Costs. As shown in S9 Appendix, four articles included data on the implications of stigma on economic cost at the macro-level (S3 Table). A majority of the included studies were conducted in high-income countries (United States, Poland, Ireland). Evidence on stigma and economic cost at the macro-level was collected through a mixed-methods study (n = 1), qualitative study (n = 1), literature review (n = 1), and regression analysis (n = 1). Data from the four articles have been synthesized to develop the following emerging theme (Table 5).

(1) Anti-abortion movements and related political action restrict abortion access for individuals through legal regulations, which can result in increased financial barriers to care [32, 40, 47, 48]. The individual decision to seek abortion services in the United States has become a topic of public discussion, as public opinion has the ability to define how easy, expensive, and safe it is to obtain an abortion [48]. The anti-abortion movement has been able to remove abortion care from other aspects of reproductive health and to shape public perception of abortion as a burdensome, immoral, and socially stigmatized act. Anti-abortion movements have also led movements to restrict and recriminalize abortion in order to restrict access for women and to reduce public funding for facilities that provide services [47]. Leading with an argument of moral values, anti-abortions movements have campaigned against public funding for abortion, claiming that people should not be forced to pay for something that is against their moral values.

As aggressive public backlash against abortion builds, more providers are unwilling to perform abortions because of the harassment and intimidation by the anti-abortion movement, the emotional stress of families in crisis, and the relatively low pay to compensate the risk [48]. As fewer providers are willing to take on abortion service provision, access to abortion services can continue to be more cost prohibitive for women who may need to visit multiple clinics and/or travel greater distances to seek care.

Due to the restrictive regulations in counties like Poland and Ireland, women must travel outside of their country in order to access abortion services [32, 40]. While women of higher socio-economic status have the potential means to travel, women in lower socio-economic classes are less likely to have the resources to do so. At the same time, those most affected by the restrictive regulations around abortion are unlikely to have the political and economic capital on their own to protest the law and enact change, trapping them in a discriminatory cycle.

Impact. Only three articles discussed the macroeconomic impact of abortion stigma (S3 Table; S10 Appendix). One of the articles examined economic impact at the global level, and the other two studies were conducted in high-income countries (United States and Poland). Evidence was gathered and presented through a mixed-methods study design (n = 1), a literature review (n = 1), and a regression analysis (n = 1). Synthesis of the data from these three articles has led to the development of the following two emerging themes (Table 5).

(1) The monopolization of abortion services within the private sector has led to unequal access to services due to their unregulated and unsubsidized prices [40]. Abortion stigma in Poland has successfully pushed safe, affordable services out of the public sector, which led to the development of a thriving, underground private sector market for abortion services [40]. Within the private sector, stigmatization of services ensures that the procedures and costs of services remain unregulated. This monopolization of abortion services in the private sector perpetuates social inequality because their services are out-of-reach to a portion of the population that is unable to afford the cost of service.

(2) The Global Gag Rule has institutionalized abortion stigma within its global foreign assistance structure [49]. The Global Gag Rule, a term referring to the United States policy that, in earlier iterations, restricted foreign assistance for reproductive health to organizations above that provide abortion services, information, or referral. The Global Gag Rule has successfully institutionalized abortion stigma within its global foreign assistance structure by enacting restrictions to available funding. Non-government organizations that receive funding from the United States are unable to use that funding for abortion services, referrals, or even to share information regarding abortion. They risk losing their funding if they do not follow these rules. With the most recent iteration of the Global Gag Rule, the restrictions have expanded.

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