The difficult process of autonomous choice: using I-poems to understand experiences of abortion-seekers in The Netherlands

Abstract

While key barriers to abortion care accessibility have been established, little is known about the experiences of people having abortions in the Netherlands. Stories of individual abortion-seekers can help counteract stereotyping, diminish abortion stigma, and improve accessibility. This study’s research question is: What experiences do abortion-seekers in the Netherlands have with abortion care and what new insights can the I-poem method of analysis provide? This qualitative feminist study used transcripts of semi-structured, in-depth interviews with abortion-seekers from previous research to create I-poems. Using a grounded theory method, the I-poems were coded deductively to validate previous findings, and inductively to generate new insights. The I-poems revealed that although abortion-seekers felt autonomous, their decision-making was complicated by doubt concerning their partner’s views and/or suitability as a parent, feelings of shame, and a lack of support. The abortion-seekers were often slowed by obstacles in policy and care; waiting caused feelings of fear and panic and routine pre-abortion ultrasounds led to anxiety. They often did not know what to expect from their body or the abortion procedure. I-poems show how autonomous choice in abortion care is socially constructed rather than purely individual. Abortion providers must pay special attention to external factors complicating the decision-making process such as partner discordance (even in stable relationships) and anxiety due to waiting times and routine pre-abortion ultrasound. Future action on normalisation of information provided on all aspects of choosing an abortion is necessary to realise informed choice and reduction of abortion stigma.

Plain language summary Abortion is a medical procedure that ends a pregnancy. In some countries, people can easily get an abortion. In others, it is illegal or difficult to access. In the Netherlands, abortion is accessible and legal before 24 weeks of pregnancy and can be performed upon request of the abortion seeker. This policy is often seen as liberal, as it allows people to make their own decisions about their bodies. Still, abortion stigma is present in Dutch society. Stigma around abortion refers to negative attitudes and beliefs that society has towards people who have had abortions or are considering having one.

Research by Holten et al⁷ looked at how easy it is for abortion seekers in the Netherlands to access abortion services. The study highlighted that people in the Netherlands still face barriers to accessing abortion services. For example: the law and regulations regarding abortions and the fact that people had difficulty in talking about their abortion due to stigma.

The abovementioned study gives a broad view on challenges in the accessibility of abortion in the Netherlands, but the individual experiences are not portrayed.

The goal of this study is to learn about the personal experiences of abortion-seekers in the Netherlands. It aims to understand what it’s like for these people to access abortion services and what we can learn from their individual stories by using a method of analysis called I-poem. I-poems are a type of poem created by the researcher by looking for sentences using the first-person pronoun “I” in interview texts. I poems show the personal experience or point of view of the person interviewed. This type of poem is often used to express emotions or share personal stories or observations.

This study used interviews with people who have had abortions to create I-poems. The grounded theory method was used to analyse the I-poems in two ways: confirming what was found in previous studies, and also providing new insights from the data.

The study found that the people contemplating having an abortion had a hard time making the decision to have an abortion because they had doubts, were worried about what their partner would think, felt ashamed to talk about it with friends and family, and didn’t have enough support. They also faced challenges like having to wait for the abortion because of clinic schedules and laws and getting ultrasounds before the procedure, which made them anxious. It was also found that the people contemplating abortion were unsure of what to expect from the abortion procedure and how their body would react, which made the decision even harder.

The study concludes that even when people felt in control of their decision, the decision-making process was still difficult. The decision is not just personal, but is also affected by society, partners, and healthcare policies. The waiting time and the ultrasound before the abortion made the process harder, and abortion seekers were not aware of what to expect from the procedure. More information and education on all aspects of having an abortion should be provided to help people to make better informed decisions and reduce the abortion stigma. Further research on experiences of routine ultrasound before abortion in the Netherlands is needed to improve abortion care.

Résumé

Si les principaux obstacles à l’accès aux soins pour avortement ont été définis, on sait peu de chose sur les expériences des personnes qui avortent aux Pays-Bas. Les récits individuels de femmes souhaitant avorter peuvent aider à lutter contre les stéréotypes, diminuer la stigmatisation de l’avortement et élargir l’accessibilité. La question de recherche de cette étude était: quelles expériences les femmes voulant avorter aux Pays-Bas ont de l’avortement et quels éclairages nouveaux la méthode d’analyse du poème à la première personne, le « je-poème », peut-elle donner? Cette étude féministe qualitative a utilisé des transcriptions d’entretiens approfondis semi-structurés réalisés avec des femmes souhaitant avorter lors de précédentes recherches pour créer des « je-poèmes ». À l’aide d’une méthode par théorisation ancrée, les « je-poèmes » ont été codés par déduction pour valider des résultats antérieurs et par induction pour produire de nouveaux éclairages. Les « je-poèmes » ont révélé que même si les femmes souhaitant avorter se sentaient autonomes, leur prise de décision était compliquée par les doutes concernant l’avis de leur partenaire et/ou ses qualités pour devenir parent, des sentiments de honte et un manque de soutien. Les femmes souhaitant avorter étaient souvent freinées par des obstacles dans les politiques et les soins; l’attente causait des sentiments de peur et de panique, et les échographies de routine avant l’avortement provoquaient de l’anxiété. Souvent, elles ne savaient pas à quoi s’attendre dans leur corps ou la procédure d’avortement. Les « je-poèmes » ont montré que les choix autonomes en matière d’avortement sont construits socialement au lieu d’être purement individuels. Les prestataires de soins pour avortement doivent accorder une attention particulière aux facteurs externes qui compliquent le processus de prise de décision comme la discordance avec le partenaire (même dans des relations stables) et l’anxiété due aux délais d’attente et aux échographies de routine avant l’avortement. Il est nécessaire de continuer d’agir pour une normalisation des informations fournies sur tous les aspects de la décision d’interrompre la grossesse afin de permettre un choix éclairé et de réduire la stigmatisation liée à l’avortement.

Resumen

Aunque se han establecido las principales barreras para obtener servicios de aborto, no se sabe mucho sobre las experiencias de las personas que tienen abortos en los Países Bajos. Las historias de las personas que buscan un aborto pueden contribuir a contrarrestar el estereotipado, disminuir el estigma del aborto y mejorar la accesibilidad. La interrogante de este estudio de investigación es: ¿Qué experiencias tienen las personas que buscan un aborto en los Países Bajos con los servicios de aborto y qué nuevas perspectivas puede ofrecer el método analítico poema Yo? Este estudio feminista cualitativo utilizó transcripciones de entrevistas a profundidad semiestructuradas con personas que buscaban un aborto, realizadas en investigaciones anteriores, para crear poemas Yo. Utilizando el método de teoría fundamentada, se codificaron los poemas Yo de manera deductiva para validar los hallazgos anteriores, y de manera inductiva para generar nuevas perspectivas. Los poemas Yo revelaron que, aunque las personas que buscaban un aborto se sentían autónomas, su toma de decisiones se complicaba por dudas sobre las opiniones de su pareja y/o la idoneidad para ser padre/madre, sentimientos de vergüenza y falta de apoyo. Esas personas a menudo eran ralentizadas por obstáculos en políticas y servicios; la espera causaba sentimientos de temor y pánico y los ultrasonidos preaborto rutinarios producían ansiedad. A menudo no sabían qué esperar de su cuerpo ni del procedimiento de aborto. Los poemas-Yo muestran cómo la elección autónoma en los servicios de aborto se construye socialmente, y no es puramente individual. Los prestadores de servicios de aborto deben prestar atención especial a los factores externos que complican el proceso de toma de decisiones, tales como la discordancia de la pareja (incluso en relaciones estables) y la ansiedad causada por tiempos de espera y ultrasonidos preaborto rutinarios. Para que las personas puedan realizar una elección informada y se pueda reducir el estigma del aborto, aún se necesitan futuras acciones para normalizar la información proporcionada sobre todos los aspectos de la elección del aborto.

Keywords:

• abortion
• I-poem
• autonomy
• choice
• stigma
• accessibility of health care
• pre-abortion ultrasound

Introduction

Abortion remains a current and controversial topic around the world. The Netherlands is often seen as a liberal country regarding abortion regulations. However, people in the Netherlands are apprehensive about losing their right to abortion care due to current world developments, and the fact that abortion is still in the Dutch penal code. Abortion in the Netherlands is illegal unless certain criteria are met: the abortion-seeker declares to be in an “emergency situation”, a doctor is assured the decision is voluntary, and the abortion is performed before 24 weeks gestation by a physician in a specially licensed clinic. Until 2023, abortion after 6 weeks and 2 days was only legal after a five-day reflection period. Dutch law thereby contributes to abortion stigma and negatively influences the social acceptance of abortion.¹

There are stereotyped images and misconceptions about people who do* abortion. Abortion stigma marks abortion-seekers as inferior to ideals of womanhood as they transgress ideals of fecundity, inevitability of motherhood, and instinctive nurturing.² Therefore, some find abortion only acceptable under extreme circumstances such as drug addiction or rape. This (internalised) stigma may influence how people feel about their unwanted pregnancy, how they cope with their feelings and can lead to psychological distress and poorer health outcomes.^3,4 Research has shown stigmatisation as related to concealment or delaying of abortion.⁵ In the Netherlands, stigma has been identified as a barrier to seeking a timely abortion through the regular system and a motivation for seeking abortion pills online.⁶

Research by Holten et al⁷ (co-author on this article) on the experience of accessibility of abortion care in the Netherlands showed that, despite the relatively permissible Dutch abortion law, difficulties in accessing abortion care exist, and confirmed that stigma plays an important role. The study analysed in-depth interviews with 20 people who had had an abortion and 14 health professionals who provide abortion care, and 200 emails of people seeking abortion care through the non-governmental organisation Women on Web. Four major themes were found: abortion-seekers felt burdened by taboo, were in a financially, socially, and emotionally vulnerable position, felt evaluated by health professionals, and felt disempowered and distressed. The overarching theme from the data was that abortion seekers did not feel fully autonomous. The key barriers to abortion access in the Netherlands included complex candidacy regulations for abortion care, the lack of permeability of abortion care for certain marginalised groups, institutionalised taboo in abortion law and care, and people’s inability to speak openly about their abortion due to stigma.⁷

While the study by Holten et al⁷ was successful in documenting obstacles to abortion care accessibility, it did not portray how individual abortion-seekers experienced their care. In the grounded theory analysis, the interviews were necessarily fragmented and coded. This generated themes validated by quotes, but the stories of individual abortion-seekers were not highlighted. In seeking a methodology to further explore the individual stories, Holten located the I-poem method of analysis. This method is a process that shows how interview participants speak about themselves through focusing on their statements using the first person “I”.⁸ The method is relevant for abortion-related content because the I-poems generate new insights on abortion experiences from existing data and I-poems can stand alone as poems or be used in spoken word performances thereby highlighting the stories of individual people doing abortion.

This secondary analysis of interview data from earlier research sets out to counteract stereotypes and diminish abortion stigma by giving insight into the lived experiences of individuals doing abortion in the Netherlands. Reducing stigma is an important step in safeguarding accessibility of abortion care. Therefore, the aim of this research is to study and portray the experiences of individual abortion-seekers in the Netherlands. The research question for this study is: What experiences do abortion seekers in the Netherlands have with abortion care and what new insights about these experiences can the I-poem method of analysis provide?

Methods

COREQ feelings, criteria for reporting qualitative research ensured comprehensive data collection and analysis.⁹

Study design

This exploratory qualitative research used a constructivist feminist approach. The study follows a reproductive justice approach by attempting to create a unifying and intersectional language (the I-poems) with which to build bridges and to empower all abortion-seekers in their right not to have a child. This approach is holistic and intersectional, it goes beyond the more individualistic, legal approach of pro-choice to link reproductive health and rights to socio-political and economic inequalities, asserting that the legal right to abortion is meaningless for people who cannot access it.¹⁰ The I-poem method and abbreviated grounded theory were used in the analysis of interviews on abortion experiences from the aforementioned research as a secondary analysis.

I-poems are a specific method for analysing interviews, developed by Carol Gilligan and colleagues.¹¹ The I-poems are formed by interview sentences containing the word “I”. The concept is that when participants use the “I” form, this is closest to their sense of self or “voice” and highlights their point of view in the narrative.¹²

I-poems are a form of data analysis and a way of presenting research results. By becoming research “findings”, I-poems privilege “telling” above “knowing” and thereby can be seen to challenge androcentric epistemology.¹³ I-poems have been found to be a useful method in studying subjects such as birth trauma,¹⁴ freebirthing,¹³ women’s workplace transition,¹⁵ and residential aged care.¹⁶

The goal of the I-poem method is not to produce poetry that is “good” by literary standards but to produce poems that provide insight into the lived experience of study participants. I-poems are often evocative, sometimes poignant. The ability of I-poems to rouse emotions can be used as a novel way of disseminating research findings beyond an academic audience thereby raising awareness and encouraging societal debate.¹³

Research team

LH is a midwife, medical anthropologist, and experienced qualitative researcher. MvdP is a health scientist and researcher. RvdW is a poet who has experience with abortion. All identify as female and feminist and find autonomy and accessible abortion care important.

Interviews

The interview transcripts from previous research by Holten et al⁷ on the accessibility of abortion care in the Netherlands were used to generate the I-poems. In-depth interviews were held with people who had had experience with abortion care from 2010 to 2020. No major changes in the abortion law or care system took place in that time period. Interviews were guided by a topic list that included barriers to access for abortion care found in the literature and was developed using the candidacy framework.¹⁷ This framework considers the ways in which people’s eligibility for medical intervention is jointly negotiated between individuals and health services. Participants were recruited by email using opportunistic sampling of pro-choice groups and the research team’s personal and professional networks. Interviews were conducted by LH, took place from February to June 2020 and lasted 30–90 min. Two interviews were face-to-face, the others were online video calls due to Covid-19 regulations at the time. The interviews were recorded, and the data transcribed verbatim by volunteer midwifery students or a professional company.

Data analysis

Creating the I-poems

The method used to create I-poems in this study was similar to the approach taken by Miller et al.¹⁶ To create the I-poems, we read each interview transcript from beginning to end highlighting all sentences in which the personal pronoun “I” appeared. We then cut and pasted these sentences in the order in which they appeared in the interview transcript, one after the other, in a new document, like the lines of a poem. We then removed words before and/or after the “I” and associated verb. We pared the text down to only the words necessary to understand the sentence. The creativity of the researchers lay in the choice of which words to remove, the selection of where the poem should begin and end, the choice of title and formatting. Neither capitalisation nor punctuation marks were added. The only words the researchers added were the poem titles; this was done to give context so that the poems could stand alone. Some lines were indented for aesthetic reasons or to emphasise a point. All I-poems were translated from Dutch to English by LH, a native English speaker, and checked by MvdP and RvdW who are fluent in English.

Analysis of the I-poems

In this study, the I-poems are presented as findings but also used as data analysed using abbreviated grounded theory.¹⁸ The I-poems (as a whole) were coded inductively and deductively by LH and RvdW. The I-poems were coded inductively to gain new insights into the interview data. Inductive open coding of the poems started from the bottom up, with each poem adding and building on the list of descriptive, interpretative, and in-vivo codes. Axial coding then grouped codes into themes. Selective coding produced an overarching theme. Deductive coding was performed to ascertain if the themes generated by the I-poems corresponded to the themes found in the previous grounded theory analysis by Holten et al⁷ thereby heightening the validity of that research through a triangulation of research methods.

Ethical considerations

Ethical approval was sought from the medical ethics committee of the Amsterdam University Medical Center. As this study does not fall within the scope of the Medical Research Involving Human Subjects Act (WMO) in the Netherlands and only involved interviews, formal assessment was not deemed necessary for ethical approval (3 March 2021, reference number W20_489 # 20.541). In conducting the study, we gave due consideration to ethical matters by following the Amsterdam UMC Research Code, hereby respecting participants’ privacy, autonomy, and dignity. Data were stored anonymously in a password-protected database. Written informed consent was provided prior to each interview wherein participants gave permission for the anonymous use of quotes (for more details see Holten et al.⁷). A member check was held and written consent was solicited once more and given specifically for the anonymous use of the I-poems.

Results

The in-depth interviews, from which the I-poems were created, took place with 20 participants who had sought abortion care in the Netherlands from 2010 to 2020. See Table 1 for an overview of the characteristics. The average age at the time of the abortion was 27 years (range 19–35 years). For most, the abortion concerned their first pregnancy. All abortions took place before 12 weeks gestation. One participant miscarried while awaiting an abortion and one participant ultimately decided not to have an abortion. One participant was an undocumented migrant. Two participants sought abortion care during a Covid-19 lockdown (March–May 2020). One abortion took place in a hospital, the rest in an abortion clinic.

Table 1. Participant characteristics⁷

	Participants’ characteristics (N = 20)*	Frequency
Nationality/Ethnicity	Dutch	12
	Dutch bi-cultural	4
	Non-Dutch (Surinam, South Africa, UK)	4
Residence	In 4 largest cities (Amsterdam, Rotterdam, The Hague, Utrecht)	11
	Smaller cities and rural areas	9
Religion	None	14
	Catholic	4
	Hindu	1
	Muslim	1
Education	Higher professional or university education	16
	General or (pre)-vocational secondary education	4
Age at time of abortion	15–19 years	1
	20–24 years	5
	25–29 years	10
	30–35 years	4
Parity	0	14
	1	2
	2	1
	>2	3
Previous abortions	0	17
	1	2
	2	1
Type of abortion**	Medical	6
	Surgical <12 weeks	12
	Surgical >12 weeks	0
Abortion location	Abortion clinic	19
	Hospital	1

*18 abortion-seekers identified as female, 2 as non-binary.

**one participant had a spontaneous miscarriage and one participant chose to continue the pregnancy.

The 20 interviews generated 101 I-poems. It was possible to create an average of five meaningful poems per interview (range 1–9). This depended on the number of times the respondent used the “I” form (rather than e.g. “you” or “we”), the coherence of the fragment of interview text and the interview flow. Interviews where the participants talked for a time without interruption generated more poems than interviews where many questions were asked to prompt the participant.

A deductive thematic analysis was performed to see if the subject of the individual I-poems corresponded to the themes found in the previous grounded theory analysis of the interview transcripts.⁷ Half (50) of the I-poems corresponded with the pre-established categories of burdened by taboo (18), being in a vulnerable position (11), feeling evaluated/judged by health professionals (13) and feeling disempowered distress (8). The other half (51) of the I-poems did not fit easily into these categories and were mostly about the decision-making process (29) and the abortion procedure itself (22).

To ascertain if the I-poem method could generate new insights compared to the previous grounded theory analysis, an inductive thematic analysis of all 101 I-poems was undertaken. The process of open, axial, and selective coding generated new themes: 1. Complicated decision-making, 2. Slowed by obstacles in policy and care 3. Not knowing what to expect. The overarching theme was: The process of autonomous choice is difficult (see Table 2).

Table 2. Coding tree: list of themes, categories and main codes

Overarching themeThe process of autonomous choice is difficult
Theme 1 Complicated decision making Doubt -Doubted suitability of partner -Partner had different opinion -Comply with partner’s opinion -Not ready for a child -Family complete -No doubt Shame -Do/don’t share with others -Afraid of other people’s opinions -Reaction family/friends -Shame 2nd abortion -Only stupid people -Don’t burden others -Anti-abortion protesters Need for support -Need for guidance -Feeling vulnerable -Vulnerable position -(no) Support partner -Do/don’t tell partner -Lonely during and after	Theme 2 Slowed by obstacles in policy and care (Un)satisfied with health care -General Practitioner inadequate -Anger -Having to justify oneself -Unpleasant treatment -Having to be pushy -Accessible care -Respectful care Waiting makes it harder -Wanting an abortion asap -The longer pregnant, the harder it is -Having to wait -5-day reflection period -Long clinic waiting time -Routine ultrasound -Anxiety surrounding ultrasound -Seeking reassurance in ultrasound -Panic -Fear	Theme 3 Not knowing what to expect Bodily functions -Happy with / proud of pregnant body -Pain and blood loss -Losing the embryo -Complications The procedure -Insufficient information -Untrustworthy websites -Choices to be made in the clinic -Atmosphere in the clinic -Sadness

Complicated decision-making [Theme 1]

Doubt

The I-poems show that doubt made the decision-making process difficult. Ten of the 20 participants voiced that their partners played a role in this feeling of doubt. Some abortion-seekers doubted the suitability of the person who had impregnated them as a future partner. Some were not in a steady relationship, and the choice not to have an abortion meant the choice for some sort of relationship, as one participant voiced: “then I am stuck with him for the rest of my life”. Several participants expressed the feeling that the partner was not supportive, one participant spoke of an abusive relationship. In some poems it became clear that the abortion seeker’s partner had a different opinion about the abortion, some partners thought “it would be nice to have a baby”, others felt that the family was complete. Several poems expressed the difficulty in making an autonomous choice when you have a partner and a family. A few poems show how people, who already had a number of children, complied with their partner to have an (in the first instance) unwanted abortion thereby “choosing for the family” and not themselves.

I tried to let it be my choice

I was doubting

I’ve always said

   make sure I don’t get pregnant

I wouldn’t want an abortion

   that it’s not something I

   I was just in the situation

   it was what it was

   and my own wishes and beliefs [put] aside

I still don’t really know if

I made the right decision

I feel that

I of course tried to see it

   as if it was my wish too

I really consciously tried to

   let it be my choice

   so it wouldn’t become something

   that comes between us

when I was pregnant

   what made that I felt pressured

   that he said I just don’t want it

I got the referral letter

I went to the clinic

that I

   two days before still had the idea 

   that we would just keep the baby

(Karen,^† 34 yrs, medication abortion at 7 weeks)

Shame

Feelings of shame complicated the decision-making process. The I-poems show that many people chose not to share with others the fact that they were considering an abortion. They were afraid of the reaction of family and friends and were afraid that this reaction would influence their decision. Several poems expressed the worry that revealing their abortion plans would burden others, especially friends with fertility problems. A second abortion was experienced as more shameful than the first and was often kept secret. Shame had to do with the stigma surrounding abortion, as the poem shows, wherein the abortion seeker felt that an unplanned pregnancy and subsequent abortion was something that only happened to stupid people.

Only stupid people

I actually felt even dumber

I felt even dumber

   ohh

   I need to cry

   because I’m thinking about it now

I felt stupid

I already felt very stupid because

I knew too

I thought that

 unintentionally getting pregnant

 would only happen to stupid people

 although

I don’t even know what stupid people are

I find few people stupid

   but that image

(Geertje, 27 yrs, surgical abortion at 8 weeks)

Need for support

Feeling vulnerable was a theme in several I-poems. Participants expressed financial, social, and emotional vulnerability, which complicated their decision-making process. Some needed help with the decision-making process. Many felt a lack of support from partner and/or family and friends. This sometimes resulted in feelings of loneliness during and after the abortion process.

Discouraged

I actually had no social support at all

I’m a little shocked

I didn’t really feel acknowledged

   there is still a kind of taboo I think

have not been able to tap the resources

   that I needed

I find that regrettable too

If I could have talked with someone about it

I tried to

I didn’t get the response and understanding

   that I needed

   that I expected

   at all

response I did get that didn’t help me

   that’s why I stopped

I got discouraged

(Renae, 28 yrs, surgical abortion at 12 weeks)

Slowed by obstacles in policy and care [Theme 2]

(Un)satisfied with health care

A few I-poems expressed satisfaction with the accessibility of abortion care and the respectful care within the abortion clinic.

Satisfied

I was helped

I was really supported

I was not sent from pillar to post

I feel I was taken seriously

I had expected that it would be much worse

so I’m happy with how it turned out

(Tracie, 21 yrs, surgical abortion at 7 weeks)

On the other hand, many I-poems were about dissatisfaction with abortion care. Some described unpleasant treatment and/or attitude by health professionals. Participants felt they had to “be pushy” and had to “justify themselves” to get the appointment. This often led to anger.

Unbelievably paternalistic

I remember that the man was very strict

   he really said

   if you do this, then there is no way back

I remember that I

I had there at that moment

   even then the idea that they were persistent

   are you sure

   are you sure

I thought yes otherwise

I would not be here

   you feel treated like a small child

I understand

I am a highly educated woman

   who knows fully well

   what she is doing

I don’t feel like being scolded by a man

   of all people

   whether I know for sure

come on

otherwise I would not be sitting here now

(Aafke, 29 yrs, medication abortion at 9 weeks)

Waiting makes it harder

Once the decision to do the abortion had been made, people wanted it to happen as soon as possible because they felt that the longer it took the harder it would be to go ahead with it. Many described a waiting period between expressing the wish for an abortion and the procedure itself due to the (at that time) mandatory five-day reflection period, abortion clinic schedules, and the obligatory pre-abortion ultrasound.

Waiting

I had to wait

I think that was the most aggravating

I thought the whole time

   no I shouldn’t do it

   I have to do it

   no I shouldn’t do it

what am I doing

(Tracie, 21 yrs, surgical abortion at 7 weeks)

The I-poems expressed feelings of fear and panic. If the pregnancy became more advanced, the person would become more hormonal, feel pregnant and see something on the ultrasound that resembled a baby – something “with arms and legs”. There was a lot of anxiety surrounding the ultrasound that was routine in the abortion clinic. Viewing the pre-abortion ultrasound was not mandatory, yet many chose to look as part of taking responsibility for their acts. Participants expressed seeking reassurance in the ultrasound that the embryo was still very small, resembling “a little circle” or “a little bean”.

A little bean

do you want to see it

I thought yes okay

   because otherwise it feels a bit hypocritical

I was like

   if you do this

   then you just have to take responsibility

   and see what you actually will

   have removed

I did look

I thought oh it’s still very small

   a little bean

some kind of reassurance and I think

I was more looking for a kind of

   it’s okay

   towards myself

(Dannee, 28 yrs, surgical abortion at 8 weeks)

For some, seeing the embryo was emotionally distressing.

Already so big

I at once saw how big

I thought it was very big

I didn’t expect that at all

I also found it a bit anxious

   that moment

if I wanted to see the ultrasound picture

   and then I said

   because I was also acting a little tough

   yes I will just do this

if I wanted to see that ultrasound thing

   then I said

   yes maybe I do want to

   then I saw it

I was completely upset

   because it was already so big

(Geertje, 27 yrs, surgical abortion at 8 weeks)

Not knowing what to expect

Bodily functions

Many I-poems showed that the abortion-seekers had not really known what to expect of their bodies. Some told of the surprise of being proud of their pregnant body and happy that they could become pregnant. Several I-poems describe the pain and blood loss as worse than expected, some underestimated the impact of losing an embryo or how long it took to recover.

Underestimated

I had expected less

   that it would hurt less

I was

I hadn’t expected

   that the actual embryo itself

   would come out

quite painful I must honestly say

   that I would get some cramps

   but it was a really stiff cramp

   which took a really long time

I had just

I had just underestimated it a bit

I thought it would come out in pieces

I wouldn’t actually recognize it

   with blood and clots

I had just never seen this before

I then also took a picture of it

   so that I could look at it later

   I hadn’t expected that

(Adrienne, 22 yrs, medication abortion at 5 weeks)

The procedure

Many I-poems showed that the abortion-seekers had not really known what to expect of the abortion procedure itself. Several spoke of not having sufficient information, sometimes due to the difficulty of finding trustworthy information on the internet. Participants did not always anticipate choices presented to them in the clinic, for example concerning medical vs. surgical abortion and the possibility of anaesthesia, nor the clinical atmosphere in the abortion clinic. Some people were overwhelmed by the sadness they felt after the procedure.

The chair

I had a first conversation with the doctor

I found that a rather bad experience

I had the ultrasound

   and there was also a very nasty chair

   the position that I really found a bit unpleasant

I was given a choice

I myself also wanted

I think it took five to ten minutes

   the conversation

I talked

   clear that I came for something

   and that’s what would happen

but it was also just the atmosphere    of the room

   and that I thought

   ohh this is real

I kind of got the feeling

   I don’t know if I want this

   I thought at that moment

I had to go sit in a chair

   that really had those kind of stirrups

   and it was also aimed at the door

I felt myself a bit

   because of that I felt a bit like

   assembly line work

and of course, I understand

   because it is an abortion clinic

(Adrienne, 22 yrs, medication abortion at 5 weeks)

Autonomous choice is a difficult process

The overarching theme in this study is the difficulty of autonomous choice. The choice for abortion was the abortion-seeker’s alone and they often had made up their mind quite quickly. But then, external factors such as the partner’s/family’s wishes, stigma, health system restraints, legal factors, missing information, and necessary support intruded on their decision-making process and complicated it.

Deciding about my body

I felt very much under pressure

I asked my aunt to support me

   and do the talking for me

I had a mother who was determining

   you’re not going to keep it

   not in my house

[my mother-in-law] started texting me

   I was a murderer

   I would go to hell

   I would get uterine cancer

I felt that she was going to convince him

   at first he had no problem with it at all

   that I wanted an abortion

   I did feel that he started to change his mind

I felt there were three women who were

   deciding about my body

   didn’t listen to what I really wanted

I don’t regret it at all

   afterwards I didn’t have any regret

   that I had it removed

   I didn’t want to be pregnant

   I didn’t want a child either

   not what I wanted for myself

but what I found very difficult is that

  so much was determined

        around me

  what I should and shouldn’t do

(Roxane, 20 yrs, surgical abortion at 8 weeks)

Once abortion-seekers had made the choice for an abortion, their autonomy was curtailed by the fact that they were often not allowed to have the abortion as soon as they wanted it.

Before I was really pregnant

I was late

   then I’ll call right away

   because I also know about myself

   when I would be pregnant longer

   then I have hormones

I can no longer think rationally and clearly

   for everyone

I just wanted it as soon as possible

   before I was really pregnant

I had the test on Friday night

I called Monday morning

   how long I thought I was pregnant

I thought

   Tuesday next week

   then I have to wait a long time

I would then clearly have an embryo

I really hated it

   now I have to walk around

   with this for a week

(Nora, a mother, 35 yrs, surgical abortion at 6 weeks)

Because abortion-seekers often did not know what to expect of their bodies, the abortion clinic, or the abortion procedure itself, an autonomous informed choice was made difficult. In contrast, there was one abortion seeker who did not experience autonomy as difficult.

No one else

I was unbelievably happy

I was only just living in Amsterdam

I really could begin my own life

I wasn’t going to give that up

   that’s why I felt especially autonomous

   as the choice was mine

I made it and no one else

(Nadine, 19 yrs, medication abortion at 6 weeks)

Discussion

This study has compared a previous thematic analysis of interviews with people who had had an abortion in the Netherlands with a secondary analysis of the same interviews using the I-poem method. The I-poems revealed that abortion-seekers found the decision-making process complicated due to doubts about their decision, influence of their partner, feeling shame in talking to friends and family and lacking support. The participants were often slowed by obstacles in policy and care, having to wait due to clinic schedules and legal regulations. Waiting made it harder for the participants and often led to feelings of fear and panic. Abortion-seekers often did not know what to expect from their body or from the abortion procedure itself. This made the autonomous choice difficult for them. Although the themes found in the present study are quite similar to those found in the earlier grounded theory analysis of the same interview transcripts by Holten et al,⁷ there are a few striking differences: The I-poems reveal the important role of the partner in the doubt that people experienced when choosing an abortion, the apprehension and anxiety surrounding the ultrasound when wanting an abortion as soon as possible, and not knowing what to expect of one’s body or the procedure.

The partner can complicate decision-making

Studies on partner involvement in abortion often focus on the presence, participation, and support of the partner in the medical facility, before, during, and after the procedure, and how this is positively associated with the abortion seeker’s wellbeing.^19,20 Often, these studies focus on partner involvement after the decision for abortion has been made. The current study adds information to the literature on the role of partners in people’s decision-making process before accessing abortion care.

A study by Chibber et al²¹ showed that in a sample of 954 abortion seekers, a third reported their partner as the reason for their abortion. The reasons cited most often were no or unstable relationship, partner unable or unwilling to support a child, and undesirable partner characteristics. Similarly, the participants in this study spoke about doubting the suitability of their impregnator as a future partner and that this influenced their decision to terminate the pregnancy.

In the current study, several abortion-seekers spoke of feeling unsupported by their partner, one participant spoke of being in an abusive relationship. Research on intimate partner violence (IPV) and abortion has shown that the perpetration of IPV is associated with men’s attempts to control abortion-related decisions by female partners.²² However, the present study shows that any kind of relationship can make the process of autonomous choice difficult. Also in non-abusive relationships, partners may exert pressure due to their own preference for or against the abortion. In this study, several I-poems expressed partner discordance. Where lack of autonomy due to partner pressure has been found to make the decision for abortion more difficult,⁴ the present study shows that being autonomous does not necessarily make the decision less difficult. Even if abortion seekers experience autonomy, the decision can be difficult because it is often not an individual choice - the choice affects the relationship with the partner, children, and family.

Anxiety surrounding routine ultrasound

Similar to the findings of the first interview analysis,⁷ the current study shows that the mandatory waiting time made it harder for the participants and often led to feelings of fear and panic. In 2022, the Dutch parliament voted to abolish the mandatory five-day reflection period for abortion-seekers, thereby increasing accessibility of abortion care in the Netherlands. However, abortion-seekers often have to wait until the embryo is visible on an ultrasound before they are eligible for an abortion. In the Netherlands, a routine pre-abortion ultrasound scan is done to confirm an intact intrauterine pregnancy and verify gestational age. Dutch abortion guidelines recommend that the patient should be informed in advance of the possibility of viewing the ultrasound, with the care provider explaining what is likely to be seen so that an informed choice can be made.²³ Research on the experience of viewing a pre-abortion ultrasound has shown that ultrasound viewing does not have a singular effect. On the one hand, ultrasound viewing can lead to emotional discomfort and can dissuade people from aborting.^24,25 On the other hand, ultrasound viewing can be experienced positively in that it can help to clarify the abortion seeker’s choice and can help to cope better with the choice of having an abortion.^26,27 The finding of emotional discomfort is consistent with the present study, which shows that abortion-seekers can experience anxiety and emotional difficulties in viewing of the ultrasound. Yet some participants wanted to see the ultrasound so as to “take responsibility” for their choice and/or to find reassurance that the fetal development was still in a very early stage, making abortion feel less reprehensible and more justifiable.

This fits in Beynon-Jones’ distinction of various “repertoires” used when speaking about pre-abortion ultrasound viewing from the perspective of the abortion-seeker. In the normative repertoire, ultrasound is a tool of maternal-fetal bonding. The personification of the fetus inherent in this discourse makes the ultrasound morally and emotionally laden and can be upsetting for the abortion-seeker. In the current study, abortion seekers spoke of not being a “hypocrite” and “taking responsibility” and feeling the obligation to see what they later would have removed. In this way, according to Beynon-Jones, the ultrasound can also represent “a means of articulating the loss, or ending, of a relationship – rather than signifying its beginning (p.711)”.²⁸ The other repertoire is one of medical objectification in which ultrasound can be seen as a tool of fetal de-personification. Herein the ultrasound is used as a medical assessment that helps to facilitate the ending of pregnancy and as evidence that the embryo is developmentally and morally insignificant. The participants in this study spoke of the relief of seeing only “a little circle” or a “little bean”. Being aware of which repertoire abortion seekers use could help reduce anxiety by meeting individual needs concerning pre-abortion ultrasound.

The difficulty in achieving informed choice

An autonomous choice is an informed choice; it is difficult to make the right choice if one does not know what choices there are and what to expect. Research has shown that many abortion-seekers are misinformed and uninformed, and that this hinders informed choice.²⁸ Widespread abortion misinformation, particularly on the Internet, makes it likely that people considering abortion will encounter inaccurate information about the physical and psychological risks and consequences of abortion including inaccurate associations between abortion and breast cancer, infertility, and negative mental health outcomes. In the earlier study by Holten et al⁷ in addition to inaccurate information, it was found that there is also a general lack of knowledge about abortion procedures and the abortion care system, knowledge that is necessary to make an informed choice in the Netherlands. Furthermore, silence is also an important means for abortion-seekers to cope with stigma and abortion stigma may cause people to feel less empowered to ask questions about abortion procedures and their health consequences.³⁰

Abortion misinformation, lack of information, and silence due to stigma can explain why participants in the current study did not know what to expect of their bodies and of the abortion procedure. But even if people considering abortion have accurate information and do feel empowered, they still may not know what to expect. Abortion clinics in the Netherlands are separate from the regular healthcare system, and although the clinic receptionists and clinic websites give information on the procedure, the day-to-day work in the abortion clinic is unknown territory for most. Even though there now is an advocacy organisation for abortion (AVA) in the Netherlands, most people keep silent and seldom share stories and images of actual abortion procedures. Abortion has been a perennial subject for filmmakers around the world. Although recently several US and European movies on abortion have been released (Never, Rarely, Sometimes, Always 2020 and L’Événement 2021, for example), it is still not common to see images of people doing abortion. Hearing more stories and seeing more images of abortion in the media could help to de-stigmatise abortion and better prepare people who seek an abortion.

Autonomy and the social construction of choice

Studies have shown that circumstance is often the primary reason people decide to have an abortion; it is not only that they do not want a child, people often wait for the circumstances to be right before having children. Socially determined factors, such as financial and relationship stability, cultural expectations, and legal restrictions often play a role.^31,32,33 Although autonomy and choice are recognised as an important aspect of reproductive rights, focusing on autonomous choice often individualises the concept of choice, while the concept of choice can be expanded by looking at the determinants of health that intersect with people’s circumstances.³³ The I-poems in the current study show the social construction of autonomous choice as they portray how politics (e.g. the mandatory waiting period), health care policies (e.g. routine ultrasound), and social realities (e.g. relationship stability and abortion stigma) are played out in abortion- seekers’ bodies.

Strengths

By using a multi-disciplinary approach (researchers have backgrounds in medical anthropology, health sciences, and poetry), and by using multiple data analysis methods on the interview transcripts (thematic and I-poem), we endeavoured to escape our own analytic biases.⁸ Triangulation of the multiple methods of analysis showed similar results, thereby heightening the validity of the study. Where thematic analysis fragments interview transcripts, losing the stories of individual people in the process, in I-poems, the individual abortion seeker is clearly present. The emotion with which the participants spoke emanates from the I-poems and emphasises the importance of acknowledging these experiences.

I-poems highlighted participant’s stream of consciousness, how they understand and spoke about themselves. The thematic analysis focused on occurring and recurring topics. Each method placed the researcher in relation to the participant in a distinct way. Edwards & Weller⁸ speak of “standing alongside” for I-poems and “gazing at” with thematic analysis. “Standing alongside”, which fits a feminist epistemology, was perhaps easier for LH because she had conducted the interviews and had seen the participants. On the other hand, RvdW had experience with abortion and could relate to the participant’s stories.

A member check also aided rigour of this study. The I-poems were shared by email with the participants, who gave positive feedback and confirmed their support of the researcher’s presentation of their words and adding a title. A few participants became emotional when reading the poems. One participant articulated the added value of the I-poem method:

“I definitely recognize myself in it yes. Another layer comes to the surface this way, one which you’re not aware of when you’re telling [the story] … Interesting that it works that way. A bit confrontational indeed, but also beautiful.” (Dannee, 28 yrs, surgical abortion at 8 weeks)

Another strength of this research is that the findings of the study, the I-poems, have been disseminated in- and outside academia in several ways: as spoken word during a feminist festival, as text in a gallery exposition during International Women’s Day, as a video entered into a multi-modal competition organised by the Dutch organisation of feminist anthropologists (it won second prize) and recited by an abortion activist on national radio. We continue to search for opportunities to disseminate the I-poems further. Hereby the I-poems reach many people and can help to counteract stereotypes and contribute to reducing abortion stigma.

Limitations

One limitation of this study lies in the subjectivity of the I-poems. The idea is that “I” statements are a pure “voice” and that this “voice” gives access to a participant’s inner world, that I-poems capture the “voices” of women.^12,14 However, we believe that for it to be truly the “voice” of the participants, the participants themselves would have had to create the poems, as the choice of fragments used in the poems determines the voice. Their voice was our choice, so to speak. Edwards & Weller⁸ posit that the use of “I” is only one form of speech and that taking account of people’s various speech patterns to produce you-poems or me-poems, or even we-poems, could also shed light on senses of self. In this study, only “I” statements were used, and only those we were able to string together to form a poem. This means that the majority of a transcript was found unsuitable for creating an I-poem. During the interviews, participants often talked about themselves in the second person, yet this was not included in the analysis for the I-poems, thereby possibly missing critical data. Furthermore, with regards to ethnicity/nationality, residence, religion, age, parity, prior abortions, percentage of medication abortions, and where the abortion took place, our sample compares reasonably well to the average abortion seeker in the Netherlands.³⁴ Although our sample included a relatively high proportion of participants born abroad or whose parents were born abroad, it did not include abortion-seekers coming from other countries where abortion is illegal, nor people seeking an abortion later than 12 weeks, thereby missing their stories. Although we actively sought and found participants from marginalised groups, most participants were highly educated people seeking abortion for the first time. Interviews with the most articulate participants resulted in transcripts that were the most useful for creating I-poems. The transcripts from interviews with participants for whom Dutch was not their first language often generated fewer I-poems. Although the I-poems were translated as literally as possible from Dutch to English, the choice of words was influenced by the research team’s proficiency, experience, and aesthetic, adding an extra layer of subjectivity.

Another limitation of this study is that new insights may be due to a wider focus rather than a new methodology. The new insights gained by this study are mostly due to the new I-poem method of analysis, but in part can also be ascribed to the fact that in the previous analysis by Holten et al⁷ the focus was on accessibility of abortion care. In the current study, there was room to analyse what the participants wanted to tell, not only what answered the research question. Markedly, in the current study, the participants seemed to want to tell the researcher about their decision-making process although the interview questions had not focused on this aspect. Perhaps the participants felt a need to justify their choice for abortion by explaining the process. Furthermore, the earlier study by Holten et al⁷ also analysed emails from abortion-seekers from vulnerable groups such as newly arrived migrants, while the current study analysed only the 20 interviews of abortion-seekers with an on-average higher socio-economic status. Despite these differences, the themes found in both studies were similar. The thematic and I-poem analysis methodologies both provide a valuable angle of understanding and interpreting an abortion experience.

Conclusions

The findings of this study give important insight into individual experiences with abortion decision-making and abortion care that we can all learn from. These new insights show that even in steady relationships and families, and in feeling autonomous, the decision-making process can be challenging since an autonomous choice for abortion is not a solely individual choice, it is a socially constructed choice that will affect others. Partner discordance and having to navigate obstacles in policy and care, such as having to wait for a desired abortion, made the decision-making process more difficult. The pre-abortion ultrasound was found to be an important moment in this process, one that requires more attention. Lastly, people who seek abortion often do not know what to expect, revealing that (normalisation of) information provision on all that is involved in choosing for abortion is necessary. Although an autonomous choice in abortion is an important aspect of reproductive rights, the concept of choice should be expanded by looking at the social construction of choice - at how political and health care policies and social realities are played out in abortion seeker’s bodies.

Implications for practice and research

Abortion providers should continue to pay special attention to the external factors which complicate people’s choice for abortion such as abortion care policy (e.g. clinic schedules and routine ultrasound), and social factors such as partner discordance (also in stable relationships).

Asking people what they want with respect to ultrasound information appears warranted. Health professionals should cultivate the sensitivity, involvement, and communication skills necessary to inform abortion-seekers of the effect that viewing an ultrasound can have, and to become aware of which repertoire abortion-seekers use concerning their pre-abortion ultrasound – a repertoire of personification or of de-personification of the fetus. This could help reduce anxiety by meeting the individual person’s needs.

Knowledge of abortion should become common knowledge so that people and their partners already have an idea of what an abortion entails before an unplanned pregnancy occurs. This could be achieved for example by paying more attention to abortion in sex education classes in schools, providing more images of abortion in the media, and videos of procedures inside the abortion clinic on clinic websites. Disseminating the I-poems, during cultural events and through the media, can help create more attention for, and awareness around, the subject of abortion experiences.

Further research on people’s experiences of routine pre-abortion ultrasound in the Netherlands is needed as findings suggest that pre-abortion ultrasounds are negatively impacting some people’s abortion experiences by increasing emotional discomfort.

Author contributions

Lianne Holten: Conceptualisation, data curation, formal analysis, investigation, methodology, project administration, supervision, visualisation, and writing – original draft. Rosalie van der Wolf: conceptualization, formal analysis, methodology, visualisation, writing-review, and editing. Marit van der Pijl: Validation, writing-review, and editing.

Acknowledgements

We would like to thank our study participants for sharing their stories with us and Julia Challinor for her precise and rapid editing.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Due to the nature of this research, participants of this study did not agree for their transcripts of the interviews to be shared publicly, therefore supporting data are not available.

Notes

* We use “doing abortion” because this emphasises people’s agency and is less passive than “having” or “undergoing” an abortion.

† All participant names are pseudonyms.