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What the data says about abortion in the U.S.

Pew Research Center has conducted many surveys about abortion over the years, providing a lens into Americans’ views on whether the procedure should be legal, among a host of other questions.

In a  Center survey  conducted nearly a year after the Supreme Court’s June 2022 decision that  ended the constitutional right to abortion , 62% of U.S. adults said the practice should be legal in all or most cases, while 36% said it should be illegal in all or most cases. Another survey conducted a few months before the decision showed that relatively few Americans take an absolutist view on the issue .

Find answers to common questions about abortion in America, based on data from the Centers for Disease Control and Prevention (CDC) and the Guttmacher Institute, which have tracked these patterns for several decades:

How many abortions are there in the U.S. each year?

How has the number of abortions in the u.s. changed over time, what is the abortion rate among women in the u.s. how has it changed over time, what are the most common types of abortion, how many abortion providers are there in the u.s., and how has that number changed, what percentage of abortions are for women who live in a different state from the abortion provider, what are the demographics of women who have had abortions, when during pregnancy do most abortions occur, how often are there medical complications from abortion.

This compilation of data on abortion in the United States draws mainly from two sources: the Centers for Disease Control and Prevention (CDC) and the Guttmacher Institute, both of which have regularly compiled national abortion data for approximately half a century, and which collect their data in different ways.

The CDC data that is highlighted in this post comes from the agency’s “abortion surveillance” reports, which have been published annually since 1974 (and which have included data from 1969). Its figures from 1973 through 1996 include data from all 50 states, the District of Columbia and New York City – 52 “reporting areas” in all. Since 1997, the CDC’s totals have lacked data from some states (most notably California) for the years that those states did not report data to the agency. The four reporting areas that did not submit data to the CDC in 2021 – California, Maryland, New Hampshire and New Jersey – accounted for approximately 25% of all legal induced abortions in the U.S. in 2020, according to Guttmacher’s data. Most states, though,  do  have data in the reports, and the figures for the vast majority of them came from each state’s central health agency, while for some states, the figures came from hospitals and other medical facilities.

Discussion of CDC abortion data involving women’s state of residence, marital status, race, ethnicity, age, abortion history and the number of previous live births excludes the low share of abortions where that information was not supplied. Read the methodology for the CDC’s latest abortion surveillance report , which includes data from 2021, for more details. Previous reports can be found at  stacks.cdc.gov  by entering “abortion surveillance” into the search box.

For the numbers of deaths caused by induced abortions in 1963 and 1965, this analysis looks at reports by the then-U.S. Department of Health, Education and Welfare, a precursor to the Department of Health and Human Services. In computing those figures, we excluded abortions listed in the report under the categories “spontaneous or unspecified” or as “other.” (“Spontaneous abortion” is another way of referring to miscarriages.)

Guttmacher data in this post comes from national surveys of abortion providers that Guttmacher has conducted 19 times since 1973. Guttmacher compiles its figures after contacting every known provider of abortions – clinics, hospitals and physicians’ offices – in the country. It uses questionnaires and health department data, and it provides estimates for abortion providers that don’t respond to its inquiries. (In 2020, the last year for which it has released data on the number of abortions in the U.S., it used estimates for 12% of abortions.) For most of the 2000s, Guttmacher has conducted these national surveys every three years, each time getting abortion data for the prior two years. For each interim year, Guttmacher has calculated estimates based on trends from its own figures and from other data.

The latest full summary of Guttmacher data came in the institute’s report titled “Abortion Incidence and Service Availability in the United States, 2020.” It includes figures for 2020 and 2019 and estimates for 2018. The report includes a methods section.

In addition, this post uses data from StatPearls, an online health care resource, on complications from abortion.

An exact answer is hard to come by. The CDC and the Guttmacher Institute have each tried to measure this for around half a century, but they use different methods and publish different figures.

The last year for which the CDC reported a yearly national total for abortions is 2021. It found there were 625,978 abortions in the District of Columbia and the 46 states with available data that year, up from 597,355 in those states and D.C. in 2020. The corresponding figure for 2019 was 607,720.

The last year for which Guttmacher reported a yearly national total was 2020. It said there were 930,160 abortions that year in all 50 states and the District of Columbia, compared with 916,460 in 2019.

• How the CDC gets its data: It compiles figures that are voluntarily reported by states’ central health agencies, including separate figures for New York City and the District of Columbia. Its latest totals do not include figures from California, Maryland, New Hampshire or New Jersey, which did not report data to the CDC. ( Read the methodology from the latest CDC report .)
• How Guttmacher gets its data: It compiles its figures after contacting every known abortion provider – clinics, hospitals and physicians’ offices – in the country. It uses questionnaires and health department data, then provides estimates for abortion providers that don’t respond. Guttmacher’s figures are higher than the CDC’s in part because they include data (and in some instances, estimates) from all 50 states. ( Read the institute’s latest full report and methodology .)

While the Guttmacher Institute supports abortion rights, its empirical data on abortions in the U.S. has been widely cited by  groups  and  publications  across the political spectrum, including by a  number of those  that  disagree with its positions .

These estimates from Guttmacher and the CDC are results of multiyear efforts to collect data on abortion across the U.S. Last year, Guttmacher also began publishing less precise estimates every few months , based on a much smaller sample of providers.

The figures reported by these organizations include only legal induced abortions conducted by clinics, hospitals or physicians’ offices, or those that make use of abortion pills dispensed from certified facilities such as clinics or physicians’ offices. They do not account for the use of abortion pills that were obtained  outside of clinical settings .

(Back to top)

The annual number of U.S. abortions rose for years after Roe v. Wade legalized the procedure in 1973, reaching its highest levels around the late 1980s and early 1990s, according to both the CDC and Guttmacher. Since then, abortions have generally decreased at what a CDC analysis called  “a slow yet steady pace.”

Guttmacher says the number of abortions occurring in the U.S. in 2020 was 40% lower than it was in 1991. According to the CDC, the number was 36% lower in 2021 than in 1991, looking just at the District of Columbia and the 46 states that reported both of those years.

(The corresponding line graph shows the long-term trend in the number of legal abortions reported by both organizations. To allow for consistent comparisons over time, the CDC figures in the chart have been adjusted to ensure that the same states are counted from one year to the next. Using that approach, the CDC figure for 2021 is 622,108 legal abortions.)

There have been occasional breaks in this long-term pattern of decline – during the middle of the first decade of the 2000s, and then again in the late 2010s. The CDC reported modest 1% and 2% increases in abortions in 2018 and 2019, and then, after a 2% decrease in 2020, a 5% increase in 2021. Guttmacher reported an 8% increase over the three-year period from 2017 to 2020.

As noted above, these figures do not include abortions that use pills obtained outside of clinical settings.

Guttmacher says that in 2020 there were 14.4 abortions in the U.S. per 1,000 women ages 15 to 44. Its data shows that the rate of abortions among women has generally been declining in the U.S. since 1981, when it reported there were 29.3 abortions per 1,000 women in that age range.

The CDC says that in 2021, there were 11.6 abortions in the U.S. per 1,000 women ages 15 to 44. (That figure excludes data from California, the District of Columbia, Maryland, New Hampshire and New Jersey.) Like Guttmacher’s data, the CDC’s figures also suggest a general decline in the abortion rate over time. In 1980, when the CDC reported on all 50 states and D.C., it said there were 25 abortions per 1,000 women ages 15 to 44.

That said, both Guttmacher and the CDC say there were slight increases in the rate of abortions during the late 2010s and early 2020s. Guttmacher says the abortion rate per 1,000 women ages 15 to 44 rose from 13.5 in 2017 to 14.4 in 2020. The CDC says it rose from 11.2 per 1,000 in 2017 to 11.4 in 2019, before falling back to 11.1 in 2020 and then rising again to 11.6 in 2021. (The CDC’s figures for those years exclude data from California, D.C., Maryland, New Hampshire and New Jersey.)

The CDC broadly divides abortions into two categories: surgical abortions and medication abortions, which involve pills. Since the Food and Drug Administration first approved abortion pills in 2000, their use has increased over time as a share of abortions nationally, according to both the CDC and Guttmacher.

The majority of abortions in the U.S. now involve pills, according to both the CDC and Guttmacher. The CDC says 56% of U.S. abortions in 2021 involved pills, up from 53% in 2020 and 44% in 2019. Its figures for 2021 include the District of Columbia and 44 states that provided this data; its figures for 2020 include D.C. and 44 states (though not all of the same states as in 2021), and its figures for 2019 include D.C. and 45 states.

Guttmacher, which measures this every three years, says 53% of U.S. abortions involved pills in 2020, up from 39% in 2017.

Two pills commonly used together for medication abortions are mifepristone, which, taken first, blocks hormones that support a pregnancy, and misoprostol, which then causes the uterus to empty. According to the FDA, medication abortions are safe  until 10 weeks into pregnancy.

Surgical abortions conducted  during the first trimester  of pregnancy typically use a suction process, while the relatively few surgical abortions that occur  during the second trimester  of a pregnancy typically use a process called dilation and evacuation, according to the UCLA School of Medicine.

In 2020, there were 1,603 facilities in the U.S. that provided abortions,  according to Guttmacher . This included 807 clinics, 530 hospitals and 266 physicians’ offices.

While clinics make up half of the facilities that provide abortions, they are the sites where the vast majority (96%) of abortions are administered, either through procedures or the distribution of pills, according to Guttmacher’s 2020 data. (This includes 54% of abortions that are administered at specialized abortion clinics and 43% at nonspecialized clinics.) Hospitals made up 33% of the facilities that provided abortions in 2020 but accounted for only 3% of abortions that year, while just 1% of abortions were conducted by physicians’ offices.

Looking just at clinics – that is, the total number of specialized abortion clinics and nonspecialized clinics in the U.S. – Guttmacher found the total virtually unchanged between 2017 (808 clinics) and 2020 (807 clinics). However, there were regional differences. In the Midwest, the number of clinics that provide abortions increased by 11% during those years, and in the West by 6%. The number of clinics  decreased  during those years by 9% in the Northeast and 3% in the South.

The total number of abortion providers has declined dramatically since the 1980s. In 1982, according to Guttmacher, there were 2,908 facilities providing abortions in the U.S., including 789 clinics, 1,405 hospitals and 714 physicians’ offices.

The CDC does not track the number of abortion providers.

In the District of Columbia and the 46 states that provided abortion and residency information to the CDC in 2021, 10.9% of all abortions were performed on women known to live outside the state where the abortion occurred – slightly higher than the percentage in 2020 (9.7%). That year, D.C. and 46 states (though not the same ones as in 2021) reported abortion and residency data. (The total number of abortions used in these calculations included figures for women with both known and unknown residential status.)

The share of reported abortions performed on women outside their state of residence was much higher before the 1973 Roe decision that stopped states from banning abortion. In 1972, 41% of all abortions in D.C. and the 20 states that provided this information to the CDC that year were performed on women outside their state of residence. In 1973, the corresponding figure was 21% in the District of Columbia and the 41 states that provided this information, and in 1974 it was 11% in D.C. and the 43 states that provided data.

In the District of Columbia and the 46 states that reported age data to  the CDC in 2021, the majority of women who had abortions (57%) were in their 20s, while about three-in-ten (31%) were in their 30s. Teens ages 13 to 19 accounted for 8% of those who had abortions, while women ages 40 to 44 accounted for about 4%.

The vast majority of women who had abortions in 2021 were unmarried (87%), while married women accounted for 13%, according to  the CDC , which had data on this from 37 states.

In the District of Columbia, New York City (but not the rest of New York) and the 31 states that reported racial and ethnic data on abortion to  the CDC , 42% of all women who had abortions in 2021 were non-Hispanic Black, while 30% were non-Hispanic White, 22% were Hispanic and 6% were of other races.

Looking at abortion rates among those ages 15 to 44, there were 28.6 abortions per 1,000 non-Hispanic Black women in 2021; 12.3 abortions per 1,000 Hispanic women; 6.4 abortions per 1,000 non-Hispanic White women; and 9.2 abortions per 1,000 women of other races, the  CDC reported  from those same 31 states, D.C. and New York City.

For 57% of U.S. women who had induced abortions in 2021, it was the first time they had ever had one,  according to the CDC.  For nearly a quarter (24%), it was their second abortion. For 11% of women who had an abortion that year, it was their third, and for 8% it was their fourth or more. These CDC figures include data from 41 states and New York City, but not the rest of New York.

Nearly four-in-ten women who had abortions in 2021 (39%) had no previous live births at the time they had an abortion,  according to the CDC . Almost a quarter (24%) of women who had abortions in 2021 had one previous live birth, 20% had two previous live births, 10% had three, and 7% had four or more previous live births. These CDC figures include data from 41 states and New York City, but not the rest of New York.

The vast majority of abortions occur during the first trimester of a pregnancy. In 2021, 93% of abortions occurred during the first trimester – that is, at or before 13 weeks of gestation,  according to the CDC . An additional 6% occurred between 14 and 20 weeks of pregnancy, and about 1% were performed at 21 weeks or more of gestation. These CDC figures include data from 40 states and New York City, but not the rest of New York.

About 2% of all abortions in the U.S. involve some type of complication for the woman , according to an article in StatPearls, an online health care resource. “Most complications are considered minor such as pain, bleeding, infection and post-anesthesia complications,” according to the article.

The CDC calculates  case-fatality rates for women from induced abortions – that is, how many women die from abortion-related complications, for every 100,000 legal abortions that occur in the U.S .  The rate was lowest during the most recent period examined by the agency (2013 to 2020), when there were 0.45 deaths to women per 100,000 legal induced abortions. The case-fatality rate reported by the CDC was highest during the first period examined by the agency (1973 to 1977), when it was 2.09 deaths to women per 100,000 legal induced abortions. During the five-year periods in between, the figure ranged from 0.52 (from 1993 to 1997) to 0.78 (from 1978 to 1982).

The CDC calculates death rates by five-year and seven-year periods because of year-to-year fluctuation in the numbers and due to the relatively low number of women who die from legal induced abortions.

In 2020, the last year for which the CDC has information , six women in the U.S. died due to complications from induced abortions. Four women died in this way in 2019, two in 2018, and three in 2017. (These deaths all followed legal abortions.) Since 1990, the annual number of deaths among women due to legal induced abortion has ranged from two to 12.

The annual number of reported deaths from induced abortions (legal and illegal) tended to be higher in the 1980s, when it ranged from nine to 16, and from 1972 to 1979, when it ranged from 13 to 63. One driver of the decline was the drop in deaths from illegal abortions. There were 39 deaths from illegal abortions in 1972, the last full year before Roe v. Wade. The total fell to 19 in 1973 and to single digits or zero every year after that. (The number of deaths from legal abortions has also declined since then, though with some slight variation over time.)

The number of deaths from induced abortions was considerably higher in the 1960s than afterward. For instance, there were 119 deaths from induced abortions in  1963  and 99 in  1965 , according to reports by the then-U.S. Department of Health, Education and Welfare, a precursor to the Department of Health and Human Services. The CDC is a division of Health and Human Services.

Note: This is an update of a post originally published May 27, 2022, and first updated June 24, 2022.

Jeff Diamant is a senior writer/editor focusing on religion at Pew Research Center .

Besheer Mohamed is a senior researcher focusing on religion at Pew Research Center .

Rebecca Leppert is a copy editor at Pew Research Center .

Cultural Issues and the 2024 Election

Support for legal abortion is widespread in many places, especially in europe, public opinion on abortion, americans overwhelmingly say access to ivf is a good thing, broad public support for legal abortion persists 2 years after dobbs, most popular.

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• Published: 02 January 2024

Psychological traits and public attitudes towards abortion: the role of empathy, locus of control, and need for cognition

• Jiuqing Cheng 1 ,
• Ping Xu 2 &
• Chloe Thostenson 1  

Humanities and Social Sciences Communications volume  11 , Article number:  23 ( 2024 ) Cite this article

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In the summer of 2022, the U.S. Supreme Court overturned the historic Roe v. Wade ruling, prompting various states to put forth ballot measures regarding state-level abortion rights. While earlier studies have established associations between demographics, such as religious beliefs and political ideologies, and attitudes toward abortion, the current research delves into the role of psychological traits such as empathy, locus of control, and need for cognition. A sample of 294 U.S. adults was obtained via Amazon Mechanical Turk, and participants were asked to provide their attitudes on seven abortion scenarios. They also responded to scales measuring empathy toward the pregnant woman and the unborn, locus of control, and need for cognition. Principal Component Analysis divided abortion attitudes into two categories: traumatic abortions (e.g., pregnancies due to rape) and elective abortions (e.g., the woman does not want the child anymore). After controlling for religious belief and political ideology, the study found psychological factors accounted for substantial variation in abortion attitudes. Notably, empathy toward the pregnant woman correlated positively with abortion support across both categories, while empathy toward the unborn revealed an inverse relationship. An internal locus of control was positively linked to support for both types of abortions. Conversely, external locus of control and need for cognition only positively correlated with attitudes toward elective abortion, showing no association with traumatic abortion attitudes. Collectively, these findings underscore the significant and unique role psychological factors play in shaping public attitudes toward abortion. Implications for research and practice were discussed.

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The U.S. Supreme Court overturned the long-time landmark ruling of Roe v. Wade in 2022 summer. Debates and legal challenges regarding legal abortion in the U.S. have been heated (Felix et al., 2023 ). Furthermore, residents in several states have or will cast their vote on a ballot measure to determine abortion rights at the state level. A Gallup poll released in 2023 summer found that about one third of voters indicated that they would only vote for a candidate who shared their views on abortion (Saad, 2023 ). Therefore, it is imperative to understand people’s attitudes toward abortion. Past research on such attitudes have mainly focused on the role of political ideology and religious belief (e.g., Hess and Rueb, 2005 ); however, to our knowledge, relatively few studies have been done to examine the psychological underpinnings. Here we propose that examining the correlations between psychological factors and attitudes toward abortion has the potential to make contributions from the perspectives of both research and practice.

First, compared to attitudes in everyday life such as attitudes toward a product or brand, attitudes toward abortion are unique because it often elicits strong emotional response and conflict experience (Foster et al., 2012 ; Scott, 1989 ). Moreover, such an attitude goes beyond individual preference as it is deeply intertwined with one’s moral and religious beliefs, cultural background, and societal norms. Debate on abortion is not merely about a personal choice; it is about the definitions of life, rights, and autonomy (Osborne et al., 2022 ; Scott, 1989 ). For abortion, the contrasting views may lead to polarized opinions. In contrast, disagreements about a product or brand preference are typically less emotionally charged and do not carry the same societal weight. Therefore, given the unique nature of attitudes toward abortion as described above, it remains unclear whether psychological factors that correlate with attitudes in other areas still apply and, if so, in what capacity they do so. Additionally, as introduced below, several studies in this area employed a qualitative approach (interview). While the qualitative approach offered valuable insights into individuals’ perspectives on abortion, we aim to expand upon these findings by employing a quantitative approach. Especially, the quantitative approach allows us to explore the unique relationship between psychology and abortion attitudes after statistically controlling for other powerful factors like religious belief and political ideology. Together, a major goal of the present study is to provide initial empirical evidence for the correlations between attitudes toward abortion and certain psychological factors. We will further detail how our study might fill research gaps when introducing specific psychological factors as described below.

Second, examining the correlations between psychological factors and attitudes toward abortion may also offer practical insights. Consider the role of thinking style, for instance. The decision to pursue an abortion is imperative and often a prominently salient one, impacting not just the pregnant woman but also her family and extensive social network. Such a decision is complex and challenging due to intense feelings (e.g., conflict) and the balance between a woman’s bodily autonomy and fetal rights. From this viewpoint, there might be a correlation between attitudes toward abortion and one’s thinking style, especially their willingness to address complex and difficult issues. Past research has highlighted the connection between rational decision-making and the availability of relevant information (Shafir and LeBoeuf, 2002 ). Hence, to facilitate informed decisions, comprehensive knowledge about abortion is both essential and beneficial. The present study will examine the relationship between thinking style and abortion attitudes. Should a correlation be identified, our study would suggest individuals engage more deeply in critical thinking about the issues of abortion to enhance abortion-related education and informed decision-making.

Together, the present study aims to shed more light on the unique role of psychology in abortion attitudes, particularly in the presence of political ideology and religious belief. Specifically, we choose to examine the factors of empathy, locus of control, and thinking style (need for cognition) based on three considerations. Firstly, from a face validity perspective, the psychological constructs are predicted to exhibit a relationship with abortion attitudes. For example, the internal locus of control aligns well with the pro-choice mantra, ‘my body, my choice. Secondly, as detailed below, although these constructs have been explored in previous studies, they have only received limited attention and their relations with abortion attitudes remain inconclusive. Hence, our study aims to fill the gaps from past research by further clarifying their roles in attitudes toward abortion. Thirdly, research has indicated significant intersections between elements like cognitive style, empathy, and locus of control with various decisions, especially in health contexts (Marton et al., 2021 ; Pfattheicher et al., 2020 ; Xu and Cheng, 2021 ). These elements are tied to motivation, information analysis, and make trade-offs (Fischhoff and Broomell, 2020 ). Building on this, our study seeks to explore the applicability of these factors to the deeply sensitive and polarizing decision of abortion. On the other hand, it is worth noting that the psychological factors examined in our study are not exhaustive or driven by theoretical considerations. However, as mentioned in recent publications (Osborne et al., 2022 ; Valdez et al., 2022 ), past research on abortion attitudes with a psychological perspective is still limited. Therefore, our hope is that the present study could provide initial yet meaningful empirical evidence to exhibit the sophisticated role of psychology in attitudes toward abortion. We detail our rationales for each factor below.

Empathy refers to a variety of cognitive and affective responses, including sharing and understanding, toward others’ experiences (Pfattheicher et al., 2020 ). Previous studies have demonstrated a positive association between empathy and prosocial behaviors, such as caring for others (Moudatsou et al., 2020 ; Klimecki et al., 2016 ), as well as a reduction in conflict and stigma (Batson et al., 1997 ; Klimecki, 2019 ). Recently, Pfattheicher et al. ( 2020 ) also demonstrated that inducing empathy for the vulnerable people could promote taking preventative measures during the Covid-19 pandemic. While researchers advocated for incorporating empathy into abortion-related mental health intervention (Brown et al., 2022 ), the role of empathy in attitudes toward abortion remains understudied. Hunt ( 2019 ) investigated the impact of empathy toward pregnant women by presenting testimonial videos in which a pregnant woman described the challenges she faced due to legal abortion restrictions in Arkansas. However, this manipulation did not significantly reduce participants’ support for the abortion restrictions. Research has found that people’s views on abortion tends to be stable over time (Jelen and Wilcox, 2003 ; Pew Research Center, 2022 ). Hence, a short video used in Hunt ( 2019 ) might not be able to change people’s long-held views on abortion. Instead, we here hypothesize that the pre-existing but not temporality induced empathy play a role in abortion attitudes.

Furthermore, in addition to the empathy toward pregnant woman, it is also reasonable to assume that (some) people may feel empathy toward the unborn. For instance, interviews with Protestant religious leaders exhibited empathy toward both pregnant women and unborn (Dozier et al., 2020 ). Embree ( 1998 ) asked participants to indicate their opinions when responding to different scenarios of abortion. As a result, the study found that 64% and 17% of participants showed a moderate and strong level of empathy for the unborn, respectively. Despite the informative findings, the relationship between attitudes toward abortion and empathy toward the unborn remains unclear, particularly when taking empathy toward pregnant woman and other factors (e.g., political ideology) into account.

Together, we raise three hypotheses regarding the role of empathy as shown below.

H1a: Empathy toward pregnant woman and unborn can coexist.

H1b: People’s empathy toward pregnant woman are positively related to the support toward abortion.

H1c: People’s empathy toward unborn are negatively related to the support toward abortion.

As empathy has been highlighted in the intervention process when dealing with abortion-related mental health issues (Brown et al., 2022 ; Whitaker et al., 2015 ), we hope our findings could generate implications for future research and practice.

Locus of control

Locus of control (LOC) refers to people’s beliefs regarding whether their life outcomes are controlled and determined by their own (internal LOC) or external resources (fate, chance and/or powerful people, external LOC) (Levenson, 1981 ). Before delving into details, it is important to note that the internal and external LOC refer to different dimensions and are not mutually exclusive (Levenson, 1981 ; Reknes et al., 2019 ). For example, a person’s success may be determined by both hardworking and support from others. Regarding abortion attitudes, Sundstrom et al. ( 2018 ) analyzed interview contents and found that some women’s thoughts on pregnancy and abortion aligned with an internal locus of control (e.g., “As women, we need to take control as much as possible of our reproductive health”), while others aligned with an external locus of control (e.g., “leave it in God’s hands…we’ll just play it by ear and if I get pregnant, I get pregnant”).

The findings from Sundstrom et al. ( 2018 ) were informative and consistent with common sense. For example, at face value level, the slogan of “my body my choice” well aligns with the concept of internal LOC. However, the role of internal LOC in abortion attitudes may be more complicated. That is, religious belief may complicate the association between internal LOC and abortion attitudes. Past studies, including a meta-analysis and a study with over 20,000 participants, found a positive relationship between internal LOC and religious belief (Coursey et al., 2013 ; Falkowski, 2000 ; Iles-Caven et al., 2020 ). As noted in these articles, there are similarities between internal LOC and religious belief. For instance, religious beliefs often provide individuals with a sense of meaning, purpose, and guidance in life. Meanwhile, people higher in internal LOC are more likely to report higher levels of existential well-being and purpose in life, which can be associated with religious belief and engagement (Kim-Prieto et al., 2005 ; Krause and Hayward, 2013 ). Thus, the relationship between internal LOC and religious belief may complicate how internal LOC is involved in the abortion attitudes. Sundstrom et al. ( 2018 ) used interviews to explore the role of LOC in thoughts about abortion. However, this method might not sufficiently differentiate the influence of religious beliefs. In this study, we adopt a quantitative approach, using a classical scale to measure LOC. We aim to empirically assess the relationship between internal LOC and attitudes toward abortion, especially when accounting for religious belief. Furthermore, considering that the relationship between internal LOC and abortion attitudes might be intertwined with religious beliefs, we refrain from positing a specific hypothesis at this point.

External LOC, on the other hand, does not appear to have a significant relationship with religious belief. Additionally, a few studies found that people higher in external LOC tended to attribute outcomes to external reasons (Falkowski, 2000 ; Reknes et al., 2019 ). Building on this concept, individuals with a higher external locus of control (LOC) may be more inclined to attribute pregnancy to external factors and place less emphasis on personal responsibility. Accordingly, we predict the hypothesis below.

H2: External LOC will be positively related to the support toward abortion.

Need for cognition

Based on face validity, thinking style might pertain to one’s perception of abortion. For instance, individuals who prioritize comprehensive and empirical data might arrive at a different conclusion than those who lean on personal stories and emotional narratives. A few studies have tapped into the relationship between thinking style and attitudes toward abortion. Valdez et al. ( 2022 ) conducted qualitative interviews on abortion and employed natural language processing techniques to analyze the interviews. The study identified analytical thinking, which involved considering abortion from multiple perspectives, had a negative relationship with the number of cognitive distortions (such as polarized and rigid thinking about abortion). However, such a finding conflicted with another study by Hill ( 2004 ) where the concept of cognitive complexity (thinking beyond surface-level observations) did not correlate with attitudes toward abortion. The inconsistency might be due to methodological issues. For example, the correlations described above in Valdez et al. ( 2022 ) were derived from a small sample consisting of 16 participants. A low reliability of the cognitive complexity scale used in Hill ( 2004 ) might (partly) address the non-significant relationship. Thus, the present study will utilize the Need for Cognition scale, a widely recognized and validated instrument that measures thinking style, to examine its correlation with attitudes toward abortion in a larger sample.

Need for cognition (NFC) pertains to the inclination to derive satisfaction from and actively participate in effortful thinking (Cacioppo et al., 1984 ). Consistent with its concept, past research demonstrated that NFC was positively correlated with information seeking (Verplanken et al., 1992 ), academic achievement (Richardson et al., 2012 ), and logical reasoning performance (Ding et al., 2020 ). As for attitudes toward abortion, we hypothesize the following.

H3: There will be a positive correlation between NFC and attitudes toward abortion.

Our prediction is based on two reasons. First, NFC drives individuals to actively seek and update information and knowledge. It was discovered that acquiring a deeper understanding of abortion correlated with increased support for it (Hunt, 2019 ; Mollen et al., 2018 ). Second and relatedly, NFC was found to be negatively associated with various stereotype memories and positively related to non-prejudicial social judgments (Crawford and Skowronski, 1998 ; Curşeu and de Jong, 2017 ).

In sum, the present study aims to provide empirical evidence for the association between attitudes toward abortion and psychology by examining and clarifying the role of empathy, locus of control, and need for cognition. Past research has repeatedly found the involvement of political ideology and religious belief in abortion attitudes (e.g., Hess and Rueb, 2005 ; Holman et al., 2020 ; Jelen, 2017 ; Osborne et al., 2022 ; Prusaczyk and Hodson, 2018 ). Given their powerful and robust effect, it is crucial to gather additional empirical evidence to elucidate the distinct contribution of psychology to attitudes toward abortion, while considering the influence of political ideology and religious beliefs. Additionally, when describing attitudes toward abortion, the dichotomization of “pro-choice” and “pro-life” have been widely used for decades. However, some studies have criticized that the dichotomization oversimplified attitudes toward abortion (Hunt, 2019 ; Osborne et al., 2022 ; Rye and Underhill, 2020 ). That is, people’s views on abortion vary across different scenarios and reasons. For instance, people showed less support toward abortion with elective reasons than with traumatic reasons (Hoffmann and Johnson, 2005 ). With confirmatory analysis, Osborne et al. ( 2022 ) derived two types of abortion: traumatic (e.g., pregnancy due to rape) vs. elective (e.g., the woman does not want the child anymore). Building on prior research, the current study aims exploring potential variations in attitudes across different abortion reasons. Furthermore, we also intend to examine whether the psychological factors described above have varying associations with different types of abortion.

Participants

The study was approved by IRB before data collection. Participants were recruited from Amazon Mechanical Turk (mTurk) on October 20th, 2022. To be eligible for the study, participants must be an adult, a U.S. citizen, and have an approval rating greater than 98% in mTurk. A total of 300 participants were enrolled into the study. Each participant received $3 for compensation. Six participants did not complete at least 80% of the items and were removed from the study. Thus, the effective sample size was 294. Demographics are presented in the Results section.

Materials and procedures

Participants took an online survey developed by Qualtrics. Our study did not set a specific time restriction. Across 294 participants, the average survey completion time was 682.8 s (SD = 286.6 s). The median completion time was 595.0 s (IQR = 344.8 s). The following questionnaires were completed.

Attitudes toward abortion

Hoffmann and Johnson ( 2005 ) and Osborne et al. ( 2022 ) analyzed attitudes toward abortion with six different scenarios (scenarios a-f below) that were measured by the U.S. General Social Survey. We further added an additional item regarding underage pregnancy for two reasons. First, compared to other Western industrialized nations, the U.S. has historically had a higher rate of underage pregnancies. Additionally, underage pregnant individuals tended to have a higher likelihood of seeking abortions compared to their older counterparts (Lantos et al., 2022 ; Kearney and Levine, 2012 ; Sedgh et al., 2015 ). Second, underage pregnancy is linked to various adverse outcomes, such as increased risk during childbirth, heightened stress and depression, disruptions in education, and financial challenges (Eliner et al., 2022 ; Hodgkinson et al., 2014 ; Kearney and Levine, 2012 ). Given the significance and prevalence of underage pregnancy, we chose to include it as a scenario to understand the public’s perception. Additionally, we understood that people might feel conflict or uncertain toward one or more scenarios. Hence, instead of using binary response (yes/no format) adopted in the U.S. General Social Survey, we employed a 1 to 7 Likert scale for each scenario, with a higher score indicating stronger support for a pregnant woman to obtain legal abortion.

The seven scenarios in the present study included: (a) there is a strong chance of serious defect in the baby; (b) the woman’s own health is seriously endangered by the pregnancy; (c) the woman became pregnant as a result of rape; (d) the woman is married and does not want any more children; (e) the family has a very low income and cannot afford any more children; (f) the woman is not married and does not want to marry the man; and (g) the woman is underage.

Following the wording used to measure empathy in Pfattheicher et al. ( 2020 ), we developed six items to measure the empathy toward the pregnant woman and unborn or fetus, respectively. The scale of empathy toward pregnant woman included: (a) I am very concerned about the pregnant woman who may lose access to legal abortion; (b) I feel compassion for the pregnant women who may lose access to legal abortion; and (c) I am quite moved by the pregnant women who may lose access to legal abortion. The scale of empathy toward unborn included: (a) I am very concerned about the fetus or unborn child; (b) I feel compassion for the fetus or unborn child; and (c) I am quite moved by the fetus or unborn child. Participants rated each item on a five-point Likert scale, with 1 being strongly disagree and 5 being strongly agree. Thus, a higher score demonstrated stronger empathy toward the target. The Cronbach’s α for the scale of toward pregnant woman was 0.90 in the present study. The Cronbach’s α for the scale of toward unborn was 0.92.

The need for cognition scale (NFC, Cacioppo et al., 1984 ) intends to measure the tendency to engage into deep thinking. It has 18 items, such as “I only think as hard as I have to” and “I find satisfaction in deliberating hard and for long hours”. Participants rated each item on a five-point Likert scale, with a higher score indicating a greater tendency to enjoy deep thinking. In the present study, the reliability of this scale was 0.93.

The present study adopted Levenson multidimensional locus of control scale (Levenson, 1981 ). Across 24 items, this scale measures three dimensions of locus of control: internality (sample item: Whether or not I get to be a leader depends mostly on my ability); powerful others (sample item: I feel like what happens in my life is mostly determined by powerful people); and chance (sample item: To a great extent my life is controlled by accidental happenings). In the present study, participants rated each item on a 1 to 6 Likert scale, with a higher score indicating a stronger belief that fate was controlled by self, powerful others, or chance. The Cronbach’s α for the subscales of internality, powerful others, and chance was 0.84, 0.91, and 0.93, respectively. As shown below, there was a high agreement between powerful others and chance subscales ( r  = 0.87, p  < 0.001). Hence, we combined these two subscales to form an external locus of control composite.

Demographics

After completing the scales described above, participants were asked to report their demographic information including race, age, gender, education, annual household income, current relationship status, abortion experience, religious belief, and political ideology. Gender was coded with 1 = male, 2 = female, and 3 = other. Race was coded with 1 = White or Caucasian, 2 = Hispanic or Latinx, 3 = Black or African American, 4 = Asian or Asian American, and 5 = Other. Education was coded with six levels: 1 = Less than high school graduate, 2 = High school graduate or equivalent, 3 = Some college or associate degree, 4 = Bachelor’s degree, 5 = Master’s degree, 6 = Doctoral degree. Annual household income was categorized into 13 levels and ranged between under $9,999 and above $120,000 with increments of $9,999. Current relationship status was coded into six levels: 1 = single and not dating, 2 = single but in a relationship, 3 = married, 4 = divorced, 5 = widowed, 6 = other. For abortion experience participants were asked “For any reason, have you had an abortion?”. For this question, the answer was coded with 1 = yes and 2 = no.

Religious belief was measured with three items. The first item asked “How often do you attend religious services?” Participants selected one option out of the following: 1 = never, 2 = a few times per year, 3 = once a month, 4 = 2–3 times a month, 5 = once a week or more. The second item asked “How important is religion to you personally?” Participants rated this question on a five-point Likert point, with 5 being most important. The third question asked “How would you describe your religious denomination”. The options included 1 = Christian, 2 = Islam, 3 = Judaism, 4 = Buddhism, 5 = Hinduism, 6 = other or atheism. In the present study, the first two items were highly correlated ( r  = 0.77, p  < 0.001). Following Hunt ( 2019 ), we combined the two items to form a general religiosity composite, with a higher score indicating a stronger religious belief.

Political ideology was measured with two items: (a) Generally, how would you describe your views on most social political issues (e.g., education, religious freedom, death penalty, gender issues, etc.)? and (b) Generally, how would you describe your views on most economic political issues (e.g., minimum wage, taxes, welfare programs, etc.)? Participants rated each item with a five-point Likert scale, with 1 = strongly conservative 2 = conservative 3 = moderate 4 = liberal 5 = strongly liberal. We found a strong correlation between the two political ideology items, r  = 0.76, p  < 0.001. Hence, we combined the two items to form a general political ideology composite.

SPSS 24.0 was employed to perform all the analyses. Across 294 participants, age ranged from 21 to 79, with a mean of 40.4 and a standard deviation of 12.4. Table 1 displays the descriptive statistics for the variables of gender, race, education, annual household income, current relationship status, religious denomination, and abortion experience.

Table 2 presents the descriptive statistics of attitudes toward abortion in different scenarios, religious belief, political ideology, and the scores of the psychological scales. Similar to the results obtained from the large-scale surveys in the U.S. and New Zealand (Osborne et al., 2022 ), the support toward abortion was strong (neutral = 4) across all scenarios.

To examine the structure of attitudes toward abortion in different scenarios, a Principal Component Analysis (PCA) with a Varimax orthogonal rotation was performed on all seven scenarios. With eigenvalue ≥ 1 as the threshold, two components were generated, accounting for 81.34% of the variability. Table 3 presents the PCA results. As shown, we obtained two distinct components. The first one included the scenarios of baby defection, pregnant woman’s health being endangered, pregnancy caused by rape, and underage pregnancy. The second component included the scenarios of not wanting the child, low income, and not wanting to marry. Such a differentiation between the two components was consistent with the notion in Osborne et al. ( 2022 ). Following this paper and the face validity of the scenarios, we labeled the two components traumatic abortion and elective abortion, respectively. Accordingly, we also computed a composite score for each component by averaging the corresponding items. In line with previous research (Hoffmann and Johnson, 2005 ), the support was significantly stronger toward the traumatic abortion (mean = 5.84, SD = 1.24) than the elective abortion (mean = 4.94, SD = 1.74), t (293) = 11.51, p  < 0.001, Cohen’s d  = 0.67.

Table 4 presents the zero-order correlations between attitudes toward traumatic and elective abortions, demographics, and scores of the psychological factors. Consistent with the findings from past research (e.g., Hess and Rueb, 2005 ; Holman et al., 2020 ), a stronger religious belief was negatively related to the support toward both types of abortions. A stronger liberal ideology was positively related to the support toward both types of abortions. Additionally, empathy toward the pregnant woman was positively associated with the support toward both types of abortions whereas empathy toward unborn or fetus had an opposite effect. Based on the zero-order correlation, we did not find a significant relationship between internal locus of control and attitudes toward either type of abortion. The external locus of control (either powerful others or chance), on the other hand, was positively related to the support toward elective but not traumatic abortion. As there was a high agreement between the two external locus of control subscales ( r  = 0.87, p  < 0.001), we formed a general external locus of control composite by averaging the two items in the following regressions. Finally, need for cognition was positively related to attitudes toward elective abortion but not traumatic abortion.

While the zero-order correlations were informative, we were mindful that the Type I error might be greatly inflated due to a vast amount of repeated testing. Moreover, one goal of the study was to examine the role of psychological factors in the presence of religious belief and political ideology. Thus, we performed a hierarchical linear regression on each type of abortion, with age, gender, income, and education in the first block, religious belief and political ideology in the second block, and psychological factors in the third block. We separated the regression between the two types of abortion because the role of predictors might vary. This approach was also employed in Osborne et al. ( 2022 ). Table 5 exhibits the regression results.

As shown in Table 5 , the demographic variables of age, gender, education, and income did not account for a significant portion of the variability in attitudes toward either type of abortion. The present study added to the literature that there might not necessarily be a difference in attitudes toward abortion between males and females (Bilewicz et al., 2017 ; Jelen and Wilcox, 1997 ). By contrast, in the second block, religious belief and political ideology collectively explained a sizable portion of the variability in attitudes toward both types of abortion. In block 3, in the presence of demographic variables including religious belief and political ideology, psychological factors could still account for a significant portion of the variability.

Looking at the individual psychological predictors (for more detailed interpretations please refer to the discussion part), consistent with our hypothesis, empathy toward the pregnant woman was positively associated with the support toward both types of abortion. By contrast, empathy toward the unborn or fetus was negatively associated the support toward abortion. For the factor of locus of control, the internal locus of control was not related to any type of abortion attitudes when zero-order correlation was used (Table 4 ); yet it was positively related to abortion attitudes after all other predictors were taken into account, indicating a suppressing effect. Upon further examination, we identified two suppressors: religious belief and empathy toward the unborn. After removing these two variables, internal locus of control was no longer significant. The observed pattern reflected our previous prediction, indicating that the role of internal locus of control could be complicated by religious beliefs. External locus of control, on the other hand, was positively correlated with the support toward elective abortion. Similarly, need for cognition (NFC) also had a positive relationship with the support toward elective abortion. Neither external locus of control nor NFC had a significant correlation with attituded toward traumatic abortion. Hence, our hypotheses regarding external locus of control and NFC were partially supported. We detailed out interpretation and discussion of the results below.

The present study aimed to provide empirical evidence for the correlations between psychological factors and attitudes toward abortion. As introduced earlier, while it is common to find the involvement of psychology in everyday life attitudes and preferences, attitudes toward abortion are unique and drastically different. Given its unique nature, it lacks empirical evidence regarding whether psychological factors that interplay with attitudes in other areas still apply and, if so, in what capacity they do so. Past research has primarily focused on the role of religious belief and political ideology. Our study demonstrated a substantial involvement ( R 2 change = 0.27 and 0.24 for traumatic and elective abortion, respectively) of the psychological factors, after controlling for religious belief and political ideology. More importantly, these effects were comparable to the variability accounted for by religious belief and political ideology combined, particularly in the elective abortion category. The results highlighted the influential role of psychological factors in shaping attitudes toward abortion.

Additionally, past research has shown the interconnection between psychology and the public’s attitudes toward major societal events. For example, during the Covid-19 pandemic, while the perception of mask-wearing and/or social distancing was highly politicized, studies found that attitudes toward these preventative measures to be related to thinking style, self-control, numeracy, and working memory capacity (Steffen and Cheng, 2023 ; Xie et al., 2020 ; Xu and Cheng, 2021 ). In line with this, our study further underscored the significant influence of psychology on another pressing societal topic: abortion. In the sections below, we detail our findings and relevant implications. We are fully aware that our study was preliminary and hope it could serve as a starting point for future research and practice. We also acknowledge the limitations of our study and address them at the end.

Some past studies on empathy and abortion only considered the empathy toward the pregnant woman (e.g., Brown et al., 2022 ; Homaifar et al., 2017 ; Hunt, 2019 ; Whitaker et al., 2015 ). The present study identified two types of empathy when dealing abortion: empathy toward the pregnant woman and empathy toward the unborn. In the presence of each other, we found that greater empathy toward the pregnant woman was associated with more support toward abortion, whereas greater empathy toward the unborn or fetus was associated with less support toward abortion. Such a pattern suggested that empathy might be a source of conflict feeling. That is, when considering abortion, concerns and care toward pregnant woman and unborn could coexist, potentially leading to conflict and dilemma when people thought about abortion. While the present study examined the public’s attitudes toward abortion with a diverse sample, pregnant women might have a similar pattern of empathy and hence feel conflict and dilemma when thinking about abortion. To cope with such a conflict, it might be beneficial for a counselor to acknowledge conflicting emotions that arise from empathizing with both the unborn and the pregnant individual. Moreover, the counselor could guide the client through the process of reconciling these emotions to alleviate feelings of isolation or confusion the client may experience. Future research in the realms of mental health and counseling should consider integrating these dual empathy perspectives and empirically assess the efficacy of such therapeutic interventions.

Additionally, Hunt ( 2019 ) did not find a significant influence of empathy on abortion attitudes change when participants were exposed to testimonial videos featuring pregnant women discussing the legal obstacles they faced. The disparity between Hunt’s ( 2019 ) findings and our own could potentially be attributed to the inherent stability and longstanding nature of abortion attitudes. Research has found that people’s views on abortion tends to be stable over time (Jelen and Wilcox, 2003 ; Pew Research Center, 2022 ). As a result, it is possible that pre-existing empathy, rather than empathy induced temporarily, was the factor correlated with individuals’ perception and consideration of abortion. Our findings were consistent with this possibility. Together, our findings supported H1a to H1c. Moreover, our study shed more light on empathy by showing its association with distinct views on abortion. The results suggest that future research could investigate how different types of empathy are formed and how they influence the shaping and persuasion of abortion attitudes.

Through qualitative interviews, Sundstrom et al. ( 2018 ) unveiled individual differences in the locus of control when discussing opinions on abortion. However, these interviews might not have fully captured the interplay between internal and external locus of control and other factors involved attitudes toward abortion. To fill the gap, our study employed a quantitative approach to delve deeper into how locus of control correlated with abortion attitudes. Consistent with Levenson ( 1981 ) and Reknes et al. ( 2019 ), we found that the constructs internal locus of control and external locus of control were differentiated but not unidimensional. For internal locus of control, interestingly, we found a suppressing effect. As discussed earlier, the role of internal locus of control in abortion attitudes might be complicated. That is, on the one hand, by face validity, the internal locus of control well aligned with the concept of “my body, my choice” (Sundstrom et al., 2018 ). On the other hand, in line with past research (Coursey et al., 2013 ; Falkowski, 2000 ; Iles-Caven et al., 2020 ), our study found that internal locus of control was positively related to religious belief. Furthermore, as shown in Table 4 , internal locus of control was also positively related to the empathy toward the unborn, and such a relationship was significantly mediated by religious belief (mediation effect = 0.21, SE = 0.5, 95% CI = [0.13, 0.31]). Therefore, when using zero-order correlation, the effect of internal locus of control might be neutralized by the two opposite parts (“my body, my choice” vs. religious belief) discussed above. By contrast, in regression, the “my body, my choice” part stood out because the religiosity part was partialled out by the variables of religious belief and empathy toward the unborn.

In addition to internal locus of control, we also discovered that external locus of control was involved in abortion attitudes. Specifically, we found a positive relationship between external locus of control and support toward elective abortion (H2 was partially supported). Past research has found that locus of control is related to attribution (Falkowski, 2000 ; Reknes et al., 2019 ). Thus, our finding was in line with the notion that those with a greater level of external locus of control might be more likely to attribute unwanted pregnancy to external reasons (not personal responsibility), and hence showed more support toward abortion.

Our findings regarding locus of control suggest that individuals might simultaneously believe in personal autonomy (“my body, my choice”) while also feeling that certain life events, like unwanted pregnancies, are influenced by external factors beyond their control. This is particularly true when thinking about elective abortion. Education and counseling practices might be designed to reflect this duality. For example, materials and discussions could simultaneously emphasize the importance of personal choices and responsibilities, while also exploring societal, cultural, or circumstantial factors that might influence abortion decision. Incorporating both perspectives would allow to create a supportive environment where individuals feel seen and acknowledged in their complexities.

As introduced earlier, past research on the relationship between thinking style and abortion attitudes was inconclusive. To clarify the relationship, the present study adopted the validated need for cognition scale. Need for cognition has demonstrated its involvement in consequential events, such as political elections and the adoption of preventive measures during the Covid-19 pandemic (Sohlberg, 2019 ; Xu and Cheng, 2021 ). In the present study, we discovered that need for cognition was positively related to the support toward elective abortion. Such a finding was consistent with the notion that need for cognition was negatively related to stereotypes (Crawford and Skowronski, 1998 ; Curşeu and de Jong, 2017 ). Additionally, as need for cognition drives individuals to seek and update knowledge, our result was also in line with the finding that gaining knowledge about abortion led to more positive view on abortion (Hunt, 2019 ; Mollen et al., 2018 ). Our study implied that future research could empirically evaluate if indeed abortion knowledge mediates the relationship between need for cognition and abortion attitudes.

It is worth noting that the present study also clarified the role of need for cognition in attitudes toward abortion by examining a potential artifact. Specifically, the observed positive relationship between need for cognition and support for abortion might be an artifact, given that liberal ideology is positively correlated with both abortion attitudes and need for cognition (Young et al., 2019 ). However, as shown in our regression, the relationship between need for cognition and elective abortion remained significant in the presence of other variables, including political ideology. Thus, the finding suggested that at least part of the relationship between need for cognition and attitude toward abortion was unique and not driven by political ideology.

Our findings related to need for cognition had an implication on abortion-related education. As discussed earlier, having adequate knowledge about abortion could facilitate the support for making informed decisions. As need for cognition was found to be related to openness and motivation to seek and update information (Russo et al., 2022 ), our finding suggested that cultivating willingness to engage into critical thinking might be beneficial for education on abortion and reproductive rights. While we are fully aware that correlation does not equate to causation, our study still offers a starting point for future research and practice on abortion-related education.

Traumatic abortion vs. elective abortion

While some researchers argued that the dichotomization of “pro-choice” and “pro-life” was oversimplified, to date, only two studies have empirically examined attitude variation between different abortion scenarios (Hoffmann and Johnson, 2005 ; Osborne et al., 2022 ). Both studies demonstrated that public views on abortion can be grouped into two categories: traumatic and elective. Our research not only replicated these findings but also introduced two significant advancements. First, we incorporated a scenario addressing underage pregnancy, given its high prevalence and significance. Secondly, instead of a binary response, we employed a 7-point Likert scale, allowing us to more accurately capture potential conflicting attitudes among participants.

Furthermore, our findings revealed that the roles of external locus of control and need for cognition varied in relation to attitudes toward the two types of abortion. Interestingly, we observed that neither of these variables significantly related to attitudes toward traumatic abortion, as indicated by both zero-order correlation and regression analyses. Conceptually, the scenarios of traumatic abortion (e.g., pregnancy caused by rape; mother life endangered) tend to be more extreme and emergent than the scenarios of elective abortion. Hence, there might be less room for psychological factors, such as thinking or attribution, to function in traumatic abortion than in elective abortion. Our interpretation was also consistent with the statistical pattern between the two abortions. That is, compared to elective abortion, the standard deviation of traumatic abortion was smaller. Additionally, there were more participants rated seven on the Likert scale in the scenarios of traumatic abortion (29.6%) than in the scenarios of elective abortion (18%). Despite the difference between the two types of abortion, it is essential to acknowledge that elective abortion does not imply a stress-free experience. Both traumatic and elective abortions involve significant levels of stress and emotional challenges. While traumatic abortion scenarios can be considered more extreme, it is crucial to recognize that individuals undergoing elective abortion may also experience considerable emotional distress.

Taken together, with concrete evidence, our study demonstrated that the public’s attitude toward abortion depended on abortion reasons. Our study also implied that future research should focus on attitudes toward specific abortion scenarios rather than a holistic concept of abortion. Furthermore, the differentiation between the traumatic and elective abortions suggested the limitation and potential ineffectiveness of one-size-fits-all legislative solutions. Given the varying and often conflicting attitudes that people harbor, it would be reasonable for legislative frameworks to be flexible, adaptive, and cognizant of the different circumstances surrounding abortion. This will not only be more reflective of public opinions but also more supportive of individuals who undergo different types of abortion experiences, each of which carries its own set of emotional and psychological challenges.

Expanding findings with a quantitative approach

Some past studies employed a qualitive approach when dealing with attitudes toward abortion (e.g., Dozier et al., 2020 ; Sundstrom et al., 2018 ; Valdez et al., 2022 ; Woodruff et al., 2018 ). These investigations have provided insights and served as inspirations for our own research. However, the relationship between abortion attitudes and pertinent factors may remain somewhat opaque. This is particularly true when considering the intricate interconnectedness among these factors. The present study demonstrated that findings from qualitative studies could be extended and enriched with a quantitative approach. For instance, we utilized quantitative scales to measure empathy toward the unborn —a variable that was previously identified through interviews in the study by Dozier et al. ( 2020 ). Moreover, we further exhibited the role of empathy toward the unborn when statistically controlled other variables, including empathy toward the pregnant. Similarly, the role of internal locus of control was revealed in interviews in Sundstrom et al. ( 2018 ). With validated scales, we exhibited the correlation with internal locus of control in both types of abortion. Furthermore, by detecting and interpreting a suppressing effect, we showed the interplay between internal locus of control, religious belief, and attitude toward abortion. Thus, our study implied that using quantitative scales and analyses was a viable approach to examine attitude toward abortion and could deepen the understanding of relevant factors.

Limitations and future directions

Despite the contributions, limitations should be acknowledged as well. First and foremost, we believe our study was still in the explorative stage. The specific psychological factors tested in the present study were not exhaustive and not theoretically driven. We hope the present study could provide initial empirical evidence to show the sophisticated role of psychology in attitudes toward abortion. Future studies could use a more theoretical driven approach to examine the specific psychological involvement in abortion attitudes. For example, given the correlation between need for cognition and attitudes toward abortion, future research could further elucidate the role of thinking style in attitudes toward abortion by incorporating the Dual-Process Theory (Evans, 2008 ). The Dual-Process Theory posits that humans have two distinct systems of information processing: System 1, which is intuitive, automatic, and fast; and System 2, which is deliberate, analytical, and slower. By examining the interplay between these two systems, researchers might gain insights into how intuitive emotional responses versus more deliberate cognitive analyses influence individuals’ attitudes toward abortion. For instance, are individuals who predominantly rely on System 1 more swayed by emotive narratives or imagery related to abortion?

Second, when analyzing and discussing the results, we proposed several possible underlying mechanisms that might elucidate the relationships observed. To illustrate, we employed the concept of attribution to shed light on the role of an external locus of control, positing that individuals with a strong external locus might attribute abortion decisions to external factors or circumstances rather than personal choices. Furthermore, we suggested that the observed positive relationship between the need for cognition and abortion attitudes might be mediated through abortion knowledge. This implies that individuals with a higher need for cognition could potentially seek out more information on abortion, leading to more informed attitudes. However, while these interpretations offer potential insights, we recognize their speculative nature. It’s crucial to emphasize that our proposed mechanisms require rigorous empirical testing for validation. For example, it would be of interest to test whether indeed, gaining various types of abortion knowledge improves views of abortion.

Third, as described above, we strived to show how our findings could be potentially used in abortion-related counseling. However, we acknowledge that our study is explorative but not counseling focused. Therefore, while we believe our findings offer meaningful implications, we caution against over-extrapolating their direct applicability to counseling contexts. Future research could delve into empirically investigating how psychological factors, such as varying empathy types and loci of control, could be utilized to alleviate negative feelings associated with abortion decisions. Additionally, understanding how various psychological factors interact with cultural and social norms could further help tailor counseling approaches.

Fourth, the present study did not include an attention check item. We believe the quality of our survey could have been improved had we included one or more attention check items. However, the reliabilities of our scales were relatively high (ranged from 0.84 to 0.93). Additionally, we also replicated some major findings from previous research (e.g., the associations between attitudes toward abortion and religious belief and political ideology). Thus, we believe that overall, inattention did not affect the quality of our data. Future online surveys could consider using attention check items for quality control.

In conclusion, the present study demonstrates the unique contribution of empathy, locus of control, and need for cognition to how people perceived abortion in different scenarios. The findings suggests that attitudes toward complex moral issues like abortion are shaped by individual psychological traits and cognitive needs, in addition to societal, religious, and cultural norms. Future research could use our study as a starting point to expand on these findings, exploring other psychological traits and cognitive processes that may similarly affect perceptions of abortion and other controversial subjects.

Data availability

Data included in this project may be found in the online repository, https://doi.org/10.7910/DVN/E5AB5R .

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Cheng, J., Xu, P. & Thostenson, C. Psychological traits and public attitudes towards abortion: the role of empathy, locus of control, and need for cognition. Humanit Soc Sci Commun 11 , 23 (2024). https://doi.org/10.1057/s41599-023-02487-z

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Methodological report of a cross-sectional survey of abortion-related knowledge, attitudes and practices amongst health professionals in Britain, strategies adopted and lessons learned: evidence from the SACHA Study

• R. S. French 1 ,
• M. J. Palmer 1 ,
• O. McCarthy 1 ,
• N. Salaria 1 ,
• R. Meiksin 1 ,
• J. Shawe 2 ,
• M. Lewandowska 1 ,
• R. Scott 1 ,
• K. Wellings 1 &

the SACHA Study Team

BMC Health Services Research volume  24 , Article number:  1614 ( 2024 ) Cite this article

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Metrics details

Most surveys examining health professionals’ knowledge, attitudes and practices around abortion have used convenience samples and have targeted doctors. Our goal in the SACHA Study, drawing on evidence-based strategies to maximise response rates, was to achieve a representative sample of a wider range of health professionals, working in general practice, maternity services, pharmacies, sexual and reproductive health (SRH) clinics and specialist abortion services in Britain, to explore the knowledge, attitudes and experience of abortion care and views on future models of delivery.

A cross-sectional questionnaire-based survey of midwives, doctors, nurses and pharmacists in England, Scotland and Wales was undertaken between November, 2021 and July, 2022. We used a stratified cluster sampling approach to select a random sample of sites and all eligible staff within those services were asked to respond to the survey. Evidence-based strategies to maximise completion rates were adopted, including postal delivery of the one-page questionnaire with personal letter of invitation and a stamped address envelope for return, inclusion of an unconditional voucher and follow-up.

Overall, 147 of the 314 (46.8%) health service sites randomly selected took part in the survey. Reasons for non-participation included local Research and Development (R&D) Department non-response, lack of resources or insufficient time to support or approve the study, lack of interest in or perceived relevance of the topic and insufficient capacity to take part, exacerbated by work demands during the COVID epidemic. Of the 1370 questionnaires sent to eligible identified participants within these services, 771 were completed and returned (56.3%). At the service level the highest proportion of returns was from SRH clinics (81.0%) and the lowest from general practice (32.4%). In relation to profession, returns were highest amongst midwives (69.6%) and lowest amongst pharmacists (36.5%).

Conclusions

Obtaining information about health professional knowledge, attitudes and practices is key to guide service development and policy and to identify gaps in training and service provision in abortion. Despite our attempts to gain a representative sample of health professionals, the challenges we experienced limited the representativeness of the sample, despite the use of an evidence-based strategy.

Peer Review reports

More patients in Britain are having early medication abortions at home, facilitated by consultations conducted remotely via video or phone [ 1 , 2 ]. These developments provide opportunities to examine which types of health services and professionals deliver, or could deliver with changes in regulations, abortion advice and care. In Britain, the 1967 Abortion Act only permits registered medical practitioners working in licensed abortion clinics or NHS hospitals to authorise abortions, prescribe abortion medication or perform abortion procedures, such as manual vacuum aspiration [ 3 ]. Obtaining information on health professional knowledge, attitudes and practices is key to guide service development and policy and to identify gaps in training and service provision in abortion, or any health area. Failing to consult health service staff about potential changes to practice and policy is arguably unethical and may result in inefficiencies and, potentially, barriers to adoption of change. However, demanding work schedules, conflicting priorities, frequency of requests to take part in surveys and “gatekeepers” hindering access can reduce health professionals’ participation in reseach [ 4 ].

Most health professional surveys on abortion care in Britain have focused on attitudes, particularly towards abortion law and conscientious objection [ 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ]. Other topics have included medical students’ future willingness to participate in abortion care [ 5 , 6 ], referral practices [ 7 ], views on models of service provision [ 13 , 14 ], and terminology [ 15 ]. These surveys have been predominantly confined to doctors, including medical students [ 9 , 10 , 12 ], general practitioners (GPs) [ 7 , 9 , 10 ], and obstetricians and gynaecologists [ 9 , 11 , 12 ]. A few surveys of participants at specialist meetings or conferences have included doctors working in community sexual and reproductive health (SRH) clinics, nurses, and midwives, but overall representation of these professionals is scarce [ 13 , 14 , 15 ]. The majority of surveys have used convenience samples, increasing the potential for bias. Recruitment from universities, conferences and general practices more actively involved in research is likely to reduce generalisability of findings to the wider workforce. Some studies have randomly selected a subset of those identified from professional organisations, including GPs via the British Medical Association [ 10 ], and obstetricians and gynaecologists via the Royal College of Obstetrics and Gynaecologists (RCOG) [ 11 , 12 ]. While these surveys, all distributed by post, have achieved high response rates (> 70%), little information is provided about the process of random selection or on the socio-demographic characteristics of the respondents and the extent to which they were representative of the intended target group. Other surveys of health professionals designed to achieve a representative sample have achieved much lower response rates. For example, an online survey of GPs recruited via the Royal College of General Practitioners (RCGP) was reported to be broadly representative of members’ characteristics, but the estimated response rate was between 7–10% [ 16 ].

Strategies to increase response rates have been shown to reduce bias. A Cochrane review on strategies used to increase survey response rates found the odds of response were at least doubled with monetary incentives, recorded postal delivery, a ‘teaser’ on the envelope to encourage respondents to open it, and an ‘interesting’ topic [ 17 ]. To a lesser extent, odds of response were also significantly increased with pre-notification, follow-up, unconditional incentives, shorter questionnaires, sending out the questionnaire again at follow-up, mentioning an obligation to respond, university sponsorship, non-monetary incentives, personalised questionnaires, handwritten envelopes, inclusion of stamped address return envelopes, assurance of confidentiality and first class outward mailing. Systematic reviews of methods to improve survey response rates specifically amongst doctors and nurses have found similar findings [ 4 ], and also noted that endorsement from professional organisations increased response rates [ 18 , 19 ]. While postal and telephone surveys were more successful than online surveys, health professionals did respond well to having different options for questionnaire completion. Surveys of a sensitive nature have been found to have lower response rates [ 4 , 17 ]. Amongst GPs, being too busy and lack of financial payment are reported as the most common reasons for non-response [ 20 ].

The goal of the SACHA (Shaping Abortion for Change) Study was to provide an evidence base to inform optimal configuration of health services for the delivery of abortion care and provision in Britain. A component of this research was a survey of health professionals to assess their knowledge, attitudes and practices relating to abortion care. Our goal, drawing on evidence-based strategies to maximise response rates, was to achieve a representative sample of British health professionals working in general practice, maternity services, pharmacies, SRH clinics and specialist abortion services. In this paper we describe our approach, the extent to which the methods used were successful and what challenges were met.

We conducted a cross-sectional questionnaire-based survey of health professionals working in primary and secondary health services in England, Scotland and Wales.

Sampling and recruitment

Health professionals who have, or could potentially have, a role in providing abortion care and support were eligible to take part. These included: midwives, doctors, nurses and pharmacists currently working (either permanently or as a locum) in the following types of services: general practices, SRH services, pharmacies, maternity services, and abortion services (for maternity services, only midwives were eligible to take part). All eligible participants were required to be working in premises with postcodes and to be providing direct patient care, either face-to-face or remotely (via video-conferencing software or phone).

With the aim of achieving a representative sample, we used a stratified cluster sampling approach to identify services from which participants were to be recruited (see Fig.  1 ) [ 21 ].

Stratified random cluster sampling process

A random sample of services, which constituted our ‘clusters’, was selected with all eligible staff within that service asked to respond. The only exception to this was midwives working in maternity services. Given larger numbers working across maternity services at each site, all midwives working within a 24-h period identified by the site manager in either antenatal, labour and postnatal wards were eligible. To ensure adequate representation of health professionals in each of England, Scotland, and Wales, these three countries constituted our strata. Furthermore, to ensure proportional regional spread of services across England and to benefit from the precision gains associated with implicit stratified sampling [ 22 ], each sampling frame in England was ordered according to region (London, the North East, North West, Yorkshire, East Midlands, West Midlands, South East, East of England and the South West) and services were selected using systematic random sampling.

The samples of each service type were drawn independently from one another using sampling frames as shown in Table  1 .

For NHS hospital-based abortion providers to be eligible, abortion services had to provide at least 100 abortions each year, of which ≥ 80% were classified as being carried out under ‘Ground C’ of the Abortion Act (i.e. “the pregnancy has NOT exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman”). For abortion services commissioned by the NHS and provided by the independent sector, which included British Pregnancy Advisory Service (BPAS), MSI Reproductive Choices, and the National Unplanned Pregnancy Advisory Service (NUPAS), up-to- date lists of clinics were sought from the relevant website, or directly from the service. We were unable to construct complete sampling frames for maternity and SRH services, and we therefore adopted a different approach to sampling. In these services our sampling frame consisted of a complete list of all six-digit postcodes in England, Wales, and Scotland. On randomly selecting a postcode, it was entered into the ‘find a service’ function on the NHS website to identify the nearest SRH clinic and maternity service (and its full postal address, contact details and website). General practices and pharmacies were identified from publicly available lists.

When selecting the sample of each service type, we also randomly selected several batches of ‘back-up samples’ using the same approach. This enabled us to approach additional randomly selected services in Batches B and C if a whole site identified in the original Batch A was found not to exist or was an ineligible service or declined to participate. For each service type, we initially sampled 45 services to approach, with the exception of pharmacies, where we initially sampled 98 services due to the likely number of eligible staff per site being lower.

On the basis of the population size of England, Scotland, and Wales (approximately 56 million, 5 million, and 3 million respectively), and assuming we would require approximately 45 of each type of service (except pharmacies), proportionate stratification would result in 39 clusters in England (0.875*45), 4 clusters in Scotland (0.078*45), and 2 clusters in Wales (0.047*45). Therefore, in order to ensure an adequate sample size in each nation, we over-sampled in Scotland and Wales so that at least six of every service type was located in each, with equivalent proportional oversampling for pharmacies, and reduced the number of sites in England accordingly to maintain feasibility.

Prior research conducted in the UK suggests that 46% of a random sample of GPs felt that the decision for an abortion should be the woman’s only, rather than the requirement of either one or, as is current practice, two doctors’ signatures [ 10 ]. We needed 1200 completed surveys to give us precision of ± 3% around this estimate and our aim was to achieve a minimum of 100 respondents in each practitioner group. No evidence from Britain was found on SRH doctor, nurse or pharmacist views to inform the sample size at the time of protocol development.

Eligible professionals working within each selected service were identified from website staff details/profiles (GP practices and pharmacies) and via contacting service managers (all services except GP practices). Where NHS staff names, professional category and contact information were shared by managers these were supplied, with staff permission, to the research team in a password-protected spreadsheet. When staff members declined to have their contact details passed to the research team, information on the total number of potential eligible participants working at that service was sought, in order to calculate the denominator for our response rate. We also worked with Clinical Research Network Local Clinical Specialty Research Leads to promote the research and support recruitment with local NHS Trusts. National professional organisations, including the British Society of Abortion Care Providers, the Faculty of Sexual and Reproductive Healthcare, the RCGP, the Royal College of Midwives, the Royal College of Nursing and the Royal Pharmaceutical Society, were informed about the survey to increase knowledge and profile of the research. For the identification of health professionals working in the NHS sites (i.e. maternity services, NHS abortion providers and SRH clinics), a Participant Identification Centre (PIC) Agreement was required with the local Research and Development (R&D) Department for each site. As names of health professionals working with general practices were in the public domain via practice websites it was not necessary to set up PIC agreements for these sites.

Data collection

A fully structured questionnaire was developed for this study (see supplementary file). Classificatory data were collected on socio-demographic characteristics; attitudes towards abortion, including legal and regulatory frameworks and demedicalisation; experience of abortion care and support; views on integrating abortion provision into routine care; perceptions of implications for their roles and workload; self-assessment of competence and needs for professional training; and awareness, use and/or opinion of novel strategies or approaches, such as telemedicine. Likert scales were used to scale response options for attitudinal statements. To avoid bias stemming from a tendency to agree with attitudinal statements (acquiescence bias), statements were formulated representing differing views. For example, when eliciting views on the extension of roles in abortion, opposing statements expressed advantages for the health professional (e.g. increased job satisfaction) versus disadvantages (e.g. increased burden of workload). The questionnaire was piloted with representatives from each service type and amendments were made to improve clarity of response options and to include other options as appropriate, e.g. “don’t know”.

Each questionnaire pack included a personal letter of invitation, a Participant Information Sheet explaining the purpose of the study and giving assurance of confidentiality, the questionnaire, a tea bag (to encourage participants to complete the questionnaire over a tea-break), an unconditional £10 shopping voucher as a thank you for their time and a stamped addressed envelope for return of the questionnaire to the research team. Packs were posted to all identified individual professionals within each service at their workplace. A postal survey was chosen as it has been shown to yield higher response rates [ 10 , 11 , 12 ]. Each professional was provided with a unique ID number, which was pre-recorded on their paper questionnaire and used in follow up emails. The ID number indicated country, type of service, site and batch, so that response rates could be calculated. To maximise response rates, we used strategies others have found effective: i) including the unconditional incentive in the first mail out; ii) following up with two emails or (where providers are based on-site) phone calls at fortnightly intervals following the initial mail out for non-responders and iii) limiting the questionnaire to a maximum of two sides of A4. In the letter of invitation and in follow-up emails health professionals were given the option of completing the questionnaire online (using Online Surveys, www.onlinesurveys.ac.uk ) [ 17 ]. The follow up emails were also a way of reaching people who may have been working from home over the COVID-19 pandemic. Completion and submission of the paper or online questionnaire implied consent (see ‘Ethics approval and consent to participate’).

Identifying information (names and contact details) were stored on a secure LSHTM server separately from the survey responses and were password-protected. Paper questionnaires were stored in a locked filing cabinet in a locked room (accessible only to the study team). Name and contact details were only used for research fieldwork purposes and will be destroyed at the end of the study.

Data analysis

Information on professional role, type of service and country were linked to questionnaire data using ID numbers. Data were entered into Online Surveys either by the research team for received paper questionnaires or direct by the participant. These were exported, and then analysed in Stata 17 [ 23 ]. At a service level, response rates were calculated by country and service type. Individual completion rates (i.e. the proportion of identified health professionals who returned a completed questionnaire) were calculated by country, service type, and professional group. Percentages (and frequencies) with 95% confidence intervals (CI) for participant socio-demographic characteristics were calculated accounting for clustering in the analysis. Cells with a count of ≤ 5 have been suppressed in tables.

Overall, 147 health service sites out of the 314 (46.8%) randomly selected took part in the health professional survey (see Table  2 ). The main reasons for site non-participation included R&D Department non-response, inability to support the study due to lack of resources or insufficient time to approve the study (maternity and SRH sites); lack of interest in the study among identified sites; a belief that that it was not relevant; reluctance to share names of staff or insufficient capacity to take part in research. In three sites (all abortion providers), approval and agreement to take part were established but no questionnaires were returned. We were unable to contact some pharmacies and SRH clinics by phone to invite eligible staff to take part, despite multiple attempts.

Site participation, defined by the participation of a least one respondent from the site, was highest amongst general practices (81.3%) and lowest amongst maternity services (26.7%). It was highest in Scotland, 52.3% of sites identified, and lowest in Wales, 39.0%.

Figure  2 illustrates the geographical spread of participating sites and individual completion rates. Of the 1370 questionnaires sent out to identified participants within these services, 771 were completed and returned (56.3%). The proportion of returns was highest in Scotland (65.2%), followed by England (56.9%) and Wales (43.2%). Services with the highest proportion of returns were SRH clinics (81.0%), followed by specialist abortion providers (78.7%), maternity services (67.4%), pharmacies (39.7%), and lastly general practice (32.4%). In relation to profession, completed returns were highest amongst midwives (69.6%), followed by nurses (62.3%), doctors (45.1%) and lowest amongst pharmacists (36.5%). On average there were four respondents per general practice site, 17 per maternity site, eight per abortion service, six per SRH clinic and one per pharmacy. It was not possible in some sites to identify how many staff were eligible via the service managers, therefore we were unable to calculate an overall participation rate.

Site recruitment numbers and individual completion rates* by region. * Individual completion rates presented are the proportions of health professionals by region who were sent a questionnaire and returned a completed questionnaire

Examining the profile of participants by service illustrated some variations (see Table 3 ). The highest proportion of male health professionals was in pharmacies. Over half of those working in general practice and SRH services had been qualified for more than 20 years. Around a third of doctors and pharmacists reported right or centre leaning political beliefs. Over a half of those working in pharmacies and over a third of those working in general practice reported that religion was very or quite important in their lives.

A few participants left free text mentioning the value of the research and appreciating the opportunity to take part.

This is a really important ongoing piece of work. Midwife England.

I hope it [the research] improves care, support and choice for women! Abortion service nurse England.

The inclusion of the voucher and a tea bag in the questionnaire pack was also welcomed.

Thank you for the teabag! I have passed on the £10 voucher to our staff who work tirelessly—much appreciated.:-) GP Scotland.

However, some practitioners returned their vouchers to the research team, with both completed and uncompleted questionnaires.

To date, this is the most comprehensive survey of health professionals’ abortion-related knowledge, attitudes and practices undertaken in Britain. Participants included nurses and midwives, whose views and experiences have been under-represented in prior surveys. The higher response rates observed amongst these professionals compared to doctors and pharmacists may reflect their more direct contact with patients having abortions and interest in participation. To our knowledge, this is the first survey about abortion amongst pharmacists in Britain. Previous British surveys of health professionals on abortion have, in the main, focused on medical students and doctors and used convenience samples or more localised populations to identify participants. Through random selection of service sites in Britain we aimed for a representative sample of eligible health professionals and through use of postal surveys, with an online completion option and an unconditional voucher we hoped to maximise the response rate.

Just under half of the sites identified through random sampling participated, with at least one eligible health professional responding. Site participation was lowest amongst NHS sites where we needed to set up PIC agreements before approaching staff, specifically maternity services and SRH clinics. Despite our requests from the participating sites, we were unable to obtain the numbers of eligible staff working in many of the SRH clinics, maternity services and abortion clinics, so were not able to obtain an overall denominator of eligible staff members for calculation of an overall participation rate. However, in terms of the completion rate amongst staff who were sent questionnaires, this was highest in SRH clinics and abortion services and lowest in general practice and pharmacies. Postal survey response rates amongst GPs are more commonly lower compared to specialist doctors and the evidence-base on strategies to increase GP response rates suggests they may have little effect [ 24 , 25 ]. Amongst pharmacists, postal versus online surveys and the offer of vouchers versus not achieve higher response rates [ 26 , 27 ]. Lack of involvement in research and familiarity with how it can be used to provide evidence for practice may also have hindered participation in our survey. For example, a systematic review by Awaisu et al. reports how reluctance of pharmacists to participate in research may, in part, be explained by lack of research knowledge and training opportunities [ 28 ].

Overall, responders to the survey were more likely to be female, qualified for more than 20 years and likely to report that religion was not important in their lives and they had no political beliefs. Workforce profiles show a higher proportion of females work across the health sector: 89% of nurses and midwifes [ 29 ], 62% of pharmacists [ 30 ], 60% of obstetricians and gynaecologists and 57% of GPs [ 31 ]. The greater representation of females in our survey compared to males, may reflect the gender profile of staff working in the services that were included, but may be also due to females being more interested in the topic. The older age profile of our participants aligns with concerns that have been raised within primary care and SRH services about an aging workforce who are retiring and are not being replaced [ 29 , 31 , 32 ]. With the exception of pharmacists, the majority of health professionals said that religion was not important in their lives. Reported religious affiliation and religiosity amongst medical students and nurses has been associated with more favourable attitudes towards conscientious objection [ 5 , 8 , 33 ]. Around a quarter of GPs and pharmacists report having no religion [ 30 , 31 ]. This is lower than the proportion reporting no religion in our survey. Those with religious beliefs may have been less likely to participate in a survey on abortion.

Despite our attempts to achieve a representative sample we experienced a number of challenges, which will affect the generalisability of our findings. First, many of the sites were experiencing severe staff shortages and huge workload demands. Fieldwork started in the general practice and pharmacy sites as PIC approvals were not required at these sites. However, questionnaires were sent out at a time when both of these services were dealing with the Autumn 2022 COVID booster programme and rising infections with the Omicron variant [ 34 , 35 ]. Lower survey responses rates amongst health professionals during the COVID pandemic have been explained by ‘survey fatigue’ [ 36 ]. Fieldwork in the SRH clinics coincided with the mpox (monkeypox) outbreak with the first cases being confirmed in May 2022 [ 37 ]. Second, local R&D approvals required in over 100 NHS sites was extremely time-consuming and resource intensive. Requirements for approval varied across departments and some sites were lost because of these delays or because the study was not viewed as a priority. As the end of the study approached there was insufficient time to replace these withdrawn sites with ‘Batch B’ ones. While we attempted to record reasons for R&D approval not being gained, they were not collected systematically as it was often difficult to determine what the specific reasons were. Third, identifying eligible health professionals in the selected sites was difficult. Staff turnover rates and reliance of locums were high in some services, and in general practice staff profiles on websites were sometimes out-of-date. Despite multiple attempts it was not possible to get through to some sites over the phone, particularly the pharmacies and SRH clinics. Some service managers were unwilling to provide the names of staff, even with their permission, despite reassurances that all ethical and R&D approvals were in place and that the dataset for analysis would be anonymised. Fourth, questionnaire packs were lost in the post and not received by sites, or questionnaires that staff said had been completed and posted back to the research team were never received. When individual work email addresses were available, online links to the survey were emailed to named staff. Sending out questionnaires by registered post may have helped, but many staff were still working at home or going into the workplace less frequently due to COVID. We did not always have individual staff email addresses for those working in general practices and pharmacies, and so had to rely on the phone for follow-up, in the case of general practice often via the practice manager. It was, therefore, in some cases not possible to confirm whether or not questionnaire packs had been received by those they had been posted to. This could have negatively impacted completion rates in these settings. Finally, despite explanations from the research team that we were seeking views of professionals not necessarily providing abortion advice or care, some managers explained that the topic was not relevant to their service or they did not agree with the topic so they would not be participating.

While it is essential that any research undertaken is ethical, unnecessary administrative procedures hinder research and result in a disproportionate amount of research funding being spent managing administration. For the SACHA health professional survey five members of the research team needed to be allocated to liaising with over 100 different R&D Departments to set up PIC agreements. The processes involved in gaining approvals for research involving the NHS seem to be based around the default assumption of any project being a randomised controlled trial involving patients. Our paper-based questionnaire to be completed by health professionals posed low risk to participants, however the regulatory frameworks we had to negotiate were no less cumbersome. A centralised system to obtain local approvals would have been much more efficient. We add our voice to calls have been made for greater harmonisation, simplifiication and proportionality of processes [ 38 ].

A recent review concluded that even in the age of declining response rates, the accuracy of results based on random sample surveys is generally higher than that achieved from non-probability convenience samples [ 39 ]. Even with the resource-intensive nature our approach, and the somewhat limited participation and completion rates, the findings reported from this sample are likely to be more reliable than had we simply opted for a convenience sample. Identifying and recruiting multi-disciplinary professional groups can be testing, however sampling frameworks should be designed to ensure knowledge, attitudes and practices across different health professionals are captured to help understand healthcare processes [ 40 ].

Despite our attempts to gain a representative sample of health practitioners, the challenges experienced reduced the effectiveness of the evidence-based strategy used. While the COVID pandemic undoubtedly affected the completion rates, the obstacles experienced in gaining locals approvals to survey health professionals and pressures within the NHS are likely to continue to affect future research. Given the crucial importance of professional opinion to improving health service provision, it is essential that ways are found to remove such obstacles and to facilitate the process of conducting empirical studies aimed at guiding health service reform.

Data availability

SACHA Study data are not available due to potential sensitivity of the topic and to maintain privacy of participating health professionals as noted in the study’s Data Protection Impact Assessment. Study materials are available on request to the corresponding author.

Abbreviations

British Pregnancy Advisory Service

General Practitioners

London School of Hygiene & Tropical Medicine

National Unplanned Pregnancy Advisory Service

Participant Identification Centre

Research & Development

Royal College of General Practitioners

Royal College of Obstetricians and Gynaecologists

Shaping Abortion for Change

Sexual & Reproductive Health

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Acknowledgements

Other members of the SACHA Study team include: Annette Aronsson (Karolinska Institute, Sweden), Paula Baraitser (Kings College London), Sharon Cameron (University of Edinburgh), Caroline Free (LSHTM), Louise Keogh (University of Melbourne, Australia), Patricia A. Lohr (BPAS), Clare Murphy (BPAS), Wendy V. Norman (University of British Columbia, Canada), Jennifer Reiter (Lambeth Local Authority), Sally Sheldon (University of Bristol) and Geoff Wong (University of Oxford).

We are grateful to all the survey participants who generously dedicated their time and shared their experiences, and to all service managers who helped identify eligible staff. We would like to thank the North Thames Clinical Research Network for their support and local R&D Departments who helped obtain approvals.

We also thank our Advisory Group for supporting the development of this study: Jonathan Lord (Chair), Marge Berer, Sue Mann, Claire Anderson, Joanne Fletcher, Becky Gunn, Charlotte Kelly, Tracey Masters, and Sam Rowlands.

This study is funded by the NIHR [HSDR Project: NIHR129529]. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

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R. S. French, M. J. Palmer, O. McCarthy, N. Salaria, R. Meiksin, M. Lewandowska, R. Scott & K. Wellings

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Contributions

R.F. and K.W. conceptualised the study. R.F, M.P. and J.S. designed the survey and materials, with input from all authors. R.F., J.S., M.P., R.M. and N.S. managed ethics/ R&D approvals and fieldwork. O.M., R.S. and M.P. contributed to the analysis. M.P. prepared Figure 1. O.M. and R.S. prepared Table 3. R.F. drafted the paper with input from M.P., R.M., R.S., N.S., M.L., J.S. and K.W. All authors and the wider SACHA Study Team have read and approved the final manuscript.

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This study is approved by NHS Health Research Authority and Health and Care Wales (IRAS Approval ID 297849), the LSHTM Observational/Interventions Research Ethics Committee (LSHTM Ethics Ref 26332), BPAS Research and Ethics Committee (reference number: 2021/08/FRE) and MSI Ethics Review Committee (application number 009–21).

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French, R.S., Palmer, M.J., McCarthy, O. et al. Methodological report of a cross-sectional survey of abortion-related knowledge, attitudes and practices amongst health professionals in Britain, strategies adopted and lessons learned: evidence from the SACHA Study. BMC Health Serv Res 24 , 1614 (2024). https://doi.org/10.1186/s12913-024-12011-x

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Received : 16 May 2024

Accepted : 27 November 2024

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DOI : https://doi.org/10.1186/s12913-024-12011-x

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