Understanding knowledge of, attitudes toward, and experiences with medication abortion among Asian Americans, Native Hawaiians, and Pacific Islanders in the United States
This piece was authored by Katherine Key, who is an Associate Research Scientist at Ibis Reproductive Health’s Cambridge office.
Asian Americans (AAs), Native Hawaiians (NHs), and Pacific Islanders (PIs) experience unique challenges accessing abortion care in the United States (US); however, AAs and NHPIs are often left out of the conversation when discussing access to health care services, especially sexual and reproductive health (SRH) care including abortion care.
In research, AAs and NHPIs are generally categorized as “Other”, “Another race/ethnicity”, or are aggregated under an umbrella term such as “AAPI” or “AANHPI.” This is often because of challenges collecting and analyzing disaggregated data among AA and NHPI populations due to language barriers, which exclude some individuals from participating in the study or result in high translation costs, and relatively small, though not insignificant, population sizes of some Asian ethnic groups in the US. But failing to disaggregate by ethnic groups or even between AAs and NHPIs fails to acknowledge the unique cultural, geographic, historical, and socioeconomic differences between groups in the US and perpetuates stereotypes such as the “model minority” myth, which assumes AAs do not have the same healthcare needs as other minority groups and often have better health outcomes than the general population. Presenting aggregated AANHPI data also leads to AAs and NHPIs being underestimated and ignored in health care, policy, and advocacy spaces. This erasure is detrimental not only to our understanding of the unique health needs of each community, but also results in disadvantages in terms of receiving economic resources and support for groups and organizations aimed at increasing access to health care services, including abortion care among AA and NHPI communities. This also further places NHPIs at an even greater disadvantage due to the assumption that health and economic support for organizations working with AA communities supports all ethnic groups under the AANHPI umbrella.
Existing research indicates that Asian ethnic groups encounter barriers to health care to varying degrees, including barriers related to culture and language, as well as barriers related to health literacy, insurance, cost, and immigration status. No research exists documenting abortion experiences specifically among AAs and NHPIs, but we assume that AA and NHPI ethnic groups also experience barriers to abortion care in different and unique ways. In fact, research among Asian women in New York found that although the abortion rate among Asian women in the sample overall was lower than other race/ethnicities, rates differed by Asian ethnic group with rates ranging from 5.1 abortions per 1000 Korean women to 30.5 abortions per 1000 Indian women.
Increasing abortion restrictions, especially following the Dobbs ruling, along with other policies that disproportionately impact and target AA and NHPI populations, further compound barriers to abortion care and decrease access for AA and NHPI communities across the US and in U.S.-territories. In fact, a blog post following the Dobbs decision indicates that over 25% of AAs and PIs ages 15–49 live in the states that have banned or were likely to ban abortion in the wake of Dobbs and a more recent report shows that nearly one-third of Asians (28%) and Native Hawaiian or Pacific Islanders (29%) live in states with abortion bans or restrictions. As attacks on abortion access continue, it is crucial to better understand and document awareness and knowledge of different abortion methods and experiences accessing these methods among AA and NHPI communities. Identifying gaps in knowledge and documenting the experiences of AAs and NHPIs accessing abortion care can help identify opportunities for increased support and resources to ensure AA and NHPI ethnic groups have equitable access to high-quality abortion care.
To fill current gaps in the literature, Ibis Reproductive Health, in collaboration with the National Asian Pacific American Women’s Forum (NAPAWF), conducted a study using a mixed-methods, community-based participatory research approach to better understand knowledge of, attitudes toward, and experiences with medication abortion among AAs and NHPIs in the US. We worked closely with a community advisory board comprised of seven community-based organizations and individuals representing AA and NHPI communities. The community advisory board was involved throughout study design, recruitment, data analysis, as well as interpretation and dissemination of findings.
Between July 2021 and February 2022, we conducted focus group discussions with AAs and NHPIs of reproductive age (18–49 years), regardless of past abortion experience, and in-depth interviews with AAs and NHPIs of reproductive age (18–49 years) who had a medication abortion within the past five years. In September 2022, we carried out a survey with AAs and NHPIs of reproductive age (16–49 years) who self-identified as Chinese, Asian Indian, Korean, Vietnamese, Filipina, and/or NHPI. We specifically recruited AAs from these ethnic groups because they are the largest AA ethnic groups in the US. The survey and focus groups were available and conducted in English and non-English languages.
Preliminary survey results indicate gaps in knowledge of medication abortion as a method, lack of knowledge of the safety of medication abortion, and limited knowledge of where to access medication abortion if needed, which likely varies by ethnic group. Qualitative results also indicate that across ethnic groups, a lack of openness regarding sexual and reproductive health, particularly abortion, fueled by the stigma and taboo nature of the topic has influenced this lack of knowledge of abortion methods, particularly medication abortion. The report from this study states that people often thought a procedural abortion was the only option and often held negative ideas of this abortion method due to what they had heard or seen in the media. Differences in knowledge of methods also emerged when looking at results among English and non-English speaking focus group participants, with lower knowledge overall among non-English participants. Additional research is needed, however, to better understand and corroborate these differences.
In addition to lack of knowledge, we identified AANHPI community-related barriers to accessing abortion services, which, again, likely vary in degree by ethnic group and geographic location but emerged among participants of all ethnic groups in this study. Participants identified barriers related to stigma and the taboo nature of SRH topics within their families and communities, which led to a lack of knowledge of abortion methods and where to access abortion care, as well as feelings of isolation before, during, and after their abortion. Some participants also explained the difficulty of living with or near family members, which made it more challenging to leave to access care and/or to manage medication abortion symptoms and side effects such as bleeding and cramping, at home when those around them did not know about the pregnancy or the decision to have an abortion. Finally, participants reflected on the lack of Asian and NHPI language options at clinics and when looking for information and support outside of the clinic. These barriers are often experienced in addition to those many abortion seekers in the US encounter, regardless of race or ethnicity including, high cost of abortion care, lack of insurance coverage, lack of transportation, long wait times at the clinic, protestors outside of clinics and legal restrictions; all of which have increased following the Dobbs decision and are further compounded for people of color, including AA and NHPIs seeking abortion care, as well as for low income individuals, people living with disabilities, immigrants, undocumented people, people living in rural areas, and young people.
Given this lack of knowledge of safe and effective abortion methods and where to access abortion care if needed, it is critical to support information sharing with AA and NHPI communities on, not just abortion-related topics, but SRH topics in general. Participants in the study shared ideas about ways to increase knowledge and reduce stigma through storytelling and highlighted the role trusted community-based organizations could play in destigmatizing abortion while sharing SRH and abortion information in Asian and NHPI languages.
Overall, our results indicate large gaps in knowledge of abortion methods, especially medication abortion, which leads to fear and misconceptions that may be further compounded by a lack of knowledge and understanding of the legal risk related to accessing abortion services in the US. This may be even more salient given the taboo and secretive nature of abortion-related topics among AA and NHPI communities.
Moving forward, there is a continued need for research documenting abortion experiences among AAs and NHPIs in the US and in U.S. territories, especially post-Dobbs. This need is heightened by the ever-changing abortion landscape and the emergence of new and adapting models of care in the US. There is also a need to better understand systems of support among AA and NHPI communities as well as awareness and utilization of abortion funds and practical support organizations given the identified knowledge gaps and lack of information available in Asian and NHPI languages.
Things to consider for future work: Despite working closely with community-based organizations, we experienced challenges recruiting for the study. In some cases, people were unwilling to participate in focus groups because they were uncomfortable discussing the topics with others due to the taboo nature of abortion in their communities. Additionally, while we successfully recruited NHPI individuals to respond to survey questions, fewer than five NHPI individuals participated in the qualitative components of the study. More specific efforts are needed to better understand the unique needs, experiences, and perspectives of NHPIs in the US, as well as the experiences of those residing in U.S. territories such as Guam, where reports indicate there are few abortion providers and limited access to abortion services, leading to individuals traveling to other locations in the US such as Hawaii for abortion care. Finally, additional work is needed to ensure SRH terms are accurately and appropriately translated to Asian and NHPI languages when conducting research with AA and NHPI communities.
Research was supported by a grant from the Society of Family Planning Research Fund. The views and opinions expressed are those of the authors and do not necessarily represent the views and opinions of the Society of Family Planning Research Fund.
