Background: Previous research indicates that women in Ontario have an established need for post-abortion support, yet often have difficulty finding and accessing affordable and timely services.
Objectives: We aimed to determine what free post-abortion support services are available to women in Ontario, the kinds of organizations offering these services, and how these services represent themselves in online materials.
Methods: In previous research, women identified three primary ways of identifying post-abortion support services: searching online, calling the clinic where their abortion was performed, and calling their local Public Health Unit. We utilized these same methods to create a directory of free services in Ontario. We then reviewed organizational websites and analyzed these materials for content and themes. We specifically focused on the medical accuracy of the provided information and the tone, frameworks, and assumptions of the employed discourse.
Results: We identified 41 unique organizations that offer post-abortion support in Ontario; 33 crisis pregnancy centers (CPCs), two sexual health centers, three religiously affiliated talklines, and three secular talklines. We were able to most easily find information about CPCs. All organizations described their services as confidential and non-judgmental, but CPCs and religiously affiliated talklines included negative and stigmatizing language about abortion, as well as medically inaccurate information, on their websites.
Conclusion: CPCs account for the majority of organizations providing free post-abortion support services to women in Ontario. Efforts to increase the online visibility and overall accessibility of non-judgmental, non-directive, medically accurate post-abortion support services in Ontario appears warranted.
reproductive health, counselling, unintended pregnancy, pregnancy termination, crisis pregnancy centers
In 1988, the landmark R V. Morgentaler decision decriminalized abortion across Canada [1]. Today, the ruling remains unchanged and without any federal restrictions on the procedure, Canada has one of the most liberal abortion laws in the world [2]. Nonetheless, since its decriminalization, abortion remains a socially contentious issue. In recent years, there has been a shift in the anti-abortion discourse, both in Canada and worldwide, to portray abortion as harmful to women [3].
The safety of induced abortion care when provided in legal environments by trained health service professionals has long been established [4-6]. Further, a body of research has demonstrated that in comparison to the delivery of an unintended pregnancy, abortion is not associated with an increased risk of mental health problems [7-10]. However, evidence suggests that opponents of abortion rights have made repeated attempts to tie abortion to a variety of mental health conditions [11,12] and most recently, this effort has been dedicated to the establishment of “post abortion syndrome” and “post abortion stress” as diagnoses [13,14]. There is no evidence to support the existence of such “syndromes” and neither the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) nor the International Statistical Classification of Diseases and Related Health Problems (ICD-10) recognize their existence [15,16]. This is consistent with an official statement issued by the American Psychological Association (APA) that concluded that a single first trimester abortion is not associated with adverse mental health outcomes, including depression and anxiety [17].
Still, as with any potentially significant life event, women can experience a complex range of emotions following a termination and may require a space to process their feelings and discuss their experience [18]. Previous research has indicated that some women in Ontario, Canada’s largest and most populous province, desire non-judgmental post-abortion support services after their termination [19]. However, these same women noted that they were often unable to find and access an affordable and timely provider [19]. Given this overarching context, our primary study objective was to identify organizations offering post-abortion support in Ontario. Further we aimed to evaluate the ways in which these organizations describe and frame their services and assess the medical and legal accuracy of the abortion-related information provided.
Our study utilized a two-step approach to explore post-abortion support services in Ontario. First, we created a directory of free services across the province. Second, we conducted a qualitative document analysis to analyze the web presence of post-abortion support providers in Ontario.
Data collection
Previous research conducted with women in Ontario found that women seeking post-abortion support identified three strategies to find services: 1) searching online, 2) calling the clinic where their termination was performed, or 3) calling their local Public Health Unit [19]. We utilized these same strategies to search for services and compile the directory. In the fall of 2014, we searched online using a pre-determined set of search terms. In many cases, the websites that we found when searching online contained links to other websites and/or organizations, which we followed. Next, one investigator (KL) called all Public Health Units (PHUs) (n=35) and freestanding abortion clinics (n=9) in Ontario. We obtained comprehensive lists of the PHUs and clinics from the Ontario Ministry of Health and Long-Term Care and the Abortion Rights Coalition of Canada, respectively [20,21]. We limited the number of contacts with each PHU and abortion clinic to a total of five calls. When we reached an appropriate person via the telephone, we asked for contact information for free post-abortion support services. We specified that we were not looking for a service provided by a clinician or for someone in crisis.
Based on our online search strategy and the recommendations from both PHUs and clinics, we assembled a list of post-abortion support providing organizations. We ultimately narrowed our list to organizations that provided free, one-on-one services. For each organization that met the inclusion criteria, we noted the service type, location, and availability, as well as their contact information and website address. This yielded 41 unique organizations.
Following the creation of the directory, in late 2014 through early 2015 we analyzed the web presence of each of the 41 post-abortion support providers serving women in Ontario. We modelled our approach after other published studies that evaluated online content [22-24]. Two investigators independently and systematically reviewed all posted content on each website. This typically began with the homepage and then involved following all tabs, uploaded documents, and internal links. We noted external links but did not analyze the content of external sites. Using a coding sheet, each investigator reviewed post-abortion related content for medical and legal accuracy, tone, frameworks, and underlying assumptions. Each investigator took notes and formally memoed throughout the process and took screen captures of exemplar content.
Data analysis
After each investigator had reviewed all content, we compared coding sheets, shared notes and memos, and discussed our evaluation. Our assessment was exceptionally consistent and both investigators often chose the same exemplars. We resolved our rare disagreements through discussion. We used ATLAS.ti to manage our data, including notes, memos, and text from the websites. After evaluating and characterizing the content, we then turned to our thematic analysis, which centered on grouping categories of information, drawing connections between ideas, and understanding relationships.
Ethical considerations
As our study did not involve engagement with human subjects and focused on publicly available information, we did not require Research Ethics Board approval.
Finding services
We identified 41 unique organizations that offer free, one-on-one post-abortion support in Ontario. The overwhelming majority (n=33) of these organizations identified themselves as crisis pregnancy centers (CPCs). The remaining eight organizations included three binational (US-Canada) religious talklines, three secular national and binational (US-Canada) talklines, and two sexual health centers.
When searching for services online, we found that CPCs not only account for the majority of service providers, but also consistently ranked first in search results. In contrast, sexual health centers and secular phone lines that offer post-abortion support were much harder to find through standard online search engines (including Google, Bing, and Yahoo) and often did not appear within the first few pages of search results.
Our calls to PHUs were met with inconsistent responses. It took an average of three calls to each PHU to speak to an appropriate person. As depicted in Figure 1, of the 35 PHUs that we called, in seven cases we were unable to get in touch with anyone at the unit after five calls. Five PHUs told us that no such service existed. We classified eight PHUs as giving us general or inappropriate referrals: three referred us to fee-for-service providers and five recommended we contact a general service, such as a mental health crisis line or a database of Ontario’s community and social services. Two PHUs referred us to a CPC; one of these PHUs also recommended we contact the hospital where the abortion was performed. Of the remaining health units, three informed us about in-person services available at the PHU, three advised us to call the facility where the abortion was performed, two referred us to a local sexual health center, and five PHUs referred us to a combination of these services.
Figure 1. Calls made to Public Health Units inquiring about free post-abortion support services.
In contrast, the information provided by the abortion clinics was much more consistent and streamlined, as it rarely took more than one call to speak with an employee. Three clinics provided a referral to a secular talkline, four clinics referred us to in-person services available at a nearby sexual health center or the clinic itself, and two clinics provided us with information about a combination of these services.
Description of services
All organizations emphasized that the support they provide to clients is both non-judgmental and confidential. Although some organizations mentioned that an appointment is required for services, most indicated that they are able to work with clients on a walk-in or call-in basis. All of the talklines identified themselves as religious or secular. Only a minority of CPCs identified themselves as religiously-affiliated, and only two centers stated on their websites that they do not offer phone-based services. The majority of CPCs were located in Southern (n=18) and Central (n=10) Ontario, which mirrors the distribution of abortion providers in the province.
The framing of post-abortion support differed considerably between different organization types. Crisis pregnancy centers positioned abortion as something that required recovery and their organizations as facilitators of that process. As written on the website of a CPC serving women in Central Ontario, “[We] offer a post-abortion recovery and healing program…” Another CPC serving women in Western Ontario stated, “[We offer a] program that allows you the opportunity to face your decision, grieve your loss and promote healing.” Religious talklines similarly framed post-abortion support as a healing process. As noted on one website, [This] is a safe place to renew, rebuild and redeem hearts broken by abortion…[We] offer you a supportive, confidential and non-judgmental environment where women and men can express, release and reconcile painful post-abortive emotions to begin the process of restoration, renewal and healing.
In contrast, two sexual health centers and three secular phone lines described their services as client-driven and did not frame the abortion experience, “[We] provide the opportunity to talk with someone who supports and respects you, in a safe and confidential environment.”
Medical accuracy
Crisis pregnancy centers were the only type of organization to provide medical information when describing their services and six included medically inaccurate information. These websites often mentioned “post abortion stress” and “post abortion syndrome” and listed symptoms associated with each. For example, the website for a CPC serving women in Southern Ontario claims,
Post Abortion Stress is described as the inability to: Process the painful thoughts and emotions about a crisis pregnancy and subsequent abortion – guilt, anger and sorrow; Identify the loss that has incurred; Come to peace with self and others.
On these websites, abortion is frequently associated with depression, grief, suicidal tendencies, eating disorders, and drug addiction. As asserted on one CPC website serving women in Southern Ontario,
Women come to the center hoping to resolve feelings of guilt, anxiety and depression. Women also inform us of secondary symptoms such as flashbacks of the abortion procedure, addictions, eating disorders, self harm, anniversary syndrome, spiritual disconnection, preoccupation with becoming pregnant again, and interruption of bonding with future children.
No websites purporting a link between abortion and negative mental health outcomes referenced peer-reviewed materials. However, several CPC websites referred to “recent research” that links negative mental health outcomes and abortion without providing a reputable citation.
Language related to abortion
Abortion has long term effects of sorrow, grief and guilt. It leaves wounds that tear at our very fabric, that scab over but never heal, and undermine our relationships with others. (Website of a CPC serving women in Central Ontario)
The language used to talk about abortion represents another key difference across organization type. Crisis pregnancy centers and religiously affiliated talklines consistently used language associated with negative emotions and feelings to describe the post-abortion period. For example, the website of a CPC serving women in Southern Ontario stated, Your abortion was supposed to end your crisis and you just wanted things back to normal again. Instead, it has left you feeling empty. The memories of your abortion are difficult to face and you are feeling angry, depressed and alone.
With rare exception, these organizations discussed the abortion experience as a loss that requires a post-abortion grieving process. As spelled out by one CPC, “[The Center] is a compassionate place to work though the difficult emotions that are often felt after an abortion loss. Sometimes it is years after the abortion that someone will begin to look for help…Grieving the loss and being able to move forward is possible.”
Further, CPCs tended to pathologize the abortion process, using medicalized words such as “symptoms,” “trauma,” and “syndrome.” Although some CPCs did acknowledge that women can experience a broad range of feelings, including relief, these websites presented women who have neutral or positive feelings after their abortion as outliers to the typical negative psychological outcomes that follow a termination. As described by a CPC in Central Ontario, “If you are struggling with your emotions because of an abortion, there is hope. Some women feel relief after an abortion, while other women experience strong negative emotions. Some of these reactions may be immediate. Some occur many years after the abortion.”
In contrast, all five of secular talklines and sexual health centers presented a more nuanced view of women’s experiences after abortion by using language that both acknowledged and validated a range of feelings. As exemplified by one binational secular talkline: The feelings you have after your abortion may be varied; sadness, relief, anxiety, happiness, grief and guilt. These feelings may change in type and intensity over time. These feelings are normal.
In general, the language used by these organizations was less emotionally charged and focused not on the presumed feelings or experiences of the client but on the non-judgmental support offered by the organization. [We provide] a talk-line staffed by people trained to listen and help you find peace. We trust you and your choice. We can help by simply listening or providing you with other resources in your area - both religious and non-religious - who can also help you connect with your decision in a way that affirms you.
Outcomes after contacting the service
Many women find that their recovery journeys teach them valuable life lessons that contribute to increased strength of character, wisdom, vision and hope. (CPC website serving women in Central Ontario)
A notable different between CPCs and religiously affiliated talklines on the one hand and secular talklines and sexual health centers on the other, was the promise of outcome. We found that CPCs in particular used emotionally charged language to entice clients to contact their service. In contrast to the “depression,” “guilt,” and “trauma” that they purport follows an abortion, CPCs routinely advertise their services as offering “hope,” “freedom,” and the ability to “live in color” once more. As one organization stated, “Living in Color is a post-abortion recovery and healing program. This program offers you help in the process of emerging from the ‘grey zone’ of unresolved loss into a life of colour, freedom, and joy.” Many of these websites also offer testimonials from women who claim to have “recovered” from their abortion experience with the assistance of the service.
I carried my abortion burdens alone for twenty-one years and felt that I could never tell anyone about them, let alone acknowledge my children and have a memorial service! I feel grateful, free, real. This program is awesome! (CPC website serving women in Central Ontario)
Other organization types did not discuss possible outcomes that could come from contacting their service. Rather, their web presence emphasized that the support offered was non-judgmental and confidential. These organizations frequently mentioned that individuals from all backgrounds contact their service and testimonials emphasized the support provided.
People of all ages, genders, races, backgrounds, religious affiliations, and political leanings call [us]. Most of our callers are people who are or have been pregnant, and want to talk about their experiences. We also speak often to partners, parents, friends and loved ones who want to talk about their own feelings and/or how they can support someone in their lives.
Previous research has indicated that women in Ontario report difficulty finding and accessing non-directive, non-judgmental, free, and timely post-abortion support services [19]. Yet, when compiling the directory, we were able to identify 41 unique organizations offering post-abortion support, a number that far exceeds the number of abortion providers in the province. In fact, at the time of the study there were three times as many CPCs (n=33) as there are abortion clinics in Ontario (n=11) [21]. Thus there does not appear to be a shortage of post-abortion support service providers in general; rather there appears to be a shortage of visible non-directive, non-judgmental post-abortion support services. The abundance of CPCs and their dominance online may make it difficult for women to find the few organizations offering client-centered services. Identifying avenues to expand the visibility of existing non-judgmental, non-directive post-abortion support services appears warranted.
A common frustration expressed by reproductive health advocates in dealing with CPCs is that they are not accountable to anyone. Unlike medical clinics, there is no provincial mechanism to regulate these organizations or their services; in fact, in Ontario the majority of CPCs are registered charities [25]. In a 2010 article in the Toronto Star, a spokesperson for the Ontario Ministry of Health and Long-Term Care was quoted as saying, “We don’t fund them [CPCs], so we don’t have a lot of oversight on them. As with these types of things that are sort of outside the ministry purview, it is ‘buyer, beware’ and a matter of people doing a bit of homework,” [26].
However, our study revealed that a subset of provincially funded Public Health Units are in fact referring women to these medically inaccurate services. Based on our interactions with these organizations, we do not believe that that these referrals were motivated by anti-abortion sentiments. Rather, we could hear the PHU employee searching the internet and the fact that s/he then recommended we contact a CPC is likely reflective of the effective advertising techniques employed by crisis pregnancy centers. For those women who are seeking services, there is an expectation that PHUs will provide them with referrals to services that are both medically accurate and non-judgmental. Indeed, contacting a PHU for a referral for post-abortion support is one of the ways that women attempt to gather unbiased information about available services. That PHUs may then inadvertently refer women to CPCs highlights the lack of visibility of other organizations offering post-abortion support.
Finally, our results suggest that the use of medically inaccurate and shaming language by CPCs and religiously-affiliated talklines represents a method for the anti-abortion movement to stigmatize abortions and pathologize the women who have them. Both the internalized and externalized stigma that continue to surround abortion contribute to the silencing of women’s experiences, a dynamic that often drives individuals to seek post-abortion support in the first place. On an individual level, the availability of non-judgmental post-abortion support is important to aid women in processing their experiences. On a societal level, the successful management of complex feelings after abortion may ultimately affect the discourse surrounding abortion services, consequently reducing the stigma and isolation that is linked with these negative outcomes.
Our study has both strengths and weaknesses. We evaluated the online presence of post-abortion support providing organizations because previous research has indicated that this is how women are most likely to find information. However, organizations may present themselves and their work differently in different media and thus our analysis does not apply to other modalities of representation. Further, our review did not include services that provide support or lay counselling, in general. There may be additional service delivery points in Ontario that provide free services through talklines or in-person visits that also offer post-abortion support, but do not advertise that activity. Finally, we did not include pay-for-service providers, including licensed therapists. Our results are confined to those organizations providing free post-abortion support services to women in Ontario.
Crisis pregnancy centers represent the majority of organizations in Ontario offering free post-abortion support services. Their web presence often contains shaming and stigmatizing language about abortion that is medically inaccurate. Expanding the visibility of existing organizations that provide non-judgmental, non-directive, client-centered services appears warranted.
We would like to thank Drs. Paul Saurette and Raywat Deonandan for their input on earlier phases of this project. Kathryn LaRoche received an Ontario Graduate Scholarship and several internal grants from the University of Ottawa in support of this project. Dr. Foster’s Endowed Chair in Women’s Health Research is funded by the Ministry of Health and Long-Term Care in Ontario and we appreciate the general support for her time that made this project possible. We also received a $15K Challenge grant from Women’s Xchange at the Women’s College Hospital that supported a body of work related to post-abortion support in Ontario. Both authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. The conclusions and opinions expressed in this article are those of the authors and do not necessarily represent the views of the organizations with which the authors are affiliated or the funders.
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