The role of health literacy in obtaining abortions in a low income, urban referral clinic
Awarded 2015
Complex Family Planning Fellowship Research
Jonah Fleisher, MD, MPH
New York University School of Medicine

Background and purpose: “Health literacy” is more than just how much a person knows about human biology or her health—health literacy is also the ability to obtain, process, and understand information about one’s health in order to make decisions about it. Health literacy has never been studied in relation to abortion care, but there is strong reason to believe that it impacts women’s ability to obtain the care they seek. Especially for abortion, which is so stigmatized, women with low health literacy may have particular difficulty accessing care. This difficulty may result in a delay in seeking abortion, which would mean higher costs, higher medical risk, and fewer providers available who are trained to perform the procedure. Once we understand how many women have low health literacy and how many women experience delays in obtaining abortion, we can start to understand the scope of the problem and how to improve our care to address it.
Goals: The primary goal was to determine how many women presenting for abortion had “low” health literacy, to determine the scope of the problem. Secondary goals focused on determining the relationship between abortion delay and health literacy. We aimed to determine if health literacy was associated with women feeling like they were delayed, and if so, what types of delay. We also wanted to determine whether health literacy was associated with actual delay—that is, do women with lower health literacy have abortions at later gestational ages? If so, how much later do women with lower health literacy present for abortions?
Methods: In this study at Bellevue Hospital in New York City, we interviewed women who presented to our abortion clinic with a standardized questionnaire (in English and Spanish) assessing whether they felt that they were delayed in obtaining their abortion, and if so, the reasons for that delay. We also assessed each woman’s health literacy level as “adequate” or “low,” according to a research survey that has been used before in many studies. We checked the gestational age of each woman’s pregnancy according to her last menstrual period and ultrasound, just as in routine pregnancy care.
Important Findings: We analyzed the responses of 49 women, of which only 5 (10.2%) were found to have low health literacy. Forty-one (83.7%) of women said they experienced a delay (i.e., they would have preferred to have the abortion earlier than they did). The most common reasons for delay were that it took a long time before the woman knew she was pregnant (42.9%), it took a long time to make arrangements (28.6%), the doctor or clinic made me wait (12.2%) and it took a long time to decide (10.2%).
Conclusions: Most women had adequate health literacy in this study, and most felt that they were delayed in seeking their abortions. The health literacy of women in this study was higher than one would expect from previous studies on health literacy. One possible explanation is that only women with adequate health literacy were able to negotiate the several bureaucratic obstacles to obtain care in this public hospital abortion clinic that is not well-known and does not advertise. This is likely, when we consider that most women in the study (85%) felt that they were delayed in seeking care. Further research at other more accessible abortion clinics would be helpful.

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