Abortion is a fundamental component of people’s ability to decide if, when, and under what circumstances to have a child. The ability to obtain an abortion is critical to both reproductive autonomy and public health. Despite this, a large body of evidence demonstrates that it is often difficult to obtain an abortion in the United States (U.S.). State-level policies restrict abortion availability and create logistical, financial, and emotional barriers. Difficulty accessing abortion disproportionately and inequitably burdens those who have been historically and systematically marginalized—low-income people, Black, Brown, and other people of color, young people, and those who live in rural or non-metropolitan areas. The existing body of literature demonstrates that the current political climate and service delivery landscape create a gap in which some people who want an abortion are not able to obtain one at all or in a manner that is acceptable to them. This amounts to an urgent public health and health equity problem—in the U.S., people’s abortion needs are not being met.
In public health, medicine, and the field of family planning, lack of access to critical services is commonly framed and documented as “unmet need,” such as with the longstanding measure of “unmet need for family planning” as a tool to understand population-level contraceptive access. Documenting “unmet need for abortion” could be one potential tool those working in abortion access could use to direct advocacy efforts, service delivery, and resource allocation to meet abortion need(s). However, it is not clear whether conceptualizing problems in abortion access as unmet need would be valuable and, if it is, how to define or measure that need.
This dissertation uses multiple methods to explore the concept of unmet need for abortion in the U.S. My first aim is to present a nuanced and critical analysis of unmet need for abortion, including its conceptualization and utility as both a concept and a tool for the abortion rights movement. My second aim is to quantitatively describe the prevalence of not obtaining a wanted abortion among a nationally representative sample.
Chapters 2 and 3 present findings from in-depth qualitative interviews with 30 stakeholders in abortion access from around the U.S. about their perspectives on unmet need for abortion. Stakeholders included people working in direct service settings, research, advocacy, grassroots abortion funds, reproductive justice organizations, and philanthropy. Chapter 2 explores the potential benefits and harms of using unmet need for abortion as a tool to frame and measure problems with abortion access in the U.S. Findings from this study point to the complexity of the concept of unmet need for abortion. As a tool for advocates, researchers, policymakers, and others working for abortion access, unmet need for abortion could draw necessary attention to and broaden public dialogue about crises in abortion access. However, participants’ hopes for positive shifts in public discourse and resource allocation for abortion were counterbalanced by their concerns—that the tool could be misused, that the limits of quantification come at too great a cost, and that by centering abortion alone it would serve to further disconnect abortion from the broader fight for reproductive justice.
Chapter 3 describes how stakeholders understood unmet need for abortion. I identified two distinct conceptualizations: outcome-based unmet need for abortion, in which need is defined as obtaining an abortion; and process-based unmet need for abortion, in which need is additionally defined in terms of the experience of getting an abortion, including navigating obstacles, preferences in method and setting, and quality of care. While some participants primarily leaned toward one conceptualization, most utilized both. Participants debated the relative importance of these conceptualizations based on which they projected could be useful for mobilizing support and resources for abortion access.
Chapter 4 describes the prevalence of not obtaining a wanted abortion in a nationally representative sample of adults (ages 18-44) who had ever been pregnant. Nearly 6% of respondents reported having wanted an abortion they did not obtain. In open-ended text describing why they did not obtain the wanted abortion, participants most frequently reported personal reasons for not getting an abortion (e.g., changing their mind; personal moral or religious opposition), though it was also common to report policy-related reasons (e.g., gestational limits set by state or facility policy). These findings suggest that people in a national sample will answer questions about whether and why they did not obtain a wanted abortion. In addition, these data provide some insight into the complexity of wanting an abortion. Rather than framing this experience as not getting a wanted abortion, for some people, it may be more accurate to describe this as not getting an abortion that was wanted at one point.
Unmet need for abortion is a complex concept that has potential benefits and potential harms as a tool to document and improve abortion access. In addition, it can be conceptualized in multiple ways that affect its utility. As threats to abortion access increase, people not getting abortions they want, either at all or in a manner that is acceptable to them, will only become of greater concern. This dissertation contributes to a growing and timely body of research about devising new ways to understand and meet abortion needs.
