“Have you ever performed a C-section on a 12-year-old?”: A content analysis of TikTok videos related to abortion as healthcare
Article information
Abstract
In recent years, many medical professionals and institutions have been sharing the message: “abortion is healthcare” (Cohen et al., 2022). This type of messaging positions abortion as essential healthcare, as opposed to a “choice.” This content analysis of videos from a search of “abortion is healthcare” on TikTok (N=90) lends understanding to what health-related content characteristics are most common and which relate to differing levels of social media engagement from TikTok users. Central findings include TikTok videos that discuss abortion access for minors have higher likes and shares, and videos that discuss the legal consequences of abortion receive less engagement. Implications for advocates for reproductive rights and ideas for future research are discussed.
Introduction
On June 24, 2022, the United States Supreme Court eliminated the constitutional right to an abortion in the Dobbs v. Jackson Women's Health Organization ruling. Many individuals, including medical professionals, reproductive rights activists, and politicians, are using social media to share their responses to the Dobbs v. Jackson Women's Health Organization decision. This research seeks to understand how the healthcare-related implications of abortion are being communicated on TikTok, as the platform has become a common place for sharing health information and stories related to abortion, as discussed in mainstream media (Kingsberry, 2022; Latifi, 2022).
In recent years, many medical professionals and institutions have been sharing the message: “abortion is healthcare” (Cohen et al., 2022). The World Health Organization (n.d.) states, “Lack of access to safe, timely, affordable and respectful abortion care poses a risk to not only the physical, but also the mental and social, well-being of women and girls” (para. 1). The American Academy of Pediatrics (2022) discusses the importance of abortion as part of healthcare specifically for adolescents, stating,
AAP is concerned that attempts to limit abortion care will not only interfere with the adolescents’ trusting, confidential relationship with their physician, but could result in real psychological and physical harm. Any delays in healthcare can increase volatility within a family, limit pregnancy options, or cause someone to seek an unsafe abortion. (para 5)
Further, the American College of Obstetricians and Gynecologists (n.d.) says, “The fact is, abortion is an essential component of women’s health care” (para. 1). Abortion is considered healthcare for many reasons, according to the American College of Obstetricians and Gynecologists (ACOG). One reason is that in the case of pregnancy complications, abortion may be the only option to save the mother’s life. Further, the organization discusses that in places where abortion is illegal or hard to access, women often pursue unsafe abortions, which account for around 13% of maternal deaths. Finally, ACOG mentions factors including rape, incest, contraceptive failure, and domestic violence also make abortion an important healthcare decision.
Banning abortion, which has happened in many U.S. states, provides many risks to mothers. Medical professionals anticipate maternal deaths will increase, and they face challenges in knowing when they can make an exception for the life of the mother. One Texas doctor told NBC News, “My lawyer told me, ‘Unless they are on that table dying in front of you, you cannot do an abortion on them or you are breaking the law,’” (Bendrix, 2022, para. 6). Abortion is an important part of healthcare as discussed by numerous medical organizations, and given the challenging landscape in a post-Dobbs America, it is important from a health communication perspective to study messaging related to abortion as healthcare.
“Abortion is healthcare” messaging is very different than “choice” discourse. Smyth (2002) argues that the discourse of abortion as a choice is problematic, for many reasons, including its trivialization of decisions women make about reproductive health issues. Further, she argues, discussing abortion as a choice means the government does not need to ensure access. Smyth’s analysis of the problem with choice is particularly evident given the Dobbs v. Jackson Women's Health Organization decision.
Given the increased discussion of abortion as healthcare, the present study explores the phrase “abortion is healthcare” on TikTok to understand what message content characteristics relate to differing levels of social media engagement. Ultimately, this study hopes to give insight into how social media can be used to advance conversations about healthcare aspects of reproductive rights.
Literature Review
Abortion in the media
Abortion coverage in the media has been researched by many scholars, given the role of media in shaping perceptions and politics of abortion (Carmines et al., 2010; Conti & Cahill, 2017). Media is an often-used source for individuals to learn about sex and abortion (Altshuler et al., 2015). Altshuler et al. (2015) found 68% of young adults said media was a source they used to learn about abortion, and was more frequently selected than friends, parents, or healthcare providers. Given the power of media in providing abortion information, it is critical to understand how the media portrays abortion.
A recent review of abortion coverage found the U.S. news media often focuses on the politics of abortion, at the expense of medical information (Conti & Cahill, 2017). In 2019, Woodruff conducted a content analysis of abortion coverage in three U.S. newspapers and found, “despite being a critical health service for women, abortion is not typically covered in U.S. newspapers as a health issue” (p. 8). Further, she found that only 4% of coverage featured the experiences of individuals who had an abortion. When considering abortion portrayal in entertainment media, Conti and Cahill (2017) discuss the focus on abortion as something characters want, not something they need. Further, in entertainment media, the negative health consequences of abortion are portrayed at rates much higher than in reality; one study found 37.5% of television characters with abortion storylines had complications, compared with 2.1% who actually do (Sisson & Rowland, 2017).
When it comes to social media, many platforms have been used by activists to share information related to health-related aspects of abortion, as well as abortion stories (Burbank, 2022; Latifi, 2022). Research has sought to understand the type of content users post on social media about abortion. A content analysis of Tweets using #HB481, the bill number of Georgia’s 2019 LIFE Act, found content focused on political mobilization and general rejection of the bill (Doan et al., 2022). Allan’s (2021) critical discourse analysis of tweets using #ShoutYourAbortion found themes of resistance to pro-life narratives, the emphasis on abortion as a healthcare right, and the normalization of abortion. However, Kosenko et al. (2019) found that the #ShoutYourAbortion hashtag was used by many antiabortion individuals who posted stigmatizing messaging using the hashtag.
Currently, no known research looks specifically at social media posts focusing on abortion as essential healthcare, nor is there content analysis of abortion messages on TikTok. Duggan (2022) argues TikTok can be a platform to engage in more understanding of abortion. Given that we know health information is often not the focus of news media’s abortion coverage, and that many abortion supporters and medical professionals are taking to social media to share health-related abortion messages, the present study seeks to understand what type of health content is shared and what messages receive the most engagement from social media users.
Engagement
Researchers have sought to understand what message characteristics increase the virality of a message on social media channels. Alhabash and McAlister (2015) consider virality from a behavioral perspective, seeking to understand how users interact with a given message. They argue that virality has three dimensions – viral reach (the volume of sharing), affective evaluation (for examples, likes and favorites), and message deliberation (comments). Their research showed that virality is impacted by the type of social network, users’ motivations, and cognitive and emotional involvement. Khan (2017) discusses engagement as encompassing both behavioral actions such as liking, commenting, sharing, and disliking, as well as through simply viewing content. His research demonstrates motivations for different types of engagement (Khan, 2017). Information seeking and relaxing entertainment can be strong motivators for liking, whereas sharing is linked more closely with information giving and status-seeking. Finally, commenting can be linked with social interaction (Khan, 2017). While there are other forms of engagement, this study will focus on the behavioral aspects of how users engage with TikTok videos, specifically, liking, sharing, and commenting.
In addition to the personal motivations of social media users impacting virality, characteristics of the content itself also play a role. Research shows content with an emotional message is more likely to go viral (Jain et al., 2020; Kim et al., 2016). Kim et al. (2016) found breast cancer information was more likely to be retweeted when it included positive emotional appeals. Another study found COVID-related TikTok videos with titles that included positive emotions were more likely to receive more likes (Chen et al., 2021).
Many reproductive rights advocates emphasize the power of storytelling in advocating for abortion rights (Kissling, 2018). Several movements, including #ShoutYourAbortion, can showcase emotions related to lived experiences of people who have had abortions. In her research, Allan (2021) shared a Tweet that said, “I let myself cry as hard as I want to. Anyone who has had an abortion is allowed to feel whatever they want to feel whether it is happy, relieved, sad, or angry. #ShoutYourAbortion.” (p. 35). In addition to providing a place to share abortion stories, social media can also be a place to find social support from others. Jones et al. (2023) analyzed responses to a social media influencer’s post asking followers why they sought an abortion. Many shared emotional considerations that influenced their decision, and others shared support and the message “any reason is valid” (p. 89). Given the power of abortion stories to evoke emotion and support, this research asks,
RQ1: Does social media engagement from TikTok users differ for content that features an abortion story?
Further, as discussed, news media most often focuses on the politics of abortion, rather than focusing on abortion as healthcare. However, social media content often focuses on more nuanced health-related discussions of abortion. TikTok has become a place where young people and adults share their experiences, some related to health-specific needs (Latifi, 2022). Latifi (2022) shares the story of a young person who was assaulted and became pregnant at age 12, and they shared their story on TikTok to advocate for abortion access. Other women have used social media to share stories about how their healthcare access has been impacted since the Dobbs decision, such as a woman who was refused healthcare while experiencing a miscarriage (Kekatos, 2023). Given that social media is used as a platform to discuss abortion as essential healthcare for individuals, including some under the age of 18, this research seeks to understand,
RQ2: Does social media engagement from TikTok users differ for content that discusses the medical necessity of abortion?
RQ3: Does social media engagement from TikTok users differ for content that features discussion of minors as related to abortion access?
Abortion was not always a partisan issue in the U.S., but communication and the media have contributed to its increased politicalization (Carmines et al., 2010). Particularly, in light of the Dobbs v. Jackson Women's Health Organization decision, politics is front and center in much of the conversation. Many states had “trigger laws” in place to immediately go into effect to restrict abortion access after the decision was official. Many existing and proposed laws provide legal consequences for healthcare providers who offer abortions or for women themselves. In South Carolina, a bill has been proposed that would make individuals who have an abortion eligible for punishment including the death penalty (Tran, 2023). The political and legal battle for abortion is constantly in flux during this time in U.S. history, so this research doesn’t attempt to provide a detailed description of the status of reproductive rights. However, it does seek to understand whether social media content that discusses the legal consequences of abortion impacts message engagement, leading to the following research question,
RQ4: Does social media engagement from TikTok users differ for content that discusses the legal consequences of abortion?
While this research seeks to understand content characteristics that impact engagement, it also seeks to understand the influence of the message source. COVID-related health information was more likely to be retweeted when the source was an official health agency (Xie & Liu, 2022). Similarly, in an analysis of Zika-related content on Twitter, researchers found content from federal agencies was 100 times more likely to be retweeted than content from local agencies (Vos & Buckner, 2016). Many health professionals have used TikTok to inform people about abortion, for example, an Oregon doctor uses TikTok to share resources on access, advocacy, and fundraising (Wolters, 2021). Given the use of TikTok by healthcare professionals, and the potential role of the source in engagement with health messages, the following question is posed,
RQ5: Does social media engagement from TikTok users differ when medical providers are talking about abortion?
Method
This project analyzes TikTok messages that focus on health-related discourse about abortion to provide an understanding of what types of messages receive the most engagement from social media users. Understanding this can be useful for consideration in message development to bring additional knowledge about and support for reproductive rights.
The unit of analysis for this study is TikTok posts, specifically those that come up when using the search term “abortion is healthcare.” TikTok is commonly used as a search engine (Huang, 2022), and because of the rising use of the term “abortion is healthcare” by the medical community, as well as abortion rights supporters, the term was used in this study. The posts were selected on November 2, 2022, which was less than 6 months after the Dobbs decision, and days before the midterm elections in the United States on November 8, 2022. More than 70% of the videos in the final sample were posted in May, June, or July of 2022. The oldest post in the final sample was from December 2020, and the most recent post was from October 2022. Fewer than 10% of posts were from before the Dobbs decision. TikTok says video reach can be affected by audience engagement, use of hashtags, and consistency in posting (TikTok, n.d.). The “top posts” setting was used in an attempt to include content that was most likely to be representative of what people are seeing on TikTok if they searched the phrase. Starting from the third post, every third post was added to the sample, up to 90 total posts. No posts added to the sample were excluded from the final analysis. While the numbers of likes, shares, and comments were coded for each video, the comments themselves were not analyzed separately.
Coders consisted of two graduate students. Practice sessions were conducted to revise the code book, and after the completion of pilot testing, coders were each assigned 55 units. Each coder was provided a link to the video, as well as a screenshot of the video. The screenshot, taken on November 2, 2022, was used to code likes, shares, and comments to provide consistency in coding. The video link was used to code all other variables. Inter-coder reliability was assessed with a 22% overlap (n=20). Krippendorff's (2011) alpha was used to determine reliability. All variables in this analysis met the suggested alpha minimum of α≥.67.
Variables
This study uses variables from a larger data set. Some of the posts in the analysis did not fit into any of the content categories included in this analysis, and others fell into more than one.
Engagement. Researchers coded number of likes (α = .90), comments (α = .95), and shares (α = .95).
Abortion Story. Abortion stories were defined as someone talking about their own abortion experience (α = 0.83). Coders also indicated whether negative (regret, anger, or sadness) emotions were present (α = .83) and whether positive emotions (gratitude, relief) were associated with the story (α = 1.00).
Medical necessity of abortion. This was assessed by looking for a discussion of the medical necessity of abortion (α = .67), including a mention of the mother’s health conditions, risk factors, or birth defects.
Abortion related to minors. Coders examined whether the post discussed access and the need for abortion for individuals under age 18 (α = 1.00).
Legal consequences of abortion. This was assessed by looking for a discussion of the legal consequences of abortion, such as the mention of potential laws that could punish providers or people who help others access abortion (α = .69).
Medical provider status. Researchers coded whether anyone featured in the post identified as providing medical care or medical-related support for someone who has had an abortion (α = 1.00).
Results
The mean number of likes for posts included in this study is 239,020.17 (SD = 468,185.08), the mean number of comments is 3,124.17 (SD = 5,671.48), and the mean number of shares is 4,723.00 (SD = 9,364.16). Posts that mentioned abortion access for minors had the highest mean number of likes, shares, and comments, and videos that featured a medical provider had the second highest mean number of each engagement variable. See Table 1 for further descriptive statistics.
Content characteristics of abortion messages
To test the research questions, an ANOVA was run for each of the three engagement variables, with all five message characteristics included in each model. Table 2 includes the results.
ANOVA for engagement and content characteristics
Engagement across all three subsets, including likes, shares, and comments, did not statistically differ for posts that featured an abortion story (RQ1), discussion of the medical necessity of abortion (RQ2), or medical provider (RQ5).
In considering RQ3, whether engagement differed based on a discussion of access and need for abortion for individuals under age 18, engagement via likes did significantly differ, F(1, 89) = 7.3, p <.008. Further, engagement via shares also significantly differed based on content related to minors and abortion, F(1, 90) = 6.34, p <.01. Engagement via comments did not significantly differ.
Specifically, stories with content related to minors and abortion had higher mean likes and shares, as shown in Table 3.
Abortion and minors content mean likes and shares
In regard to RQ4, engagement via likes did significantly differ based on content related to legal consequences of abortion, F(1, 89) = 4.98, p <.03. However, engagement via shares and comments did not differ.
Specifically, stories with content related to legal consequences had lower mean likes (M=164,564.21, SD=233,112.44) than those that didn’t feature this type of content (M=266,511.60, SD=528,224.22).
Discussion
This research sought to understand how content characteristics of health-related abortion discourse on social media relate to viewer engagement. Two significant findings emerged. First, posts that featured discussions of minors as related to abortion had a higher engagement in regard to likes and shares. In one such post that received 850,000 likes, a medical provider asks,
Have you ever performed a C-section on a 12-year-old who was raped by her father in Mexico, whose mother sent her here to give her some kind of hope after the life that she had already experienced? And then she labored for hours and needed a C-section because she hadn't finished puberty yet, so her pelvis wasn't big enough for that baby to fit. Have you? Because I have, and if you haven't, I'm sorry. You don't get to have an opinion on what other people do with their uteruses. (@katiee_e16, 2021)
As previous research has demonstrated, emotion plays a role in engagement with social media content (Jain et al., 2020; Kim et al., 2016). It is possible that messages such as this video that discuss young individuals and need for abortion as related to their health could have a high emotional impact, and could help increase support and understanding for viewing abortion as an important component of healthcare. As Khan (2017) theorized, information seeking is a strong motivator for liking, and information about access for young people may be particularly important to young people who use TikTok. Further, sharing is linked more closely with information-giving and status-seeking (Khan, 2017), and so these messages may be deemed important to share in terms of providing information to inform others. Finally, commenting can be linked with social interaction, and while it might be surprising that this was not also significant, it is important to note that content creators can turn off commenting, and may be more likely to do so when posts are about sensitive information.
While videos that discussed abortion access for minors received higher engagement, videos with content related to the legal consequences of abortion did not receive as much engagement in the form of likes. This could be because this content does not have the more emotional element present in other content. Further, these posts also did not focus on health outcomes as closely as the other variables and were more political in nature. As Khan (2017) discusses, information-seeking and relaxing entertainment can be strong motivators for liking, and videos that talk about negative legal outcomes related to abortion would arguably not be viewed as relaxing, and overall the information may not be as relevant to viewers as they may be more statespecific.
It was somewhat surprising that engagement did not differ for abortion stories, as these often have high levels of emotion. Further, engagement did not differ when the source was a healthcare provider. Posts from medical providers received the second-highest mean numbers on all engagement variables, and abortion stories received the third-highest mean numbers on all engagement variables – both well above the mean number of likes for videos in the sample. Although not statistically significant, significant findings may have emerged with a larger sample and future research should continue to explore how social content from medical providers and content that discusses abortion stories impact engagement as well as attitudes.
There are limitations to studying social media content. The TikTok algorithm is specific to an individual (Huang, 2022). For the present study, the researcher downloaded the app just before this study began and had no other search terms prior to searching for abortion is healthcare, in hopes of avoiding content being targeted to the researcher’s specific interests. But this is not the case for the average user of TikTok. The role of the algorithm, as well as a creator’s follower count, are factors in message virality that are unaccounted for in this research.
In terms of future directions, continuing to look at content on TikTok as well as other social media platforms related to abortion as healthcare will provide greater insights. For example, looking at other creator characteristics, such as race, gender, follower count, and political status would provide richer insights, as would analyzing the comments on these posts. In addition, researchers should look at the effects of viewing these types of messaging on social media on viewers. It would be important to know if seeing content that uses messaging related to “abortion is healthcare” can influence attitudes about the necessity of abortion and increase support and/or action for abortion rights. For example, an experiment could examine whether posts that talk about the medical necessity of an abortion affect attitudes or beliefs about abortion as compared to posts that focus on the politics of abortion.
Finally, this research offers some practical implications for abortion advocates. Posts that feature discussions of minors as related to abortion have higher engagement in regard to likes and shares, so abortion advocates and politicians should continue to talk about the importance of abortion as healthcare for minors. Further, although it was not statistically significant, the higher engagement means for content that featured medical providers and abortion stories should be a positive sign to continue sharing information to demonstrate the importance of reproductive rights in individuals’ healthcare.