The watchword of campaigners for abortion services has been that it is the woman's right to freely choose between abortion and pregnancy 38. Studies reviewed for this paper suggest that although moral values are important 15212627, the choice to seek TOP is a pragmatic one that reflects the impact of pregnancy and childbearing on personal and household circumstances 171821262729. A number of studies described the role male partners played in women's decision of whether to undergo the procedure 162021222430. Lone mothers are often economically disadvantaged, but in Sweden, where universal childcare provision makes lone parenthood economically viable, one study showed that participants (n = 5) preferred not to bring up children on their own 26. Partnered or married women were also concerned about planning their families well 27, taking into consideration their partners' attitudes and the needs of their children 18 and their quality of life 17. However, a U.S. study reported that women were more likely to confide in their female friends about their pregnancy than family members or partners 25. Women's childhood experiences such as growing up in a broken home could also affect women's decisions 26. Studies conducted with women under the age of 21 revealed that other factors such as immaturity, parental attitudes, and education and employment prospects were more important than moral considerations 242930

Whatever women's circumstances, studies in this review suggest that the decision to seek TOP usually precedes any encounter with heath care professionals 172829. However, such decisions are moderated by the value systems and social norms of the society or community in question 151922232429. Feelings of ambivalence in the decision-making process were highlighted in a Swedish study 26, where women felt positive towards the right to abortion, but negative about their own decision to abort. It is argued that TOP allows women to return to 'normality' psychologically, physiologically and socially, and women appreciated being treated in a non-stigmatised way 19. However, a study conducted in the UK found that the majority of teenage mothers who were interviewed did not associate motherhood with lack or loss of opportunity 29.

The range of services available also affects the choices of women. However, papers identified for review provided little about how the choice of TOP provider is framed, or even what choices are available. One study of young women in the UK 29 found that they preferred family planning services rather than general practitioners for their first point of contact and referral, for reasons of greater anonymity and specialised treatment. Anonymity and confidentiality are key issues in all settings where TOP is stigmatised 21222324. For this reason, Israeli women tended to avoid publicly subsidised formal procedures opting instead for private abortion providers 23.

In the UK, expectations of better personal treatment and confidentiality were also reasons why some women chose private or voluntary sector clinics over National Health Service (NHS) clinics, although cost is an issue 19. Those who had used independent providers reported more positive experiences than those who had used the NHS 29. Further evidence of this comes from another British study 28, where participants (n = 21) reported difficulties in getting an urgent appointment with their family doctor, problems with the NHS telephone booking system and being asked by doctors to further consider their decision, thus delaying the process.

Finally, the choice of method is dependent not only on service availability but on medico-legal considerations such as the gestational age. Once again, data on this topic are very limited. Pragmatic reasons such as effectiveness and the side effects were found to over-ride women's moral and political considerations in one US study 17. Previous experiences of surgical abortion may have led women to seek medical rather than surgical TOP in two other US studies 1617. The experiences of other family members or friends who had undergone abortion can also be influential 1730.

Studies that concentrated on women's experiences of the TOP procedure prefaced their findings with an account of the specific medical regimens in place at the time of the study. The US studies focused on women's perceptions of medical abortion as a new procedure, and often compared this with surgical TOP. In this context, women identified medical abortion as a way to avoid surgery, and anaesthesia and that permitted them privacy, autonomy and a greater sense of control 15171819. Simonds et al 15, in particular, explored the idea of abortion being 'natural' describing this as 'not-really-abortion, but rather as a late period that finally comes' (p1316). As such, medical TOP was associated with reduced feelings of guilt for some participants in her study. This 'naturalness' (a subjective association with a miscarriage or menstruation without the insertion of instruments) seems to outweigh the pain and prolonged nature of the procedure, including the sight of fetus. Other women focused on the pain as a necessary part of the process 16.

Complex emotional experiences appear to be integral to TOP. These include regret and guilt 1722, distress and anxiety 172227 and grief, loss, emptiness and suffering 21. These experiences are related to gestational age, for example, in one study a medical termination before any symptoms of pregnancy were perceived was described as involving a 'loss' whereas a surgical termination was described as a 'death' 16. Anxiety about sterility and death is also experienced by some women 161826. Women were also found to associate an abortion with taking responsibility 27 for the consequences of what they considered was an irresponsible act 19, especially in medical TOP where women were conscious during the procedure 15. Another study 16 described the experience of a medical abortion as a chance to grieve, and the pain experienced was described by the authors as 'cathartic', one woman describing this as 'a personal investigation into your own pain' (p171).

Such perceptions are mediated by the moral context within which the women are located. In Indonesia, for example, women's perception of the fetus is influenced by the Islamic view that ensoulment takes place at 120 days of pregnancy 22. In the US, Pro-Life argument against TOP is rich with images of a destructive, act, often explicitly called murder, leading some women to think that they 'killed a baby', but also realising 'it wasn't really a child' 17. In a study by Fielding and Schaff 25, reservations about abortion in the second trimester onwards were unanimous except in relation to abnormalities. The language used to describe the fetus reflects the closeness or distance that women feel towards the life growing in their bodies and impacts on women's post-abortion emotional reactions 253032. In one trial, women were encouraged to look at the expelled fetus at home, but the authors say that 'dramatic' responses were rare 15. Some women in this study described relief in not seeing a distinguishable human being when the fetus was expelled.

Feminist researchers provide insights into the interaction of TOP with notions of reproductive independence. A study 27 on the long term emotional effects of abortion found that more than half of the women who had reported both positive and painful feelings continued to report these feelings after 12 months. However, respondents reported they coped well, experiencing strengthened self-esteem, personal growth and maturity over the year. A study 30 of young Swedish women (n = 10) found that they encountered an understanding of themselves, their bodies, their fertility, and the meaning of adult motherhood. A study 24 of African-American adolescents (n = 12), aged between 15–18, highlighted their poor knowledge of reproductive processes and health and suggested that elective TOP was a 'positive, growth-enhancing experience' (p432), with participants being empowered by their experience of decision-making. However, Simonds et al 15 showed that in a clinical trial, medical abortion may have been perceived no less invasive as surgical abortion because of repeated insertions of pessaries, pelvic examinations, and ultrasound examinations, to ensure the success of the procedure.

Other studies highlight the isolation of women undergoing TOP and their concerns to conceal it from others 2126. In studies of the home use of misoprostol 1718, there are accounts of women who undergo the abortion alone, or in secret with others such as family members around but unaware of the situation. In contrast, women in another clinical trial 16 described the active participation of partners or friends who helped to minimise their discomfort by rubbing their backs, bringing them tea, or monitoring their blood loss. Women with knowledge of how TOP works, and who have support from both their clinic and their partner seem more likely to experience a better outcome 18. Women's cultural affiliations and beliefs also have a bearing on their emotional experiences 182227. For example, Israeli women tended to interpret abortion as a personal failure whereas Russian immigrants looked upon it as bad luck or a mistake 23. In relation to the emotional impact of the abortion experience, a woman's preparedness and post-abortion support 32 as well as the emotional work required from nurses in family planning and abortion clinics 26 were important considerations.

The role of service providers is examined in most of the studies and British studies have focused especially on health services access and quality 192829. The process of seeking abortion in the UK is sometimes confusing because of inadequate information and extended because of delays in referrals. In three US studies 151617 participants compared positive experiences of treatment by professionals providing medical TOP in clinical trials with professionals' negative attitudes and impersonal clinic settings in ordinary services. A Canadian study 21 identified a mismatch between women's normative expectations that health care providers should provide them with options and access to whatever medical services they might need, and what they perceived to be an unsympathetic reception from medical staff. The effect of such attitudes is assumed to discourage women from seeking abortion, but there is no systematic evidence to support this assumption. In an Israeli study, Russian immigrants objected to state interference into their choice to abort, but were impressed with the quality of publicly provided abortion services and sympathetic staff 23.

Women's experiences of patient care during an abortion are also affected by the method of termination. In US trials on medical TOP, women relied on health professionals to assure them about the safety of the new procedure and to determine if the termination had been successful 17. Women needed more counselling from clinical staff about the procedure of medical termination 17. This may reflect the need to assess if they were appropriate candidates for the procedure 15. Women also had to be assured of ready access to medical information and help from clinical staff. In reports 15 of experiences with surgical TOP, treatment by medical staff figured more prominently than the actual physical experience of abortion.

In some contexts, the attitudes of health providers to abortion were relative to the marital status of the women 22. In Indonesia for example, medical staff endorse abortions as a form of birth control for married women, but held disapproving attitudes towards pre-marital sex which impact on young women's feelings of guilt and shame. A study on teenage mothers in the UK 29 also reported doctors' disapproval. In the UK, clinical attitudes appear to be more negative towards the termination of pregnancies after the first trimester and some NHS clinics do not offer services for late abortions.

Studies that included primary care primary care professionals suggested that these were perceived as less sympathetic and supportive than professionals working in abortion services. The latter were perceived to be more caring and less judgemental 1928. This distinction was also found in one of the U.S. studies, although clinical trial staff were also perceived as more conscientious than women's usual health care providers.

Counselling is referred to in different ways in the studies but most particularly as counselling prior to the TOP to discuss the different methods, their benefits, what to expect, compliance and follow-up 17 and in relation to decision-making 28. Other studies take a nursing perspective referring to the emotional work of nurses 26 and the importance of providing opportunities for women to express their suffering 27. The importance of counselling is highlighted particularly where women had not told family or friends about their pregnancy 28. However, unnecessary or superficial counselling has also been questioned 2829. In some parts of the non-Western world where women are more vulnerable, women's decision-making regarding abortion was influenced by the recommendations of the abortion provider and cost implications 182223. In most studies, information provision and knowledge were critical factors. An American study recommended that each patient be given a choice in the amount of information she receives, and information packs could be provided accordingly 17. In relation to contraception however, knowledge needs to be integrated into practice for effective family planning 20. The physical setting e.g. waiting rooms, and cold, unfamiliar wards was also referred to in some studies 1926. While some women appreciated the presence of other women in alleviating the loneliness of the experience, others were concerned about privacy and the risk of meeting someone they knew in the waiting room 21.

Some studies also investigated women's experiences of medical TOP at home rather than at a clinical facility 16171822. In the US, Fielding 17 and Elul 16 identified familiar surroundings, privacy and not having to encounter strangers, as adding to women's appreciation of home TOP. However, there are situations in which home abortions are problematic, for example where the abortion needs to be kept hidden from the rest of the household because of shame 1822. This is particularly complicated where women are victims of domestic or sexual violence. Women also fear the risks of having an abortion at home where health professionals are not readily available to them.