The abortion decision: reasons and ambivalence

Factors affecting unintended pregnancy resolution from the perspectives of pregnant women and people: A systematic review of qualitative evidence

BACKGROUND

Unintended pregnancy is a global issue with significant consequences for individuals and society. It impacts maternal and neonatal health, educational attainment, and interpersonal relationships. The decision-making process surrounding unintended pregnancies is complex, influenced by factors like ambivalence, societal norms, and maternal responsibilities. Understanding pregnant women and people's experiences is crucial to providing support and addressing barriers to access. Therefore, this systematic review aimed to consolidate and synthesize qualitative evidence regarding individual's experiences and the factors influencing their decision-making in unintended pregnancies.

METHOD(S)

Ten databases (PubMed, Embase, CINAHL Complete, Cochrane Library, PsycINFO (Ovid), Scopus, Web of Science Core Collection and Social Science Database (ProQuest), MedNar and ProQuest Dissertations and Theses Global) were systematically searched for published and unpublished primary qualitative studies from their inception to December 2022. Relevant qualitative data were extracted and meta-summarized using Sandelowski and Barroso's approach and analyzed using Thomas and Harden's thematic analysis framework.

RESULTS

Eighteen studies met the inclusion criteria and were included in the review. Four themes were identified from the meta-synthesis: 1) Navigating the head and heart, 2) Involvement and influence of others, 3) Hindrance and help in decision-making, and 4) Growing and gaining.

CONCLUSION

This review emphasized the significance of both internal and external factors in shaping pregnant women and people's experiences, and influencing their choices when faced with unintended pregnancies. Recognizing and addressing the multifaceted nature of these decisions; is crucial for different stakeholders such as healthcare professionals, and policymakers to better support pregnant women and people, and promote their well-being. This review sets the stage for future research and practice, emphasizing the ongoing need to empower pregnant women and people, ensure accessible and safe reproductive healthcare services, and promote informed decision-making.

Coerced Abortion - The Neglected Face of Reproductive Coercion

Reproductive coercion encompasses a collection of pregnancy promoting and pregnancy avoiding behaviours. Coercion may vary in severity and be perpetrated by intimate partners or others. Research is complicated by the inclusion of behaviours that do not necessarily involve an intention to influence reproduction, such as contraceptive sabotage. These behaviours are the most common, but are not always included in survey instruments. This may explain why the prevalence of reproductive coercion varies widely. Prevalence also varies when coerced abortion is included in survey instruments. When it is, it seems roughly comparable in prevalence to coercion intended to impregnate. The extent and nature of coerced abortion can also be derived from studies that explore the reasons why women access abortion, the relationship between abortion and intimate partner violence, and online blogs and forums. This narrative review of reproductive coercion examines the evidence and attempts to comprehend why coerced abortion has been neglected.

Pre-abortion counselling from women's point of view

OBJECTIVE

The value of mandatory pre-abortion counselling for women seeking abortions has been repeatedly questioned. The aim of this study was to explore the perspectives and feelings of almost 1000 women regarding pre-abortion counselling in Flanders.

METHODS

Participating women (N = 971) - all requesting an abortion at one of the five Flemish abortion centres - were offered a questionnaire prior to the counselling session and immediately afterwards. Both questionnaires measured their emotional and cognitive state as well as aspects of the content and the perceived value of the counselling session.

RESULTS

Prior to the counselling, women are hesitant regarding the value of the sessions, feel distressed, yet decisive about their abortion. After the counselling session, women assign an increased value to the counselling, are very satisfied, and experience less distress and greater decisiveness. During counselling the abortion procedure (89%), the use of contraceptives (83%) and the individual decision-making process (81%) are nearly always addressed. The sessions are tailored to each woman and to the needs they expressed with regard to the content of the counselling.

CONCLUSIONS

Pre-abortion counselling in Flanders is standardised as well as personalised. The women in this study positively valued it.

Attitudes and decision making among women seeking abortions at one U.S. clinic

CONTEXT

Various restrictions on abortion have been imposed under the pretense that women may be uninformed, undecided or coerced in regard to their decision to terminate a pregnancy. Understanding whether certain women are at risk of low confidence in their abortion decision is useful for providing client-centered care and allocating counseling time to women with the greatest needs.

METHODS

Data were abstracted from the precounseling needs assessment form and clinical intake form of 5,109 women who sought 5,387 abortions at one U.S. clinic in 2008. Multivariate logistic regression was used to analyze variables associated with women's high confidence in their abortion decision.

RESULTS

For 87% of the abortions sought, women had high confidence in their decision before receiving counseling. Certain variables were negatively associated with abortions' being sought by women with high confidence: being younger than 20, being black, not having a high school diploma, having a history of depression, having a fetus with an anomaly, having general difficulty making decisions, having spiritual concerns, believing that abortion is killing and fearing not being forgiven by God (odds ratios, 0.2-0.8). Having a supportive mother or male partner was associated with increased odds of high confidence (1.3 and 1.2, respectively).

CONCLUSIONS

Regulations requiring state-approved information or waiting periods may not meet the complex needs of all women. Instead, women may benefit more from interactions with trained staff who can assess and respond to their individual needs.

Existential experiences and needs related to induced abortion in a group of Swedish women: a quantitative investigation

OBJECTIVE

To investigate the prevalence of existential experiences and needs among women who have requested an induced abortion.

METHODS

A questionnaire was used to collect information from 499 women who had requested an induced abortion. A principle component analysis resulted in three components of existential experiences and needs: existential thoughts, existential practices, and humanisation of the foetus. These components were analysed in relation to background data and other data from the questionnaire.

RESULTS

Existential experiences and needs were common. For 61% of women existential thoughts about life and death, meaning and morality were related to the abortion experience. Almost 50% of women reported a need for special acts in relation to the abortion; 67% of women thought of the pregnancy in terms of a child. A higher presence of existential components correlated to difficulty in making the abortion decision and poor psychological wellbeing after the abortion.

CONCLUSION

Women's experiences of abortion can include existential thoughts about life, death, meaning and morality, feelings of attachment to the foetus, and the need for symbolic expression. This presents a challenge for abortion personnel, as the situation involves complex aspects over and above medical procedures and routines.

[Experience of women who request voluntary abortion: relationship with their health care environment]

OBJECTIVE

To describe women's perception of health care after they decided to have a voluntary termination of pregnancy and their referral to the abortion clinic.

DESIGN

Qualitative method, using semi-structured interviews carried out between April and June 2005.

SETTING

Primary Health Care District of Seville, Spain.

PARTICIPANTS

Women living in the city of Seville and attending subsidized abortion clinics.

MAIN MEASUREMENTS

Thirty-six women of varying ages and educational level were interviewed. The interview studied the assessment and information given by health professionals, and accessibility and use of family planning services. The results were analysed and triangulated with other studies and experts in the field.

MAIN RESULTS

Most of the women interviewed were satisfied with the health care provided. Occasionally they perceived a bureaucratic attitude from physicians, who transmitted their disapproval and lack of support for an abortion decision. There were important differences in the way they were referred to abortion clinics, and in the information given to the women. Older women opted for private care, because this accelerated procedures and protected their privacy. Most women did not use family planning services before the abortion decision, except for requesting contraception.

CONCLUSIONS

The study found there is a need to reduce the variety of patterns of care for women requesting an abortion, to speed up the proceedings and to train family doctors in assessment and information delivered to women during the process.

Exclusion of TCOF1 mutations in a case of bilateral Goldenhar syndrome and one familial case of microtia with meatal atresia

A number of different disorders involving first and second branchial arch anomalies have been described as distinct entities, including Treacher-Collins-Franceschetti syndrome, Goldenhar syndrome, Nager syndrome and Miller syndrome. The significant phenotypic overlap between these disorders raises the issue of a common developmental origin. After the identification of mutations in TCOF1 as a general cause of the Treacher-Collins-Franceschetti syndrome, TCOF1 mutations were excluded in patients with unilateral signs of the Goldenhar syndrome spectrum. We also present two rare cases of bilateral Goldenhar syndrome and familial microtia with meatal atresia, respectively, in whom we also excluded TCOF1 mutations. Thus, genetic heterogeneity in different disorders of the first and second branchial arch development is supported.

Wellbeing and mental growth—long-term effects of legal abortion

The present study aims to increase knowledge about coping with legal abortion by studying women's reasoning, reactions and emotions over a period of 1 year. The study comprises interviews focusing on the experiences and effects of abortion in 58 women, 4 and 12 months after the abortion. The women also answered a questionnaire before the abortion concerning their living conditions, decision-making process and feelings about the pregnancy and the abortion. Majority of the women did not experience any emotional distress post-abortion and almost all the woman reported that they had coped well at the 1-year follow-up, although 12 had had severe emotional distress directly post-abortion. Furthermore, almost all described the abortion as a relief or a form of taking responsibility and more than half reported only positive experiences such as mental growth and maturity of the abortion process. Those without any emotional distress post-abortion stated clearly before the abortion that they did not want to give birth since they prioritised work, studies and/or existing children. The study shows that women generally are able to make the complex decision to have an abortion without suffering any subsequent regret or negative effects, as ascertained at the 1-year follow-up.

Social context and the experience of a sample of U.S. women taking RU-486 (mifepristone) for early abortion

Of 50 women seeking an abortion in Rochester, New York, between November 1999 and January 2001, 35 went on to complete an in-depth interview from 1 to 6 weeks after their follow-up clinical visit. A higher proportion of women who defined their pregnancy as a baby indicated emotional distress during their in-depth interview compared to those who saw their pregnancy as only having the potential to become a baby. The authors conclude that abortion might be made less difficult through public education about the different views of pregnancy and abortion throughout U.S. history. It might be important for abortion counselors to first ask a woman how she defines her pregnancy. A larger study is warranted.

Women's life cycle and abortion decision in unintended pregnancies

OBJECTIVE

To study the impact of sociodemographic, financial, and reproductive factors and of characteristics related to intimate relationships on the decisions of women in different age groups about whether or not to continue an unintended pregnancy.

DESIGN

Cross sectional population based survey.

SETTING

Telephone interview survey between September 2000 and January 2001 in France. From a representative sample (n=14704) of 18 to 44 year old women, those who in the past five years had an abortion or whose last pregnancy was unintended were oversampled (sampling fraction=100%, n=1034) while the other women were randomly selected (sampling fraction =19%, n=1829). Altogether, 2863 women answered the questionnaire.

PARTICIPANTS

All women whose last pregnancy was unintended and ended in induced abortion or birth (n=645).

MAIN RESULTS

Factors associated with the abortion decision varied strongly according to age. Younger women's abortion decisions were mainly related to being a student and being single. Wanting to stop childbearing when the desired number of children was achieved best explained the decision to have an abortion among 25 to 34 year old women. Older women chose abortion especially when childbearing did not fit their work situation or when the relationship with the partner was unstable. A high level of education of a woman and her partner increased the likelihood of abortion, especially among young women.

CONCLUSIONS

The impact of socioeconomic and relationship factors on the decision to have an abortion is not the same at different stages in life, and refers to the social representations and perceptions of what good conditions are for being a mother.

Legal abortion: a painful necessity

This study was conducted to increase knowledge about the psychosocial background and current living conditions of Swedish women seeking abortion, along with their motives for abortion and their feelings towards pregnancy and abortion. Two hundred and eleven women answered a questionnaire when they consulted the gynaecologist for the first time. The study indicates that legal abortion may be sought by women in many circumstances and is not confined to those in special risk groups. For example, most women in the sample were living in stable relationships with adequate finances. The motives behind a decision to postpone or limit the number of children revealed a wish to have children with the right partner and at the right time in order to combine good parenting with professional career. The study shows that prevailing expectations about lifestyle render abortion a necessity in family planning. One-third of the women had had a previous abortion(s) and 12% had become pregnant in a situation where they had felt pressured or threatened by the man. Two-thirds of the women characterised their initial feelings towards the pregnancy solely in painful words while nearly all the others reported contradictory feelings. Concerning feelings towards the coming abortion, more than half expressed both positive and painful feelings such as anxiety, relief, grief, guilt, anguish, emptiness and responsibility, while one-third expressed only painful feelings. However, almost 70% stated that nothing could change their decision to have an abortion. Thus, this study highlights that contradictory feelings in relation to both pregnancy and the coming abortion are common but are very seldom associated with doubts about the decision to have an abortion.

Ambivalence--a logical response to legal abortion: a prospective study among women and men

The aim of the study was to elucidate ambivalence in relation to legal abortion by studying emotions, attitudes, motives for abortion and ethical reasoning in a strategic sample of women and men who, 1 year after abortion, expressed both positive and painful feelings in relation to the abortion. The study shows that social perspectives legitimate the decision to have an abortion whilst ethical perspectives complicate the decision. Nearly all women and men described having the abortion as an expression of responsibility. Almost one-half also had parallel feelings of guilt, as they regarded the abortion as a violation of their ethical values. The majority of the sample expressed relief while simultaneously experiencing the termination of the pregnancy as a loss coupled with feelings of grief/emptiness. In spite of the ambivalence, only one woman regretted the abortion. For the vast majority, the impact of the abortion had led to increased maturity and deepened self-knowledge. Thus, ambivalence might be regarded not only as problematic but also as indicating openness to the complexity of the abortion issue. Since incompatible values clash in connection with abortion, experiences of ambivalence become both logical and understandable.

The male partner involved in legal abortion

This study comprises 75 men who have been involved in legal abortion. The men answered a questionnaire concerning living conditions and attitudes about pregnancy and abortion. Most men were found to be in stable relationships with good finances. More than half clearly stated that they wanted the woman to have an abortion while 20 stressed that they submitted themselves to their partner's decision. Only one man wanted the woman to complete the pregnancy. Apart from wanting children within functioning family units, the motivation for abortion revealed that the desire to have children depended on the ability to provide qualitatively good parenting. More than half the men had discussed with their partner what to do in event of pregnancy and half had decided to have an abortion if a pregnancy occurred. More than half expressed ambivalent feelings about the coming abortion, using words such as anxiety, responsibility, guilt, relief and grief. In spite of these contradictory feelings, prevailing expectations concerning lifestyle make abortion an acceptable form of birth control. A deeper understanding of the complexity of legal abortion makes it necessary to accept the role of paradox, which the ambivalence reflects. Obviously, men must constitute a target group in efforts to prevent abortions.

The abortion decision: fantasy processes

This paper considers that features intrinsic to pregnancy and to an unwanted pregnancy/abortion decision heighten the likelihood of the occurrence, and the importance, of fantasy in the decision-maker's thinking. In addition, investigation of fantasy or non-rational processes in an abortion decision emphasizes the complexity of decision-making in a way which may challenge ideas of decision-making in general. The results of a pilot study using a short fantasy inventory with 20 women facing an abortion decision are presented to highlight fantasy, not as irrational or pathological, but as legitimately coexisting with logical, reasoning, non-fantasy thought in the abortion decision. The clinical value of the fantasy inventory is explored.