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

Social Science & Medicine 58 (2004) 2559–2569

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doi:10.1016/j.so

Wellbeing and mental growth—long-termeffects of legal abortion

A. Kero, U. H .ogberg, A. Lalos*

Department of Clinical Sciences, Obstetrics and Gynecology, University Hospital, SE-901 85 Ume (a, Sweden

Abstract

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.

r 2003 Elsevier Ltd. All rights reserved.

Keywords: Legal abortion; Emotional distress; Sweden

Introduction

The Swedish abortion law of 1975 grants the woman

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

the 18th week of pregnancy (The Swedish Ministry of

Health 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 final 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

1975 at 17–21 per 1000 women between 15 and 44 years

of ages (Official Statistics of Sweden, 2002). Most

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

ess: [email protected] (A. Lalos).

e front matter r 2003 Elsevier Ltd. All rights reserve

cscimed.2003.09.004

abortion are performed in the age group of 20–24 years,

followed by the 25–29 years group, 30–34 years and then

teenagers. Contraceptives are easily available and all

abortions in Sweden are carried out in public hospitals.

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

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 emotional

response post-abortion. One study conducted almost

30 years ago showed that 94% of the women felt

satisfied with their decision to have an abortion and that

negative psychological reactions to abortion were rare

immediately afterwards and at 1–2 years follow-up

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

d.

ARTICLE IN PRESSA. Kero et al. / Social Science & Medicine 58 (2004) 2559–25692560

following 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,

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

that 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 reflect

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 identified 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 defined as negative, are neither confirmed

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

women’s reasoning, reactions and emotions before and 4

and 12 months after legal abortion.

Methods

Sample

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% was

due mainly to lack of time and delay at the hospital

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

the first 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 first contacted

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

interviews lasted about 30–40min and were conducted

over the phone by two experienced medical social

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

a combination of quantitative and qualitative methods

has been chosen.

Measures

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

ARTICLE IN PRESSA. Kero et al. / Social Science & Medicine 58 (2004) 2559–2569 2561

opinion 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.

Analyses

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 classified by the research group in

order to reach dialogical intersubjectivity (Kvale, 1996).

Then three subgroups was decided based on women’s

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

abortion.

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 as

statistically significant.

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 finances, 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 the

abortion, the partner’s attitude to the abortion and

experiences of previous abortion/s in all women. The

results from all these comparisons show that there were

no significant 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 (Fisher’s Exact test, po0.030).

Results

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 first 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 first 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

finances 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 five reported that the

abortion had influenced 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-

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

knew 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 five also

used the word ‘‘crisis’’ (Table 1).

ARTICLE IN PRESS

Table 1

Percentage of women choosing words to express their feelings

facing abortion and feelings related with the abortion 1-year

later

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 —

Maturityc — 76

Indifference 0 0

a Information missing from one woman. The question was to

be omitted by undecided women.bThese words occurred only in the questionnaire before

abortion.cThis word occurred only in the interview study after

abortion.

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

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

undecided women) and feelings 1 year post-abortion (n=58).

A. Kero et al. / Social Science & Medicine 58 (2004) 2559–25692562

The follow-up 1-year post-abortion showed that one

woman regretted the abortion, and one talked about it

as a mistake. However, the majority associated it with

feelings of relief or release (43/58) (Table 1). Further-

more, 50 women regarded the termination of the

pregnancy as a form of taking responsibility. However,

two women reported ‘‘some’’ mental disturbances which

they related to the abortion. Although most women

experienced the abortion as a relief, half (29/58) also

expressed parallel painful feelings such as grief, empti-

ness and guilt (Table 1). When comparing the women’s

feelings when facing abortion with their feelings related

to the abortion at the 1-year follow-up (Fig. 1), it was

found that the number who primarily reported only

positive feelings had increased from 16% to 47%

(po0.05), while the number who reported only painful

feelings had decreased from 30% to 3% (po0.05).

However, those who had reported both positive and

painful feelings remained numerically almost the same

(54% and 50%, respectively).

In spite of contradictory feelings, most women (52/58)

at 1-year follow-up considered their ability to cope with

the abortion as ‘‘very good’’ or ‘‘good’’, five described it

as ‘‘rather good’’ and one as bad. Fifty-seven percent of

the women stated that they never or almost never

thought of the abortion, 31% thought of the abortion

some times a month and 12% sometimes a week. More

than half the women (32/58) reported only positive

experiences such as maturity, deeper self-knowledge,

strengthened self-esteem and identity of the abortion

process. Several had become aware of an inner strength

they had not realised they possessed. Furthermore,

maternal feelings, the knowledge that they were fertile

and specific female experiences were mentioned among

the positive effects. Others had become more tolerant of

others, and some mentioned improvement in their

partner relationship or in contraceptive practice. Those

who had mixed or bad experiences related them to the

emotional or mental suffering, bad treatment received at

the hospital and/or disturbed sexual life.

Three subgroups of women

Most women (56/58) were satisfied with their decision

to have an abortion in the 4-month follow-up and 48

stated that they experienced the abortion as a relief and/

or a release. Overall, the reactions of the women 4

months post-abortion did not differ from the result at

the 1-year follow-up. However, one woman reported

‘‘much’’ and three ‘‘some’’ mental disturbances related

to the abortion. At the 4-month follow-up, the women

also were asked retrospectively about their immediate

post-abortion reactions, and three main subgroups were

found: women without emotional distress (62%),

women with mild/moderate emotional distress (17%)

and women with severe emotional distress (21%). No

significant differences were found between these


subgroups concerning age, educational level, civil status,

personal finances, children and previous abortions.

Women without emotional distress

Almost two-thirds of all women (36/58) reported no

emotional distress neither directly post-abortion nor at

the 4-month or 1-year follow-up. The questionnaire

before abortion revealed that the decision to have an

abortion had been relatively free of conflict for this

subgroup of women. The majority (26/36) had not

experienced any conflict of conscience before the

abortion and only one had expressed any desire to

continue the pregnancy. None had experienced pressure

in the situation when she became pregnant or during the

decision-making process. Furthermore, asked for their

motives for having an abortion, these women stressed

that they did not want to give birth since they either had

enough children or it was not the right time to become a

parent. However, the only woman who had an abortion

due to foetal damage was at the 1-year follow-up

pregnant again.

This subgroup of women considered that the abortion

process was more or less finished when the abortion was

performed and most of them confirmed that the

abortion decision had been taken as a matter of course

and/or was the only alternative. Those who had

experienced difficulties related them to the period before

abortion. Table 2 shows some typical statements

concerning immediate experiences of the abortion given

at the 4-month follow-up. These women frequently

reflected on the fact that they had not experienced

having abortion as very distressing and that they had felt

better than they had expected. They believed, in

accordance with the social context, that they were

expected to experience having abortion as a difficult and

horrible thing. Two wondered if they appeared to be

inhuman, as they had not felt any regret, guilt or grief.

Table 2 also shows typical statements in this subgroup 1

year after the abortion. Although, these women had not

experienced any feelings of distress as a result of the

abortion, nearly a third (11/36) associated the abortion

with such feelings as grief, emptiness and guilt.

Women with mild/moderate emotional distress

In this subgroup of women (10/58), most motives for

having an abortion had to do with external circum-

stances such as the partner or the fact that the pregnancy

had occurred in a problematic relationship. The ques-

tionnaire before abortion also showed that half had had

a conflict of conscience and three stated that their

religion had made the decision more difficult. One

woman had felt pressured to have abortion against her

wish and one had got pregnant in a situation where the

man had pressured her.

At the 4-month follow-up, this subgroup of women

described their feelings directly post-abortion in terms of

sadness, loneliness, shame, guilt and regret (Table 3).

However, none described their reactions as severe or as a

crisis. It was found that the distress was short-lived and

none reported mental disturbances either at the 4- or the

12-month follow-up. Furthermore, nearly all expressed

feelings of relief both 4 and 12 months after abortion (8/

10 and 7/10, respectively) and eight viewed the abortion

as a form of taking responsibility, at both the follow-

ups. None had regretted the decision although all except

two related feelings such as grief, guilt and emptiness

with the abortion 1 year later. Reflections in this

subgroup were connected with ethical considerations

and/or the disappointment of the partner. Table 3 shows

typical statements in this subgroup 1-year post-abortion.

Women with severe emotional distress

In this subgroup (12/58), the decision to have an

abortion had been made with difficulty and entailed

much conflict. For example, three clearly stated that

they wanted to give birth and another five were

ambivalent. Furthermore, nine had experienced having

an abortion as causing a conflict of conscience. Two

stated that their religion had made the decision even

more difficult. It was also found that facing abortion

these women, to a larger extent than the women in the

other subgroups, used words as grief (po0.01), doubt

(po0.01) and crisis (po0.01) and to a lesser extent the

word relief (po0.05). However, concerning the words

anxiety, self-respect, powerlessness, guilt, anger, release,

anguish, responsibility, impatience, shame, emptiness,

injustice and violation no significant differences was

found between the subgroups. In addition, this sub-

group gave explicit reasons why they could not continue

the pregnancy such as the partner’s attitude and lack of

socio-economic resources. In spite of ambivalent feelings

most were settled in their decision to have the abortion,

and all, except two, declared that in the end the decision

to have an abortion was their own.

In the 4-month follow-up, this subgroup described

their reactions directly post-abortion in terms of a

mourning process, a crisis and/or depression (Table 4).

Five had mourned the loss of a child; four related their

reactions mostly to ethical conflicts and three to lack of

support and/or unpleasant treatment at the hospital.

Five had been on sick leave. However, most women

experienced the abortion as a relief (7/12) and/or as an

act of taking responsibility (8/12) 4-month post-abor-

tion. After 1 year, most women were still reconciled to

the abortion although all of them linked painful feelings

such as injustice, grief and emptiness with the abortion.

Ten viewed their abortion as a necessity or a sacrifice. It

was also found that two women had already given birth

ARTICLE IN PRESS

Table 2

Examples of reasons for abortion and typical statements concerning experiences of the abortion process in women without any

emotional distress directly post-abortion (n=36)

Reason for abortion at the time of

abortion

Statements 4months later Statements 1 year later

‘‘yI do not want to have children

now. I am not mature enough either

mentally or practically to have

childreny’’ (Woman no 237)

‘‘yknew what I wanted at

onceypleased when it was overyI

did not need to work on it,

everything has gone finey’’

(Woman no 237)

‘‘yright decision, I would never

have had the ability to care for the

childyI do not want to have

childreny I was not ready/

matureyit was a brave decision to

an have abortiony’’ (Women no

237)

‘‘yI do not want to have any more

childreny’’ (Woman no 213)

‘‘yit was a very hard 10 days

between the decision and the

procedure ysomething that

surprised meyI became aware of

new sides of myselfyit was useful to

work it throughyit was not difficult

afterwardsyno regretsy’’ (Woman

no 213)

‘‘yI have not felt any doubt or any

regretsyI know and I believe I can

have children if I should want

toybut I am not the same now as I

was thenyI have changed for the

betteryI did not know I had so

much insidey (Woman no 213)

‘‘ythe relationship is too newymy

age I am 35 years oldytogether we

have five children that we must be

able to take care ofy’’ (Woman no

219)

‘‘y it was hard before the abortion,

I thought I had been carelessyI

have worked it through and I have

left the abortion behind mey’’

(Woman no 219)

‘‘ythe best thing I didyno guilt,

no sorrowyam I inhumany?

(Woman no 219)

‘‘yneither of us is ready to bring

children into the worldyboth of us

want to have planned children so the

child feels that it is loved and longed

forychildren need love and care

especially in this hard worldy’’

(Woman no 205)

‘‘yI was relieved when it was

overy I was happy that I had made

the decisiony it would have been

heavy to have an unwanted child, y

it would have been a tremendous

burdeny’’ (Woman no 205)

‘‘y I have not told anyone about

ityabortion is something

sinfulydo not want to stir up bad

bloodyI suppose it sounds

inhuman but I have never

regretted,yvery pleased with the

decisionyI was shocked when I

learned that I was pregnantyI have

to bear it I thought, but it was not

what I felt, wanted or had thought

to do and then I felt sorry for the

childy (Woman, no 205)

‘‘I live aloneyunsure if I can keep

my job, small incomey’’ (Woman

no 131)

yit has gone fine, better than I

expectedy’’ (Woman no 131)

‘‘ythe decision is still the right

oneyno relationship with the

manyI have been feeling much

better than I expectedyI felt

strongly that the decision was mine,

not something I did against my own

willy’’ (Woman no 131)


to a child at 1-year follow-up. Table 4 also shows typical

statements from this group 1 year after the abortion.

Discussion

Wellbeing and mental growth

The present study highlights the fact that nearly all

women experienced legal abortion as a relief or as a

form of taking responsibility, not only immediately after

the abortion but also 4 and 12 months post-abortion.

Furthermore, almost two-third had not experienced any

emotional distress post-abortion and described only

positive experiences. Overall, the reactions at the 1-year

follow-up did not differ from the results at the 4-month

follow-up. The study also shows that the majority of the

women viewed the sequels to the abortion as a process of

growth and maturation, which is in agreement with

results of some previous studies (Smith, 1973; Freeman,

1978). Furthermore, the present study establishes that

almost all the women considered their ability to cope

with the abortion as good, although a fifth had

experienced crisis reactions and almost as many reported

ARTICLE IN PRESS

Table 3

Examples of reasons for abortion and typical statements concerning experiences of the abortion process in women with mild/moderate



abortion

Statements 4 months later Statements 1 year later

‘‘yI already have three children and

I do not think I could manage one

morey’’ (Women no 39)

‘‘yat the beginning my thoughts

were often centred on the abortion,

it was hard, painful but not

negativey I still think of it a little, it

is not possible to stop thinking

about it but I do not have any guilt

feelingsy’’ (Women no 39)

‘‘ysaw the abortion as the only

possibility, I did not need a long

time to work it throughyI knew

why and everything worked wellyI

got support from my husbandybut

it is a bit of bothyI believe in God

and I was brought up to believe that

to have an abortion is to take the

foetus lifeymaybe this sounds

strangeybut it is not difficult for

me nowyI have worked through

my feelings and I know the causes of

those feelingsy’’ (Woman no 39)

‘‘yI have no jobymy partner does

not want to have children nowy’’

(Woman no 197)

‘‘yI have talked about the abortion

sometimes and it has worked quite

welly felt regret now and then y I

think I have been feeling good, I

think I have worked it through

nowy’’ (Woman no 197)

‘‘yI think it was the best thing to

do, otherwise my partner and I

would not have been togetheryI

also did it because I think that a

child must have two parentsythere

was no crisis, little hard the first

monthsy had some sorrows, could

not talk to my partnery if my

partner had wanted the child I

would not have the abortiony’’

(Woman no 197)

‘‘ythe relationship with the father

is not working outy’’ (Woman no

233)

‘‘yit was little difficult the first two

months and I thought about what

would have become of itybut today

it is OKy’’ (Woman no 233)

‘‘yI think it is unpleasant that I had

to have an abortion but in that

situation and with that father there

was no alternativeystill I can feel a

sadness inside about the fact that I

had to choose abortionysometimes

I think of what it would have

becomeyreally I think abortion

should not be allowedyit is life

ythough it can be the best

alternativey’’ (Woman no 233)

‘‘yhave no time, no moneyyI am

too youngyI want to realise my

dreams firsty’’ (Woman no 181)

‘‘ythe difficult thing was to be

alone and abandoned by my

partnery’’ (Woman no 181)

‘‘yI was not certain about who the

father wasya love affair or my

previous partner who had met a new

womany my partner deceived me

and I felt very alone and

abandonedythe decision was for

the bestyI am happy about the

possibility to have abortiony’’

(Woman no 181)

‘‘yabove all reasons connected with

my health and then our family

situationy my partner has 4

children and I have 3y sometimes

we have all the children in our

homey’’ (Woman no 161)

‘‘yfelt I was worthless and

cheapy’’ (Woman no 161)

‘‘yI often think that it was good

that there was no childyI do not

think the child would have been

looked after wellyfeel relief about

the decisionyI still think about

what is morally right but I do not

experience any conflicty’’ (Woman

161)

A. Kero et al. / Social Science & Medicine 58 (2004) 2559–2569 2565

ARTICLE IN PRESS

Table 4

Examples of reasons for abortion and typical statements concerning experiences of the abortion process in women with severe



abortion

Statements 4 months later Statements 1 year later

‘‘yI really wanted to give birth to

the child but our finances would not

allow ity’’ (Woman no 101)

‘‘y considered if I did right or

wrongyafraid of sterilityyhave

been alone in all thisya friend is

pregnantyI am reminded all the

timeyI don’t think so much any

morey try to forget ity’’ (Woman

no 101)

‘‘yit is not possible to undo it,

could not have done otherwise, have

no anxietyy but I am so afraid of

being pregnant, have no desire for

sex and I get tense because of it

ymy husband does not understand

ityI had maternal feelings when I

understood that I was pregnantyI

try to convince myself ythat I do

not want to have childrenya

defence when you have an abortion

though I did not wanted ity’’

(Woman no 101)

‘‘yfinancial and emotional

insecurity, insecure futurey

enormous responsibilityyyou have

to think of the good of the childy’’

(Woman no 235)

‘‘yfelt like a murdereryabortion is

completely wrongyI have been

depressed since the abortion suffered

anguish and sleeping

problemsyisolated myselfy a

week ago I asked the child and God

to forgive me and now I have started

to talk to my partneryit has been

better and this last week I have felt

much bettery’’ (Woman no 235)

‘‘the abortion has been very

hardyit has been a hard and

painful yearythe decision feels

wrong and I regret itythe first four

months were terrible and I thought I

would never feel good

againythought I acted ethically

wronglyy but I can live with ityI

do not feel ashamed anymore for

having had an abortionyregarded

the abortion as a paradoxygreat

pain, release and reliefy’’ (Woman

no 235)

‘‘yhave no stable partner

relationship, poor finances yit is

for the good of the childy’’

(Woman no 107)

‘‘ysuffered very much mentally yI

have been against abortionyhe did

not want me to keep the childy

(Woman no 107)

‘‘ybefore I thought that abortion

was something awfulyI do not

think that todayyI do not feel

ashamed of having had an

abortionyit is good to have

abortion as an alternativeyhave a

new partnerymanaged the abortion

much better than I expectedy’’

(Woman no 107)

‘‘yI have two children who are just

leaving the small child stageynow I

want to do thing for myself, educate

myselfy’’ (Woman no 27)

‘‘ythe first week it was very

hardyI cried and thought a lot of

the childyworked it through and

talked a loty then it has diminished

yI do not think so much about it

nowy’’ (Woman no 27)

‘‘ythe right decision in the situation

I was inymourn the child, got

pregnant againyfelt ashamed of the

new child because of the abortion

ythe pregnancy was not

plannedythought of abortion but I

could not manage to have another

oney it is right to have this

childy’’ (Woman no 27)

‘‘ya doubtful relationshipytime of

crisisy’’ (Woman no 137)

‘‘yI got into a crisisyfelt regret,

thought I had made the wrong

decision yworked through the

crisis in therapy for some

monthsynow it is alrightyI am

pregnant in 8–9 weeksy’’ (Woman

no 137)

‘‘ywhat I did is not possible to

undoybut I will always regret

ityabortion is wrong for meyI am

so much stronger and happier now

since I got a childynow I would

manage her aloney’’ (Woman no

137)



mild/moderate emotional distress directly post-abortion.

The study also shows that contradictory and painful

feelings in the face of abortion do not imply that the

women per se belong to a risk group for negative

reactions post-abortion.

Several authors (Romans-Clarkson, 1989; Adler et al.,

1990; Turell et al., 1990; Dagg, 1991; Allanson &

Astbury, 1995) have identified numerous methodologi-

cal limitations in post-abortion studies. Biases that arise

from ideological viewpoints or a focusing on negative

outcome, sampling problems, short follow-up, lack of

information about subjects who choose not to partici-

pate and high percentages of dropouts. In the present

study, about one-third of the women did not want to

participate in the follow-up study. This may be

explained by the fact that the procedure put too much

pressure on several women. In an already stressful

situation and after participating in the questionnaire

study, the women were not only asked to decide whether

they would agree to participate in a prospective inter-

view study but also if they would give a questionnaire to

the man involved. However, we have not found any

other study that investigates long-term as well as short-

term outcome of legal abortion combining qualitative

and quantitative methods, which also follows each

individual woman for a period of 1 year. Furthermore,

the present study has both a well-defined population and

a thorough drop-out analysis showing almost no

differences between participants and non-participants

concerning e.g. psychosocial characterisation, current

living conditions, decision-making process and feelings

towards pregnancy and abortion. In addition, the study

has not only focused on the experiences of abortion but

also on reactions towards pregnancy.

The issue of abortion is complicated and multifaceted,

which is also confirmed in this study. Pregnancy and

legal abortion are definitely life events. Although most

women in the present study did not experience abortion

as traumatic, it is important not to trivialise the

termination of a pregnancy. The womens’ response to

abortion are complex. Though they were satisfied with

their decision and had not experienced any emotional

distress post-abortion, nearly half the women connected

the abortion with painful as well as positive feelings at

the 1-year follow-up. In a previous study, we have

shown that ambivalent feelings in relation to abortion

can be regarded as a logical response since incompatible

values and interests often clash in the decision to have an

abortion (Kero & Lalos, 2000). The complexity of the

abortion issue is also reflected in findings from

psychotherapy, which show that feelings of relief post-

abortion do not exclude other feelings such as sorrow

and grief (Lemkau, 1988). However, in the present

study, the number of women experiencing only positive

feelings in the face of abortion had increased at the 1-

year follow up, whilst the number of women experien-

cing only painful feelings had decreased during the same

period. Thus, both our present study and our previously

mentioned study (Kero & Lalos, 2000) show that women

have the capacity to cope with painful and contradictory

feelings and even view the abortion as the start of a

maturing process.

To renounce motherhood

Our findings highlight that abortion can be regarded

as the obvious course of action and/or the only

alternative when the pregnancy is unplanned and/or

unwanted. Before the abortion, a great majority stated

that nothing could change their mind about having an

abortion. Statements in the 4-month follow-up such as

‘‘y I knew what I wanted at oncey ‘‘yI was so sure

about the decisiony‘‘, ‘‘y I was so definite y had no

ambivalencey‘‘ illustrate this. In addition, we have

reported in a previous paper that the whole group of 211

women in the initial questionnaire study before abortion

were deeply committed to their decision although most

also experienced painful feelings in the face of having an

abortion (Kero et al., 2001a). The present study also

indicates that 42% of the women had previously thought

of abortion as a possible solution to an unwanted

pregnancy and 54% had not experienced any conflict of

conscience when facing the abortion. The motives

behind abortion showed that the women did not reject

childbearing or children in general but except a planned

family i.e. having children with the right partner and at

the right time, and they wanted to limit the number of

children. A study in men established similar motives

(Kero, Lalos, H .ogberg, & Jacobsson, 1999). It was

characteristic of those women who did not experience

any distress post-abortion that they stated from the start

that they did not want to give birth since they gave

priority to other factors such as their work, studies and

already existing children.

Thus, the present study indicates that in a country like

Sweden where women as well as men are expected to be

financially independent, most women assume the right

to renounce motherhood and the right to plan their

families. On the other hand, the study also indicates that

women may find it controversial to admit that they can

experience abortion as a relief. This is illustrated for

example by a statement such as ‘‘am I inhuman in I did

not experience any regret, guilt or grief post-abortion?’’

Obviously, public attitudes towards abortion have an

impact on the expectations and reactions in women who

choose to have an abortion and several studies have

discussed whether women applying for abortion give

‘‘adapted’’ answers about their reactions (Zimmermann,

1977; S .oderberg et al., 1998). It is therefore of the

utmost importance that studies are set up so as to make

it easier for women to feel free and independent of the

interviewer. Several women in our study confirmed that

ARTICLE IN PRESSA. Kero et al. / Social Science & Medicine 58 (2004) 2559–25692568

they knew that there are expectations from others/and

‘‘society’’ which made them feel they ought to say in

their answers that they have experienced abortion as a

difficult and horrible act. However, having an abortion

is not a deviant or uncommon act—abortion is legalised

in most developed countries and a common phenomen-

on in all kinds of contexts, e.g., in Sweden (Kero et al.,

2001a).

Conversely, having children and becoming a mother

are highly valued in most societies and womanhood is

strongly associated with motherhood, care and goodness

in most cultural contexts. In addition, abortion is a

controversial issue, which deals with existential ques-

tions about life and death. From these points of view it

might be regarded as offensive and shocking if women

not only renounce motherhood but also experience relief

and wellbeing post-abortion. However, if it is taboo to

highlight and admit that legal abortion can be experi-

enced as a relief without any emotional distress post-

abortion, feelings related not only to abortion but also

to on-going pregnancy will in consequence remain

hidden and private. If this is so, there is a risk that

essential parts of women’s reproductive health and living

conditions will become invisible and impossible to

problematise or improve.

Openness concerning both unwanted pregnancies and

legal abortions is crucial, especially as these life events

are often a woman’s first experience of her reproductive

ability. In one of our previous papers, we have shown

that 43% of the whole group of 211 women in the initial

questionnaire study were pregnant for the very first time

(Kero, H .ogberg, & Lalos, 2001b). The corresponding

number in the present study was similar. Although,

abortion was regarded as the best solution, about a third

spontaneously described discovering maternal feelings

for the first time and confirmation of fertility and

womanhood were some of the most overwhelming

reactions to the actual pregnancy. Unwanted pregnancy

and abortion are not only life events, but also important

development phases in preparing for a postponed full-

term pregnancy and motherhood. Thus, the impact of

unwanted pregnancy and legal abortion on future

experiences of pregnancy, delivery and parenthood are

important issues for future research.

Emotional distress post-abortion

The present study highlights that reactions post-

abortion cannot be separated from experiences of the

pregnancy and the decision-making process before

abortion. A previous study also showed that distur-

bances post-abortion were more often related to the

unwanted pregnancy than to the termination of that

pregnancy (Trost, 1982). According to immediate post-

abortion reactions in the present study, three main

subgroups were found, almost two-thirds had not

experienced any emotional distress, about a fifth had

had mild/moderate emotional distress and another fifth

had experienced severe emotional distress. Characteristic

of the latter group was that they had severe ambivalent

feelings and made their decision after a lot of conflict,

which are central predictors for post-abortion distress

reported in some previous studies (Major et al., 1985;

Adler et al., 1990; Turell et al., 1990). In the aftermath,

some of these women described that they had mourned

the loss of the child, some had suffered due to ethical

conflicts or because they lacked support and/or because

of unsympathetic treatment at the hospital. It is

important to note that almost all of these women, in

spite of their ambivalent feelings, had been determined

in their decision to have an abortion and had also

declared that the decision in the end was their own.

Those who considered the decision their own were able

to adapt to their reactions and had succeeded in coping

with the abortion at the 4-month follow-up. Concerning,

the two women who were found to have emotional

distress at 1-year follow-up both had been ambivalent

about the decision before abortion. These results show

that decision-making process that precedes abortion is

of decisive importance for reactions post-abortion. This

is also suggested in some earlier studies (Trost, 1982;

Turell et al., 1990; Adler et al., 1992).

Notable is that those reactions and feelings, which

involve pain usually, are interpreted as ‘‘negative’’

consequences in most abortion studies. For example,

women applying for abortion who experience their

pregnancy as meaningful are identified as a group at

risk of having ‘‘negative’’ reactions post-abortion and

are found to cope worse than those who did not have

such an attitude to their pregnancy (Major et al., 1985).

However, women in the present study who had

experienced a mourning process valued it as an

important and appropriate reaction. Obviously, it can

be misleading to indicate painful experiences as negative

one’s and not to consider them as valid within the

context. The present study points out that it is important

not to ignore that emotional distress post-abortion must

be regarded as normal and relevant when a women, for

example, chose abortion although for ethical or other

reasons she would have liked to continue the pregnancy.

Our study indicates that it is important during the

decision-making process to give women the opportunity

to respond to their feelings towards both the actual

pregnancy and the presumptive parenthood. Thus,

women should be encouraged to express grief and

suffering even if they do not regret their decision.

Conclusion

In summary, the pregnancy was found to cause

painful feelings in almost all the women, while the


abortion at both 4-month and 12-month follow-up was

experienced by almost all as a relief and was regarded as

the best possible solution. Almost two-thirds reported

only positive experiences as sequels of the abortion

process, such as a feeling of wellbeing and mental

growth at the 1-year follow-up. In conclusion, this study

shows that these Swedish women in general are able to

make the complex decision to have an abortion without

suffering any regret or negative effects 1 year later.

Acknowledgements

The authors would like to thank social worker

Katarina Bergstr .om for professional assistance in

conducting the study. The project was supported by

the Swedish Council for Social Research and the

Swedish National Institute of Public Health and the

Ume(a Medical District, County of V.asterbotten.

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Documents

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