Structural barriers or patient preference? A critical appraisal of the medical abortion revolution in England and Wales

In this thesis I assess the extent to which structural barriers are limiting choice of abortion method in England and Wales and the relationships between abortion method choice, inequities, and abortion stigma. I adopt three theoretical frameworks (socio-ecological framework, stigma theory, and a multidisciplinary framework for understanding choice and equity) to approach abortion method choice with a systemic, critical lens using mixed methods. These include key informant interviews with abortion service providers, managers, and commissioners, in-depth interviews with abortion care-seekers, a multilevel analysis of national abortion statistics, and an analysis of provider survey data. These analyses highlight that the supply of surgical abortion care has been restricted by the legal framework for abortion and by other institutional barriers relating to funding, infrastructure, and workforce. These health system constraints have limited the options offered by health care providers, which generates inequities in people's ability to make an informed decision about their abortion method. Although these analyses suggest that abortion providers' method preferences and provision in this context are not significantly associated with abortion provider stigma, I find that abortion stigma is produced in the institutional structures of the health system which reduces access to patient-centred care, including method choice, and can reinforce individual level stigma. This thesis makes use of novel data sources and methodologies to further our understanding of the structural factors that have influenced the shift towards medical abortion in England and Wales and reveals how these constraints are imposed and experienced inequitably. These findings pose challenges for dominant discourses that focus on the potential of medical abortion to empower care-seekers and indicate the need for changes in policy and practice to protect method choice. The thesis concludes with implications for policy, practice and research in England and Wales and elsewhere.