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

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    the 18th week of pregnancy (The Swedish Ministry of

    1975 at 1721 per 1000 women between 15 and 44 years

    In spite of differences in study design, there is a strong

    response post-abortion. One study conducted almost

    ARTICLE IN PRESSof ages (Ofcial Statistics of Sweden, 2002). Most 30 years ago showed that 94% of the women felt

    satised with their decision to have an abortion and that

    negative psychological reactions to abortion were rare

    immediately afterwards and at 12 years follow-up

    (Smith, 1973). Another study found that up to 8 years

    *Corresponding author. Tel.: +46-90-785-2173; fax: +46-


    E-mail address: ann.lalos@obstgyn.umu.se (A. Lalos).

    0277-9536/$ - see front matter r 2003 Elsevier Ltd. All rights reserved.doi:10.1016/j.soHealth and Social Affairs, 1983). After the 18th week,

    abortion may only take place on so-called exceptional

    grounds. In these cases, the National Board of Health

    and Welfare makes the nal decision as to whether or

    not the abortion will be performed. The law was

    followed by an expansion in the number of family

    planning clinics and the amount of wider access to

    information on contraception and sexual relations. The

    abortion rate has remained relatively unchanged since

    consensus, regarding results from international studies

    on abortion outcome, that relief is the dominant feeling

    in the immediate and short-term aftermath and the

    incidence of severe negative responses is low (Osofsky &

    Osofsky, 1972; Freeman, 1978; Lazarus, 1985; Adler

    et al., 1990; Dagg, 1991; Scotland, 1992; Zolese &

    Blacker, 1992). Swedish studies show similar results

    (Trost, 1982; Holmgren, 1988). On the other hand, few

    studies have investigated the long-term emotionalabortion. 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


    r 2003 Elsevier Ltd. All rights reserved.

    Keywords: Legal abortion; Emotional distress; Sweden


    The Swedish abortion law of 1975 grants the woman

    the right to have an abortion on demand until the end of

    abortion are performed in the age group of 2024 years,

    followed by the 2529 years group, 3034 years and then

    teenagers. Contraceptives are easily available and all

    abortions in Sweden are carried out in public hospitals.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 theSocial Science & Medicine

    Wellbeing and menteffects of le

    A. Kero, U. H

    Department of Clinical Sciences, Obstetrics and Gyn


    The present study aims to increase knowledge about

    reactions and emotions over a period of 1 year. The studycscimed.2003.09.004004) 25592569

    growthlong-terml abortion

    erg, A. Lalos*

    gy, University Hospital, SE-901 85 Ume (a, Sweden

    ng with legal abortion by studying womens reasoning,

    prises interviews focusing on the experiences and effects

  • 1996). Additionally, a Swedish follow-up study showed

    ARTICLE IN PRESSA. Kero et al. / Social Science & Medicine 58 (2004) 255925692560that 16% of women experienced emotional distress 1-

    year post-abortion (S .oderberg, Janzon, & Sj .oberg,

    1998). However, in a recent study on women and men

    with ambivalent feelings 1-year after abortion, we found

    that ambivalent feelings did not necessarily imply that

    women and men regretted the abortion or experienced

    emotional distress (Kero & Lalos, 2000).

    Factors found to predict post-abortion distress reect

    the complexity of the abortion issue. Women most at

    risk seem to be those who experienced the pregnancy as

    meaningful, who lacked support and/or experienced

    ambivalence or coercion during the decision-making

    process (Adler, 1975; Trost, 1982; Major, Mueller, &

    Hildebrandt, 1985; Turell, Armsworth, & Gaa, 1990;

    Adler et al., 1992). Other factors identied are low age,

    long-term length of pregnancy, previous psychiatric

    history, religiosity and adverse attitude to abortion

    (Osofsy & Osofsky, 1972; Adler, 1975; Ashton, 1980;

    S .oderberg et al., 1998). However, most studies elucidat-

    ing effects of abortion represent previous periods and

    are short-term and retrospective. Furthermore, most

    studies classify feelings, in relation to abortion as either

    positive or negative. Thus, painful feelings, which

    are usually dened as negative, are neither conrmed

    nor considered as expressions of relevant or valuable

    aspects of the abortion situation. This might result in

    such feelings not being considered valid or run the risk

    of being regarded only as something problematic and

    threatening. Therefore, the purpose of the present study

    is to increase knowledge about the complexity of coping

    with legal abortion by means of prospectively studying

    womens reasoning, reactions and emotions before and 4

    and 12 months after legal abortion.



    The present study was carried out at the University

    Hospital of Ume(a in the north of Sweden. During a

    period of 9 months in 1995, 250 women applying

    consecutively for legal abortion were asked to partici-

    pate in a questionnaire study. Eighty-eight percent

    agreed to participate and the refusal rate of 12% wasfollowing abortion, no negative associations occurred

    with regard to self-esteem (Russo & Zierk, 1992).

    Furthermore, a recent study from US have shown that

    most women do not experience psychological problems

    or regret their abortion 2 years post-abortion (Major

    et al., 2000). In contrast, a Danish study showed that

    16% of the women had psychological problems at a 4-

    month follow-up, which they related to circumstances

    connected with the abortion, though none regretted the

    abortion itself (Schleiss, Mygind, Borre, & Petersson,due mainly to lack of time and delay at the hospital

    (Kero, H .ogberg, Jacobsson, & Lalos, 2001a). Among

    the rst 100 women, every third woman and thereafter

    every second were likewise consecutively asked if they

    would also be willing to participate in a prospective

    interview study (a few days after the questionnaire

    study, and 4 and 12 months after abortion). Thus, 98

    women were asked to participate. In all, 65 women

    (66%) agreed to participate in the follow-up study. It

    transpired later that four women were either not

    pregnant or chose to continue their pregnancies to full

    term. These were excluded from the study, which thus

    comprised 61 women at the 4-month follow-up and 58

    women at the 12-month follow-up. To create the best

    possible conditions, the responders were rst contacted

    in order to set up a suitable time for the interview. The

    interviews lasted about 3040min and were conducted

    over the phone by two experienced medical social

    workers of whom one is the rst author (A.K.). Thus,

    a combination of quantitative and qualitative methods

    has been chosen.


    Primarily, a questionnaire was constructed based on

    previous research, clinical experience and exploratory

    interviews with three women who had had an abortion.

    The questionnaire study covered questions about life

    conditions, reasons for abortion, the decision-making

    process and feelings and attitudes towards the preg-

    nancy and abortion. Feelings were elicited by asking

    women to select from lists of words the ones describing

    their feelings. Emotions other than those listed could

    also be added. In addition to recording the frequency

    with which each emotion was endorsed, three categories

    of respondents were noted: those who expressed only

    positive feelings, only painful feelings or both positive

    and painful feelings.

    Based on the questionnaire, a semi-structured inter-

    view was designed focusing on attitudes, feelings and

    experiences 4 and 12 months after the abortion. At the

    4-month follow-up, the interviews focused not only on

    the current situation but also retrospectively on im-

    mediate post-abortion reactions. Thus, the study design

    made it possible to carry through comprehensive

    analyses since each individual woman was followed

    during a period of 1 year. Apart from questions with

    given response alternatives and a list of words (regarding

    feelings), there were a number of open-ended questions

    that encouraged the respondents to express themselves

    freely and allowed the interviewer to go more deeply

    into the issues. The open-ended questions concerned e.g.

    post-abortion psychological disturbances, experiences

    and attitudes and coping behaviour concerning the

    abortion. Overall, the focus in the follow-up interviews

    was expressed in questions such as What is your

  • ness. Furthermore, a third (18/58) reported that they

    ARTICLE IN PRESSA. Kero et al. / Social Science & Medicine 58 (2004) 25592569 2561opinion about your ability to cope with the abortion?

    How do you feel about the abortion today, one year

    later? and What has the abortion meant to you? In

    addition, the women were asked if they had any positive

    or negative experiences subsequent to the abortion. The

    precise procedure when putting questions, which had

    given response alternatives, was for the interviewer to

    ask the question without mentioning the different

    response alternatives and the participant to give her

    free answer. To avoid misunderstandings, the inter-

    viewer with the participant then chose the most suitable

    response alternative.


    The answers from the open-ended questions were

    written down during and in direct connection with each

    interview (no tape-recording). In the analysis, the text

    was discussed and classied by the research group in

    order to reach dialogical intersubjectivity (Kvale, 1996).

    Then three subgroups was decided based on womens

    descriptions about their immediate post-abortion reac-

    tions: those who did not report any suffering (Women

    without emotional distress), those who had had some

    emotional distress (Women with mild/moderate emo-

    tional distress) and those who reported suffering and

    mourning (Women with severe emotional distress).

    Thus, the results of the present study emanate from

    three sources, the questionnaire in connection with the

    abortion and the interviews 4 and 12 months after the


    Statistical analyses were performed using the statis-

    tical package programmes (SPSS) version 10.0. Discrete

    variables were compared with the Chi square test (Exact

    test, Monte Carlo). A p-value o0.05 was considered asstatistically signicant.

    The study was approved by the Ethics Committee of

    the Medical Faculty of Ume(a University.

    Analysis of non-participants

    As mentioned previously, the initial refusal rate in the

    questionnaire study was 12%. Thereafter, a strategic

    sample was asked to participate in a prospective

    interview study. Out of these, 98 women (34%) did

    not want to participate in this follow-up study.

    Statistical tests of comparison were carried out between

    women who did (n=58) and those who did not

    participate in the follow-up study (n=33). As both

    groups had participated in the questionnaire study

    before abortion they could be compared concerning a

    large number of variables for example age, civil status,

    education, personal nances, children, partner relation-

    ship, sexual life, contraceptive use and social support.

    Furthermore, there were also data on attitudes and

    feelings in connection with the pregnancy and theknew even before getting pregnant that they would

    choose to have an abortion if they became pregnant. In

    total, 76% of all women stated before termination the

    pregnancy that nothing could make them change their

    mind. However, when facing abortion almost a third

    (17/58) reported only painful feelings such as anxiety,

    grief, guilt, emptiness and anguish and of these ve also

    used the word crisis (Table 1).abortion, the partners attitude to the abortion and

    experiences of previous abortion/s in all women. The

    results from all these comparisons show that there were

    no signicant differences between these two groups of

    women except for a tendency towards a lower educa-

    tional level among those who did not participate in the

    follow-up study (Fishers Exact test, po0.030).


    Demographic information

    At the time of abortion the women had a mean and

    median age of 28 years. The great majority (48/58) had a

    partner relationship and more than half (34/58) was

    married or cohabiting. The current pregnancy was

    found to be the rst one for almost half the women

    (25/58). However, most of the remaining women had

    children and several had three or more (11/28). All

    women except two were in the rst trimester and about a

    fourth (15/58) had had a previous abortion. Further-

    more, half the women (29/58) were employed and 18

    were students. The rest (11/58) were mainly unemployed

    or had parental leave. The majority (41/58) valued their

    nances as adequate, while the rest reported that their

    income was to low or just met their needs.

    At the 1-year follow-up it was found that the majority

    (40/58) still had a partner relationship with the man they

    had become pregnant with. Seventeen women (17/40)

    described their relationship as unchanged in quality, 18

    felt it had improved, while ve reported that the

    abortion had inuenced it in a negative way. Four

    women had got pregnant again and two had already

    given birth and one had had a legal abortion. Half the

    women (29/58) reported changes concerning employ-

    ment; either they had started to work or worked to a

    greater extent than before the abortion.

    Reactions and emotions post-abortion

    The questionnaire study performed before abortion

    showed that most women (37/58) experienced only

    painful initial feelings towards the pregnancy, such as

    unreal, despair, panic and grief while the rest (21/58)

    also had positive feelings, such as wonder and happi-


    Fig. 1. Feelings in women facing abortion (n=57; Information

    missing from one woman. The question was to be omitted by

    A. Kero et al. / Social Science & Medicine 58 (2004) 255925692562Table 1

    Percentage of women choosing words to express their feelings

    facing abortion and feelings related with the abortion 1-year


    Facing abortion

    (n=57)a1-Year after

    abortion (n=58)

    Responsibility 20 86

    Relief 54 72

    Release 34 52

    Grief 43 31

    Injustice 11 24

    Guilt 30 22

    Emptiness 25 22

    Anguishb 23

    Impatienceb 11

    Anger 13 14

    Regret/doubt 7 14

    Shame 15 12

    Powerlessness 5 12

    Respectb 4

    Crisis 9 2

    Violationb 2

    Self-respectb 4

    Anxietyb 61 The follow-up 1-year post-abortio...


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