mifepristone and Misoprostol). Australian Government. Accessed 11 July 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMedication Abortion Up to 70 Days of Gestation. Contraception. Medication Abortion Up to 70 Days of Gestation. Contraception. 2020;102(4):225\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFootman K. Revolution in abortion care? Perspectives of key informants on the importance of abortion method choice in the era of telemedicine. Sex Reprod Health Matters. 2023;31(1):2149379.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlaylock R, Makleff S, Whitehouse KC, Lohr PA. Client perspectives on choice of abortion method in England and Wales. BMJ Sex Reprod Health. 2021;48:246\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eACT Government. Abortion Access. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.health.act.gov.au/services-and-programs/sexual-health/abortion-access\u003c/span\u003e\u003cspan address=\"https://www.health.act.gov.au/services-and-programs/sexual-health/abortion-access\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2023) Accessed 24 May 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEly GE, Hales T, Jackson DL, Maguin E, Hamilton G. The undue burden of paying for abortion: An exploration of abortion fund cases. Soc Work Health Care. 2017;56(2):99\u0026ndash;114.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurdoch J, Thompson K, Belton S. Rapid uptake of early medical abortions in the Northern Territory: A family planning-based model. Aust N Z J Obstet Gynaecol. 2020;60(6):970\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTait-Orr T, Isster R. Girlie does a deep policy dive. Altern Law J. 2023;48(1):74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Costa C, Douglas H, Hamblin J, Ramsay P, Shircore M. Abortion law across Australia\u0026ndash;a review of nine jurisdictions. Aust N Z J Obstet Gynaecol. 2015;55(2):105\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSorhaindo A, Rehnstrom Loi U. Interventions to reduce stigma related to contraception and abortion: a scoping review. BMJ Open. 2022;12(11):e063870.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakleff S, Belfrage M, Wickramasinghe S, Fisher J, Bateson D, Black KI. The intersection of stigma, quality of care, and structural barriers. a qualitative study of interactions between abortion seekers and healthcare workers in Australia; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDepartment of Health and Aged Care. National Women\u0026rsquo;s Health Strategy 2020\u0026ndash;2030. Australian Government, Department of Health and Aged Care. 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.health.gov.au/resources/publications/national-womens-health-strategy-2020-2030\u003c/span\u003e\u003cspan address=\"https://www.health.gov.au/resources/publications/national-womens-health-strategy-2020-2030\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Accessed 10 May 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDawson AJ, Nicolls R, Bateson D, Doab A, Estoesta J, Brassil A, et al. 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The use of social networking sites for public health practice and research: a systematic review. J Med Internet Res. 2014;16(3):e2679.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevesque J-F, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Abortion, healthcare access, Australia, COVID-19, qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-3209353/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3209353/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eUniversal access to sexual and reproductive health services is a global priority. Yet barriers to abortion access remain, including legal restrictions, cost, stigma, and limited availability of services and information. The COVID-19 pandemic exacerbated barriers to abortion care. The aim was to identify barriers to and facilitators of abortion by examining experiences of access during the COVID-19 pandemic.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis qualitative phenomenological study examined abortion access during the pandemic in Australia, where abortion is decriminalised. We used social media and flyers in clinics to recruit adults who sought abortion care since March 2020, then conducted in-depth interviews. We mapped participant experiences to five dimensions of access identified by Levesque et al.\u0026rsquo;s patient-centred access to healthcare framework: approachability, acceptability, availability and accommodation, affordability, and appropriateness.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe 24 participants lived across Australia and sought abortion in a range of pandemic-related restrictions. \u003cem\u003eApproachability\u003c/em\u003e: Most lacked information about abortion and where to seek it. \u003cem\u003eAcceptability\u003c/em\u003e: Many were uncomfortable disclosing their abortion to family, friends, and healthcare providers, and providers demonstrated varying levels of support. \u003cem\u003eAvailability and accommodation\u003c/em\u003e: Regional participants travelled far and faced long wait-times, exacerbated by pandemic restrictions. \u003cem\u003eAffordability\u003c/em\u003e: Participants described financial stress paying for the service, travel, and related expenses. \u003cem\u003eAppropriateness\u003c/em\u003e: Most participants expected judgement in care. Providers commonly assumed they wanted to remain pregnant, and some provided unempathetic and rushed care. Some participants reported non-judgmental and supportive services with appropriate emotional support and time spent with providers.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eAbortion seekers experienced varying obstacles when seeking care, exacerbated by the COVID-19 pandemic. Challenges during the pandemic illustrated the importance of ensuring social support during care and choice between abortion modalities and service types. The findings illustrate the need for population- and system-level initiatives such as: providing accurate information about and normalising abortion; implementing system-level efforts to reduce wait times, travel, and costs, especially for rural populations; and developing regulatory and quality improvement initiatives to increase the workforce and its readiness to provide high-quality, non-judgemental abortion care. Consumer voices can help understand the diverse pathways to abortion care and inform solutions to overcome the multidimensional barriers to access.\u003c/p\u003e","manuscriptTitle":"Experiences of abortion care in Australia during the COVID-19 pandemic: examining multiple dimensions of access","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-08-22 06:23:00","doi":"10.21203/rs.3.rs-3209353/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2023-10-13T16:58:51+00:00","index":"","fulltext":""},{"type":"decision","content":"Major revision","date":"2023-10-13T16:58:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-09-24T01:58:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"de01a732-7e8a-4fe2-b30f-805dde1dd944","date":"2023-09-16T09:58:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25c3990e-a672-4d0d-a89f-eaefee95f174","date":"2023-09-04T01:10:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-08-29T00:34:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-08-24T00:30:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-08-17T08:44:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-08-17T08:44:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2023-07-27T10:19:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ce5e37d1-a832-4965-a277-273ae07df17f","owner":[],"postedDate":"August 22nd, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-14T16:00:17+00:00","versionOfRecord":{"articleIdentity":"rs-3209353","link":"https://doi.org/10.1186/s12884-024-06758-8","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2024-10-07 15:57:14","publishedOnDateReadable":"October 7th, 2024"},"versionCreatedAt":"2023-08-22 06:23:00","video":"","vorDoi":"10.1186/s12884-024-06758-8","vorDoiUrl":"https://doi.org/10.1186/s12884-024-06758-8","workflowStages":[]},"version":"v1","identity":"rs-3209353","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3209353","identity":"rs-3209353","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}