The experience of abortion for Cook Islands women: exploring the socio-cultural dimensions of abortion safety

Abstract

Abortion is significantly restricted by law in most Pacific Island countries, impacting the rights, health and autonomy of people who experience pregnancy. We undertook qualitative research between February and August 2022 on Rarotonga, Cook Islands, where abortion is illegal under most circumstances. We conducted interviews with women who had accessed or tried to access abortion services; people who had supported women to access abortion services; health workers; and advocates to understand their experiences regarding abortion. We conducted focus groups to explore broader social perceptions and experiences of sexual and reproductive health and rights, including abortion. Participants described their abortion decisions and methods, and their negotiation of the personal context of their sexual behaviours, pregnancies, and abortions relative to their socio-cultural context and values. As defined by the World Health Organization, safe abortion relates to the methods and equipment used and the skills of the abortion provider. We argue for an expansion of this definition to consider inclusion of reference to individuals’ ‘abortion safety nets’ as the sum of their access to financial, political, health care and socio-cultural resources. These safety nets are shaped by discourses related to abortion and socio-cultural support and values, impacting physical, emotional, psychological, social and spiritual health.

Keywords:

• Illegal abortion
• Pacific islands
• Cook Islands
• abortion stigma
• safe abortion
• ‘akama

Introduction

Abortion is a necessary and important feature of reproductive health care for a variety of health, socioeconomic, safety, and other reasons for those who are capable of pregnancy (WHO 2022). Abortion can be safely performed according to the methods and standards recommended by the World Health Organization. These include medical abortion safely administered outside a health facility by individuals with accurate information and quality-assured medicines (WHO 2022).

Despite this, legal and other practical restrictions such as poor service availability and high cost, render abortion difficult to safely access, particularly for those with limited resources, information, and supportive contacts (WHO 2019). In these contexts, those requiring abortion services may resort to unsafe abortion, where a pregnancy is terminated by an unskilled provider, using dangerous, invasive methods, and/or in an environment that does not conform to minimum medical standards, contributing to death and injury particularly among the most marginalised women (WHO 2019). Additionally, Mavuso, Macleod and du Toit (2022) argue for abortion un/safety to be considered on a continuum that includes psychological and emotional harm caused by directive anti-abortion counselling. Such “counselling” draws on broader anti-abortion discourse of abortion as a threat and dangerous practice to cis-gender women; foetal personhood paired with the essentialising of motherhood for cis-gender women; and religious discourse which constructs abortion as immoral (Mavuso, Macleod and du Toit 2022).

Many Pacific Island women navigate their sexual and reproductive lives in the context of sexuality stigma; high rates of gender-based violence and reproductive control; difficulty accessing safe, comprehensive, and confidential sexual and reproductive health services; and significant legal restrictions on abortion (Baigry et al. 2023; Center for Reproductive Rights 2022; Te Marae Ora Cook Islands Ministry of Health 2014). There exists very little research on how Pacific Island women navigate abortion access in the context of these constraints (Dawson et al. 2021). Existing qualitative studies from Pacific Island countries suggest women often undertake unsafe means to end unwanted pregnancies (Vallely et al. 2015; Drysdale 2015; Linhart et al. 2020; McMillan et al. 2020; Burry et al. 2022).

The socio-cultural and political context of abortion

Safe abortion protects women from unwanted, unsafe or non-viable pregnancy, resolving (and not creating) their immediate health concern (Millar 2020, 4). However, women may have to navigate abortion access and their physical and emotional safety in contexts where abortion seekers are generally constructed as debased or as otherwise ‘inferior to the ideals of womanhood’ (Kumar, Hessini, and Mitchell 2009, 628) compared to women who are mothers or who are sexually abstinent. However, individuals are impacted differentially by these social constructions based on how they are positioned against normative, idealised woman/motherhood, which includes judgements about their sexual and contraceptive behaviour, relationships and pregnancies (Kumar 2013; Millar 2020; Ross and Solinger 2017; Kimport and Littlejohn 2021).

In the research context of the Cook Islands, a useful concept to consider in relation to the socio-cultural context (and containment) of sexual and reproductive practices is that of ‘akama. ‘Akama may be described as encompassing individuals’ alertness to, fear, anticipation and experience of shame, humiliation, inadequateness and shyness regarding actual or imagined wrongdoing in the eyes of others in the community, including failure to exhibit important socio-cultural values, rules and customs or prioritise the needs of the group over one’s own (McDonald 2001; Sachdev 1990; Makiuti Tongia, (personal communication, 24-25 June, 2023). ‘Akama may also relate to Alexeyeff’s (2000) analysis of Cook Islands personhood as defined by the relationship (and tension) between the personal and social context (and the obligations this latter context entails), with kin relationships as central to self-concepts. The concept and experience of ‘akama also reflects 200 years of socio-cultural adaptation of introduced values and systems of authority, including Christianity, colonial and post-colonial governments and legal systems (Makiuti Tongia, personal communication, 24-25 June, 2023).

Research context

This research was undertaken on the island of Rarotonga in the Cook Islands, an archipelago nation made up of 15 islands in nearly two million square kilometres of ocean. The population of the Cook Islands in 2021 was 15,040, with 10,898 people being located on Rarotonga. The majority (84.4%) report affiliation to a Christian denomination (Cook Islands Statistics Office 2022). Since 1965, the Cook Islands has been in free association with New Zealand, meaning that Cook Islanders are New Zealand citizens and use New Zealand currency, but govern their own islands and have full responsibility for external affairs (Marsters 2016). Accordingly, Cook Islanders may travel to New Zealand for education, jobs and services, including healthcare, although temporary visitors may not qualify for enrolment in the public health system (Marsters 2014, 2016).

Sexual and reproductive health and rights in the Cook Islands

In many Pacific Island countries and territories, there is evidence from early explorer and missionary accounts of abortion being allowed under community-sanctioned circumstances (Cambie and Brewis 1997). However, lengthy missionary and colonial engagement in the region from the early-1800s onwards contributed to the surveillance of, and attempts to shape the social institution of mothering and the criminalisation of abortion under new legal systems (Cambie and Brewis 1997; Jolly 1998, 1991; Dureau 1993). In the Cook Islands, following the introduction of Christianity in 1821, missionaries implemented strict codes of behaviour, particularly in relation to sexual conduct (Jonassen and Tikivanotau 2003; Scott 1991). The enforcement of these codes included fines, hard labour, and sometimes torture for real or suspected sexual transgressions, such as adultery, pre-marital sex and women’s refusal to cohabitate with men selected by the mission (Ama 2003; Scott 1991).

More recent studies on sexual and reproductive health (SRH) and teenage pregnancy in the Cook Islands suggest that most 15- to 24-year-olds have had at least one penetrative sexual experience. However, participants in these studies noted the lack of reliable SRH education and information; barriers to accessing services (such as concerns over privacy); and discomfort with discussing issues related to SRH in the context of general social conservatism regarding this subject matter, particularly related to young women’s sexuality (Eijk 2007; Futter-Puati 2017; White, Mann, and Larkan 2018a, 2018b). Young people in the Cook Islands have also noted concerns related to sexual consent, with 71% of young women in one survey reporting having been pressured into sex (Futter-Puati 2017). One third of ever-partnered Cook Islands women reported having experienced physical and/or sexual violence from an intimate partner in their lifetime (Te Marae Ora Cook Islands Ministry of Health 2014).

Pregnancy has been highlighted as a major risk factor for suicide among younger Cook Islander women in the context of relationship breakdown or pre-marital sex, with young pregnant women facing potential rejection or physical violence from family, being sent away to minimise shame to the family or being made to marry or move in with the father of the baby (Futter-Puati 2017; White, Mann, and Larkan 2018a; Youth Suicide Prevention Steering Committee 2015). This violence may relate to pregnant young women’s transgression of idealised behaviour for Cook Islands young women as virginal, humble, gentle, peaceful-hearted and not overtly or publicly sexual (Alexeyeff 2000). These reports suggest a reality, particularly for younger women, that stands in contrast to the general Cook Islands idealisation of motherhood as essential to notions of womanhood and women’s position within the extended family unit (Futter-Puati 2017; George 2010; White, Mann, and Larkan 2018a).

White, Mann and Larkan’s (2018a) qualitative study of ten young women’s experiences of unplanned pregnancy in the Cook Islands highlights the sensitive nature of abortion in this context. Abortion is a criminal offence under the Cook Islands Crimes Act 1969 except to preserve the life of the woman. It is also a criminal offence to supply the means of procuring an abortion. Accordingly, some of the young women in White, Mann and Larkan’s (2018a) study described seeking abortion services in New Zealand or Australia. However, financial and other restrictions were usually insurmountable for the young women in White, Mann and Larkan’s (2018a) study and some instead tried to unsafely terminate their pregnancies using self-injury methods or herbal abortifacients, which caused pain but were unsuccessful at inducing an abortion. In another study, 3.2% of Cook Islands women reported ever having had an abortion, with higher rates for those who also reported lifetime experience of sexual and/or physical violence from a partner compared to women who did not report partner violence (4.7 per cent versus 2.7%, respectively) (Te Marae 2014).

The present study is one of the few studies from the Pacific Island region  to specifically explore, in-depth, the subject of abortion, including from the perspectives of those with lived experience (Dawson et al. 2021). In this paper, we analyse women’s navigation of the socio-cultural dimensions of their sexualities, pregnancies and abortions in the Cook Islands (Millar 2020; Kumar, Hessini, and Mitchell 2009; Kimport and Littlejohn 2021). We draw on recent theorising of abortion stigma and safety, and personal communication and the scarce literature regarding the concept of ‘akama to argue for a broader conceptualisation of abortion safety that encompasses people’s socio-cultural contexts (Mavuso et al. 2022; Millar 2020; Kumar, Hessini, and Mitchell 2009; Makiuti Tongia, (pers. comm., June 24 & 25, 2023).

Methods

This research was conducted on Rarotonga, Cook Islands, between late February and early August 2022 in partnership with the Cook Islands Family Welfare Association, which has a trusted position in the community for providing confidential SRH services, education and advocacy. This research received ethical approval from the UNSW Sydney Human Research Ethics Committee (HC 210407), the Cook Islands Research Committee and the Cook Islands Foundation for National Research (Reference: 12-21).

The first author conducted in-depth semi-structured interviews with four different groups: participants who had accessed or tried to access abortion services at least once; participants who had supported others to access abortion services; healthcare workers; and advocates working in SRH. The first author also conducted focus groups to gain broader contextual information about SRH awareness and education; women’s (including younger women’s) experiences with pregnancy, abortion and mothering; and awareness and socio-cultural perceptions of abortion. All participants provided informed consent and had time with the interviewer afterwards to debrief on the interview experience, discuss any distress experienced and options for further support. A professional counsellor was available at the Cook Islands Family Welfare Association (CIFWA) for participants to speak to if desired.

Interviews and focus groups were conducted by the first author, a (cis)woman New Zealander descended from the Anglo/European settler population. Given her position as a cultural outsider, she worked hard to remain sensitive to power dynamics, meanings and interpretations and prioritised forming trusting, kind and respectful relationships with local organisations, interviewees and focus group participants (Farrelly and Nabobo-Baba 2014). All interviews and focus group discussions were conducted in a private room at CIFWA. Interviews with advocates and health workers were conducted at CIFWA, at the interviewee’s place of work or through video conferencing for those not based on Rarotonga during the research period.

Interviews were transcribed verbatim and analysed thematically; that is, interview transcripts were read multiple times and codes were developed based on recurrent themes (Braun and Clarke 2006). Inductive coding of the interviews and focus groups comprised the identification and development of descriptive (e.g. ‘Decision to terminate’, ‘Logistics’) and conceptual (e.g. ‘Stigma’, ‘Concept of choice’) codes, that were further developed into overarching themes, including the socio-cultural dimensions of abortion safety discussed in this article (Terry et al. 2017; Braun and Clarke 2006). NVivo version 12 (QSR International Pty Ltd. 2018) was used for data management. Apart from abortion emerging as a theme in White, Mann and Larkan’s (2018a) study on adolescent unplanned pregnancy in the Cook Islands, this is the first study to focus on Cook Islands women’s experiences of abortion or attempts at accessing abortion. Accordingly, it is important that the data form the basis for analysis and the development of concepts (Braun and Clarke 2006; Terry et al. 2017).

All identifying information has been removed from the informant quotations used in this article. The women who participated in this study are identified by their participant number (e.g. P1, P2, etc.) along with their age range as opposed to their actual age to minimise chance of identification. Advocates, health workers and support people are identified by the initials A, HW, and SP, respectively, and interview number (e.g. SP1). Focus group discussions are identified by the focus group number and the age range of participants (e.g. FG1, 27-36 years).

Results

In-depth semi-structured interviews were conducted with 12 women who had accessed or tried to access abortion services at least once, including one woman who was in the Cook Islands on a temporary work visa; four people who had supported others to access abortion services; three health workers (two Cook Islands-based and one New Zealand-based); and six advocates working in sexual and reproductive health and rights. Three focus group discussions were also conducted with Cook Islands women aged 19-22 years (n = 3), 27-36 years (n = 4) and 50+ years (n = 2) who were recruited by CIFWA.

An overview of research findings

The women interviewed in this study were between the ages of 18 to their early 70s. Some participants were reflecting on experiences that had occurred only weeks or months prior, while some were recalling experiences from 30-50 years ago. One woman was pregnant during the interview after her efforts to terminate her pregnancy were unsuccessful, although she described a previous successful abortion in Australia. One was a migrant worker. The Cook Islands abortion legislation has not changed during this period. However, New Zealand first liberalised its abortion legislation in 1977 to allow abortion where the woman’s life, physical or mental health was judged to be at risk by two certifying medical consultants. In 2020, New Zealand decriminalised abortion prior to 20 weeks’ gestation.

Research participants described the following paths that women take to end their pregnancies: accessing abortions overseas, including specifically travelling to New Zealand or (less often) to Australia for an abortion (including one participant who had to travel from New Zealand to Australia for an abortion before the 1977 law change in the former country), although this was not an option for the migrant woman in this study; ordering medications online from overseas to induce abortion and self-administering them alone or with the support of friends; or undertaking alternative, unsafe methods, including excessive intake of strong alcohol or visiting a ta’unga (priest or master of a craft) who provides traditional abortifacients, prayer, uterine massage and instruction on behavioural restrictions such as sexual abstinence and fasting. One participant described her experience of successfully inducing an abortion by drinking excessively strong coffee (half a tin of dried coffee topped up with hot water and drunk daily until bleeding began).

Participants described grappling with circumstances that meant that continuing their pregnancy and giving birth would have caused hardship, distress and significant disruption to their lives. Participants described their decision to have an abortion as related to their young age; complex and unstable or non-existent relationship with the sexual partner; fear of backlash and judgement from their family and community (including church community); financial position; being a single mother already; a wish to continue with education; and concern over the impact of a pregnancy and motherhood on their life, job, income and career goals and progression. The reasons participants gave for needing an abortion did not vary significantly based on the different age groups in this study.

Several participants reported that contraceptive failure had led to their pregnancy, while others described dishonesty from sexual partners about condom use or their failure to withdraw. Others did not know about or feel confident and comfortable accessing contraceptive services. This limited awareness of SRH was highlighted in focus group discussions, with added barriers of SRH topics being considered taboo or subject matter that generally causes shame and embarrassment amongst young people, parents and in the wider community. Additionally, many participants reflected on their concerns over privacy and confidentiality when accessing services given the small and tight-knit community. Young women’s sexuality was discussed by most participants, including in focus groups, as something that many families tightly control due to the shame associated with overt displays of sexuality and/or teenage pregnancy, including preventing young women from going out with the threat of a ‘hiding’ (physical abuse).

Navigating the socio-cultural context(s) of abortion

Participants often described abortion as a topic that was not openly discussed and related this to the concept of sin: namely, that ‘it’s a sin but it’s such a huge sin that it’s not even really spoken of.’ (A3). Several women reflected on the idea of abortion as sinful when they spoke about their abortions. For these women, God featured as a figure from whom forgiveness could be sought and/or who could distribute punishment for their ‘sin’.

Like, ‘cause I’ve been praying every night, you know. But yeah. I haven’t forgiven myself yet. (P5, 25-34 years)

Participants’ accounts of their abortions as sinful and not yet forgiven were also sometimes discussed in the context of subsequent negative experiences following their abortions, such as experiencing a miscarriage or relationship breakdown.

The nature and experience of shame that some participants described also appeared to be shaped by their socio-cultural context and compounded by the social stigma attached to women’s expressions of sexuality, for example, outside of marriage and at a younger age. One theme across the interviews and focus groups was that an individual’s behaviour was not so much a reflection of their own (poor) character, but a reflection of their upbringing and (lack of) guidance and teaching by their family. As one focus group participant described it, recalling her upbringing and the treatment of peers who had become pregnant: ‘Family reputation was more important than the person who was suffering.’ (FG1, 27-36 years).

This, combined with the small, inter-connected communities and families on Rarotonga, meant that the prospect and experience of shame was overwhelming for some. One support person who had supported two women through their abortions, described the context of shame for Cook Islands women:

Our girls are trained and conditioned to put family first. Always put family first. Put church first. Put the village first. Put other people first. So, putting yourself first is almost a betrayal to your cultural values and belief. […] And then like a Cook Island expression that is constantly, we constantly use: ‘I mua ake ite mata tangata’ which means how the people … it’s very much if you do something wrong your family raised you wrong. It’s never your fault. It’s, “Oh, this is what your family has taught you to do.” So, it is never just me. It is my family, my community. […] So, for a single woman making that decision to have the abortion is, mm … (SP3)

A4 also reflected on kinship structures in the Cook Islands as broad and non-nuclear; children are not just the birth parents’ children but are shared by the extended family, which means negative outcomes are also shared in this context. Similarly, SP2 and A5, both of whom had daughters become pregnant as young teenagers, reflected on their experience or expectation of shame or chastisement from others, even those from whom they sought support.

I had some negative comments about her getting pregnant. You know, they do turn around and look at the family and the mum in particular, eh? One lady said, “Oh, I’m so disappointed that this happened to you.” (A5)

Navigating shame in decision-making on abortion

Participants described their own or others’ transgressions of gender ideals by being sexually active and becoming pregnant under the age of 21 (the age of adulthood in the Cook Islands), outside of marriage and with men who were deemed unacceptable by the family (as was the case for most women in this study). Several participants noted that, as the sense of shame arising from these pregnancies was shared by family in this setting, decisions regarding teenage pregnancies were sometimes made by parents instead of the young woman who experienced the pregnancy, to control their collective exposure to the shame.

Some families with teenage pregnancies and because of the embarrassment and stigma they would just fly the, the teenager down to New Zealand [to have an abortion], if you’ve got the money. (FG3, 50+ years)

Several participants described considering and protecting others (usually their family and sexual partner), as well as themselves, by having an abortion, reflecting the socio-cultural and gendered conceptualisation of shame discussed above. P3 (25-34 years) reported differing relationships to shame regarding her sexuality and family expectations, and gender norms related to her decision to have an abortion. P3 said that she did not want to ‘create a bad name’ for herself and her family by having a child from a one-night-stand, yet also described resisting an expectation that she, as the eldest of her siblings, would have the first grandchild for her parents as this was not what she wanted. P1’s (35-44 years) recounting of her decision to have an abortion was similarly complex. She described her conservative religious background, becoming pregnant as a single mother after contraceptive failure and facing financial and emotional hardship. She described making an immediate decision that she could not continue with the pregnancy and she selectively disclosed her situation to trusted friends who were supportive of her decision. However, P1’s recounting of her decision to have an abortion fluctuated between the clarity and importance of her decision and the conflict brought about by contravening socio-cultural gender norms in prioritising her own needs. Perhaps to address this conflict, she described others’ failures to prevent the abortion and highlighted the (passive) role of her sexual partner in the abortion decision, thereby de-emphasising her personal needs.

Like I had everybody say, “We’ll be there for you. Like whatever you want, that’s what we’re gonna do,” but I had nobody to tell me, “Shit. Don’t do it! Like just, just don’t get the abortion. Just go on with it [the pregnancy].” But I had nobody there for it [the pregnancy]. And then like … And I had said that to him [the sexual partner] and he was like, “No, but this is about you,” and I was like, “But really it was about you too. Like it’s about you too. I’m thinking of you. I’m not thinking of me. I’m thinking about the consequences that’s gonna happen to you. Like what’s your family gonna say […]?” (P1, 35-44 years)

Many participants, including P3 (25-34 years) and P1 (35-44 years), described experiencing relief once the abortion began or was complete, but this was often complicated by their relationship to broader socio-cultural values of selflessness and abortion as sinful. P5 (25-34 years) reported that she used to be ‘100 per cent against abortion ‘cause I was pretty much raised like that’, but the circumstances of her pregnancy and her relationship with her sexual partner were such that ‘to be honest, a decision for me to do an abortion didn’t take long for me. I was just like, “No. I can’t keep it.”’ When describing her medical abortion, she noted experiencing relief, however some tension also seemed to arise:

So, you know, when we did the scan and it was all clear, and I was just … a weight lifted off my shoulders, to be honest. Yeah. I was like, “Oh, God …” I was, I still think about like I shouldn’t have but I needed to, you know. It comes in my mind nearly every day. Yeah. “Did I do the right thing?” Or … yeah. I question myself all the time, yeah. (P5, 25-34 years)

Some participants described being shamed or humiliated by their partners. P7 (45-54 years), P11 (18-24 years), and P12 (35-44 years) reported that their partners had used their abortion or abortion attempt as a threat or a form of humiliation, sometimes as part of a broader pattern of abuse.

When we have issues, he would, you know, he would say things like to me, you know, “One day, I will tell our son that you tried to get rid of him.” (P7, 45-54 years)

Social support and self-assurance

Participants discussed the socio-cultural concept of abortion as sinful, which they managed and resisted in various ways. SP2 described accessing an abortion overseas as a practical shame-management strategy because there ‘won’t be stigmas and there won’t be, you know, marked in the, on the island for future.’

Despite a general recognition by participants of socio-cultural perceptions of abortion as sinful, selective disclosure provided participants with the opportunity to receive social support in this context, alongside information and logistical support. Disclosure to those individuals who were perceived as safe and supportive was especially important given participants noted that women who do interact with the public health system regarding their pregnancies are either not given information about how to access abortions or receive judgement or chastisement for raising the topic. Support people researched and assisted with the processes of ordering medications, arranging appointments abroad, providing transportation, and accompanying women to and from the clinic.

So, a lot of the research [on how to access an abortion] I did myself […] I checked on-line for open clinics in New Zealand who could do that. I sought out counsellors who would be able to help her [SP3’s friend] and give her an assessment. (SP3)

Although some participants reflected on the complexity of their relationship to socio-cultural values in context of their abortion experience, others resisted the notion of abortion as shameful. These participants challenged the assumption that abortion causes shame for women even in contexts where abortion is generally understood to be a sin and is criminalised. These participants said that as pregnancy and motherhood affected their lives, decisions should only be made by themselves:

It was my decision. Yeah. Well, it was not affecting him [her sexual partner], you know. I mean it was affecting me mostly, you know. […] It’s not gonna be him. I worried about with my training, my work, my job, you know? Am I gonna be able to … But I can’t really rely on him to do everything, you know, to help me. (P10, 55+ years)

Furthermore, when P10 (55+ years) discussed her awareness of abortion being considered sinful in her church, she differentiated between her relationship with God and her relationship with the church as an institution. P8 (55+ years) described dismissing anti-abortion protestors whom she encountered because it was her who would have to take care of another child and so the decision had ‘nothing to do with them [the protestors].’

Additionally, support people and women who had sought abortions in this study reflected on the social, spiritual and emotional support they provided or received, including open and non-coercive responses to their own or their friend’s situation and abortion.

They [P2’s parents, siblings, cousin and close friends] were really supportive. […] They’ll always be here and, and they will always message me every day about how I’m feeling, and after the surgery they would keep messaging me and sending me love, and prayers too. And I would cry sometimes just reading their messages ‘cause I know they will always be here for me. When I came back, they were just not talking about it but just asking me if I was okay and things like that. Buying me just little gifts and … yeah. (P2, 18-24 years)

Finally, participants’ relationships to their socio-cultural context regarding their abortion experience was not only one of silence, isolation and shame. Some participants also described the importance of feeling connected to their cultural identity during and after their abortion. For example, after her abortion in Australia, P4 (55+ years) said that she bought and prepared taro and surrounded herself with cultural symbols to bring a sense of warmth, comfort and healing. This included pinning Cook Islands woven hats and a map of the Cook Islands to her wall. P3 (25-34 years) described a poignant moment in the recovery room after her abortion in New Zealand with another young woman whom she identified as ‘Islander’ (i.e. Pacific Islander). P3 (25-34 years) described consoling the young teenager, who was crying and had shared that she had the abortion because her family and partner did not want a baby.

I felt good that I was able to console her there because it felt like something I needed to hear as well. Even though I’d come to terms with everything and was set in my decision, I felt like she was that part of me that, yeah, that would have regretted it afterwards. So, in comforting her, it felt like I was also doing myself a service. […] That moment has stayed with me since that day. […] I think I was just meant to be there at that time. (P3, 25-34 years)

For P3, the connection generated by their shared experience and similar cultural background appeared to offset her sense that she ought to have had negative feelings about her own abortion.

Discussion

Participants in this study described multiple reasons for needing an abortion, relating their decision to their limited capacity to parent in contexts of fear, abuse, financial instability, relationship difficulties, age and stage in life, isolation from family support, solo parenthood and a desire to better their lives through continuing their education or career progression. In these multifaceted contexts, most participants described their decision to seek an abortion as clear, even in a context where abortion is marked as a crime and a moral transgression.

Participants explained that many Cook Islands women access abortion services abroad (usually in New Zealand and sometimes in Australia), although the migrant woman in this study did not have this option (White, Mann, and Larkan 2018a). Some participants in this study described inducing their abortions by using prescribed medicines obtained through an overseas website following an online consultation. However, only those with the necessary human and financial resources and support could access the safest abortion options, with others relying on ta’unga or self-medication (essentially poisoning) with strong alcohol or coffee.

Participants in this study reflected on the gendered expectation of the prioritisation of others’ needs and the generalised notion of abortion as sinful within conservative religious institutions, which for many were integral to family and community life. For some, their relationship to these broader socio-cultural values complicated their personal context and experience (e.g. of relief) and usually clear decision to have an abortion, perhaps speaking to the experience of ‘akama and the tension inherent in the relationship between the personal and social context for Cook Islanders (Alexeyeff 2000; Makiuti Tongia, (pers. comm., June 24 & 25, 2023). Others emphasised the personal context of their sexualities, pregnancies and abortions, and resisted these socio-cultural values in this context (Alexeyeff 2000; Makiuti Tongia, (pers. comm., June 24 & 25, 2023). Furthermore, participants described the safety and comfort found in familiar cultural symbols and supportive family and friends. Such support could relate to another Cook Islands cultural value of aro’a, which could be defined as love, caring and concern for the welfare of others, and can connote bravery in acts of caring for others (Jonassen and Tikivanotau 2003; Makiuti Tongia, (personal communication 24-25 June 2023).

The socio-cultural context and process of shame related to abortion was also part of a larger context of sexual and reproductive behaviour for participants, which often transgressed ideal notions of gendered sexual behaviour as outwardly modest (Kimport and Littlejohn 2021; Alexeyeff 2000; Millar 2020). Participants’ expressions of their sexuality (for example, at a young age; out of wedlock; or with a man who was rejected by the family) and other life experiences also tied to sexuality and motherhood (fallible contraceptive behaviour; single motherhood; financial and relationship instability) featured in participants’ accounts of their abortion decisions (Kimport and Littlejohn 2021; Millar 2020; Kumar, Hessini, and Mitchell 2009). In this context, gendered conceptualisations of shame were also layered and implicated women’s family networks, complicating notions of choice and reproductive control (Ross and Solinger 2017). This complexity regarding notions of choice and reproductive control could also speak to the multiple variables related to power and authority in the Cook Islands and other parts of Polynesia, which includes gender, as well as age, rank and kin relationships (Alexeyeff 2020).

Cook Islands women face similar obstacles to women in other Pacific Island communities around their ability to confidently access comprehensive, confidential and non-judgemental sexual and reproductive health services, including abortion (Baigry et al. 2023; Dawson et al. 2021). One difference, however, is that Cook Islands women have New Zealand citizenship and therefore have more freedom to travel to New Zealand (and Australia) to access legal and safe abortion services through the public health system (Marsters 2014). This can serve to reduce reliance on illegally accessed medical abortion (with sometimes limited or incorrect information) or unsafe methods (Vallely et al. 2015; McMillan et al. 2020; Linhart et al. 2020; Burry et al. 2022). However, the practical and financial obstacles to accessing abortions overseas for Cook Islands women, including socioeconomic inequity in New Zealand, demonstrates the injustice for those who cannot afford to make this trip, as well as for migrant workers who are unable to access New Zealand’s public health care system (Ross and Solinger 2017).

Many participants and many of those assisted by the support people interviewed in this study may have had physically safe abortions in New Zealand or Australia or by correctly administering medical abortions (WHO 2019). Participants had to manage the practical and financial aspects of abortion access in their restrictive contexts. Participants also described what may be understood as ‘akama in their negotiation of the personal context of their sexual behaviours, pregnancies and abortions relative to socio-cultural values associated with these behaviours and experiences (Alexeyeff 2000; Makiuti Tongia, personal communication, 24-25 June, 2023). To counteract this, however, participants also explained what could be described as aro’a, that is, caring for the welfare of others by supporting friends or relatives (or even strangers in the recovery room) throughout their abortions, which inevitably involved bravery on the part of those providing support given the religious opposition and legal restriction of abortion in the Cook Islands (Jonassen and Tikivanotau 2003; McDonald 2001; Makiuti Tongia, (personal communication, 24-25 June, 2023). This speaks to the centrality of the value of aro’a in enhancing participants’ safety in a socio-cultural, emotional, and spiritual sense, providing individuals with an alternative social-cultural value from which to relate the personal context of their abortion experiences (Alexeyeff 2000). However, the availability of safe, non-judgemental support people within participants’ personal and social networks varied significantly, given participants described their necessary selectivity when seeking support. Access to physically safe abortion is dependent on the extent of legal restrictions, availability of quality medications and care and access to the resources needed to obtain this care (WHO 2019). Additionally, to expand on Mavuso, Macleod and du Toit’s (2022) argument, socio-cultural and emotional abortion safety is dependent on people’s access to meaningful socio-cultural support that prioritises their welfare and allows people to relate to more affirming and embedded socio-cultural values. Overall, individuals’ abortion safety nets contain threads related to their health, legal and policy environments; their positionality vis-à-vis socio-cultural discourses related to abortion, sexuality, pregnancy and mothering; and their access to social and family support throughout decision-making, critical aspects of access, as well as culturally embedded recognition and reassurances. The extent of individuals’ financial, political, health care and socio-cultural resources in casting this net varies, with layered health implications (Mavuso, Macleod and du Toit 2022; Purcell 2015; Millar 2020).

Limitations

This was a qualitative study with a limited convenience sample, so the findings are not generalisable beyond the sample. Additionally, participants in the study were recalling abortion experiences from across a broad timeframe, with some describing recent experiences and others experiences from 20-30 years ago, which could be subject to inadequacies regarding their memory of events. Furthermore, interviews and focus groups were conducted in English, in which participants were all proficient; however, some cultural concepts are difficult to adequately communicate about, and convey the meaning of, in English.

Conclusion

This study intended to provide qualitative insights on an under-researched aspect of Pacific Island women’s reproductive health and rights. Research participants’ negotiation of the personal contexts of their sexual behaviours, pregnancies and abortions relative to their socio-cultural context and values, in which abortion is a sin and a crime, was often complicated and could be understood through the Cook Islands concept of ‘akama. This, for some, was ameliorated by the support and care they received and provided, especially where women had access to larger support networks. Overall, based on the findings of this study, we argue for a conceptualisation of abortion safety that speaks to the breadth (and limits) of individuals’ abortion safety nets as the sum of their access to financial, political, health care and socio-cultural resources. These safety nets are shaped by individuals’ access and relationships to prevailing discourses related to abortion and embedded socio-cultural support and values, which impact on their physical, emotional, psychological, social and spiritual health.

Acknowledgements

We acknowledge and extend our gratitude to everyone who participated in this study. Thank you for entrusting us with your stories. We thank the Cook Islands Family Welfare Association, without whose support, dedication to sexual and reproductive rights and trusted place within the community, this research could not have taken place. We also thank the University of the South Pacific Cook Islands Campus Te Puna Vai Mārama | Centre for Research for its support. Finally, a heartfelt thank you goes to Makiuti Tongia for sharing his knowledge, experience, guidance and insights.

Disclosure statement

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

Additional information

Funding

This study received funding support from the University of the South Pacific Cook Islands Campus Te Puna Vai Mārama | Centre for Research