Repeat abortion: a qualitative study

Obstetric and psychological characteristics of women seeking multiple abortions in the region of Monastir (Tunisia): results of a cross-sectional design

Background

Repeat abortion is a public health concern favored by many obstetric and social factors.

The purpose of our study was to identify associated factors to repeated abortion in the region of Monastir (Tunisia). Common mental disorders (CMD) such as anxiety and depression were also evaluated in women seeking voluntary repeated abortion.

Methods

We carried out a cross sectional study between January and April 2013 in the Reproductive Health Center (RHC) of the region of Monastir in Tunisia (This study is part of a prospective design on mental disorders and intimate partner violence among women seeking abortions in the RHC).

Among women referred to the RHC we selected those seeking voluntary abortion (medical or surgical method). Data on women’s demographic characters, knowledge and practices about contraceptive methods and abortion were collected the abortion day via a structured questionnaire. Data about anxiety and depression status were evaluated during the post-abortal control visit at 3–4 weeks following pregnancy termination.

Results

Of the 500 interviewed women, 211 (42.2 %; CI_95% [37.88 – 46.52]) were seeking repeated abortions. Multivariate analysis showed that increased age, lower level of women school education, single status, poor knowledge about birth control methods and history of conflict/abuse by a male partner, were uniquely associated with undergoing repeat compared with initial abortion.

CMD were significantly higher in women undergoing second or subsequent abortion (51.1 %) single and lower educated women. Women relating a history of conflicts/abuse report more CMD than others (30.6 % vs 20.8 %).

Conclusion

Health facilities providing abortion services need to pay more attention to women seeking repeat abortion. Further studies are needed to well establish the relation between the number of abortion and the occurrence and the severity of CMD.

Australian women's fertility experiences prior to a termination of pregnancy

Objective. This research aimed to investigate the fertility management of women aged over 30 years prior to a termination of pregnancy (TOP) to inform primary health care service delivery providers and policy makers. Design. An ethically approved, two-phase sequential explanatory mixed methods design was used. This paper reports on part of that study. Setting. The study was conducted in five South Australian TOP clinics. Patients. Women aged over 30 years attending for a TOP in 2009 were invited to participate. Interventions. The Contraception Sexual Attitude Questionnaire (modified version) of women attending termination of pregnancy services was used. Main Outcomes Measures. Quantitative data analysis utilized SPSS V16 where simple descriptive statistics were described. Results. There were 101 questionnaire respondents where 70.5% were Australian women, predominantly married and with children. Women used contraception but experienced method failure, were beginning a new method, or were afraid of side effects. Risk-taking behaviours were reported such as putting the possibility of pregnancy out of their mind, getting carried away and not thinking of pregnancy risk, or frequently having unprotected intercourse. Conclusion. Service delivery needs to include age specific programs, and policy makers need to include policies which are adequately funded and evaluated. Further research is required to provide greater depth of knowledge in this area.

Changes in sexual function after medical or surgical termination of pregnancy

INTRODUCTION

Voluntary termination of pregnancy (TOP) is a social issue; however, even if it is one of the most common procedures performed in the world, few studies evaluated sexual function changes after medical or surgical TOP.

AIM

The aim of this study was to evaluate how first trimester TOP by either surgical (group 1) or medical procedure (group 2) affects sexual function.

METHODS

This prospective observational study included 211 patients (132 in group 1 and 79 in group 2) who requested first trimester TOP between September 2010 and May 2012. Medical TOP (mifepristone and misoprostol) was offered to patients up to 49 days of gestation. Surgical TOP was performed up to 12 weeks. The Female Sexual Function Index (FSFI) was used to evaluate sexual function before TOP, after 1, 3, and 6 months from TOP.

MAIN OUTCOME MEASURES

Changes in the FSFI values and number of sexual active patients after 1, 3, and 6 months from the TOP and the self-reported quality of sexual life at 6 months, with the two different procedures, were the main outcome measures.

RESULTS

At 4-week follow-up, 23.6% of women in group 1 did not resume sexual intercourse compared with 5.4% of women in group 2 (P = 0.003). At 6 months, 3.3% of women in the group 1 and no women in the group 2 did not resume sexual intercourses (P = 0.123). Compared with women in group 2, those in group 1 had lower FSFI score and number of sexual intercourses at 1, 3, and 6 months follow-up (P < 0.001).

CONCLUSIONS

This study shows that the number of sexually active women and the overall FSFI are reduced in women undergoing surgical TOP compared with those undergoing medical TOP. Counseling regarding sexual function changes should be included in the discussion of morbidity related to medical or surgical TOP.

Public Health Impact of Legal Termination of Pregnancy in the US: 40 Years Later

During the 40 years since the US Supreme Court decision in Doe versus Wade and Doe versus Bolton, restrictions on termination of pregnancy (TOP) were overturned nationwide. The use of TOP was much wider than predicted and a substantial fraction of reproductive age women in the U.S. have had one or more TOPs and that widespread uptake makes the downstream impact of any possible harms have broad public health implications. While short-term harms do not appear to be excessive, from a public perspective longer term harm is conceiving, and clearly more study of particular relevance concerns the associations of TOP with subsequent preterm birth and mental health problems. Clearly more research is needed to quantify the magnitude of risk and accurately inform women with the crisis of unintended pregnancy considering TOP. The current US data-gathering mechanisms are inadequate for this important task.

Reasons women give for abortion: a review of the literature

The aim was to identify from empirical research that used quantitative or qualitative methods the reasons women give for having an abortion. A search was conducted of peer-reviewed, English language publications indexed in eight computerized databases with publication date 1996-2008, using keywords 'abortion' and 'reason' (Medline: 'induced abortion' OR 'termination of pregnancy' OR 'elective abortion' and 'reason'). Inclusion criteria were empirical research on humans that identified women's reasons for undergoing an abortion, conducted in 'high-income' countries. 19 eligible papers were found. Despite variation in methods of generating, collecting, and analysing reasons, and the inadequacy of methodological detail in some papers, all contributed to a consistent picture of the reasons women give for having an abortion, with three main categories ('Woman-focused', 'Other-focused', and 'Material') identified. Ambivalence was often evident in women's awareness of reasons for continuing the pregnancy, but abortion was chosen because continuing with the pregnancy was assessed as having adverse effects on the life of the woman and significant others. Women's reasons were complex and contingent, taking into account their own needs, a sense of responsibility to existing children and the potential child, and the contribution of significant others, including the genetic father.

Induced abortion and intimate relationship quality in the Chicago Health and Social Life Survey

OBJECTIVES

To examine associations between abortion and relationship functioning.

STUDY DESIGN

Independent variables included abortion in a previous relationship and abortion in a current relationship. Perceptions of quality-of-life changes associated with terminating the relationship, conflict, aggressiveness and sexual dysfunction were the outcome measures.

METHODS

Data were derived from interviews with an ethnically diverse urban sample of men (n=658) and women (n=906). Surveys were conducted in person using computer-assisted personal interview technology by the National Opinion Research Center affiliated with the University of Chicago, USA.

RESULTS

For men and women, the experience of an abortion in a previous relationship was related to negative outcomes in the current relationship; perceptions of improved quality of life if the current relationship also ended and intimate partner violence. Experience of an abortion within a current relationship was associated with 116% and 196% increased risk of arguing about children for women and men, respectively. Among females, experience of an abortion within a current relationship was associated with increased risk for various forms of sexual dysfunction (122-182%), increased risk of arguments about money (75%), increased risk of conflict about the partner's relatives (80%), and increased risk of arguing about the respondent's relatives (99%). Men whose current partners had experienced an abortion were more likely to report jealousy (96% greater risk) and conflict about drugs (385% greater risk).

CONCLUSION

Abortion may play a vital role in understanding the aetiology of relationship problems.

Experiences of abortion: a narrative review of qualitative studies

BACKGROUND

Although abortion or termination of pregnancy (TOP) has become an increasingly normalized component of women's health care over the past forty years, insufficient attention has been paid to women's experiences of surgical or medical methods of TOP.

OBJECTIVE

To undertake a narrative review of qualitative studies of women's experiences of TOP and their perspectives on surgical or medical methods.

METHODS

Keyword searches of Medline, CINAHL, ISI, and IBSS databases. Manual searches of other relevant journals and reference lists of primary articles.

RESULTS

Qualitative studies (n = 18) on women's experiences of abortion were identified. Analysis of the results of studies reviewed revealed three main themes: experiential factors that promote or inhibit the choice to seek TOP; experiences of TOP; and experiential aspects of the environment in which TOP takes place.

CONCLUSION

Women's choices about TOP are mainly pragmatic ones that are related to negotiating finite personal and family and emotional resources. Women who are well informed and supported in their choices experience good psychosocial outcomes from TOP. Home TOP using mifepristone appears attractive to women who are concerned about professionals' negative attitudes and lack of privacy in formal healthcare settings but also leads to concerns about management and safety.

Increased contraceptive use one year post-abortion

BACKGROUND

The aim of the study was to investigate the impact of abortion on contraceptive use, partner relationship and sexual satisfaction.

METHODS

In a longitudinal study, 58 women answered a pre-abortion questionnaire and participated in two interviews, one in connection with the abortion and a second 1 year later.

RESULTS

Most women (40/58) had retained the same partner 1 year after the abortion. More than half of these (22/40) experienced no change in the quality of the partner relationship, while the rest (18/40) had deepened their relationship. Furthermore, the majority of the women (45/58) had not experienced any negative influence on their sexual satisfaction. Most women who were sexually active 1 year post-abortion (42/47) used some contraceptive method; the number who used hormonal methods or intrauterine devices had, for example, increased from four to 35, although one-third of them had been doubtful about these methods before abortion. Conversely, 15 women had tried these methods during the follow-up year but had not continued because of negative effects. Overall, contraceptive use 1 year post-abortion had increased.

CONCLUSIONS

To achieve well-founded decisions about contraceptives, counsellors should be aware of women's ambivalence about the use of modern, effective contraceptive methods. In order to prevent abortion it is important to discuss gender differences in sexual behaviour and encourage communication with both sexes about the pros and cons of coitus-dependent and coitus-independent methods.

Repeat induced abortions and contraceptive practices among unmarried young women seeking an abortion in China

OBJECTIVE

To determine the rates of repeated abortion and contraceptive use among unmarried young women seeking an abortion in China.

METHODS

We used an anonymous self-administered questionnaire at abortion clinics in Beijing, Changsha, and Dalian from January to September 2000.

RESULTS

Of 4547 unmarried young women seeking an abortion, 33.0% reported having had one previous induced abortion. Of those who had had more than one abortion, only 29.7% used a contraceptive method at their first sexual intercourse after the procedure; and of the 446 women who chose contraception, 41.3% used the traditional methods of withdrawal or rhythm. Although 65.0% of the young women had used condoms at least once, only 9.6% did so consistently and correctly; 47.7% of the current pregnancies were associated with nonuse of any contraceptive, and 52.3% were related to contraceptive failure.

CONCLUSION

The rate of unmarried young women seeking repeated abortions was high in China on 2000. The rate of consistent condom use was low, and the rate of contraceptive failure was higher.

Can we identify women at risk of more than one termination of pregnancy?

One in five women will have more than one abortion in her lifetime. This study was designed to identify risk factors in women requesting termination of pregnancy (TOP) after previous TOPs so that women at risk of recurrence, attending for the first time, could be identified. A retrospective case note review of 358 women undergoing TOP during October and November 2000 was performed. Twenty-six percent of women had had a previous TOP. Women undergoing a second or subsequent therapeutic abortion were more likely to be older and have experienced more pregnancies to full term, but these two factors were confounded. When women were both parous and deprived, the risk of them having had more than one TOP was over 50%.

Women's experiences in connection with induced abortion - a feminist perspective

Although abortions are common, few researchers have explored the experiences of women related to abortions. The aim of this qualitative study was to analyse women's experiences of induced abortion from a feminist perspective. Five women aged 19-33 years were interviewed about 1 month after their abortion. The interviews were analysed using thematic content analysis from which the following themes were identified: experiences connected with the decision-making process, experiences connected with the abortion and experiences after the abortion. Childhood experiences of divided families, financial problems, being too young, and an insecure partnership influenced the women's decision to have an abortion. Ambivalence about abortion was strongly expressed throughout the process. Despite positive attitudes towards abortion in general, the women had negative attitudes towards their own abortion. They described receiving most support from their mothers and friends, in the decision-making process, and least from their partners. After the abortion the women gained a feeling of maturity and experience although their ambivalence persisted. One conclusion drawn from our study is that nurses and midwives need to be aware of women's complex experiences with abortions in order to support and empower women who seek an abortion.

Reactions and reflections in men, 4 and 12 months post-abortion

BACKGROUND

in general, men involved in legal abortion constitute an invisible group and there is scarcely any knowledge about their experiences and opinions. Therefore, the aim of the present study was to increase knowledge about reactions and reflections by means of a prospective study of men's attitudes and feelings towards abortion.

METHODS

twenty-six men answered a questionnaire before abortion, and participated in interviews at the time of abortion and 4 and 12 months post-abortion.

RESULTS

nearly all of the men were happy with the women's decision to have an abortion at both follow-ups. They experienced the abortion as a relief and a responsible act. Simultaneously, abortion could also be experienced as a painful and ethically problematic act. Overall, most men had only positive experiences post- abortion, such as a feeling of maturity. More than half of those who accompanied their partners to the hospital felt that the staff did not have a welcoming attitude. It was also found that 1-year post-abortion, more than a third consistently did not use a reliable contraceptive method.

CONCLUSIONS

there is a need for further studies concerning men's experiences and reactions in the context of abortion and it is of fundamental importance that a gender perspective is incorporated into this specific field of reproductive health research.

The effects of induced abortion on emotional experiences and relationships: a critical review of the literature

This paper reviews post-1990 literature concerning psychological experiences and sexual relationships prior to and following induced abortion. It assesses whether conclusions drawn from earlier reviews are still supported and evaluates the extent to which previous methodological problems have been addressed. Following discovery of pregnancy and prior to abortion, 40-45% of women experience significant levels of anxiety and around 20% experience significant levels of depressive symptoms. Distress reduces following abortion, but up to around 30% of women are still experiencing emotional problems after a month. Women due to have an abortion are more anxious and distressed than other pregnant women or women whose pregnancy is threatened by miscarriage, but in the long term they do no worse psychologically than women who give birth. Self-esteem appears unaffected by the process. Less research has considered impact on the quality of relationships and sexual functioning, but negative effects were reported by up to 20% of women. Conclusions were generally concordant with previous reviews. However, anxiety symptoms are now clearly identified as the most common adverse response. There has been increasing understanding of abortion as a potential trauma, and studies less commonly explore guilt. The quality of studies has improved, although there are still some methodological weaknesses.

Knowledge about contraception in women undergoing repeat voluntary abortions, and means of prevention

AIMS

Despite reliable and effective means of contraception, cases of repeat abortion are on the increase in all developed countries. The aim of this work was to determine whether women undergoing repeat abortions are exposed to risk factors which might be amenable to preventative measures, and the methods employed by carers in these cases.

METHODS

We set out to evaluate practices in the Family Planning Centre of l'Hôpital Jean Verdier (Bondy, France) by sending a questionnaire to 147 women who had undergone two abortions up to 1997, and by conducting interviews with the care team. Thirty patients responded to the questionnaire.

RESULTS

Twenty-two women (73%) underwent one or more further abortions between 1999 and 2000. Twenty-seven out of 30 women were unaware of the existence of emergency contraception. The 'morning after' pill, indicated for cases of unprotected sex, was unknown to one woman in two (15), nine out of 30 did not know what 'back-up' measures they should take after missing a dose of the contraceptive pill. Psychological problems were found in nine cases. These were followed up with a psychological consultation in three cases. The information given to the patients by the carers was the same irrespective of the number of abortions. Poverty and psychological problems were noted by the carers.

CONCLUSION

Patients who have undergone two abortions might benefit, in addition to their routine visits, from a consultation with a psychologist and a consultation providing information about contraception. Providing the contraceptive pill free of charge to low-income patients is essential.

Reasons for pregnancy termination, contraceptive habits and contraceptive failure among Swedish women requesting an early pregnancy termination

BACKGROUND

More than 30 000 legal abortions are performed every year in Sweden despite sexual education in schools, widespread youth-clinics and family planning services that are free of charge. The aim of this study was to investigate reasons for induced abortion, contraceptive habits and reasons for contraceptive failure among women presenting for induced abortion.

METHODS

A questionnaire was administered to 591 Swedish-speaking women consecutively attending three different health care providers concerning an induced abortion during spring 2000.

RESULTS

The response rate was 88% (n = 518). As many as 43%, among daily smokers 53%, had experienced one or more previous legal abortions. The majority of the women (97%) had discussed the decision about abortion with someone. The most cited reasons contributing to their decision were financial concerns, worries about the relationship and bad timing of the pregnancy. Though 85% had used contraception during the previous year, 36% of the women had not used any contraceptive method at the time of conception. The main reason given for not using contraception was the belief that they could not at that time become pregnant (35%). Ninety percent of the women planned to use contraception after the abortion.

CONCLUSION

Women's decisions regarding induced abortion are multifactorial. One important reason was "poor economy". One out of three did not use any contraception, as they believed they could not become pregnant. Women presenting for induced abortion are a risk-group for further terminations. Counseling must include information about the fertile window, effective contraceptives and the emergency contraceptive pill.

Repeat use of contraceptive crisis services among adolescent women

"They don't get pregnant twice unless they are hopeless." This was one Doctor's reported assessment of women who had more than one abortion. There is some evidence that the repeated use of pregnancy testing 'scares', emergency contraception and abortion is increasing across all women. However, there may also be an interaction between this general trend and the difficulties faced by particularly vulnerable groups of teenagers who also have higher rates of teenage parenthood. This paper aims to provide an overview of the research and international statistics in this sparsely researched area. It will draw on the author's own qualitative work with 'high risking' teenage girls, and that of other researchers, in order to attempt to reach an understanding of the mechanisms behind this increasingly common phenomenon. The indications from this work refutes the notion that these women form a special or 'hopeless' group, but point towards general problems with contraception and services common to all women that may become compounded through structural vulnerability such as deprivation.