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

Multiple induced abortions - implications for counselling and contraceptive services from a multi-centre cross-sectional study in Sweden

OBJECTIVES

To investigate factors associated with multiple induced abortions.

MATERIALS AND METHODS

A multi-centre cross-sectional survey among abortion-seeking women (n = 623;14-47y) in Sweden, 2021. 'Multiple abortions' was defined as having had ≥2 induced abortions. This group was compared to women with a previous experience of 0-1 induced abortion. Regression analysis was conducted to determine independent factors associated with multiple abortions.

RESULTS

67.4% (n = 420) reported previous experience of 0-1 abortion, and 25.8% (n = 161) ≥2 abortions (42 women chose to not respond). Several factors were associated with multiple abortions, but when adjusted in the regression model, the following factors remained; parity ≥1 (OR = 2.96, 95%CI [1.63, 5.39]), low education (OR = 2.40, 95%CI [1.40, 4.09]), tobacco use (OR = 2.50, 95%CI [1.54, 4.07]) and exposure to violence over the last year (OR = 2.37, 95%CI [1.06, 5.29]). More women in the group who had 0-1 abortion (n = 109/420) believed they could not become pregnant at the time of conception, compared to women who had ≥2 abortions (n = 27/161), p=.038. Mood swings, as a contraceptive side-effect, were more often reported among women with ≥2 abortions (n = 65/161), compared to those with 0-1 abortion (n = 131/420), p=.034.

CONCLUSION

Multiple abortions is associated with vulnerability. Sweden provides high quality and accessible comprehensive abortion care; however, counselling must be improved both to achieve contraceptive adherence and identify and address domestic violence.

Women's decision-making related to induced abortion - a cross sectional study during a period of Covid-19 pandemic, in Sweden

OBJECTIVES

To investigate women's decision-making on induced abortion.

MATERIALS AND METHODS

A multi-centre cross-sectional survey among 623 abortion-seeking women in Sweden (2021). The perceived difficulty to decide on abortion was measured using a 7-point Likert scale, and analysed with univariate and multivariate analysis (odds ratios [OR], 95% confidence intervals [CI]).

RESULTS

About half (n = 322;52%) scored 1-4, suggesting the decision was perceived as easier compared to those (n = 292;48%) who scored 5-7. Reasons for the abortion were: poor economy (n = 166;27%), too early in the relationship (n = 154;25.1%), want to work first (n = 147;23.9%), want to study first (n = 132;21.5%), uncertain about the relationship (104;16.9%), and too young (n = 104;16.9%). Predictors for perceiving the decision as difficult: partner's hesitance (OR = 3.18, CI:1.76-5.73), being born outside the Nordic countries (OR = 2.23, CI:1.28-3.87), having discussed the decision with someone (OR = 2.42, CI:1.67-3.50), age ≥30 (OR = 2.22, CI:1.03-4.76), the Covid-19 pandemic (OR = 2.08, CI:1.20-3.59), and the desire to have children in the future (OR = 1.96, CI:1.18-3.28). After confirmed pregnancy, poor mental well-being was more common among those who scored 5-7 (n = 140;47.9%) compared to those who scored 1-4 (n = 122;37.9), p = .029.

CONCLUSION

Women's decision-making on abortion is complex; in times of crises, the decision procedure may be even more difficult. This valuable knowledge could be used to improve and promote satisfactory counselling beyond medical routines.

Ritualizing Abortion: A Qualitative Study on Ritual and Its Meanings in The Netherlands

The present study investigates ritualizing abortion in the Netherlands. Explorative, qualitative research was conducted with semi-structured interviews (n = 13) with women who looked for counseling and 43 online personal stories about the abortion from the website of a national care and expertise center. The results reveal three main categories of ritualizing: (1) creating and using symbols privately and online, (2) remembering or honoring the experience and (3) embodied ritualizing. The data reveal that respondents find meaning in the ritualizing through sharing the experience with others, expressing various feelings through symbolic and ritual forms, fostering a connection with the child-to-be, showing respect, seeking closure and transforming the experience in a meaningful way. This research reveals types of ritualizing practices in relation to a meaningful life event such as abortion. For a specific group of women experiencing decision difficulty or existential concerns in relation to the abortion, ritualizing might be an interesting tool to be incorporated into post-abortion care practices.

The relationship of existential well - being to identity, religious coping, mental and general health among Norwegian aging women

The aim of this study was to explore the relationship of existential spirituality to identity processing, religious coping and mental and general health among younger and older aged women in Norway. Participant's included 120 women aged 31-91 who took part in a postal survey. Results showed that both accommodative and balancing identity processes were associated with existential well -being among both the younger and older aged. Among the younger - aged, mental health was also significantly associated with existential well-being, Moreover, among the older aged, religious coping in the form of discontent, was found to be associated with existential well-being.

Investigation of the Experiences of Mothers Living Through Prenatal Loss Incidents: A Qualitative Study

BACKGROUND

Fetal death causes women to experience negative feelings after the loss. These lived experiences influence the future pregnancies and maternal health of women negatively.

PURPOSE

The aim of this study was to investigate the experiences of women whose pregnancies were terminated because of medical indications.

METHODS

A "design for definitive status study" type of qualitative research design was used. Ten women who were hospitalized between April and July 2017 at the Akdeniz University Clinic of Obstetrics and Gynecology and had subsequently experienced pregnancy loss during their hospitalization were enrolled as participants. Thematic analysis was used to analyze the data.

RESULTS

The pregnancy loss experiences of participants were investigated under the five main themes of (a) lived experiences before the termination of pregnancy, (b) lived experiences after pregnancy termination, (c) willingness to see the baby after termination, (d) posttermination care requirements, and (e) physical condition of hospital rooms during hospitalization. The participants expressed feelings of hope, fear, and worry over being unsuccessful before fetal death and feelings of loneliness, disappointment, blame, and avoidance after fetal death.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

In the aftermath of fetal death, health professionals should use insightful and empathic communication skills to help mothers cope with their loss. In addition, some of the participants wanted to see their babies, and some did not. Thus, individualized care is very important for women who experience pregnancy loss.

A qualitative analysis of decision-making among women with sexual violence-related pregnancies in conflict-affected eastern Democratic Republic of the Congo

BACKGROUND

Sexual violence is prevalent in conflict-affected settings and may result in sexual violence-related pregnancies (SVRPs). There are limited data on how women with SVRPs make decisions about pregnancy continuation or termination, especially in contexts with limited or restricted access to comprehensive reproductive health services.

METHODS

A qualitative study was conducted in Bukavu, Democratic Republic of the Congo (DRC) as part of a larger mixed methods study in 2012. Utilizing respondent-driven sampling (RDS), adult women who self-reported sexual violence and a resultant SVRP were enrolled into two study subgroups: 1) women currently raising a child from an SVRP (parenting group) and 2) women who terminated an SVRP (termination group). Trained female research assistants conducted semi-structured interviews with a subset of women in a private setting and responses were manually recorded. Interview notes were translated and uploaded to a qualitative software program, coded, and thematic content analysis was conducted.

RESULTS

A total of 55 women were interviewed: 38 in the parenting group and 17 in the termination group. There were a myriad of expressed attitudes, beliefs, and emotional responses toward SVRPs and the termination of SVRPs with three predominant influences on decision-making, including: 1) the biologic, ethnic, and social identities of the fetus and/or future child; 2) social reactions, including fear of social stigmatization and/or rejection; and 3) the power of religious beliefs and moral considerations on women's autonomy in the decision-making process.

CONCLUSION

Findings from women who continued and women who terminated SVRPs reveal the complexities of decision-making related to SVRPs, including the emotional reasoning and responses, and the social, moral, and religious dimensions of the decision-making processes. It is important to consider these multi-faceted influences on decision-making for women with SVRPs in conflict-affected settings in order to improve provision of health services and to offer useful insights for subsequent programmatic and policy decisions.

Paracervical block as pain treatment during second-trimester medical termination of pregnancy: an RCT with bupivacaine versus sodium chloride

STUDY QUESTION

Can paracervical block (PCB) administered before the onset of pain decrease women's pain experience during second-trimester medical termination of pregnancy (MToP)?

SUMMARY ANSWER

There were no clinically significant differences between groups receiving PCB with bupivacaine or saline with regard to the highest and lowest pain intensity, morphine consumption or induction-to abortion interval.

WHAT IS KNOWN ALREADY

The most common side effect of misoprostol is pain; nevertheless, there are sparse studies in pain and pain treatment during MToP, especially in second-trimester abortion. Pain reported in second-trimester medical abortion is often intense, and peaks when the fetal expulsion occurs.

STUDY DESIGN, SIZE, DURATION

A double-blinded RCT was carried out from May 2012 until April 2015. A power calculation was based on a previous pilot study showing that the proportion of women with severe pain [visual analogue scale (VAS) ≥7] was 63%. A clinically significant reduction was considered to yield 35% with severe pain, and with a power of 80% and significance level of 5% (two-sided) 112 women were needed. Accounting for a 20% drop-out rate, a total of 140 women were needed. The primary outcome, pain intensity measured as any VAS ≥7, was analysed using a generalized estimating equations model. The level of significance was set to P < 0.05 two-sided. A computer generated randomization list with block size of 10 was used. The treatment allocation was placed in a sealed, opaque, envelope and picked consecutively.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 589 women attending a gynaecological clinic had a second-trimester abortion during the study period and 276 were invited to participate. A total of 113 women undergoing abortion from 13 weeks of gestation and above were recruited, of which 55 were randomly allocated to receive a PCB with bupivacaine and 58 a PCB with sodium chloride 1 h after the first dose of misoprostol. The full analysis set (FAS) population was defined as all randomized women that had at least one value for any of the outcomes (n = 102). The per-protocol (PP) population was defined as a subset of the FAS excluding patients with major protocol deviations or without a value for the primary outcome (n = 99). Pain was measured by VAS at misoprostol initiation (baseline) and repeated every 30 min until fetal expulsion. The primary outcome was the highest VAS pain intensity at any time point.

MAIN RESULTS AND THE ROLE OF CHANCE

The highest pain intensity, did not show any differences at a cut-off of VAS ≥7 [risk ratio (RR): 1.1; 95% confidence interval (CI): 0.9-1.5; P = 0.0.292]. In the PP analyses, there were 75% women in the bupivacaine group and 64% in the sodium chloride group with VAS ≥7 (RR: 1.2; 95% CI: 0.9-1.5; P = 0.235). Most women did not experience pain at the misoprostol start, 19 women scored a VAS of >0, ranging from 1 to 4 with a mean of 1.8 and median of 2 (P = 1.000). Immediately prior to PCB, 61 women scored a VAS of >0, from 1 to 10 with a mean of 2.0 and median of 1 (P = 0.771). There was a 48% loss of VAS scores at the time of expulsion and the remaining scores did not differ between groups (RR: 1.5; 95% CI: 0.9-2.5). A subgroup analysis of primipara did not show any difference in highest pain intensity VAS ≥7 (RR: 1.2; 95% CI: 0.9-1.6; P = 0.283). No statistically significant differences were observed between groups with regard to the highest and lowest (P = 553 and 0.182) pain intensity and morphine consumption (P = 0.772). Side effects were reported by 28 women (14 women in each group), with no differences between groups. Most common was nausea and vomiting in connection to morphine injection.

LIMITATIONS, REASONS FOR CAUTION

Nearly 60% of the invited women did not want to participate in the study (fear of needles and fear of receiving the placebo) therefore women who tolerate pain may have been overrepresented in the study population. Data collection was stopped, in error, when 113 participants had been recruited. The loss to follow-up was, however, only 11 women (10%), which was lower than expected but intrinsically the study did not fully reach the intended number of women, which may have influenced the results. In addition, the obstetrical and gynaecological background of participating women differs. The participants were informed that they had a 50% chance of receiving a PCB with active substance, which could theoretically have affected their expectations and pain experience (placebo effect). The frequent attention at VAS scoring and the overall care provided may also have affected the participants in a positive way, and helped women to feel supported and more relaxed during the abortion.

WIDER IMPLICATIONS OF THE FINDINGS

The highest pain intensity was severe (VAS: 7-10) among 65-75% of the participants, as reported for first-trimester medical abortion; however, the maximal pain scores remain high despite the PCB. There is, therefore, a clear need for more optimal pain treatment but only limited data exist on pain treatment during MToP over all gestational lengths. As PCB was well tolerated, did not cause any serious side effects and had no negative impact on the abortion process and efficacy, another approach may be worth exploring, namely PCB given on demand at the onset of painful contractions.

STUDY FUNDING/COMPETING INTERESTS

The study was supported by grants from the Swedish Research Council (grant no: 2012-2844), ALF (Karolinska Institutet - Stockholm County Council, Agreement on Medical Research and Training) funding, the Karolinska Institutet, Stockholm South General Hospital, and Swedish Nurses in the Area of Pain - SSOS together with GlaxoSmithKline. None of the authors have any conflicts of interest.

TRIAL REGISTRATION NUMBER

The trial was registered with ClinicalTrials.gov (identifier: NCT01617564) and The EudraCT (number: 2010-020780-21) and was approved by The Regional Ethical Review Board at Karolinska Institutet (dnr: 2007/1277-31/2 and 2010/410-31/1).

TRIAL REGISTRATION DATE

Clinical trial registration was done in May 2012 before initiation of patient recruitment.

DATE OF FIRST PATIENT'S ENROLMENT

29 May 2012.

Experiences, feelings and thoughts of women undergoing second trimester medical termination of pregnancy

Main Objective

The objective of this study was to explore women's expectations and experiences of undergoing second trimester abortion.

Methods

This is a cross-sectional study using a screening questionnaire and semi-structured interviews for data collection. Thirty-one women filled out the questionnaire and 23 of them were later interviewed. The questionnaires were analyzed by descriptive statistics. The interviews were recorded, transcribed verbatim and analyzed with qualitative content analysis.

Most Important Findings

Indications for the abortion were fetal malformation or unintended pregnancy. The women expressed similar feelings and these were irrespective for the reason for having an abortion. Both physical and mental pain was experienced during the abortion process and described by the women. Taking the mifepristone-pill was experienced as especially emotionally difficult for many participants. Professional support from the staff together with support from the partner, a friend or relative helped in transforming the worries related to something unknown to feelings of coping with a new and hard experience. Prior to the abortion most women stated that they did not want to view the fetus but women who chose to view the fetus described this as a way of confronting the reality and an opportunity to say farewell to the pregnancy/fetus. The analysis of the interview transcripts revealed five themes mirroring the women's experiences, thoughts and feelings related to the abortion.

Conclusions

The decision to undergo second trimester abortion sometimes exposes women to strong and conflicting emotions which are irrespective for the reason for having an abortion. Despite this women do not regret their decision to terminate the pregnancy. This analysis shows that their rational thinking outweighs their emotionally difficult feelings. It is important for the attending staff to be responsive to the needs of each individual woman whatever the indication is for the abortion.

Psychological ill-being experienced by first-time mothers and their partners in pregnancy after abortion: a cohort study

The psychological effects of abortion have been much discussed lately, with recently published studies indicating that induced abortion (IA) may, contrary to the general consensus, be contributing to psychological symptoms post-abortion. Using a cohort of first-time mothers, we assessed the likelihood of them experiencing psychological ill-being at the midpoint of their pregnancy, depending on their IA history. We also examined the psychological symptoms of their partners, the hypothesis being that ill-being in IA-experienced mothers might reflect onto their partners. Altogether 680 future first-time mothers (9.8% of whom had an IA history) and their partners were selected. Most mothers attended their 16 check-ups at maternity health clinics (MHC), where the family's physical and emotional well-being were checked. Several internationally validated questionnaires, which gauged psychological ill-being, were filled in at the 20th week of pregnancy. There were no significant differences between the study and the control group in terms of psychological ill-being during the pregnancy. The contribution of prior IA to psychological ill-being during the next pregnancy seems to be minimal. The availability of IA procedures, intensive MHC services in Finland, as well as this society's neutral attitude towards IA, may be among the reasons why the results are so positive for mothers who have previously undergone one or more IAs.

Demographic factors determining termination of pregnancy following the detection of lethal fetal malignancy

OBJECTIVE

To identify demographic and clinical variables differentiating pregnant Polish women who decided to terminate the pregnancy in the case of lethal fetal malformation from those who preferred to continue the pregnancy in such a situation.

STUDY DESIGN

Cross-sectional study.

RESULTS

The group of women who decided to abort contained a higher fraction of multiparas than the group of patients who chose to continue their pregnancies, and was characterized by significantly lower mean gestational age at diagnosis of lethal fetal malformation. The only demographic variable approaching statistical significance was the presence of siblings, which was significantly more frequent amongst women who decided to terminate the pregnancy.

CONCLUSIONS

As the decision-making process on pregnancy termination is multimodal, pregnant women require particular support in the case of detecting lethal malformation in their fetuses.