abortion sociology research paper

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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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Abortion as a sociological case

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Abstract: For over a century, abortion has been politically and socially contested, affecting people's lives through personal experience and/or public discourse. In the United States (US), abortion is sometimes exceptional—treated differently from other procedures, professions, and political issues—and sometimes an exemplar—an accessible example of a commonly occurring social, political, or personal phenomenon. It is, in other words, an excellent sociological case study. Yet the sociological literature on abortion is relatively thin. In this essay, we review research on abortion and opportunities for future sociological work in eight areas: gender; race; the body and embodiment; political economy; organizations, occupations, and work; medical sociology; law and society; and social movements. Sociologists have much to contribute to characterizing and understanding abortion, particularly following the 2022 US Supreme Court decision overturning the constitutional right to abortion. The discipline also has much to learn from studying abortion as a case. With its multifaceted social and political status and intersections with key areas of sociological interest, abortion offers a generative case for advancing sociological concepts, subfields, and constructs. While not exhaustive, our review aims to spark interest and inquiry, showcasing how a topic that spurs strong opinions can also catalyze sociological insights.

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Sociology and abortion: legacies and strategies

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PIP: A survey essay sees the sociological view of abortion practice in 1979 appearing as a dense web of philosophical conundrums and at times violent political strategies; with abortion still not typically seen as 1 form of birth control among others. Attention is called to the variety of approaches to abortion in books and articles about its medical, demographic, religious, historical, political, philosophical, psychological, practical, and personal aspects. These include: James C. Mohr's Abortion in America: The Origins and Evolution of National Policy 1800-1900; Abortion, by Potts, Diggory, and Peel; Abortion in Psychosocial Perspective: Trends in Transnational Research, edited by Davis, Friedman, Van der Tak, and Seville; Linda Francke's The Ambivalence of Abortion; Mary K. Zimmerman's Passage Through Abortion: The Personal and Social Reality of Women's Experiences; Abortion Politics: The Hawaii Experience, by Steinhoff and Diamond; John Connery's Abortion: the Development of the Roman Catholic Perspective; Abortion: New Directions for Policy Studies, by Manier, Liu, and Solomon; and Harry Harris' Prenatal Diagnosis and Selective Abortion.

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• America’s Abortion Quandary

2. Social and moral considerations on abortion

Table of contents.

• 1. Americans’ views on whether, and in what circumstances, abortion should be legal
• Public views of what would change the number of abortions in the U.S.
• A majority of Americans say women should have more say in setting abortion policy in the U.S.
• How do certain arguments about abortion resonate with Americans?
• In their own words: How Americans feel about abortion 
• 3. How the issue of abortion touches Americans personally
• Acknowledgments
• Methodology

Relatively few Americans view the morality of abortion in stark terms: Overall, just 7% of all U.S. adults say abortion is morally acceptable in all cases, and 13% say it is morally wrong in all cases. A third say that abortion is morally wrong in  most  cases, while about a quarter (24%) say it is morally acceptable most of the time. About an additional one-in-five do not consider abortion a moral issue.

There are wide differences on this question by political party and religious affiliation. Among Republicans and independents who lean toward the Republican Party, most say that abortion is morally wrong either in most (48%) or all cases (20%). Among Democrats and Democratic leaners, meanwhile, only about three-in-ten (29%) hold a similar view. About four-in-ten Democrats say abortion is morally  acceptable  in most (32%) or all (11%) cases, while an additional 28% say abortion is not a moral issue. 

White evangelical Protestants overwhelmingly say abortion is morally wrong in most (51%) or all cases (30%). A slim majority of Catholics (53%) also view abortion as morally wrong, but many also say it is morally acceptable in most (24%) or all cases (4%), or that it is not a moral issue (17%). And among religiously unaffiliated Americans, about three-quarters see abortion as morally acceptable (45%) or not a moral issue (32%).

There is strong alignment between people’s views of whether abortion is morally wrong and whether it should be illegal. For example, among U.S. adults who take the view that abortion should be illegal in all cases without exception, fully 86% also say abortion is always morally wrong. The prevailing view among adults who say abortion should be legal in all circumstances is that abortion is not a moral issue (44%), though notable shares of this group also say it is morally acceptable in all (27%) or most (22%) cases. 

Most Americans who say abortion should be illegal with some exceptions take the view that abortion is morally wrong in  most  cases (69%). Those who say abortion should be legal with some exceptions are somewhat more conflicted, with 43% deeming abortion morally acceptable in most cases and 26% saying it is morally wrong in most cases; an additional 24% say it is not a moral issue. 

The survey also asked respondents who said abortion is morally wrong in at least some cases whether there are situations where abortion should still be legal  despite  being morally wrong. Roughly half of U.S. adults (48%) say that there are, in fact, situations where abortion is morally wrong but should still be legal, while just 22% say that whenever abortion is morally wrong, it should also be illegal. An additional 28% either said abortion is morally acceptable in all cases or not a moral issue, and thus did not receive the follow-up question.

Across both political parties and all major Christian subgroups – including Republicans and White evangelicals – there are substantially more people who say that there are situations where abortion should still be  legal  despite being morally wrong than there are who say that abortion should always be  illegal  when it is morally wrong.

Asked about the impact a number of policy changes would have on the number of abortions in the U.S., nearly two-thirds of Americans (65%) say “more support for women during pregnancy, such as financial assistance or employment protections” would reduce the number of abortions in the U.S. Six-in-ten say the same about expanding sex education and similar shares say more support for parents (58%), making it easier to place children for adoption in good homes (57%) and passing stricter abortion laws (57%) would have this effect. 

While about three-quarters of White evangelical Protestants (74%) say passing stricter abortion laws would reduce the number of abortions in the U.S., about half of religiously unaffiliated Americans (48%) hold this view. Similarly, Republicans are more likely than Democrats to say this (67% vs. 49%, respectively). By contrast, while about seven-in-ten unaffiliated adults (69%) say expanding sex education would reduce the number of abortions in the U.S., only about half of White evangelicals (48%) say this. Democrats also are substantially more likely than Republicans to hold this view (70% vs. 50%). 

Democrats are somewhat more likely than Republicans to say support for parents – such as paid family leave or more child care options – would reduce the number of abortions in the country (64% vs. 53%, respectively), while Republicans are more likely than Democrats to say making adoption into good homes easier would reduce abortions (64% vs. 52%).

Majorities across both parties and other subgroups analyzed in this report say that more support for women during pregnancy would reduce the number of abortions in America.

More than half of U.S. adults (56%) say women should have more say than men when it comes to setting policies around abortion in this country – including 42% who say women should have “a lot” more say. About four-in-ten (39%) say men and women should have equal say in abortion policies, and 3% say men should have more say than women. 

Six-in-ten women and about half of men (51%) say that women should have more say on this policy issue. 

Democrats are much more likely than Republicans to say women should have more say than men in setting abortion policy (70% vs. 41%). Similar shares of Protestants (48%) and Catholics (51%) say women should have more say than men on this issue, while the share of religiously unaffiliated Americans who say this is much higher (70%).

Seeking to gauge Americans’ reactions to several common arguments related to abortion, the survey presented respondents with six statements and asked them to rate how well each statement reflects their views on a five-point scale ranging from “extremely well” to “not at all well.” 

The list included three statements sometimes cited by individuals wishing to protect a right to abortion: “The decision about whether to have an abortion should belong solely to the pregnant woman,” “If legal abortions are too hard to get, then women will seek out unsafe abortions from unlicensed providers,” and “If legal abortions are too hard to get, then it will be more difficult for women to get ahead in society.” The first two of these resonate with the greatest number of Americans, with about half (53%) saying each describes their views “extremely” or “very” well. In other words, among the statements presented in the survey, U.S. adults are most likely to say that women alone should decide whether to have an abortion, and that making abortion illegal will lead women into unsafe situations.

The three other statements are similar to arguments sometimes made by those who wish to restrict access to abortions: “Human life begins at conception, so a fetus is a person with rights,” “If legal abortions are too easy to get, then people won’t be as careful with sex and contraception,” and “If legal abortions are too easy to get, then some pregnant women will be pressured into having an abortion even when they don’t want to.” 

Fewer than half of Americans say each of these statements describes their views extremely or very well. Nearly four-in-ten endorse the notion that “human life begins at conception, so a fetus is a person with rights” (26% say this describes their views extremely well, 12% very well), while about a third say that “if legal abortions are too easy to get, then people won’t be as careful with sex and contraception” (20% extremely well, 15% very well).

When it comes to statements cited by proponents of abortion rights, Democrats are much more likely than Republicans to identify with all three of these statements, as are religiously unaffiliated Americans compared with Catholics and Protestants. Women also are more likely than men to express these views – and especially more likely to say that decisions about abortion should fall solely to pregnant women and that restrictions on abortion will put women in unsafe situations. Younger adults under 30 are particularly likely to express the view that if legal abortions are too hard to get, then it will be difficult for women to get ahead in society.

In the case of the three statements sometimes cited by opponents of abortion, the patterns generally go in the opposite direction. Republicans are more likely than Democrats to say each statement reflects their views “extremely” or “very” well, as are Protestants (especially White evangelical Protestants) and Catholics compared with the religiously unaffiliated. In addition, older Americans are more likely than young adults to say that human life begins at conception and that easy access to abortion encourages unsafe sex.

Gender differences on these questions, however, are muted. In fact, women are just as likely as men to say that human life begins at conception, so a fetus is a person with rights (39% and 38%, respectively).

Analyzing certain statements together allows for an examination of the extent to which individuals can simultaneously hold two views that may seem to some as in conflict. For instance, overall, one-in-three U.S. adults say that  both  the statement “the decision about whether to have an abortion should belong solely to the pregnant woman” and the statement “human life begins at conception, so the fetus is a person with rights” reflect their own views at least somewhat well. This includes 12% of adults who say both statements reflect their views “extremely” or “very” well. 

Republicans are slightly more likely than Democrats to say both statements reflect their own views at least somewhat well (36% vs. 30%), although Republicans are much more likely to say  only  the statement about the fetus being a person with rights reflects their views at least somewhat well (39% vs. 9%) and Democrats are much more likely to say  only  the statement about the decision to have an abortion belonging solely to the pregnant woman reflects their views at least somewhat well (55% vs. 19%).

Additionally, those who take the stance that abortion should be legal in all cases with no exceptions are overwhelmingly likely (76%) to say only the statement about the decision belonging solely to the pregnant woman reflects their views extremely, very or somewhat well, while a nearly identical share (73%) of those who say abortion should be  illegal  in all cases with no exceptions say only the statement about human life beginning at conception reflects their views at least somewhat well.

When asked to describe whether they had any other additional views or feelings about abortion, adults shared a range of strong or complex views about the topic. In many cases, Americans reiterated their strong support – or opposition to – abortion in the U.S. Others reflected on how difficult or nuanced the issue was, offering emotional responses or personal experiences to one of two open-ended questions asked on the survey. 

One open-ended question asked respondents if they wanted to share any other views or feelings about abortion overall. The other open-ended question asked respondents about their feelings or views regarding abortion restrictions. The responses to both questions were similar. 

Overall, about three-in-ten adults offered a response to either of the open-ended questions. There was little difference in the likelihood to respond by party, religion or gender, though people who say they have given a “lot” of thought to the issue were more likely to respond than people who have not. 

Of those who did offer additional comments, about a third of respondents said something in support of legal abortion. By far the most common sentiment expressed was that the decision to have an abortion should be solely a personal decision, or a decision made jointly with a woman and her health care provider, with some saying simply that it “should be between a woman and her doctor.” Others made a more general point, such as one woman who said, “A woman’s body and health should not be subject to legislation.” 

About one-in-five of the people who responded to the question expressed disapproval of abortion – the most common reason being a belief that a fetus is a person or that abortion is murder. As one woman said, “It is my belief that life begins at conception and as much as is humanly possible, we as a society need to support, protect and defend each one of those little lives.” Others in this group pointed to the fact that they felt abortion was too often used as a form of birth control. For example, one man said, “Abortions are too easy to obtain these days. It seems more women are using it as a way of birth control.” 

About a quarter of respondents who opted to answer one of the open-ended questions said that their views about abortion were complex; many described having mixed feelings about the issue or otherwise expressed sympathy for both sides of the issue. One woman said, “I am personally opposed to abortion in most cases, but I think it would be detrimental to society to make it illegal. I was alive before the pill and before legal abortions. Many women died.” And one man said, “While I might feel abortion may be wrong in some cases, it is never my place as a man to tell a woman what to do with her body.” 

The remaining responses were either not related to the topic or were difficult to interpret.

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Factors Influencing Abortion Decision-Making Processes among Young Women

Mónica frederico.

1 International Centre for Reproductive Health (ICRH), Ghent University, 9000 Gent, Belgium; [email protected]

2 Centro de Estudos Africanos, Universidade Eduardo Mondlane, C. P. 1993, Maputo, Mozambique; [email protected]

Kristien Michielsen

Carlos arnaldo, peter decat.

3 Department of Family Medicine and primary health care, Ghent University, 9000 Gent, Belgium; [email protected]

Background: Decision-making about if and how to terminate a pregnancy is a dilemma for young women experiencing an unwanted pregnancy. Those women are subject to sociocultural and economic barriers that limit their autonomy and make them vulnerable to pressures that influence or force decisions about abortion. Objective : The objective of this study was to explore the individual, interpersonal and environmental factors behind the abortion decision-making process among young Mozambican women. Methods : A qualitative study was conducted in Maputo and Quelimane. Participants were identified during a cross-sectional survey with women in the reproductive age (15–49). In total, 14 women aged 15 to 24 who had had an abortion participated in in-depth interviews. A thematic analysis was used. Results : The study found determinants at different levels, including the low degree of autonomy for women, the limited availability of health facilities providing abortion services and a lack of patient-centeredness of health services. Conclusions : Based on the results of the study, the authors suggest strategies to increase knowledge of abortion rights and services and to improve the quality and accessibility of abortion services in Mozambique.

1. Introduction

Abortion among adolescents and youth is a major public health issue, especially in developing countries. Estimates indicate that 2.2 million unplanned pregnancies and 25% (2.5 million) unsafe abortions occur each year, in sub-Saharan Africa, among adolescents [ 1 ]. In 2008, of the 43.8 million induced abortions, 21.6 million were estimated to be unsafe, and nearly all of them (98%) took place in developing countries, with 41% (8.7 million) being performed on women aged 15 to 24 [ 2 ].

The consequences of abortion, especially unsafe abortion, are well documented and include physical complications (e.g., sepsis, hemorrhage, genital trauma), and even death [ 3 , 4 , 5 , 6 ]. The physical complications are more severe among adolescents than older women and increase the risk of morbidity and mortality [ 6 , 7 ]. However, the detrimental effects of unsafe abortion are not limited to the individual but also affect the entire healthcare system, with the treatment of complications consuming a significant share of resources (e.g., including hospital beds, blood supply, drugs) [ 5 , 8 ].

The decision if and how to terminate a pregnancy is influenced by a variety of factors at different levels [ 9 ]. At the individual level these factors include: their marital status, whether they were the victim of rape or incest [ 10 , 11 ], their economic independence and their education level [ 10 , 12 ]. Interpersonally factors include support from one’s partner and parental support [ 12 ]. Societal determinants include social norms, religion [ 9 , 13 ], the stigma of premarital and extra-marital sex [ 14 ], adolescents’ status, and autonomy within society [ 12 ]. At the organizational level, the existence of sex education [ 10 , 14 ], the health care system, and abortion laws influence the decisions if and where to have an abortion.

Those factors are related to power and (gender) inequalities. They limit young women’s autonomy and make them vulnerable to pressure. Additionally, the situation is exacerbated when there is a lack of clarity and information on abortion status, despite the existence of a progressive law in this regard.

For example, Mozambican law has allowed abortion if the woman’s health is at risk since the 1980s [ 15 , 16 , 17 , 18 ]. In 2014, a new abortion law was established that broadened the scope of the original law: women are now also allowed to terminate their pregnancy: (1) if they requested it and it is performed during the first 12 weeks; (2) in the first 16 weeks if it was the result of rape or incest, or (3) in the first 24 weeks if the mother’s physical or mental health was in danger or in cases of fetus disease or anomaly. Women younger than 16 or psychically incapable of deciding need parental consent [ 19 , 20 ].

Notwithstanding the progressive abortion laws in Mozambique, hospital-based studies report that unsafe abortion remains one of the main causes of maternal death in Mozambique [ 3 ]. However, hospital cases are only a small share of unsafe abortions in the country. Many women undergo an abortion in illegal and unsafe circumstances for a variety of reasons [ 3 ], such as legal restrictions, the fear of stigma [ 21 , 22 , 23 ], and a lack of knowledge of the availability of abortion services [ 3 , 9 , 23 ].

According to the 2011 Mozambican Demographic Health Survey (DHS), at least 4.5% of all adolescents reported having terminated a pregnancy [ 24 ]. Unpublished data from the records of Mozambican Association for Family Development (AMODEFA) which has a clinic that offers sexual and reproductive health services, including safe abortion, indicate that from 2010 to 2016 a total of 70,895 women had an induced abortion in this clinic, of which 43% were aged 15 to 24. Of the 1500 women that had an induced abortion in the AMODEFA clinic in the first three months of 2017, 27.9% were also in this age group [ 25 ]. These data show the high demand for (safe) abortion among young women.

For all this described above, Mozambique is an interesting place to study this decision-making process; given the changing legal framework, women may have to navigate gray areas in terms of legality, safety, and access when seeking abortion, which is stigmatized but necessary for the health, well-being, and social position of many young women.

The objective of this study is to explore the individual, interpersonal and environmental factors behind the abortion decision-making process. This entails both the decision to have an abortion and the decision on how to have the abortion. By examining fourteen stories of young women with an episode of induced abortion, we contribute to the documentation of the circumstances around the abortion decision making, and also to inform the policymakers on complexity of this issue for, which in turn can contribute to improve the strategies designed to reduce the cases of maternal morbidity and mortality in Mozambique.

2. Materials and Methods

This is an exploratory study using in-depth interview to explore factors related to abortion decision-making in a changing context. As research on this topic is limited, we opted for a qualitative research framework that aims to identify factors influencing this decision-making process.

2.1. Location of the Study

The study was conducted in two Mozambican cities, Maputo and Quelimane. These cities were selected because they registered more abortions than other cities in the same region. According to the 2014 data from the Direcção Nacional de Planificação, 629 and 698 women, respectively, were admitted to the hospital due to induced abortion complications in Maputo and Quelimane [ 26 ]. Furthermore, the two differ radically in terms of culture, with Maputo in the South being patrilineal and Quelimane in the Central Region matrilineal, which could influence the abortion decision-making process. The fieldwork took place between July–August 2016 and January–February 2017.

2.2. Data Collection

The data were collected through in-depth interviews, asking participants about their experiences with induced abortion and what motivated them to get an abortion. To approach and recruit participants ( Figure 1 ), we used the information collected during a cross-sectional survey with women in the reproductive age (15–49), These women were selected randomly applying multistage cluster based on household registers. The survey was designed to understand women’s sexual and reproductive health and included filter questions that allowed us to identify participants who had undergone an abortion. The information sheet and informed consent form for this household survey included information about a possible follow-up study.

The process of recruitment of the participants.

Participants who were within the age-range 15–24 years and who reported having had an abortion were contacted by phone. In this contact, the researcher (MF) introduced herself, reminded the participant of the study she took part in, explained the follow-up study and asked whether she was willing to participate in this. If she did, an appointment was made at a convenient location. Before each interview, we explained to each participant why she was invited to the second interview. Participants were also informed of interview procedures, confidentiality and anonymity in the management of the data, and the possibility to withdraw from the interview at any time. In total 14, young women (15–24) agreed to participate: nine in Maputo and five in Quelimane. Six of them were interviewed twice to explore further aspects that remained unclear after the first interview. The interviews were conducted in Portuguese.

To start the interview, the participant was invited to tell her life history from puberty until the moment when the abortion occurred. During the conversation, we used probing questions to elicit more details. Gradually, we added questions related to the abortion and factors that influenced the decision process. The main questions were related to the pregnancy history, abortion decision-making, and help-seeking behaviour. The guideline was adapted from WHO tools [ 27 , 28 ]. Before the implementation of the guideline, it was discussed first with another Mozambican researcher to see how they fell regarding the question. After those questions were revised or removed from the guideline.

2.3. Data Analysis

The analysis consisted of three steps: transcription, reading, and codification with NVivo version 11(QSR International Pty Ltd., Doncaster, Australia). After an initial reading, one of the authors (MF) developed a coding tree on factors determining the decision-making. A structured thematic analysis was used to make inferences and elicit key emerging themes from the text-based data [ 29 , 30 ]. The coding tree was based on the ecological model, which is a comprehensive framework that emphasizes the interaction between, and interdependence of factors within and across all levels of a health problem since it considers that the behaviour affects and is affected by multiple levels of influence [ 31 , 32 ].

Next, the codes and the classification were discussed among the researchers (Mónica Frederico, Kristien Michielsen, Carlos Arnaldo and Peter Decat). Finally, the data was interpreted, and conclusions were drawn [ 33 ].

2.4. Ethical Consideration

Before the implementation of this research, we obtained ethical approval from the Institutional Committee of the Faculty of Medicine and Nacional Bioethical Committee for Health (IRB00002657). We also asked for the institutional approval of the Minister of Health and authorities at the provincial and community levels. The participants gave their informed consent after the objectives and interview procedures had been explained to them. The participants were informed that they might be contacted and invited, within six months, to participate in another interview.

2.5. Concepts

The providers are the people who carried out the abortion procedure. These may be categorized into skilled and unskilled providers: the former refers to a professional (i.e., nurse or doctor) offering abortion services to a client, while the latter is someone without any medical training. Another concept that requires further explanation is the legal procedure. This corresponds to a set of steps to be followed to comply with the law [ 19 , 20 ]. Specifically, this means that a committee should authorize the induced abortion and an identification document should be available, as well as an informed consent form from the pregnant woman. If the woman is a minor, consent is given by her legal guardian. An ultrasound exam is required to determine the gestational age.

3.1. Characteristics of the Participants

The characteristics of the interviewees are summarized in Table 1 . The 14 participants were aged 17 to 24 years. Eight had completed secondary school, four had achieved the second level of primary school, and two were university students. Almost all (13) were Christian. Five participants were studying, eight were unemployed, and one was working. The median age of their first sexual intercourse was 15.5 years. Participants reported living with one or both parents (12), with their uncle (1) or alone (1). They lived in suburban areas of Maputo and Quelimane, which are slums with poor living conditions. In these areas, most households earn their income through small businesses that also involve child labour (e.g., selling food or drinks).

Socio-demographic characteristics and abortion procedure.

Among the participants, five reported more than one pregnancy. One interviewee first had a stillbirth and then two abortions. Another woman gave birth to a girl and afterward terminated two pregnancies. Two interviewees reported two pregnancies, the first of which was brought to full term and the second one terminated. One woman first had an abortion and afterward gave birth to a child. In short, 14 interviewees in total reported on the experiences and decision-making of 16 abortions. One participant stated that the pregnancy was the consequence of rape. Of the 16 reported abortions, seven were performed after the new law came into force at the end of 2014, and nine were carried out before this time.

3.2. Abortions Stories

In this study, 12 abortions were done by skilled providers and two by unskilled providers. The unskilled providers were a mother and a husband, respectively. None of the cases, whose abortion was done by a skilled provider, included in this study followed the legal procedure.

In the analysis of the interviews, we studied the personal, interpersonal and environmental factors that influenced six different types of abortion stories, see Table 2 : (1) an abortion was performed because the pregnancy was unwanted; (2) an abortion was carried out although the pregnancy was wanted; (3) the abortion was done by an unskilled provider at home; (4) an abortion was carried out by a skilled provider outside the hospital; (5) a particular abortion procedure (medical or chirurgical) was chosen, and (6) the legal procedure was not followed in the hospital. Factors influencing the choice for a particular technical procedure were also examined.

Summary of induced abortion stories. (We changed the table format, please confirm.)

* The result of rape; ** Seven participants; *** six participants.

3.3. Abortion Following an Unwanted Pregnancy

In the stories about unwanted pregnancies, mostly personal factors were mentioned as reasons, with some interviewees stating that they felt unable to be a mother at the time of the pregnancy: “ (It) was at the time that I was taking pills that I got pregnant, and I induced abortion because I was not prepared (for motherhood). ” (24 years)

Some had had a bad experience in the past: “ Maybe I would be abandoned and it would be the same. (Sigh)... I learned with my first pregnancy. ” (23 years)

Also, the existence of another child was mentioned as a reason to have an abortion: “ I got pregnant when I was 20, and I had a baby. When I became pregnant again, my daughter was a child, and I could not have another child. ” (23 years)

For other participants, studies were the main reason why the pregnancy was not wanted: “ He was informed about it, and he said that I should keep it. However, as I wanted to continue my studies, I told him no, no (I) do not. ” (17 years)

At the interpersonal level, a lack of support from the partner was often mentioned as a reason for not wanting the baby: “ He said that he recognizes the paternity, but it is not to keep that pregnancy. ” (22 years)

Women frequently mentioned environmental circumstances related to their poor socio-economic situation: “ I am staying at Mom's house; it is not okay to still be having babies there.” (23 years)

“ At home, we do not have any resources to take care of this child! ” (20 years)

3.4. Abortion Following a Wanted Pregnancy

In these cases, the decision to abort the pregnancy was not made by the woman herself but imposed by others or by the circumstances.

Some participants reported that their parents/family had decided what had to be done: “ They decided while I was at school. If (it) was my decision I would keep it because I wanted it. ” (18 years).

Other young women indicated the refusal of paternity as a reason to terminate the pregnancy.

“ Because my son’s father did not accept the (second) pregnancy. There was a time, we argued with each other, and we terminated the relationship. Later, we started dating again, and I got pregnant. He said it was not possible. ” (21 years)

“ (he) impregnated me and after that, he dumped me, (smiles)… I went to him, and I said that I was pregnant. He said eee: I do not know, that is not my child. ” (20 years).

Some women told the interviewers that they were convinced by their boyfriend to have an abortion: “ I talked to him, and he said okay we are going to have an abortion and I accepted. ” (22 years)

Others mentioned their partner’s indecision and changing attitude as a reason to get an abortion, even though they did want the baby:

“ I told him I was pregnant. First, he said to keep it. (Next) He was different. Sometimes he was calling me, and other times not. I understood that he did not want me. ” (20 years)

The fear of being excluded from their family due to their pregnancy was another reason reported by participants: “ So I went to talk with my older sister, and she said eee, you must abort because daddy will kick you out of our home. ” (20 years)

“ As I am an orphan, and I live with my uncle, they were going to kick me out. No one would assist me. ” (20 years)

3.5. Location of the Abortion: Home-Based Versus Hospital-Based

Two young women reported having had the abortion at home by an unskilled provider. It seems that these unskilled providers than the women (i.e. family members, partner) made the decisions.

“ It was mammy and my sister (who provided the induced abortion services). My sister knows these things. ” (18 years)

“ He (the father of the child) came to my house and took me back to his house. It was that moment when I aborted. ” (21 years)

Of the 16 abortions, seven were performed through health services, by a skilled provider. For some of them, the choice for a health service was influenced by the fact of knowing someone at the health facility.

“ I went to talk to her (friend), and she said that “I have an aunt who works at the hospital, she can help you. Just take money”. ” (20 years)

“ I Already knew who could induce it (abortion). No, I knew that person. I went to the hospital, and I talked to her, (and) she helped me. ” (22 years)

Other participants went to the health facility, but due to the lack of money to pay for an abortion at the facilities they sought help out of the health facility: “ They charged us money that we did not have. The ladies did not want to negotiate anything. I think they wanted 1200 mt (17.1 euros) if I am not wrong. He had a job, but he (boyfriend) did not have that amount of money. ” (22 years)

Some participants reported that they had an abortion outside regular facilities because the health provider recommended going to his house: “ She (mother) was the one who accompanied me. She is the one who knows the doctor. We went to the central hospital, but he (the doctor) was very busy, and he told us to go to his house. ” (17 years)

Others reported the fear of signing a document as a reason to seek help outside of official channels: “ I heard that to induce abortion at the hospital it is necessary for an adult to sign a consent form. I was afraid because I did not know who could accompany me. Because at that time I only wanted to hide it from others. ” (22 years).

3.6. Abortion Procedure

The women were not able to explain why a particular abortion procedure (i.e., pills or aspiration, curettage) was used. It appears that they were not given the opportunity to choose and that they submitted themselves to the procedure proposed by the provider.

“ The abortion was done here at home. They just went to the pharmacy, bought pills and gave them to me. ” (18 years)

3.7. Legal Procedure

None of those treated at the hospital stated that legal procedures were followed. They also mentioned that they had to pay without receiving any official receipt.

“ First we got there and talked to a servant (a helper of the hospital). The servant asked for money for a refreshment so he could talk to a doctor. After we spoke (with servant), he went to the doctor, and the doctor came, and we arranged everything with him. ” (22 years)

“ We went to the health center, and we talked to those doctors or nurses I mean, they said that they could provide that service. It was 1200 mt (17.1 euros), and they were going to deal with everything. They did not give us the chance to sign a document and follow those procedures. ” (20 years)

4. Discussion

The objective of this study was to describe abortion procedures and to explore factors influencing the abortion decision-making process among young women in Maputo and Quelimane.

The study pointed out determinants at the personal, interpersonal and environmental level. Analysing the results, we were confronted with four recurring factors that negatively impacted on the decision-making process: (1) women’s lack of autonomy to make their own decisions regarding the termination of the pregnancy, (2) their general lack of knowledge, (3) the poor availability of local abortion services, and (4) the overpowering influence of providers on the decisions made.

The first factor involves women’s lack of autonomy. In our study, most women indicate that decisions regarding the termination of a pregnancy are mostly taken by others, sometimes against their will. Parents, family members, partners, and providers decide what should happen. As shown in the literature, this lack of autonomy in abortion decision-making is linked to power and gender inequality [ 34 , 35 , 36 , 37 , 38 ]. On the one hand, power reflects the degree to which individuals or groups can impose their will on others, with or without the consent of those others [ 34 , 37 , 38 ]. In this case, the power of the parent/family is observed when they, directly or indirectly, influence their daughters to induce an abortion, for instance by threatening to kick them out of their home. On the other hand, gender inequality is also a factor. This refers to the power imbalance between men and women and is reflected by cases in which the partner makes the decision to terminate the pregnancy [ 38 ]. Besides this, the contextual environment of male chauvinism in Mozambique also makes it more socially acceptable for men to reject responsibility for a pregnancy [ 34 , 35 , 37 , 39 , 40 ]. Finally, women’s economic dependence makes them more vulnerable, dependent and subordinated. For economic reasons, women, have no other choice but to obey and follow the family or partner’s decisions. Closely linked with women’s lack of autonomy is their lack of knowledge. Interviewees report that they do not know where abortion services are provided. They are not acquainted with the legal procedures and do not know their sexual rights. This lack of knowledge among women contributes to the high prevalence of pregnancy termination outside of health facilities and not in accordance with legal procedures.

Our participants often report that abortion services are absent at a local level, as has also been pointed out by Ngwena [ 41 ]. This is a particular problem in Mozambique. Not all tertiary or quaternary health facilities are authorized to perform abortions. The fact that only some tertiary and quaternary facilities are allowed to do so creates a shortage of abortion centres to cover the demand. In fact, only people with a certain level of education and a sufficiently large social network have access to legal and proper abortion procedures.

Finally, our study shows that providers mostly decide on the location, the methods used and the legality of abortion procedures. Patients are highly dependent on the health providers’ commitment, professionality and accuracy and the selected procedures are not mutually decided by the provider and the patient. Providers often do not refer the client to the reference health facility or do not inform them of the legal procedures, creating a gap between law and practice that stimulates illegal and unsafe procedures. The reasons for this are unclear. It might be due to a lack of knowledge among health providers too, and, perhaps, provider saw here an opportunity to supplement the low salary [ 42 ]. Participants who seek help at the health facility they do so contacting the provider in particular, as indication given by someone.

This corroborates with studies conducted by Ngwena [ 41 , 43 ], Doran et al. [ 44 ], Pickles [ 45 ], Mantshi [ 46 ], and Ngwena [ 47 ], which pointed out the obstacles related to the availability of services and providers’ attitudes towards safe abortion, although the law grants the population this right [ 41 , 43 , 44 , 45 , 46 , 47 ]. As Ngwena [ 41 , 43 ] argues, the liberalization of abortion laws is not always put into practice and abortion rights merely exist on paper. Braam’ study [ 48 ] therefore highlights the necessity of clarifying and informing women and providers of the current legislation and ensuring that abortion services are available in all circumstances described in the law.

Finally, despite cultural differences between Maputo and Quelimane, the result did not suggest differences between two areas studied regarding factors influencing the decision to terminate and how the abortion is done. However, the Figure 1 suggests that there was trend to have more participants from Maputo reporting abortion episode in her life than Quelimane. This difference maybe be because Maputo is much more multicultural and the people of this city have more access to information that gives them the opportunity to learn about matter of reproductive health including abortion, than Quelimane. So, due to this there is trend decrease the taboo relation to abortion in Maputo than in Quelimane.

These abortion stories illustrate the lack of autonomy in decision-making process given the power and gender inequalities between adults and young women, and also between man and women . They also show the lack of knowledge not only on the availability of abortion services at some health facilities, as well as, on the new law on abortion. All these lacks that women have are reinforced by poor availability of abortion services and the fact that the providers we not taking their role to help those women, as it is exposed in the next sections.

This study interviewed young women who had an induced abortion at some point in their lives (15 years up to their age at interview date). As such, it does not provide any information on the factors behind the decisions of those who did not terminate their pregnancy.

The results presented in this paper only reflect the perceptions of the young women who had an induced abortion, not those of their parents or partners. The paper is based on qualitative data that provides insights into factors influencing abortion decision-making. Since the sample included in the study is not representative for the population of young women in Mozambique, the results cannot be generalized.

5. Conclusions

Based on the results of the study, we recommend the following measures to improve the abortion decision-making process among young women:

First, strategies should be implemented to increase women's autonomy in decision-making: The study highlighted that gender and power inequalities obstructed young women to make their decision with autonomy. We reiterate the Chandra-Mouli and colleges [ 49 ] message. There is a need to address gender and power inequalities. Addressing gender inequality, and promotion of more equitable power relations leads to improved health outcomes. The interventions to promote gender-equitable and power relationships, as well as human rights, need to be central to all future programming and policies [ 49 ].

Second, patients and the whole population should be better informed about national abortion laws, the recommended and legal procedures and the location of abortion services, since, despite the decision to terminate pregnancy resulted to the imposition, if they were well informed on that, maybe they could be decide on safe and legal abortion, avoiding double autonomy deprivation. At the same time, providers must be informed about the status of national abortion laws. Additionally, they should be trained in communication skills to promote shared decision-making and patient orientation in abortion counseling.

Third, the number of health facilities providing abortions services should be increased, particularly in remote areas.

Finally, health providers should be trained in communication skills to promote shared decision-making and patient orientation in abortion counseling.

The abortion decision-making by young women is an important topic because it refers the decision made during the transitional period from childhood to adulthood. The decision may have life-long consequences, compromising the individual health, career, psychological well-being, and social acceptance. This paper, on abortion decision-making, calls attention to some attitudes that lead to the illegality of abortion despite it was done at a health facility.

Acknowledgments

Authors gratefully acknowledge the support, contribution, and comments from all those who collaborated direct or indirectly, especially Olivier Degomme, Eunice Remane Jethá, Emilia Gonçalves, Cátia Taibo, Beatriz Chongo, Hélio Maúngue and Rehana Capruchand.

Author Contributions

All authors contributed significantly to the manuscript. Mónica Frederico collected data and developed the first analysis. The themes were intensively discussed with Kristien Michielsen, Carlos Arnaldo and Peter Decat. The subsequent versions of the article were written with the active participation of all authors.

Conflicts of Interest

The authors declare no conflicts of interest.