Microeconomic costs and consequences of abortion stigma.

Costs. Of the 32 included studies with economic outcomes, nearly half examined the implications of stigma on economic cost at the micro level (15/323) (S3 Table; S4 Appendix). Studies on stigma and the costs of abortion at the micro level were conducted most often in the United States (n = 3) and Ireland (n = 2). One study examined micro-level costs from a global perspective and one article collected data at the regional level (Sub-Saharan Africa). The rest of the studies were conducted in individual countries (Bangladesh, India, Hong Kong, Cambodia, Australia, Kenya, Nepal). Evidence on the relationship between stigma and micro-economic cost outcomes came primarily from qualitative studies (n = 7) and data from mixed-methods studies (n = 4). The synthesis of this data has generated the following two themes regarding the associations between stigma and cost at the microeconomic level (Table 5).

1. (1) People who are unable to confide in and rely on their social support network are less likely to have adequate financial resources to access abortion services [25–33]. Fear of being stigmatized by a partner or family members could result in women reporting fewer financial resources and a lack of support in seeking abortion services [25, 26, 32, 33]. In these cases, women have had to make a difficult decision between their desire for confidentiality, the fear of being stigmatized by their social network, and having the financial resources to afford the costs of abortion services. In some cases, lack of financial resources and the fear of stigma from family and friends prevented some women from seeking abortion services entirely [29].

In India, seeking out private practitioners could offer young women the additional confidentiality some sought due to the social stigma surrounding abortion in their communities [30]. Although abortion is legal in India, some private providers take advantage of young women’s need for confidentiality and fear of social ostracism, charging three to five times the normal rate for abortion services. At this high cost, women can only feasibly access these services with financial support from their parents, brothers, or partner.

Similarly, abortion service fees in Indonesia are inflated and uncontrolled, particularly for unmarried women, because most abortion services are provided outside of the legal indications. While abortion is illegal except in cases to save the life of the woman, unmarried women are also unable to access maternal or family planning health services in general [28]. To avoid social condemnation, unmarried women seek out more confidential abortion services through private providers operating outside of the legal system.

The average cost of abortion services in Indonesia is beyond what most women can afford without the support of their partner, family, or friends [28]. The follow-up appointments are typically free, though women are usually not informed of this and many more miss these appointments due to the need for secrecy and to preserve their social reputation. Without the support from family or friends, women are less likely to attend the follow-up appointments, potentially leaving them at risk if they have any complications.

Conversely, women who could rely on their social support network for accurate information, facility recommendations, and financial support were more likely to be able to access and afford the costs of abortion services [27, 31]. In one study, women who received financial support from family members were able to visit private doctors in confidential settings with higher quality of care [27]. In addition to the direct cost of service, women’s social support networks were found to be essential to help minimize indirect costs associated with clinic visits, including transportation costs and childcare [26].

1. (2) Abortion stigma can prevent individuals from obtaining correct information about abortion services and laws, which can lead to unnecessary increases in direct and indirect costs of care [34–36]. Abortion stigma can make it challenging for women to find accurate and timely information about abortion services. Even in countries where abortion is legal, availability of information on abortion may vary throughout the country [35]. The desire for secrecy can also lead people to travel to clinics outside their communities for consultations [31]. Women may also feel uncomfortable asking for information due to the possibility of facing stigma from peers.

In some settings, women with low incomes can find it challenging to find affordable and accessible basic primary care services with qualified service providers [36]. These barriers can compound when seeking out providers for stigmatized services, like abortion or incomplete abortion care, as information around where to safely access these services can be challenging to find. Even in cases where care was subsidized, many low-income women were unaware of these services and were therefore not coming into facilities for consultations [36].

Delays in receiving accurate information on abortion services can result in unnecessary increases in direct and indirect costs of care. In Australia, one study participant reported traveling four hours for an abortion procedure despite living near a hospital that could have offered the same service [34]. Another study participant had to visit five general practitioners before she was able to receive a referral for abortion services, which delayed the timing of the procedure and resulted in compounded, unnecessary costs [34]. Reducing abortion stigma is necessary in order for women to receive accurate information in a timely manner and to reduce costs of service.

Impact. Only four articles included data on the economic impact of abortion stigma at the micro level (S3 Table; S5 Appendix); fewer than the previous section on economic cost and abortion stigma. These studies were conducted in individual countries (Indonesia, Ireland, Columbia, and Zambia). Data were primarily collected through qualitative methods (n = 3), though one study used a mixed-methods approach. Despite the limited evidence, the following two emerging themes highlight the potential economic impact of abortion stigma at the micro level (Table 5).

1. (1) Having a child outside of marriage or without the financial means to raise the child can lead to greater social stigma than choosing to have an abortion [28, 32, 37]. In Colombia, several study participants claimed that the social stigma attached to having a child in their current unmarried and financially unstable position would outweigh any stigma around having an abortion. The participants also explained that dropping out of school to raise the funds to support a new child would lead to judgment from their families [37]. In Ireland, a woman reported a doctor crying after she expressed a desire for abortion and trying to convince her that it was possible to raise a child while at college [32]. The stigma of having a child when not financially ready to do so was an important factor in the study participant’s decision-making.

Similarly, study participants in Indonesia said that while they strongly believed that abortion was a sin, it could be acceptable under certain specific circumstances [28]. In general, women tended to think that abortion was acceptable if marriage was not possible or if the man wanted to have an abortion. Many women also believed that abortion was necessary to avoid personal and family shame if the man refused to take responsibility of the child and get married, as having a child out of wedlock is perceived as a greater sin than abortion.

1. (2) Accessing abortion services in a highly stigmatized environment can lead to loss of employment [38]. In Zambia, stigma around receiving abortion services can have an adverse impact on a woman’s livelihood. One participant mentioned that she travelled to another town to receive abortion care services in an attempt to keep her abortion confidential. However, her employer found out about the procedure and she was ultimately fired from her job as a result [38].

Benefits. Only one of the 32 articles included findings on abortion stigma and economic benefits, and it presented evidence at the micro level (S3 Table; S6 Appendix). This study, conducted in Côte d’Ivoire, generated qualitative evidence on the relationship between abortion stigma and benefits. The main emerging theme from this study is: (1) Women may act outside of their standard moral or religious values in order to advance their status in society [39]. Study participants explained how abortion typically fell in strong opposition to their values and norms both in their community and as Muslims. However, they have begun to act outside of their standard moral and religious norms because of a shift in priorities. As Muslim women in Côte d’Ivoire are seeking access to education and financial independence in their communities, they found themselves advocating for abortion access as a means to achieve educational and financial goals for independence [39].

Mesoeconomic costs and consequences of abortion stigma.

Costs. The implications of stigma on economic cost is the most frequently reported outcome at the meso level (10/32) (S3 Table; S7 Appendix). Studies were conducted most often in the United States (n = 3) while the rest of the studies were conducted in individual countries (Indonesia, Colombia, Poland, Zambia, Mexico, India, Kenya). Evidence on the relationship between stigma and meso-level cost outcomes came mostly from qualitative studies (n = 5). Synthesis of the evidence within these articles has generated the following two themes (Table 5).

1. (1) Community and provider-based stigma around abortion can lead individuals to abortion care services outside of the formal sector or outside of legal restrictions, which can have a meaningful impact on the cost of abortion services [28, 30, 40–42]. Pervasive community-based and perpetuated stigma can lead women to seek abortion services outside of the public sector, which can result in exorbitant, unregulated service fees. Providers outside of the formal sector can capitalize on abortion stigma, using it to charge unofficial and illegal fees to women who are in desperate need of confidential services [41].

In Poland, public-sector doctors refused to provide safe, affordable care in their facility because the doctors counted on women to “cope” with their abortion needs in the private sector [40]. Some of these doctors refused to provide care in the public sector but referred women to their own private practices. The private practice of abortion services is unregulated and untaxed, which can be an appealing source of income for some providers [40]. In one study in India, providers would refer to abortion services requested by unmarried adolescents as “illegal” services, even though these cases are legal under the abortion law in India [30]. Some providers mentioned that unmarried women were also charged, on average, three to five times the normal rate for an abortion.

As abortion services in Indonesia are only available to save the life of the woman, many women seek out services outside of the formal health sector. Additionally, unmarried women are largely unable to access any maternal health care services, so unmarried women in particular rely on confidential services to avoid social stigma and ostracization. However, confidentiality came at a high price, as providers charged between 60,000–300,000 rupiah for abortion services [28]. This cost usually covers the fee for the service, but does not include the cost of necessary drugs (i.e., pain management pills). Unmarried women interviewed mentioned that prices within this range are typically more than a woman could afford on her own, while one respondent said that her abortion fee was equal to two months of her boyfriend’s wages. The high, unregulated costs charged by providers outside of the formal sector represent a substantial barrier to women accessing safe abortion services. Many women interviewed stated that they delayed contacting a qualified provider due to the inaccessible cost of the service.

One participant from a study in Kenya said that some public-sector providers are willing to provide abortion services, but they only perform those services in their own private practice and for a considerable sum of money, noting that the cost of the service tends to depend on the demand for the service and whether the patient appears to have the means to pay [42]. As long as unofficial payments are made outside of the formal health sector, it will continue to be challenging for women to know how much an abortion should cost as well as their legal right to obtain that service within the formal sector [41].

1. (2) Insurance companies can create a financial barrier to safe abortion services [37]. One study in Colombia found that insurance companies, and more specifically company representatives, acted as a barrier to safe, affordable abortion care [37]. This study found that some company representatives refused to provide accurate information about coverage for abortion services, even though they were legally obligated to both provide the information and cover the procedure. The representatives were religiously motivated to not provide abortion service information [37].

Impact. Four articles included data on the economic impact of abortion stigma at the meso level (S3 Table; S8 Appendix). A majority of the articles took place in high-income countries (Canada, United Kingdom, United States). Evidence on economic impact of abortion stigma at the meso level was collected through qualitative studies (n = 3) and a cross-sectional survey (n = 1). Despite the relatively limited evidence base, data from these articles have been synthesized to develop the following two emerging themes that highlight the potential economic impact of abortion stigma at the meso level (Table 5).

1. (1) Refusal to provide abortion services and/or referrals can result in substantial delays in care [43–46]. Providers who refuse to provide care or referrals, despite the legal availability of abortion, can lead to long delays in care. In a study in the United Kingdom, four women reported seeking abortion outside of their home country because of the procedural barriers to legal abortion care [44]. One of the greatest barriers was the obstruction of access to care by clinicians, many of whom refuse to provide care due to their own personal beliefs. In various settings where abortion services are legally permitted, some abortion providers reported harassment or faced stigma from their colleagues. For example, in Mexico City, obstructing providers and other healthcare professionals would create an atmosphere of hostility in the facility, resulting in longer wait times for abortion services [46].

A study participant in Canada explained how their doctor refused to provide care or refer to another facility because it was against the doctor’s beliefs [43]. Others participants in the United States were unable to get referrals from their doctors to receive abortion services in the hospital, which would have been covered by Medicare (the federal government health coverage program), because of the doctor’s personal beliefs [45]. Even in cases where providers do not hold personal views against abortion, perceptions of abortion opposition in the community can lead facility staff to withhold information about available services to women [45]. These findings point to the importance of continuing to investigate how refusals to provide abortion care are defined by providers and communicated to their patients [44], and to determine the overall economic impact on women and their decisions around care.

1. (2) Facility staff and providers may provide inadequate information to individuals regarding public funding for abortion services [45]. In the United States, confusion regarding state funding and rules regarding abortion can jeopardize that funding and lead to procedural barriers for women [45]. Facility staff may be reluctant to provide women with information about abortion out of fear that sharing information could threaten their state family planning funding. In an effort to protect their facility and livelihood, some providers may withhold critical, timely information to their patients regarding abortion-related care.

Macroeconomic costs and consequences of abortion stigma.

Costs. As shown in S9 Appendix, four articles included data on the implications of stigma on economic cost at the macro-level (S3 Table). A majority of the included studies were conducted in high-income countries (United States, Poland, Ireland). Evidence on stigma and economic cost at the macro-level was collected through a mixed-methods study (n = 1), qualitative study (n = 1), literature review (n = 1), and regression analysis (n = 1). Data from the four articles have been synthesized to develop the following emerging theme (Table 5).

1. (1) Anti-abortion movements and related political action restrict abortion access for individuals through legal regulations, which can result in increased financial barriers to care [32, 40, 47, 48]. The individual decision to seek abortion services in the United States has become a topic of public discussion, as public opinion has the ability to define how easy, expensive, and safe it is to obtain an abortion [48]. The anti-abortion movement has been able to remove abortion care from other aspects of reproductive health and to shape public perception of abortion as a burdensome, immoral, and socially stigmatized act. Anti-abortion movements have also led movements to restrict and recriminalize abortion in order to restrict access for women and to reduce public funding for facilities that provide services [47]. Leading with an argument of moral values, anti-abortions movements have campaigned against public funding for abortion, claiming that people should not be forced to pay for something that is against their moral values.

As aggressive public backlash against abortion builds, more providers are unwilling to perform abortions because of the harassment and intimidation by the anti-abortion movement, the emotional stress of families in crisis, and the relatively low pay to compensate the risk [48]. As fewer providers are willing to take on abortion service provision, access to abortion services can continue to be more cost prohibitive for women who may need to visit multiple clinics and/or travel greater distances to seek care.

Due to the restrictive regulations in counties like Poland and Ireland, women must travel outside of their country in order to access abortion services [32, 40]. While women of higher socio-economic status have the potential means to travel, women in lower socio-economic classes are less likely to have the resources to do so. At the same time, those most affected by the restrictive regulations around abortion are unlikely to have the political and economic capital on their own to protest the law and enact change, trapping them in a discriminatory cycle.

Impact. Only three articles discussed the macroeconomic impact of abortion stigma (S3 Table; S10 Appendix). One of the articles examined economic impact at the global level, and the other two studies were conducted in high-income countries (United States and Poland). Evidence was gathered and presented through a mixed-methods study design (n = 1), a literature review (n = 1), and a regression analysis (n = 1). Synthesis of the data from these three articles has led to the development of the following two emerging themes (Table 5).

1. (1) The monopolization of abortion services within the private sector has led to unequal access to services due to their unregulated and unsubsidized prices [40]. Abortion stigma in Poland has successfully pushed safe, affordable services out of the public sector, which led to the development of a thriving, underground private sector market for abortion services [40]. Within the private sector, stigmatization of services ensures that the procedures and costs of services remain unregulated. This monopolization of abortion services in the private sector perpetuates social inequality because their services are out-of-reach to a portion of the population that is unable to afford the cost of service.
2. (2) The Global Gag Rule has institutionalized abortion stigma within its global foreign assistance structure [49]. The Global Gag Rule, a term referring to the United States policy that, in earlier iterations, restricted foreign assistance for reproductive health to organizations above that provide abortion services, information, or referral. The Global Gag Rule has successfully institutionalized abortion stigma within its global foreign assistance structure by enacting restrictions to available funding. Non-government organizations that receive funding from the United States are unable to use that funding for abortion services, referrals, or even to share information regarding abortion. They risk losing their funding if they do not follow these rules. With the most recent iteration of the Global Gag Rule, the restrictions have expanded.