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UBC Theses and Dissertations

Expressed needs of women having abortions McKay, Reta Lynn 1974

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EXPRESSED NEEDS OP WOMEN HAVING ABORTIONS by BETA LYNN MCKAY B.A., U n i v e r s i t y of Toronto, 1971 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n the School of N u rsing We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 197^ In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l m e n t of the requirements fo r an advanced degree at the U n i v e r s i t y of B r i t i s h Co lumbia , I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r re ference and study . I f u r t h e r agree t h a t permiss ion for e x t e n s i v e copying o f t h i s t h e s i s fo r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s r e p r e s e n t a t i v e s . It i s understood that copy ing or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l ga in s h a l l not be a l lowed wi thout my w r i t t e n p e r m i s s i o n . The U n i v e r s i t y o f B r i t i s h Columbia Vancouver 8, Canada EXPRESSED NEEDS OP WOMEN HAVING ABORTIONS The purpose of t h i s study was to explore the ab o r t i o n experience from the woman's p o i n t of view to d i s -cover any unmet needs. A l l the women were having a b o r t i o n s w i t h i n twelve weeks of t h e i r l a s t menstrual p e r i o d . The study i n c l u d e d i n t e r v i e w s w i t h nineteen women at three stages: before the o p e r a t i o n , two weeks f o l l o w i n g , and f o u r months f o l l o w i n g the op e r a t i o n . A b a s i c a l l y u n s t r u c t u r e d , open-ended i n t e r v i e w method was used, a l l o w i n g f o r e x p l o r a t i o n of areas important to the women. R e f e r r a l s to the study were made by (1) a l a y women's h e a l t h education and a b o r t i o n r e f e r r a l group, and (2) a g y n e c o l o g i s t . The f i n d i n g s were d e s c r i b e d u s i n g f r e q u e n c i e s of c a t e g o r i e s a r i s i n g from the data. 1 The r e s u l t s of t h i s study suggest t h a t some women having a b o r t i o n s do experience unmet needs. The most common needs i d e n t i f i e d were: 1 . the need f o r thorough d i s c u s s i o n of b i r t h c o n t r o l options coupled w i t h d i s c u s s i o n of s e x u a l i t y ; 2. the need f o r r e a d i l y a v a i l a b l e i n f o r m a t i o n about I a l l aspects of a b o r t i o n ; 3 . the need f o r a b o r t i o n c o u n s e l l i n g , i n c l u d i n g d i s c u s s i o n of a l t e r n a t i v e s to a b o r t i o n ; 4. the need f o r emotional support d u r i n g h o s p i t a l -i z a t i o n and, p o s s i b l y , afterwards; 5 . the need to explore the meaning of t h i s event i i w i t h i n the context of the woman's l i f e , i n terms of her expectations of h e r s e l f and her r e l a t i o n s h i p s w i t h o t h e r s . At the time of the t h i r d i n t e r v i e w , many of the women d e s c r i b e d changes i n t h e i r sexual r e l a t i o n s h i p s r e l a t e d to increased f e e l i n g s of c o n t r o l and det e r m i n a t i o n . The con-si s t e n c y between the developed r e c o g n i t i o n of s e x u a l i t y and use of r e l i a b l e c o n t r a c e p t i o n was evi d e n t i n twelve of the f i f t e e n women seen at t h a t time. T h i s i n t e r v i e w r e v e a l e d t h a t a l l of the women f e l t they had made the best d e c i s i o n at the time, but f o u r s a i d they could not go through w i t h an abortion again. The event was profoundly d i s t u r b i n g to t h e i r p h i l o s o p h i c a l b e l i e f s . This aspect of the women's l i v e s i s not a need of the same order as the o t h e r s ; r a t h e r , i t i s an area to be understood and a p p r e c i a t e d , but not sub j e c t to s p e c i f i c I n t e r v e n t i o n . This study has i d e n t i f i e d , from a sm a l l sample, c e r t a i n unmet needs experienced by a b o r t i o n p a t i e n t s . Areas which r e q u i r e f u r t h e r research, i n v o l v i n g l a r g e r numbers, centre around the f o l l o w i n g q u e s t i o n s : 1 . What are the most e f f e c t i v e ways of meeting the i d e n t i f i e d needs of women having a b o r t i o n s ? 2. What are the longer range e f f e c t s on a woman's a b i l i t y to cope w i t h the a b o r t i o n , and on her l i f e g e n e r a l l y , of meeting these needs? i i i TABLE OP CONTENTS Page LIST OP TABLES . . v i i ACKNOWLEDGEMENT v i i i Chapter 1. INTRODUCTION TO THE STUDY 1 THE PROBLEM . 1 J u s t i f i c a t i o n of the Problem . . . . . . . 2 D e f i n i t i o n s of Terms Used 5 CONCLUSION . . . . . 5 2. REVIEW OF THE LITERATURE . . . . . . . . . . . . . 6 MEDICAL PERSPECTIVES . . . ?. PSYCHOLOGICAL/PSYCHIATRIC PERSPECTIVES . . 9 SOCIAL PERSPECTIVES l4> WOMEN»S NEEDS AND EXPERIENCES 18 NURSING PERSPECTIVES ON ABORTION 21 SUMMARY 23 3. METHODOLOGY 25 DESIGN . . . . . . ......... 25 PROCEDURE 27 SAMPLE 28 LIMITATIONS OF THE STUDY 31 CONCLUSION 3?-i v V Chapter Page 4. FINDINGS AND DISCUSSION 3 3 PROFILE OF POPULATION 3 4 CONTRACEPTIVE USiGE 4 0 DECISION-MAKING PROCESS 44 THE SEARCH FOR HELP 47 IMPLICATIONS OF DECISION IN LIFE SITUATION 49 NEEDS FOR INFORMATION 52 Concerning the Law 52 Concerning the H o s p i t a l Experience . . . 52 Concerning P o s t - o p e r a t i v e E x p e c t a t i o n s 53 Concerning Future C o n t r a c e p t i o n . . . . . . 54 Other Needs . . . . . . 54 FIRST FOLLOW-UP VISIT 55 H o s p i t a l Experience 55 P h y s i c a l Response 57 Contraception . 57 R e l a t i o n s h i p w i t h Sexual P a r t n e r . . . . 58 F e e l i n g s R e l a t e d to the A b o r t i o n . . . . 59 SECOND FOLLOW-UP VISIT 6 l F e e l i n g s i n Response to Event 6 l S e x u a l i t y and R e l a t e d Needs . 63 Contraception 6 4 Other Areas of Expressed Need . . . . . . 65 SUMMARY 66 v i Chapter Page 5. CONCLUSION 68 SUMMARY 68 IMPLICATIONS 72 RECOMMENDATIONS 74 RECOMMENDATIONS FOR FUTURE RESEARCH . . . 75 BIBLIOGRAPHY 77 APPENDIXES 82 A. THE FACE SHEET 82 B. BROCHURE • 84 C. SECTION 251, CRIMINAL CODE OF CANADA (SUBSECTIONS 1 TO 4—MARTIN'S CODE, 1973)* • 86 0 LIST OF TABLES TABLE Page I . M a r i t a l Status of Women Having A b o r t i o n s . . 34 I I . Age D i s t r i b u t i o n of Women Having A b o r t i o n s 34 I I I . Occupation of Women Having A b o r t i o n s . . . . 35 IV. R e l a t i o n s h i p Between Women Having A b o r t i o n s and P u t a t i v e Fathers . . . . . . 36 V. L i v i n g Arrangements of Women Having A b o r t i o n s 37 V I . Length of Time Since L a s t Menstrual P e r i o d of Women Having A b o r t i o n s 38 V I I . H o s p i t a l i z a t i o n P a t t e r n of Women Having A b o r t i o n s . . 38 V I I I . Timing of Interviews i n R e l a t i o n to A b o r t i o n . . . . . . . . 39 IX. Method of B i r t h C o n t r o l P r i o r to Ex p e r i e n c i n g an Unwanted Pregnancy . . . . 40 X. Contraceptive Choice Two Weeks F o l l o w i n g A b o r t i o n 58 X I . Contraceptive P r a c t i c e s Four Months F o l l o w i n g A b o r t i o n . . . . . . . 65 v i i v l i i ACKNOWLEDGEMENTS Many people have a s s i s t e d me In completing t h i s study. I wish to thank the women whose t h o u g h t f u l par-t i c i p a t i o n made the study p o s s i b l e . My thanks a l s o are due because of the encouraging a s s i s t a n c e and cooperation of the Vancouver Women's Health C o l l e c t i v e , Dr G. Korn, and Darlene Larson. I am indebted to my committee members, Mrs. Helen E l f e r t and Dr. George Povey, f o r t h e i r warm support and c l e a r i n s i g h t s . My thanks a l s o go to f r i e n d s who read and commented on the t e x t . Others who have been c l o s e t o me d u r i n g t h i s process have been my classmates: I thank them f o r t h e i r encouragement and sense of humour. F i n a l l y , I thank my s p e c i a l f r i e n d and husband, Ian McKay, f o r h i s c o n t i n u i n g support and c o n s c i e n t i o u s t y p i n g of the t e x t . Chapter 1 INTRODUCTION TO THE STUDY U n t i l r e c e n t l y , women i n Canada who were f a c e d w i t h an unwanted pregnancy had few a v a i l a b l e o p t i o n s . However, sin c e the l i b e r a l i z a t i o n of S e c t i o n 2 5 1 of the C r i m i n a l Code of Canada i n 1969» many women now have a g r e a t e r range of ch o i c e . * There are s t i l l r e g i o n a l d i s p a r i t i e s i n the ease w i t h which women may o b t a i n a b o r t i o n s , s i n c e the respons-i b i l i t y f o r i n t e r p r e t a t i o n of the changed law r e s t s s o l e l y w i t h each h o s p i t a l board, which may o r may not choose to e s t a b l i s h a "Therapeutic A b o r t i o n Committee." However, a b o r t i o n as a way of d e a l i n g w i t h an unwanted pregnancy i s an i n c r e a s i n g s o c i a l event. THE PROBLEM The problem w i t h which the present study i s concerned i s t h i s : Do women ex p e r i e n c i n g a b o r t i o n s have unmet needs? Th i s problem w i l l be explored once before the op e r a t i o n and a t two I n t e r v a l s f o l l o w i n g , i n order to d e t e r -mine app r o p r i a t e n u r s i n g i n t e r v e n t i o n s a t the d i f f e r e n t times and i n the d i f f e r e n t s e t t i n g s — h o s p i t a l , community, See Appendix f o r t e x t of S e c t i o n 2 5 1 . 1 2 and s c h o o l — i n which nurses are i n r e l a t i o n s h i p w i t h women experiencing a b o r t i o n . J u s t i f i c a t i o n of the Problem In the l a s t f o u r years, w i t h the l i b e r a l i n t e r -p r e t a t i o n of the law concerning a b o r t i o n , there has been an increase i n the number of t h e r a p e u t i c a b o r t i o n s performed. A study c a r r i e d out by the Vancouver General H o s p i t a l s t a t e s : The number of th e r a p e u t i c a b o r t i o n s performed a t the Vancouver General H o s p i t a l i n 1969 w a s double the average number f o r the previous f o u r years. I n 1969» 79 a b o r t i o n s were recorded. One year l a t e r , w i t h r e v i s i o n of the Canadian C r i m i n a l Code, the number had r i s e n to 1465. These f i g u r e s correspond to those d e s c r i b e d by P e l r l n e In her book d i s c u s s i n g the a b o r t i o n s i t u a t i o n i n Canada: There i s no doubt t h a t i n c e r t a i n p a r t s of Canada, more women are r e c e i v i n g h o s p i t a l a b o r t i o n s under the new law than were p r e v i o u s l y . Taking the example of one h o s p i t a l board w i t h a l i b e r a l p o l i c y , a b o r t i o n s performed by the Toronto General H o s p i t a l Increased n e a r l y t e n f o l d i n the twelve months a f t e r the law took e f f e c t , from s i x t y - s i x I n the p r e v i o u s twelve months to 628.-' These s t a t i s t i c s are i n d i c a t i v e of the i n c r e a s i n g Incidence of a b o r t i o n i n our s o c i e t y . The res e a r c h e r has chosen to look a t the expressed needs of women having an ab o r t i o n f o r s e v e r a l reasons. F i r s t , previous research,has ''"A Study to I d e n t i f y Problems Experienced by P a t i e n t s having Tnerapeutic A b o r t i o n s on the One-Day S u r g i c a l S l a t e , " P r o j e c t D i r e c t o r , Mary L. Richmond-MacBean. N a t i o n a l Health Grant ( P r o j e c t Number 610 - 2 1 - 2 5 ) , June 1972, Vancouver. ^Eleanor W. P e l r l n e , A b o r t i o n i n Canada, (Toronto: new press, 1971), p. 36". focused p r i m a r i l y on p h y s i c a l needs and on p s y c h o l o g i c a l o r p s y c h i a t r i c e f f e c t s of a b o r t i o n , r a t h e r than on conse-quent " p r o b l e m s - i n - l i v i n g " or expressed needs. While the p r e v i o u s l y mentioned areas are important and need c o n s i d -e r a t i o n , a d i f f e r e n t approach to t h i s event may w e l l y i e l d i n f o r m a t i o n more s u i t a b l e to the m a j o r i t y of women who do not experience medical o r p s y c h i a t r i c need. Such an approach has not been widespread i n the l i t e r a t u r e , which very o f t e n has d e a l t p r i m a r i l y w i t h the moral and l e g a l i m p l i c a t i o n s . The need f o r research i n t o the p u b l i c h e a l t h o r " p r o b l e m s - l n - l i v i n g " concerns of those experiencing a b o r t i o n has been s t a t e d by David: such research should Include e f f o r t s to i d e n t i f y women at high r i s k f o r u n i n -tended pregnancy o r repeated a b o r t i o n seeking, o r those i n need of s p e c i a l c o u n s e l l i n g before or a f t e r abortion.^" The present study, then, proposes to add to n u r s i n g knowledge by e x p l o r i n g the needs of women i n d i f f e r e n t areas of t h e i r l i v e s as they undergo an a b o r t i o n . Secondly, another reason f o r the s i g n i f i c a n c e of the problem i s that a t present there i s no systematized way of seeing women a f t e r a b o r t i o n i n Vancouver, apart from the recommendation f o r a six-week check-up—a recommendation Henry P. David, " A b o r t i o n : P u b l i c Health Concerns and Needed P s y c h o s o c i a l Research," American J o u r n a l of  P u b l i c H e a l t h , 6 l : 3 (March, 1 9 7 D , 3 lJ I 4 which I s s p o r a d i c a l l y given and not always heeded. Concerning follow-up, a comprehensive study e v a l u a t i n g the outreach family planning s e r v i c e s i n Vancouver s t a t e d : While the m a j o r i t y of t h e r a p e u t i c a b o r t i o n s are arranged through c o n s u l t a t i o n w i t h p r i v a t e p h y s i c i a n s , i t cannot be assumed that c o n t r a c e p t i o n i s f u l l y d i s -cussed a t t h i s time. Nor can the general p r a c t i t i o n e r be expected to provide the k i n d of foll o w - u p s e r v i c e necessary, e s p e c i a l l y where the r e l a t i o n s h i p w i t h the pa t i e n t s may begin and end w i t h the t h e r a p e u t i c a b o r t i o n . Thus, a systematic body of n u r s i n g knowledge regarding r e a c t i o n s to t h i s unexpected l i f e event has not been com-p i l e d . The areas expl o r e d i n the present study may provide I n s i g h t s f o r more r e f i n e d r e s e a r c h to a i d i n the g a t h e r i n g of t h i s n u r s i n g knowledge. T h i r d l y , s i n c e the primary f u n c t i o n of n u r s i n g i s to nurture, t h a t i s , "to f o s t e r , p r o t e c t , s u s t a i n , and teach, nurses should understand when and how to c a r r y out these f u n c t i o n s . There i s general knowledge a v a i l a b l e to a s s i s t nurses who are w i t h women having a b o r t i o n s ; but more needs to be known about the s p e c i f i c a l t e r a t i o n s which may occur i n the l i v e s of these women. With such improved know-ledge, n u r s i n g I n t e r v e n t i o n can occur i n a s e n s i t i v e and appropriate manner. ^Babies by Choice not by Chance (Volume 2 ) , Outreach Services, S o c i a l P o l i c y and Research Department, U n i t e d Community S e r v i c e s of Greater Vancouver Area, (June, 1973)> P. 17. "Model f o r Nursing, U n i v e r s i t y of B r i t i s h Columbia School of Nursing, 1973 (mimeographed). D e f i n i t i o n s of Terms Used- A b o r t i o n i n t h i s paper r e f e r s to the l e g a l induced t e r m i n a t i o n of a pregnancy w i t h i n a twelve week i n t e r v a l f o l l o w i n g the l a s t normal menstrual p e r i o d . Expressed need i s d e f i n e d as a p e r c e i v e d l a c k , or a d e f i c i t w i t h i n the person's experience which was com-municated to the researcher. Nursing i s d e f i n e d as the n u r t u r i n g of man d u r i n g c r i t i c a l p e r i o d s i n h i s l i f e so that he may develop and u t i l i z e a range of coping behaviours which permit him to s a t i s f y h i s b a s i c human needs and thereby move toward o p t i m a l health.? Nursing i n t e r v e n t i o n i s "a p l a n of a c t i o n designed to a l t e r , r e verse, o r s u s t a i n a course of development. CONCLUSION The purpose of t h i s paper, then, i s to e x p l o r e , from the woman's p o i n t of view, the a b o r t i o n experience. Expressed needs w i l l be examined, before the o p e r a t i o n and at two i n t e r v a l s f o l l o w i n g . The p o s s i b i l i t y of n u r s i n g i n t e r v e n t i o n a s s i s t i n g i n meeting those needs w i l l be considered. ?Model f o r N u r s i n g , U n i v e r s i t y of B r i t i s h Columbia. ^E. Maloney, I n t e r p e r s o n a l R e l a t i o n s , (Dubuque: C. Brown Co., 1966), p. 62. Chapter 2 REVIEW OF THE LITERATURE L i t e r a t u r e on the s u b j e c t of a b o r t i o n d e a l s at l e n g t h w i t h the medical, l e g a l , p s y c h o l o g i c a l and moral aspects of the s i t u a t i o n . A review of t h i s l i t e r a t u r e shows tha t the p o i n t of view most o f t e n used f o r such w r i t i n g s was t h a t of the p r o f e s s i o n a l — w h e t h e r general p r a c t i t i o n e r , clergyman, p s y c h i a t r i s t , g y n e c o l o g i s t , lawyer, medical o f f i c e r of h e a l t h o r s o c i o l o g i s t . Many d i v e r s e o p i n i o n s are o f f e r e d r e g a r d i n g the moral p i m p l i c a t i o n s of a b o r t i o n . I t i s not the purpose of t h i s paper to engage i n the moral debate, but r a t h e r to l e a r n more about what a c t u a l l y i s experienced by the woman having an a b o r t i o n . I n r e v i e w i n g the l i t e r a t u r e , the i n v e s t i g a t o r was searching f o r i n f o r m a t i o n r e l a t i n g to the needs experienced and expressed by the women who had a b o r t i o n s . There was a dearth of such m a t e r i a l . This review, then, w i l l l o o k at r e p r e s e n t a t i v e North xSee f o r example a r t i c l e s i n Robert E. H a l l , (ed.), A b o r t i o n i n a Changing World ( I and I I ) , (New York: Columbia U n i v e r s i t y Press, 1970), and David T. Smith, ( e d . ) , A b o r t i o n  and the Law, (Cleveland* The Press of Western Reserve U n i v e r s i t y , 1967). 2 F o r two d i f f e r e n t i n t e r p r e t a t i o n s of the moral i m p l i c a t i o n s of a b o r t i o n , see D a n i e l C a l l a h a n , A b o r t i o n ; Law, Choice and M o r a l i t y , (London: MacMillan Co., 1970) ,and R u s s e l l Shaw, A b o r t i o n on T r i a l , (Ohio; Pflaum P r e s s , 1968.) 6 7 American a r t i c l e s w r i t t e n from the medical, p s y c h o l o g i c a l / p s y c h i a t r i c , and s o c i a l p e r s p e c t i v e s . These w i l l be examined to determine t h e i r u s e f u l n e s s i n c o n t r i b u t i n g to "knowledge about women's needs. MEDICAL PERSPECTIVES Reporting on a study of the f i r s t 500 cases of a b o r t i o n performed at the Vancouver General H o s p i t a l ( t h a t i s from 1965 to J u l y , 1 9 7 0 ) , Claman w r i t e s t h a t "the b i g g e s t s i n g l e f a c t o r l e a d i n g to c o m p l i c a t i o n s when pregnancy i s terminated by curettage i s the d u r a t i o n of g e s t a t i o n . " 3 This f i n d i n g was corroborated l a t e r i n an American study, the most comprehensive study of medical c o m p l i c a t i o n s of a b o r t i o n c a r r i e d out i n the U n i t e d S t a t e s . This study, r e p o r t e d i n 1972 by T i e t z e and L e w i t t , i n c l u d e d 72,988 women having a b o r t i o n s w i t h i n a one year i n t e r v a l . ^ Among the major f i n d i n g s were th a t three out of f o u r a b o r t i o n s were performed i n the f i r s t t r i m e s t e r of pregnancy; t h a t most a b o r t i o n s i n t h i s f i r s t t r i m e s t e r were performed by vacuum a s p i r a t i o n ; and t h a t e a r l y medical c o m p l i c a t i o n s ( i n c l u d i n g minor complaints) during the f i r s t t r i m e s t e r were on the order of one i n 3A. David Claman e t . a l . , "Impact on H o s p i t a l P r a c t i c e of L i b e r a l i z i n g A b o r t i o n s and Female S t e r i l i z a t i o n s , " Canadian Medical A s s o c i a t i o n J o u r n a l , 105 ( J u l y 10, 1971) , 39 . ^ C h r i s t o p h e r T i e t z e and Sarah L e w i t t , " J o i n t Program f o r the Study of A b o r t i o n (JPSA): E a r l y Medical Complications of Legal A b o r t i o n , " Studies i n Family P l a n n i n g , 3:6 (June, 1972). . — 8 twenty a b o r t i o n s , whereas major c o m p l i c a t i o n s were one i n two hundred a b o r t i o n s . The r e p o r t s t a t e s t h a t "the r i s k to h e a l t h a s s o c i a t e d w i t h a b o r t i o n s was three to f o u r times as high In the second t r i m e s t e r of pregnancy as i n the f i r s t t r i m e s t e r . "-5 ( T l e t z e r e f e r s to the f i r s t t r i m e s t e r as the f i r s t twelve weeks since the l a s t menstrual period.) The study found that the compl i c a t i o n r a t e s were lowest " f o r a b o r t i o n s by s u c t i o n , f o l l o w e d In ascending order by c l a s s i c a l D&C, s a l i n e , h y s t e r -otomy, and h y s t e r e c t o m y . T h e best time f o r m i n i m i z i n g complications was seven to e i g h t weeks a f t e r the l a s t menstrual p e r i o d . From t h i s time on, the c o m p l i c a t i o n r a t e increased s t e a d i l y to f i f t e e n weeks or more. The r e s u l t s of t h i s study i n d i c a t e t h a t an e a r l y a b o r t i o n i n a hea l t h y woman performed by a s k i l l e d prac-t i t i o n e r i s a r e l a t i v e l y safe procedure accompanied by m i n i -mal r i s k . The study was a l s o able to i d e n t i f y p o t e n t i a l h i g h - r i s k p a t i e n t s from the medical p e r s p e c t i v e . As the number of a b o r t i o n s i n c r e a s e s , h o s p i t a l f a c i l i t i e s attempt to accommodate the change. T i e t z e looked i a t a comparison of c o m p l i c a t i o n r a t e s between h o s p i t a l i z e d p a t i e n t s and o u t p a t i e n t s , and found that c o m p l i c a t i o n r a t e s f o r a b o r t i o n s by s u c t i o n , ex-c l u d i n g women w i t h p r e - e x i s t i n g c o m p l i c a t i o n s , . . . were -^Tietze, p. 98 . ^ T l e t z e , p. 98. 9 lower f o r c l i n i c s than f o r h o s p i t a l s and lower f o r h o s p i t a l o u t - p a t i e n t s than f o r h o s p i t a l i n - p a t i e n t s . These d i f f e r e n t i a l s were due i n p a r t to v a r i a t i o n s i n periods of g e s t a t i o n and i n type of s e r v i c e ( p r i v a t e versus n o n - p r i v a t e ) . Other f a c t o r s t h a t probably c o n t r i b u t e d to the d i f f e r e n t i a l s were: (a) more r i g o r o u s s e l e c t i o n of p a t i e n t s ; (b) g r e a t e r experience of p h y s i c i a n s ; and (c) l e s s complete r e c o r d i n g of compli-c a t i o n s . 7 This f i n d i n g supports a study at the Vancouver General H o s p i t a l i n 1972 which proposed to i d e n t i f y problems experienced by p a t i e n t s having a b o r t i o n s on a one-day s u r g i c a l b a s i s . T h i s report s t a t e d t h a t " e a r l y discharge d i d not create any major problems t h a t the p a t i e n t h e r s e l f could not handle a t home."^ Th i s statement was based on follow-up v i s i t s made w i t h i n Zk hours of the a b o r t i o n . The value of the res e a r c h mentioned here i n adding to an understanding of women's needs r e l a t i n g to a b o r t i o n I s obvious: the incidence of p h y s i c a l need r e l a t i n g to complic a t i o n s i s low, p a r t i c u l a r l y i n women i n the e a r l y g e s t a t i o n p e r i o d who have been screened to determine h i g h -r i s k p o t e n t i a l . PSYCHOLOGICAL/PSYCHIATRIC PERSPECTIVES Other s t u d i e s have focused more on the p s y c h o l o g i c a l and p s y c h i a t r i c r e a c t i o n s of women having a b o r t i o n s . In 1971» 7 T I e t z e , p. 9 8 . 8"A Study to I d e n t i f y Problems Experienced by P a t i e n t s having Therapeutic A b o r t i o n s on the One-Day S u r g i c a l S l a t e , " p. 28. 10 Brody e t . a l . attempted to l o o k f o r p o s s i b l e p s y c h o l o g i c a l d i s t u r b a n c e s i n women a p p l y i n g f o r a b o r t i o n s , by a s k i n g whether t h e r a p e u t i c a b o r t i o n s had any e f f e c t on measurable p s y c h o l o g i c a l disturbance ( i f demonstrated), and whether r e f u s i n g a b o r t i o n caused p s y c h o l o g i c a l i l l - e f f e c t s . The study, used a c o n t r o l group of women i n the same stage of pregnancy f o r comparison.9 Using e l a b o r a t e t e s t s (Minnesota M u l t i p h a s i c Person-a l i t y Inventory; Pregnancy Research Questionnaire; Minnesota-B r l g g s S o c i a l H i s t o r y ; Mooney Problem C h e c k l i s t ; C o r n e l l Medical Index; F o r e r Sentence Completion and Semantic D i f f e r e n t i a l ) , the study suggested the f o l l o w i n g c h a r a c t e r -i s t i c s of women who a p p l i e d f o r a b o r t i o n : These i n c l u d e a h i g h degree of depre s s i o n , c o n s i d e r -able concern w i t h b o d i l y preoccupations, d i f f i c u l t i e s i n obeying r u l e s and r e g u l a t i o n s , t r o u b l e i n c o n t r o l l i n g impulses to an extent t h a t leads to s e r i o u s s o c i a l d i f f i c u l t i e s , a tendency to be touchy and c r i t i c a l o f ot h e r s , being an easy prey to a n x i e t y and i r r a t i o n a l f e a r s , a marked tendency to withdraw and uneasiness In s o c i a l s i t u a t i o n s . 1 0 This study, however, begs the qu e s t i o n : to what extent can a survey of p s y c h i a t r i c c h a r a c t e r i s t i c s be v a l i d , when based on t e s t s a d m i n istered to a woman who i s upset i n the p a r t i c u l a r circumstances, but who a l s o knows that she must p l e a d a case before a committee, c o n v i n c i n g them th a t ^Harry Brody, Stewart M e i k l e , and Ri c h a r d G e r r i t s e , "Therapeutic A b o r t i o n : A P r o s p e c t i v e Study. 1 ," American  J o u r n a l of O b s t e t r i c s and Gynecology, 109:3 (February 1, 1971) , 347-353. 1 0 B r o d y , p. 352. her good h e a l t h depends on having an abortion? The authors themselves s t a t e t h a t "the a p p l i c a n t s may have attempted to fake a p s y c h o l o g i c a l disturbance i n order to maximize t h e i r chances of being a c c e p t e d , " 1 1 although they b e l i e v e d t h a t t h i s was not done s y s t e m a t i c a l l y ; r a t h e r , an i n d i v i d u a l may have exaggerated an e x i s t i n g symptom i n p r e s e n t i n g her case. Brody e t . a l . conclude t h a t a b o r t i o n does seem to be p s y c h o l o g i c a l l y t h e r a p e u t i c s W i t h i n 6 weeks of the procedure, our p a t i e n t s showed a marked improvement i n t h e i r r e p o r t e d psycho-l o g i c a l s t a t u s , and t h i s improvement continued up to one year a f t e r i n t e r v e n t i o n . 1 2 Studies which I n t e r p r e t data i n r e l a t i o n to the whole context of the experience seem to provide more u s e f u l understanding of the woman's s i t u a t i o n . An example of such a study, one t h a t does look at the t o t a l s i t u a t i o n f o r the e x p l a n a t i o n of behaviour, i s t h a t done by Marder i n 1970 i n C a l i f o r n i a . For Instance, Marder s t a t e s t h a t " h o s t i l i t y and resentment toward the p a t i e n t by s t a f f and n u r s i n g personnel have been r e s p o n s i b l e f o r some of the emotional disturbance experienced by p a t i e n t s . m 1 3 Such a statement makes i t seem questionable f o r Brody e t . a l . to c o n s i d e r p s y c h o l o g i c a l c h a r a c t e r i s t i c s of women a p p l y i n g f o r a b o r t i o n i n I s o l a t i o n i : LBrody, p. 352. 1 2 B r o d y , p. 352. 13Leon Marder, " P s y c h i a t r i c Experience w i t h a L i b e r a l i z e d A b o r t i o n Law," American J o u r n a l of P s y c h i a t r y , 126*9 (March, 1970) , 70. 12 from the other s i t u a t i o n a l dynamics. In Doth these s t u d i e s , an attempt was made to f o l l o w -up women who had "been r e f u s e d a b o r t i o n s . Not s u r p r i s i n g l y , much d i f f i c u l t y was encountered i n f i n d i n g these women. As Marder says, "Attempts to evaluate the e f f e c t s of r e j e c t i o n f o r t h e r a p e u t i c a b o r t i o n have been d i f f i c u l t because of the h o s t i l i t y developed by many of the a p p l i c a n t s . " - ^ Brody e t . a l . concluded that "there seems to be l i t t l e t h e r a p e u t i c value i n f o r c i n g a woman to c a r r y an unwanted pregnancy to term,"^^ but tha t a b o r t i o n does seem to have t h e r a p e u t i c p s y c h o l o g i c a l e f f e c t s . Marder found t h a t a n x i e t y and depression which develop under the s t r e s s of unwanted pregnancy are ameliorated a f t e r a b o r t i o n . ^ He a l s o found t h a t serious emotional problems of g u i l t o r remorse d i d not occur i n the p o s t - a b o r t a l p e r i o d . I n f a c t , " p a t i e n t s g e n e r a l l y have d e s c r i b e d marked r e l i e f of symptoms and r e p o r t improvement i n t h e i r r e l a t i o n s h i p s w i t h o t h e r s , along w i t h an improved l i v i n g s i t u a t i o n , f o l l o w i n g the ' t h e r a p e u t i c ' a b o r t i o n . " 1 7 Marder's data, as much as can be determined, seem to have been gathered through p s y c h i a t r i c i n t e r v i e w s ; as mentioned, Brody e t . a l . used an extensive s e r i e s of person-1 h a r d e r , p. 6 8 . l 5 B r o d y , p. 352. l 6 M a r d e r , p. 70. ^ M a r d e r , p. 70. a l l t y t e s t s . In 1968, W h i t t l n g t o n used the " s e l f - r e p o r t " method to t r y to evaluate t h e r a p e u t i c a b o r t i o n . Thirty-one women responded to h i s q u e s t i o n n a i r e . The data suggest t h a t respondent women who have r e c e i v e d a thera p e u t i c a b o r t i o n f e e l t h e i r mental h e a l t h and s t a t e of happiness have been b e n e f i t t e d by the procedure and would make the d e c i s i o n again.1° These previous three s t u d i e s a l l d e a l t w i t h s i t u a t i o n s where the woman was accepted f o r a b o r t i o n on p s y c h i a t r i c grounds; that i s to say, she was r e s p o n s i b l e f o r p e t i t i o n i n g her case before a committee. Osofsky e t . a l . . ( 1 9 ? 1 ) d e s c r i b e a d i f f e r e n t s i t u a t i o n i n Syracuse, New York, where a l l requests f o r a b o r t i o n are granted f o r pregnancies of under twelve weeks.19 The program a t the i n s t i t u t i o n i n v o l v e d includes education, c o n t r a c e p t i o n and a b o r t i o n s e r v i c e s . The comprehensiveness of t h i s program stands i n marked con-t r a s t to other f a c i l i t i e s . S h o r t l y a f t e r the a b o r t i o n , the p a t i e n t i s i n t e r -viewed i n order both to provide her wit h support, and to determine her r e a c t i o n s to the procedure. A d d i t i o n a l i n f o r m a t i o n i s gathered concerning her p e r c e p t i o n of options other than l e g a l i z e d a b o r t i o n , and her a t t i t u d e s and f u t u r e plans r e l a t e d to c o n t r a c e p t i o n , marriage, c h i l d r e n , and l i f e s t y l e . 2 0 x oH.G. Wh i t t l n g t o n , " E v a l u a t i o n of Therapeutic Abor-t i o n as an Element of Prev e n t i v e P s y c h i a t r y , " American Jour-n a l of P s y c h i a t r y . 126:9 (March, 1970) , 61. ! 9 j o y D. Osofsky e t . a l . , "Psychologic E f f e c t s of Legal A b o r t i o n , " C l i n i c a l O b s t e t r i c s and Gynecology: L e g a l  Abortions i n New York S t a t e : M e d i c a l , L e g a l , N u r s i n g , S o c i a l  Aspects ( J u l y 1-December 31% 1970). ed. George Schaefer, (March, 1971), (New York: Harper & Row Medic a l Department, 1 9 7 D , 215-234. Osofsky, p. 223. 14 Longer term follow-up was "being planned at the time of w r i t i n g . The r e s u l t s of t h i s study, which i n v o l v e d 250 women, showed t h a t few women have f e l t strong g u i l t , unhappiness, o r s e l f - a n g e r ; r e l a t i v e l y few have "been o b j e c t i v e l y d i s -t r e s s e d . Although many have p h y s i c a l l y f e a r e d the procedure and although a con s i d e r a b l e number would have l i k e d to bear the c h i l d i f p o s s i b l e , g i v e n the e x i s t e n t s o c i a l and/or economic circumstances, the predominant moods have been r e l i e f and happiness.2 1 This study a l s o found t h a t the experience of the a b o r t i o n increased the d e s i r e f o r e f f e c t i v e c o n t r a c e p t i o n . The authors s t r e s s t h a t more sex education and c o n t r a c e p t i v e a v a i l a b i l i t y are needed because the women i n the study d i d not p r e f e r o r d e s i r e a b o r t i o n as a means of c o n t r a c e p t i o n . SOCIAL PERSPECTIVES Some w r i t e r s have been concerned w i t h the psycho-s o c i a l and s o c i a l e f f e c t s of a b o r t i o n , on the s o c i e t y i n general and on the woman In tha t s o c i e t y i n p a r t i c u l a r . David (1971) s t r e s s e s the need f o r more adequate p r e p a r a t i o n f o r medical and h e a l t h workers i n terms of d e a l i n g w i t h human s e x u a l i t y . Such people, i n the p a s t , have been p o o r l y prepared to d e a l w i t h the changing s o c i a l r e a l i t y of l e g a l i z e d a b o r t i o n and need "e d u c a t i o n a l programs designed 2 1 0 s o f s k y , p. 231. 15 to enhance awareness and s k i l l f o r d e a l i n g adequately and a p p r o p r i a t e l y w i t h a b o r t i o n r e q u e s t s . " 2 2 He a l s o "believes that more knowledge i s r e q u i r e d about "the d i f f e r e n c e s In b e l i e f s , a t t i t u d e s , v a l u e s , and m o t i v a t i o n s i n f l u e n c i n g human behavior" i n the area of f a m i l y p l a n n i n g and abor-t i o n . 2 - ^ David thus adds to an understanding of the s o c i a l i m p l i c a t i o n s of a b o r t i o n by s t r e s s i n g r e l a t e d needs i n terms of h e a l t h p r o f e s s i o n re-education and i n d i v i d u a l m o t i v a t i o n . Schwartz (1972) d i s c u s s e s the s o c i a l e f f e c t s of l e g a l a b o r t i o n u s i n g such sweeping g e n e r a l i z a t i o n s t h a t no new i n s i g h t s are gained; i n f a c t , erroneous i n f o r m a t i o n i s pre-sented concerning the p o s i t i v e s o c i a l e f f e c t s of l e g a l a b o r t i o n . S p e c i f i c a l l y , Schwartz s t a t e s t h a t l e g a l a b o r t i o n i s the best s i n g l e method f o r decreasing the b i r t h r a t e and consequently p r e s e r v i n g the environment from f u r t h e r d e t e r -i o r a t i o n , f o r decreasing the incidence of poverty, and f o r improving the q u a l i t y of c h i l d care, " l e a d i n g to decrease i n the p o t e n t i a l i n c i d e n c e of c r i m i n a l i t y , p s y c h o s i s , drug a d d i c t i o n , a l c o h o l i s m , and ot h e r severe d i s o r d e r s of b e h a v i o r . " 2 ^ C l e a r l y , t h i s i s too s i m p l i s t i c an approach to complex s o c i e t a l concerns. 22Davld, "Abortions P u b l i c H e a l t h Concerns and Needed P s y c h o s o c i a l Research," p. 5 1 ^ . 2 3Dav ld , p. 513. 2 i f R i c h a r d A. Schwartz, "The S o c i a l E f f e c t s of L e g a l A b o r t i o n , " American J o u r n a l of P u b l i c H e a l t h , 62:10 (October, 1972) , 1335. . 16 More u s e f u l i n s i g h t s are provided by Schwenger (1973) who s t u d i e d a b o r t i o n i n Canada and r a i s e s some impor-t a n t questions r e g a r d i n g the s o c i a l i n e q u a l i t i e s of our present system, s p e c i f i c a l l y as they are manifested i n the s i t u a t i o n s of pregnant women.25 Women's needs are met d i f f e r e n t l y i n d i f f e r e n t p a r t s of the country. There i s , f o r example, a geographical d i f f e r e n c e : i t i s over t h i r t y times e a s i e r to o b t a i n an a b o r t i o n i n B r i t i s h Columbia than i n Newfoundland. Women i n r u r a l areas have a more d i f f i c u l t time o b t a i n i n g a b o r t i o n s than do c i t y women, because of l a c k of h o s p i t a l f a c i l i t i e s or l a c k of s u f f i c i e n t p h y s i c i a n s to form Therapeutic A b o r t i o n Committees. Another i n e q u a l i t y i s the f a c t that i t i s s t i l l more d i f f i c u l t f o r poor women to get a b o r t i o n s , i f t r a v e l to another c i t y i s r e q u i r e d . Yet another source of i n e q u a l i t y l i e s i n the f a c t t h a t i n d i v i d u a l committees may decide whether to accept a broad d e f i n i t i o n of h e a l t h ( i n c l u d i n g the p a t i e n t ' s p h y s i c a l , mental, and s o c i a l concerns), o r a narrow one. Those, then, are some of the ways i n which i n d i v i d u a l women w i t h i n our s o c i e t y are a f f e c t e d by a b o r t i o n and a b o r t i o n laws. Schwenger a l s o d e s c r i b e s some of the o v e r a l l p u b l i c h e a l t h e f f e c t s , one of which i s t h a t "the drop i n the r a t e s of neonatal m o r t a l i t y and p e r i n a t a l m o r t a l i t y over the past 2 5cope W. Schwenger, "Abortion i n Canada as a P u b l i c Health Problem and as a Community Health Measure," Canadian  J o u r n a l of P u b l i c Health, 64:3 (May-June, 1973) , 223-229. 17 f i v e years shows the g r e a t e s t r e d u c t i o n from 1970-1971, presumably from the incidence of l e g a l a b o r t i o n . " 2 ^ While r e c o g n i z i n g the c o n t r i b u t i o n t h a t i n c r e a s e d a v a i l a b i l i t y of abortion has made to p u b l i c h e a l t h , Schwenger s t r e s s e s t h a t "more acceptable a l t e r n a t i v e methods of b i r t h c o n t r o l such as contraception and s t e r i l i z a t i o n must be made more r e a d i l y a v a i l a b l e . h 2 7 He emphasizes the need f o r c o u n s e l l i n g as an In t e g r a l p a r t of a b o r t i o n s e r v i c e s that should be " f r e e l y entered i n t o , s u p p o r t i v e , non-judgmental, and e d u c a t i o n a l . " 2 ^ The preceding d i s c u s s i o n has shown t h a t , g e n e r a l l y , women expe r i e n c i n g a b o r t i o n s do not have great need i n t h e i r p h y s i c a l or p s y c h o l o g i c a l responses to the event. The areas of need seem to focus on the woman's p s y c h o s o c i a l s i t u a t i o n . Does she have access to a b o r t i o n f o r an unwanted pregnancy? What contraceptive a d v i c e , i f any, had she been given? Are there adequate c o u n s e l l i n g f a c i l i t i e s a v a i l a b l e to her? The r e s t of t h i s l i t e r a t u r e review w i l l l ook at information regarding women's needs w i t h an emphasis on the woman h e r s e l f as the primary e v a l u a t o r of her experience. 2^Schwenger, p. 227. ^Schwenger, p. 228. 2 8Schwenger, p. 229. 18 WOMEN'S NEEDS AND EXPERIENCES A report of an experiment i n a " m u l t i d i s c i p l i n e d approach" to the care of women having a b o r t i o n s i n an Ontario c l i n i c s t a t e s that the most common needs of the women were f o r : (1) a comprehensive assessment of p s y c h o s o c i a l problems; (2) concerned h e a l t h team members who can help a p a t i e n t s o r t out her f e e l i n g s and s e l e c t a s a t i s f a c t o r y s o l u t i o n to her problem; (3) ongoing emotional support; (4) a v a i l a b i l i t y of i n d i v i d u a l and f a m i l y treatment resources e i t h e r w i t h i n the team o r a c c e s s i b l e to i t ; (5) follow-up assessments, c o n t r a c e p t i v e c o u n s e l l i n g , and follow-through by a c a r i n g i n d i v i d u a l who may w e l l be I n the p a t i e n t ' s own community.29 . Smith (1973) r e p o r t s a study i n M i s s o u r i i n v o l v i n g 154 women, where the aim was to l o o k a t other aspects of the woman's l i f e i n r e l a t i o n to the a b o r t i o n . She s t a t e s : I n order to more f u l l y understand the e f f e c t s of a b o r t i o n and the immediate and l o n g e r range adjustment p a t t e r n s , i t was decided to ask women who had obtained a b o r t i o n s to evaluate t h e i r experience and i t s e f f e c t upon them. T h e i r s u b j e c t i v e r e a c t i o n s to a b o r t i o n , t h e i r c u r r e n t f u n c t i o n i n g , r e l a t i o n s h i p s w i t h the sexual p a r t n e r , c o n t r a c e p t i v e usage, and subsequent unwanted pregnancies were explored.30 The group, which was t y p i c a l l y white, s i n g l e , P r o t e s t a n t c o l l e g e students, p r i m a r i l y f e l t t h a t the a b o r t i o n had had a p o s i t i v e e f f e c t on t h e i r l i v e s . Adverse p s y c h o l o g i c a l symp-29joan M. Rogers and David W. Adams, "Therapeutic A b o r t i o n : A M u l t i d i s c i p l i n e d Approach to P a t i e n t Care from a S o c i a l Work P e r s p e c t i v e , " Canadian J o u r n a l of P u b l i c H e a l t h , 64 :3 (May-June, 1973) , 257. 3°Elizabeth M. Smith, "A Follow-up Study of Women Who Request A b o r t i o n , " American J o u r n a l of O r t h o p s y c h i a t r y , 43:4 ( J u l y , 1973) , 576. 19 toms were experienced "by only a sm a l l number of women and were u s u a l l y s e l f - l i m i t i n g . Most of the women remained s e x u a l l y a c t i v e a f t e r the experience, and the m a j o r i t y of these were u s i n g r e l i a b l e c o n t r a c e p t i o n a t the time of fol l o w - u p . Of the women i n t h i s study, almost h a l f (44-percent) had separated from the sexual p a r t n e r a f t e r the a b o r t i o n , and 13 percent had married the pa r t n e r . The author of the study concludes t h a t there i s a need f o r f u r t h e r systematic s t u d i e s of a b o r t i o n and development of methods of p r e d i c t i n g women who are at r i s k f o r p o s t - a b o r t i o n r e a c t i o n and sub-sequent unwanted pregnancies. 31 Monsour and Stewart (1973) conducted a study of twenty c o l l e g e women to assess "the consequences of a b o r t i o n as seen i n changes i n s e l f - p e r c e p t i o n , a l t e r a t i o n s i n sexual f e e l i n g s and behavior, and m o d i f i c a t i o n s of a t t i t u d e s toward c h l l d b e a r i n g and c h i l d r e n . " 3 2 The average time i n t e r v a l u n t i l f o l low-up was seven and one-half months. A l l of the s u b j e c t s were s i n g l e . The authors i n d i c a t e t h a t c o l l e g e years are a p e r i o d of p s y c h o s o c i a l development, and so, f o r these women, "the t r a n s i e n c e of these r e l a t i o n s h i p s and d i s i n t e r e s t i n t h e i r continuance were important f a c t o r s i n choosing abortion. " 3 3 3 1 S m l t h , p. 585. 3%arem J . Monsour and Barbara Stewart, " A b o r t i o n and Sexual Behavior i n C o l l e g e Women," American J o u r n a l of Ortho-p s y c h i a t r y . 43:5 (October, 1973) , 80c~ 33Monsour, p. 808. 20 Most women In the study f e l t t h a t the p e r i o d of pregnancy was more s t r e s s f u l i n personal terms than the a b o r t i o n i t s e l f . However, f o r one woman, the a b o r t i o n was most s t r e s s f u l , s ince she f e l t accused i n the eyes of the nurses and doctors who made derogatory remarks about her a l l e g e d sexual p r o m i s c u i t y and choice of a b o r t i o n . 3 ^ Regarding the use or non-use of c o n t r a c e p t i o n , the authors describe what was a common p a t t e r n w i t h these young women: a "conspiracy of s i l e n c e " develops i n f a m i l i e s when human s e x u a l i t y i s a for b i d d e n s u b j e c t . The daughters l e a r n e d "to become 'partners* i n m a i n t a i n i n g a f a m i l y atmosphere of secrecy about sexual behavior. In c o l l e g e , as r e l a t i o n s h i p s w i t h men become I n c r e a s i n g l y important to them, these women appear to continue to keep the " s e c r e t " of t h e i r sexual behavior from themselves. They behave.towards thenselves as t h e i r parents behaved towards them. They preserve the "con-s p i r a c y of s i l e n c e , " of not "knowing" about t h e i r own sexual behavior.3 ° The authors conclude t h a t g r e a t e r openness about s e x u a l i t y , l e a d i n g to personal and emotional knowledge and awareness, i s more Important "than most of the e d u c a t i o n a l and i n f o r -mational programs now being used i n high schools and co l l e g e s . " 3 7 The study found the major r e a c t i o n to the a b o r t i o n i t s e l f was r e l i e f . No untoward e f f e c t s were observed 34Monsour, p. 809. 36Monsour, p. 812. 35Monsour, p. 812. 37Monsour, p. 813. 21 on personal a t t i t u d e s to motherhood, c h l l d b e a r i n g , or t h e i r bodies. "The major e f f e c t on t h e i r s e x u a l a t t i t u d e s and behavior was to increase t h e i r sense of f u t u r e c a u t i o n and acceptance of p e r s o n a l r e s p o n s i b i l i t y f o r t h e i r own behavior. " 3 8 NURSING PERSPECTIVES ON ABORTION L i t t l e has been w r i t t e n by nurses Involved w i t h women having a b o r t i o n s when compared to the s t u d i e s and r e p o r t s done by p h y s i c i a n s and s o c i a l workers. A r t i c l e s appearing i n the n u r s i n g l i t e r a t u r e are o f t e n a defence on one s i d e or the other of "the a b o r t i o n i s s u e " i n moral terms.39 Recently, nurses have begun to d e s c r i b e t h e i r experiences with women i n d i f f e r e n t a b o r t i o n f a c i l i t i e s . Danon (1973) d e s c r i b e s her work wi t h three p h y s i c i a n s i n c r e a t i n g an a b o r t i o n s e r v i c e i n J e r s e y C i t y . I n t h i s s i t u a t i o n , the nurse was p l a c e d i n the r o l e of nurse-c o u n s e l l o r , and "when h i r i n g , we sought a nurse who c o u l d respond warmly and e a s i l y to the p a t i e n t on a woman-to-woman b a s i s . " ^ 3 8Monsour, p. 813. 3 W f o r example, P a u l E h r l i c h and John P. Holdren, "Abortion and M o r a l i t y , " Canadian Nurse, 68:6 (June, 1 9 7 2 ) , 37; and R.E. Groves. " I s A b o r t i o n Murder?" N u r s i n g Times, 68:20 (May 18, 1972) , 624-625. ^°Ardis Hyland Danon, "Organizing an A b o r t i o n S e r v i c e , " Nursing Outlook, 21:7 ( J u l y , 1973) , 5^2. 22 Some f i n d i n g s of t h i s c l i n i c experience were t h a t women having a b o r t i o n s undergo the usu a l a n x i e t y f e l t before a s u r g i c a l procedure and tha t women o f t e n f e e l q u i t e "alone" when having an a b o r t i o n . I t was n o t i c e d t h a t emotional support " f a r exceeding anything we could p r o v i d e " was given by the women to each other i n the w a i t i n g room.^-*-The group method was found u s e f u l at t h i s c l i n i c f o r p r e paring the women and a l l a y i n g some f e a r s p r e o p e r a t i v e l y as w e l l as f o r conducting i n f o r m a l , open e d u c a t i o n a l s e s s i o n s before the women l e f t the c l i n i c . Another program which emphasizes the r o l e of nurse-c o u n s e l l o r i s found i n B e l l e v u e H o s p i t a l , New York C i t y . A t t h i s c l i n i c , the goal I s "to create a comfortable atmos-phere where the p a t i e n t s f e e l f r e e to i n t e r a c t w i t h each other and w i t h the nurse i n an open exchange of ideas."** 2 Contraceptive t e a c h i n g i s s t r e s s e d , as i s d i s c u s s i o n of s e x u a l i t y . The authors of t h i s r e p o r t conclude: The combination of medical knowledge, s o c i a l aware-ness, and feminine understanding a l l o w s the p r o f e s s i o n a l nurse to be the n a t u r a l person to whom the a b o r t i o n p a t i e n t w i l l r e l a t e . We s t r o n g l y f e e l t h a t the nurse has a unique c o n t r i b u t i o n to make In the t o t a l care of these women.43 ^Danon, p. 463. 42chri s t a K e l l e r and Pamela Copeland, " C o u n s e l l i n g the A b o r t i o n P a t i e n t i s More Than Ta l k , " American J o u r n a l  of Nursing. 72:1 (January, 1972) , 104. ^ K e l l e r , p. 106. 23 1 SUMMARY The l i t e r a t u r e reviewed i n t h i s chapter has shown that f o r the most p a r t women ex p e r i e n c i n g e a r l y a b o r t i o n s do not develop s e r i o u s medical c o m p l i c a t i o n s ^ t h a t they do not s u f f e r from p s y c h i a t r i c c o n d i t i o n s of extreme g u i l t or severe depression; that they do, however, a p p r e c i a t e emotional support and the oppo r t u n i t y to explore t h e i r f e e l i n g s ; that they experience the us u a l a n x i e t y before sur-g i c a l procedure, which i s reduced by e x p l a n a t i o n of what w i l l occur; and t h a t they are i n t e r e s t e d i n l e a r n i n g how to take more r e s p o n s i b l e care of t h e i r bodies. The g r e a t e r p a r t of res e a r c h done on women's needs a f t e r an a b o r t i o n has had a p a t h o l o g i c a l f o c u s : there has been a search f o r the unusual. Only r e c e n t l y have s t u d i e s begun to de s c r i b e what t h i s experience has meant to the woman's ongoing l i f e , and whether i t has had a s i g n i f i c a n t e f f e c t on her f a m i l y r e l a t i o n s h i p s , her f e e l i n g s about her-s e l f , her m o t i v a t i o n f o r e f f e c t i v e c o n t r a c e p t i o n , and her ideas about c h i l d r e a r i n g and mothering. The researcher was i n t e r e s t e d i n e x p l o r i n g these ideas f u r t h e r , to add to n u r s i n g knowledge on the care of women undergoing a b o r t i o n . Nursing i s i n an i d e a l p o s i t i o n to be i n r e l a t i o n s h i p w i t h women who may have needs re g a r d i n g t h e i r a b o r t i o n , because n u r s i n g a l l o w s f o r many d i f f e r e n t focuses. The home, h o s p i t a l , and wider community are a l l places where n u r s i n g knowledge about women having a b o r t i o n can be u t i l i z e d . By studying how d i f f e r e n t women adapt to t h i s u n s e t t l i n g l i f e event, n u r s i n g can b e t t e r understand the dynamic i n f l u e n c e s which operate i n t h i s s i t u a t i o n . With t h i s knowledge, n u r s i n g i n t e r v e n t i o n can be planned, a p p r o p r i a t e , and op e r a t i v e i n the pr e v e n t i v e stages. Chapter 3 METHODOLOGY The research p r o j e c t was planned to interview_ women, scheduled f o r an a b o r t i o n , about t h e i r expressed needs by u t i l i z i n g an open-ended i n t e r v i e w format. The t a r g e t p o p u l a t i o n Included anyone who a p p l i e d f o r an a b o r t i o n a t e i t h e r of the two r e f e r r a l sources d u r i n g the p e r i o d under study. The study was c a r r i e d out i n a l a r g e Canadian c i t y between A p r i l , 1973, and A p r i l , 1974. The m a j o r i t y of women had t h e i r a b o r t i o n s on an o u t p a t i e n t b a s i s (twelve out of twenty). The remainder were admitted o v e r n i g h t , not because of any d i f f e r e n c e i n l e n g t h of g e s t a t i o n , but because of crowded operating-room schedules on the o u t p a t i e n t department s l a t e . The women ranged i n age from f o u r t e e n to t h i r t y - s e v e n years, w i t h the g r e a t e r number (twelve) between nineteen and twenty-eight years. DESIGN The s c a r c i t y of n u r s i n g r e s e a r c h on the subject of women's needs a f t e r an a b o r t i o n meant that the i n v e s t i g a t o r was not able to use an e x i s t i n g r e s e a r c h t o o l f o r t h i s e x p l o r -a t i o n . Studies by other h e a l t h p r o f e s s i o n a l s u t i l i z e d t o o l s which were not s u i t e d to t h i s p a r t i c u l a r task. What d i d seem 25 26 s u i t a b l e f o r t h i s study was an e x p l o r a t o r y s t y l e of r e s e a r c h , w i t h the r a t h e r broad purpose of ga t h e r i n g p r e l i m i n a r y data, and t r y i n g to der i v e i n s i g h t s and p o s s i b l y i d e n t i f y hypo-theses amenable to more formal study. The l o g i c a l s t r a t e g y of e x p l o r a t o r y s t u d i e s c o n s i s t s of p r o v i d i n g a framework which may f a c i l i t a t e the process of a s k i n g p e r t i n e n t questions i n the i n v e s t i g a t i o n of a phenomenon. The process of d i s c o v e r y . i s not a r t i c u l a t e d s u f f i c i e n t l y so tha t a researcher can f o l l o w a p r e s c r i b e d set of r u l e s ; indeed such a c r e a t i v e process does not n e c e s s a r i l y f o l l o w o r d e r l y r u l e s of l o g i c . 1 The r e s e a r c h p r o j e c t , then, made use of an e x p l o r a t o r y , open-ended i n t e r v i e w design to determine the expressed needs of women having a b o r t i o n s . This design was chosen f o r i t s f l e x i b i l i t y i n a l l o w i n g e x p l o r a t i o n without r e s t r i c t i o n of areas meaningful to the women. The same format was used on each of three v i s i t s to each woman to determine her needs r e l a t i n g to the a b o r t i o n , as perceived at three d i f f e r e n t times: before the o p e r a t i o n , two weeks f o l l o w i n g , and f o u r months f o l l o w i n g . The i n i t i a l i n t e r v i e w was designed to explore whether the woman a n t i c i p a t e d any areas of need and what they were. The second i n t e r v i e w had the purpose of l o o k i n g a t her r e a c t i o n to the o p e r a t i o n , the h o s p i t a l experience, her r e l a t i o n s h i p w i t h her sexual p a r t n e r , and her plans f o r c o n t r a c e p t i o n . I n the f i n a l i n t e r v i e w , any changes i n f e e l i n g , xTony A. T r i p o d i e t . a l . , S o c i a l Program E v a l u a t i o n , ( I t a s c a : Peacock P u b l i s h e r s , 1971) , p. 4 5 . 27 p e r c e p t i o n , o r need r e l a t i n g to the a b o r t i o n were to be discussed. The review of the l i t e r a t u r e had suggested some of the areas to be explored: the need f o r c o n t r a c e p t i v e Information; the need to speak openly about s e x u a l i t y ; the need f o r emotional support; and the concern about the ongoing r e l a t i o n s h i p w i t h the sexual p a r t n e r . The i n v e s t i g a t o r added other areas of e x p l o r a t i o n concerned witht e x p e c t a t i o n s In r e l a t i o n to the a v a i l a b i l i t y of a s s i s t a n c e ; the l e g a l s i t u a t i o n ; the p o s t - o p e r a t i v e experience; and the woman's f e e l i n g s about h e r s e l f . A l l of these areas were Included i n the Interviews where they were a p p l i c a b l e . The i n t e r v i e w was p r e - t e s t e d on f o u r women. Areas f o r d i s c u s s i o n which were i n c l u d e d a f t e r the p r e - t e s t were: previous f e e l i n g s and thoughts r e g a r d i n g a b o r t i o n i n ge n e r a l ; method of seeking h e l p ; c o n s i d e r a t i o n of having the baby; and the e f f e c t of the d e c i s i o n to have an a b o r t i o n on the f a m i l y s i t u a t i o n . PROCEDURE The f o l l o w i n g steps were taken i n pl a n n i n g the study a f t e r the i n i t i a l i d e a was formulated. 1. V i s i t s were made to d i f f e r e n t community resource people to assess whether t h i s was a v i a b l e research t o p i c . 2. The l i t e r a t u r e review was begun. 3. P o t e n t i a l committee members were approached, and secured. 28 4. A research design was drawn up and submitted to the committee chairwoman. 5« F o l l o w i n g the committee's ap p r o v a l , an o u t l i n e of the proposed p r o j e c t was submitted to the U n i v e r s i t y of B r i t i s h Columbia Health Sciences Screening Committee f o r Research I n v o l v i n g Human Subjects. . 6 . When approval was granted by the l a t t e r Committee, the two community s e r v i c e s were approached: (a) d i s c u s s i o n was c a r r i e d on wit h a gy n e c o l o g i s t and h i s n u r s e - r e c e p t i o n i s t , s t a t i n g the purpose of the study and re q u e s t i n g t h e i r par-t i c i p a t i o n ; they were w i l l i n g to a s s i s t the re s e a r c h e r , (b) D i s c u s s i o n was h e l d with a women's h e a l t h education and r e f e r r a l group, s t a t i n g the purpose of the study and the nature of t h e i r p o s s i b l e a s s i s t a n c e . The group agreed to cooperate w i t h the p l a n . 7. Data c o l l e c t i o n began i n May, 1973, and was completed i n March, 1974. SAMPLE The sample was obtained by us i n g a l l a v a i l a b l e subjects as they were r e f e r r e d from the two sources: the community-organized women's h e a l t h e d u c a t i o n a l and r e f e r r a l group and the p r i v a t e g y n e c o l o g i s t ' s o f f i c e . These two sources were chosen w i t h the i n t e n t i o n of o b t a i n i n g as re p r e s e n t a t i v e a sample as p o s s i b l e . The rese a r c h e r o r i g i n -a l l y thought that the women's r e f e r r a l group, which does comprehensive female h e a l t h teaching and a b o r t i o n r e f e r r a l , 2 9 would Introduce her to a younger p o p u l a t i o n , l e s s e s t a b l i s h e d i n permanent r e l a t i o n s h i p s , and that the g y n e c o l o g i s t , who saw women r e f e r r e d by many general p r a c t i t i o n e r s , would p o s s i b l y be r e f e r r i n g women who were o l d e r and i n e s t a b l i s h e d f a m i l y s i t u a t i o n s . Both sources were to approach every woman who came re q u e s t i n g an a b o r t i o n , a s k i n g whether she would p a r t i c i p a t e i n the study. AIT those who i n d i c a t e d and maintained an i n t e r e s t were i n c l u d e d i n the study. A l i m i t of twenty women was decided upon f o r two reasons: f i r s t , the time l i m i t of the researcher was a major c o n s i d e r a t i o n ; and second, a group of t h i s s i z e was considered ample f o r an e x p l o r a t o r y study. I t was recognized t h a t s t a t i s t i c a l t e s t s would not apply to such a s m a l l group but th a t d e s c r i p t i v e i n f o r m a t i o n would r e s u l t . Content a n a l y s i s would be the primary method of examining the data. The o n l y c r i t e r i o n f o r the study s u b j e c t s was t h a t the a b o r t i o n was to be performed by e i t h e r the d i l a t i o n and curettage o r the vacuum a s p i r a t i o n method. Both r e f e r r a l sources were aware of t h i s c r i t e r i o n , although one woman, at fo u r t e e n weeks' g e s t a t i o n , and scheduled f o r a s a l i n e i n d u c t i o n , was r e f e r r e d to the researcher. This woman moved and was subsequently l o s t to fol l o w - u p . Therefore, i t was decided to have a t o t a l a c t u a l sample of nine t e e n women. The sample was obtained d u r i n g two d i f f e r e n t time i n t e r v a l s because of the researcher's p r i o r commitments. The f i r s t p a r t of the sample (nine women) was Interviewed f o r the 30 f i r s t and second times i n May and June, 1973• The f o u r month follow-up i n t e r v i e w s were done i n October, 1973. The remaining ten women were contacted i n October and November, 1973, and t h e i r f ollow-up i n t e r v i e w s were i n March, 197^. As mentioned e a r l i e r , the women were i n i t i a l l y " contacted through the s e r v i c e which they had approached. Both s e r v i c e s were given a short brochure to giv e to the i n t e r e s t e d women, s t a t i n g who the rese a r c h e r was, what she was doing, and how the woman could help. The two s e r v i c e s kept a l i s t of women who had i n d i c a t e d i n t e r e s t ; the researcher c o l l e c t e d t h i s l i s t twice weekly by telephone. The researcher then contacted the woman by telephone, i d e n t i f i e d h e r s e l f , and made arrangements to meet. The i n t e r -views were h e l d i n a place chosen by the woman: her home, the researcher's home, or n e u t r a l t e r r i t o r y ( f o r example, a rest a u r a n t o r a u n i v e r s i t y lounge). Each i n t e r v i e w l a s t e d approximately one hour. The i n t e r v i e w e r took notes d u r i n g the i n t e r v i e w , which were e l a b o r a t e d upon immediately f o l l o w i n g the i n t e r v i e w . Of the o r i g i n a l l i s t of i n t e r e s t e d women which the researcher obtained from the two s e r v i c e s , twenty-nine contacts were made before nineteen women agreed to continue w i t h the study.: Some of the s t a t e d reasons f o r not t a k i n g p a r t were: "Since I went to the doctor, I have had my p e r i o d . " ?I thought I had to agree to the i n t e r v i e w i n order 31 to get the a b o r t i o n . " " I j u s t want to get i t over w i t h and f o r g e t about I t . " "I'm so upset—my parents want me to have the a b o r t i o n and I don't want to go through w i t h i t . I don't want to t a l k to anyone." (Aged l 6 years.) The researcher attempted to d i s c u s s the l a t t e r three reasons w i t h the women and a l l but two continued to be ti n i n t e r e s t e d . Another e i g h t women were unreachable at the given address o r phone number. LIMITATIONS OF THE STUDY A major l i m i t a t i o n of t h i s study was t h a t the sampling was non-random, w i t h the r e s u l t t h a t the sample i s perhaps not r e p r e s e n t a t i v e of the p o p u l a t i o n . Time permitted o n l y nineteen women to be i n t e r v i e w e d , which i s a l i m i t a t i o n i n terms of ga t h e r i n g a l a r g e body of data. The r e l a t i v e l y u n s t r u c t u r e d i n t e r v i e w method meant th a t the women's r e c a l l a b i l i t y was depended upon to e l u c i d a t e areas of need. However, I f t h i s was a l i m i t a t i o n i n i t i a l l y , i t seemed to be compensated f o r by the two follow-up v i s i t s which allowed f o r mentioning p r e v i o u s l y omitted areas. 32 CONCLUSION This e x p l o r a t o r y study u t i l i z e d an u n s t r u c t u r e d , open-ended i n t e r v i e w on each of three v i s i t s to nineteen women to gather i n f o r m a t i o n about the needs women experienced r e l a t e d to having an a b o r t i o n . The women were r e f e r r e d to the p r o j e c t by (1) a l a y women's e d u c a t i o n a l and a b o r t i o n r e f e r r a l group, and (2) a g y n e c o l o g i s t . Categories a r i s i n g from the data w i l l be used to describe the f i n d i n g s . Chapter 4 FINDINGS AND DISCUSSION The women i n t h i s study were v i s i t e d three times so that t h e i r needs r e l a t e d to having an a b o r t i o n could be explored. As the researcher t a l k e d w i t h these women of d i f f e r i n g age, i n t e r e s t , and a s p i r a t i o n , the s i g n i f i c a n c e of t h i s experience to these women became c l e a r e r : o f t e n , i n the r e s o l u t i o n of t h i s problematic event, major changes occurred i n the l i f e experience of the woman and the people c l o s e s t to her. Consequently, the needs expressed by the women d i d not always seem d i r e c t l y r e l a t e d to the a b o r t i o n i t s e l f but r a t h e r to t h e i r t o t a l l i v e s . To d i s c u s s the i n f o r m a t i o n obtained from the i n t e r -views, the researcher has decided to present the m a t e r i a l which w i l l give an o v e r a l l p r o f i l e of the women i n the study and then describe the experience these women r e l a t e d , beginning with t h e i r sexual a c t i v i t y and c o n t r a c e p t i v e prac-t i c e s , and f o l l o w i n g through to pregnancy and the d e c i s i o n to have an a b o r t i o n . What needs d i d the women have and what d i d they do about them? A f t e r the a b o r t i o n , what were the s t a t e d areas of need? Did these change over a f o u r month period? Did new areas emerge? What d i d the women de s c r i b e as t h e i r ways of d e a l i n g w i t h these? 33 34 PROFILE OF POPULATION The m a j o r i t y of women i n t h i s study were s i n g l e , between nineteen and twenty-eight years of age, and employed at a job outside the home. (TABLES I , I I , I I I . ) TABLE I M a r i t a l Status of Women . . Having Abo r t i o n s Status . . . . . Number Married 3 Single 10 Common-law 6 T o t a l 19 TABLE I I Age D i s t r i b u t i o n of Women Having A b o r t i o n s Age i n Years Number 14-18 6 19-23 4 24-28 7 29-33 0 34-38 2 T o t a l 19 35 TABLE I I I Occupation of Women Having A b o r t i o n s Type Number. Employed 10 High School Student 2 U n i v e r s i t y o r Community College Student 2 At Home 5 T o t a l 19 Most of the r e l a t i o n s h i p s w i t h the p u t a t i v e f a t h e r s were long-term; i n f a c t , the m a j o r i t y of the women were l i v i n g w i t h t h e i r sexual p a r t n e r s . (TABLES IV, V.) TABLE IV R e l a t i o n s h i p Between Women Having A b o r t i o n s and P u t a t i v e Fathers. R e l a t i o n s h i p . . . . Number Husband 3 Common-law Husband 6 Fiance 1 B o y f r i e n d 7 Casual F r i e n d 1 Unknown . . 1 T o t a l 19 37 TABLE V L i v i n g Arrangements of Women Having A b o r t i o n s Type . . Number With Husband or B o y f r i e n d 11 With Parents 4 With G i r l f r i e n d 1 S i n g l e Parent w i t h C h i l d 1 Alone . . . 2 T o t a l . 19 38 A l l of the women were w i t h i n the f i r s t t r i m e s t e r of pregnancy ( f i r s t t r i m e s t e r i s d e f i n e d as the twelve weeks since the l a s t menstrual p e r i o d ) ; the m a j o r i t y had the ab o r t i o n on an o u t p a t i e n t b a s i s during the evening. (TABLES V I , VII.) TABLE VI Length of Time Since L a s t Menstrual P e r i o d of Women Having Abortions' Weeks Number 6 or 7-12 l e s s 6 13 T o t a l 19 TABLE V I I H o s p i t a l i z a t i o n P a t t e r n of Women Having A b o r t i o n s Type Number Outpatient Overnight Unknown 11 7 1 T o t a l 19 39 This was the f i r s t pregnancy f o r eleven of the women. Of the e i g h t who had been pregnant before, three had given a c h i l d up f o r adoption at b i r t h , and f o u r were c u r r e n t l y mothers l o o k i n g a f t e r t h e i r c h i l d r e n . Four women i n t h i s study had had an a b o r t i o n p r e v i o u s l y , three of which were done l e g a l l y and one i l l e g a l l y ( t h i s l a t t e r i n The p r i v a t e g y n e c o l o g i s t was the r e f e r r a l source f o r eleven women, and the women's h e a l t h education and a b o r t i o n r e f e r r a l group was r e s p o n s i b l e f o r e i g h t . 1969). The number of women seen at each i n t e r v i e w i s shown i n TABLE V I I I . TABLE V I I I Timing of Inte r v i e w s i n R e l a t i o n to A b o r t i o n I n t e r v i e w Number Pre - o p e r a t i v e I n t e r v i e w 19 Two Week Po s t - o p e r a t i v e I n t e r v i e w 18 Four Month P o s t - o p e r a t i v e I n t e r v i e w 15 T o t a l xOne woman, whose a b o r t i o n was u n s u c c e s s f u l , was v i s i t e d f o u r times, b r i n g i n g the a c t u a l t o t a l to 53 i n t e r -views. CONTRACEPTIVE USAGE Six t e e n of the nineteen women were u s i n g some form of b i r t h c o n t r o l when they became pregnant. (TABLE IX.) A l l but three of these s i x t e e n were u s i n g a method which, by i t s e l f , could be c l a s s i f i e d as u n r e l i a b l e . 2 TABLE IX Method of B i r t h C o n t r o l P r i o r to -Ex p e r i e n c i n g Unwanted Pregnancy "' ' —• Type Number I n t r a u t e r i n e Device Condoms Foam Rhythm Withdrawal None T o t a l ^ " R e l i a b l e " methods In t h i s study i n c l u d e the p i l l , IUD, diaphragm and j e l l y , and condom w i t h foam. " U n r e l i a b l e " methods i n c l u d e rhythm, withdrawal, condom, o r foam. For a repor t of the Incidence of c o n t r a c e p t i v e f a i l u r e , see Norman B. Ryder, "Contraceptive F a i l u r e i n the U n i t e d S t a t e s Family Planning P e r s p e c t i v e s , 5 :3 (Summer, 1973) , 133-1^2. 3 3 2 3 4 l Looking at age i n r e l a t i o n to choice of b i r t h c o n t r o l method y i e l d s some i n t e r e s t i n g i n s i g h t s . For i n s t a n c e , of the s i x youngest women (between the ages of 14 and 18), f o u r were using condoms (although not r e g u l a r l y ) and had begun t h e i r sexual a c t i v i t y only r e c e n t l y (three w i t h i n two months and the f o u r t h f i v e months p r e v i o u s l y ) . This comprised the t o t a l number who had chosen to use condoms. ( I t i s perhaps more accurate to say t h a t condoms were used by, and probably chosen by, the male. Thus, wh i l e condoms were used, i t i s not assumed t h a t these young women were i n f a c t t a k i n g r e s p o n s i b i l i t y f o r t h e i r use.) E x p l o r a t i o n of the women's f e e l i n g s i n r e l a t i o n to t h e i r sexual experience showed that s e v e r a l i n t h i s young age group d i d not p a r t i c u l a r l y enjoy sexual a c t i v i t y . Three mentioned that they f e l t pressure from t h e i r b o y f r i e n d s to p a r t i c i p a t e , p a r t i c u l a r l y i f the f r i e n d s h i p was to continue. Thus, f e e l i n g s of i n s e c u r i t y i n the r e l a t i o n s h i p were expressed, as w e l l as some resentment t h a t they were "caught" (by pregnancy). One woman s a i d t h a t she p r e f e r r e d condoms because by t a k i n g the p i l l , she "would be a d m i t t i n g what I am doing" s e x u a l l y . The other two i n t h i s age group were two of the three who were not, a t the time of conception, u s i n g any b i r t h c o n t r o l ; however, both of these young women had a t one time been on the p i l l . One had d i s c o n t i n u e d because she had moved away from her b o y f r i e n d and had not a n t i c i p a t e d the need f o r continued c o n t r a c e p t i o n . The ot h e r woman had given 4-2 b i r t h to a c h i l d f i v e months p r e v i o u s l y , begun on the b i r t h c o n t r o l p i l l , developed uncomfortable s i d e e f f e c t s , and had been advised by her p h y s i c i a n , to "go o f f the p i l l and wait f o r your p e r i o d . Then come i n and see me a g a i n . M These data show t h a t the young women were not com-p l e t e l y ignorant about the need f o r c o n t r a c e p t i o n , nor were they u n f a m i l i a r w i t h a method which, p o t e n t i a l l y , i s r e l i a b l e . The area t h a t seemed more d i f f i c u l t f o r them to come to terms wi t h surrounded t h e i r s e x u a l i t y . They d i d not a l l f e e l that they had any c o n t r o l i n t h e i r sexual experience. They "gave i n , " because " I d i d n ' t want to l o s e my boy-f r i e n d . " The i n t e g r a t i o n of the s p e c i f i c knowledge and prac-t i c a l use of b i r t h c o n t r o l w i t h the woman's s e x u a l i t y seemed to be an area of great need. This statement seems to apply, In general, t o many of the women i n the study. Other methods of c o n t r a c e p t i o n were v a r i e d among the d i f f e r e n t age groups. What were some of the m o t i v a t i o n s f o r other women's choices of b i r t h c o n t r o l ? One woman had been t r e a t e d f o r "hormonal problems" s e v e r a l years ago and had been t o l d by her p h y s i c i a n that she was "probably i n f e r t i l e . " That i n f o r -mation, p l u s the r e g u l a r use of foam, had served her w e l l f o r a two year p e r i o d . Two o t h e r women had been u s i n g foam by i t s e l f f o r s h o r t e r p e r i o d s of time, as they had exper-ienced s e r i o u s symptoms on the b i r t h c o n t r o l p i l l . Two women had managed w i t h the rhythm method f o r two ye a r s , and one used withdrawal with success f o r the same l e n g t h of time. 43 Another f o u r women had been on the p i l l and had experienced side e f f e c t s ranging from p a i n f u l breast and a x i l l a r y lumps, chronic v a g i n a l i n f e c t i o n and dysparunia, to v i s u a l changes, d i z z i n e s s , and headaches. These women were In the process of d e c i d i n g on an a l t e r n a t i v e c o n t r a -c e p t i v e method, but e i t h e r were not f u l l y aware of the a l t e r n a t i v e s or were a f r a i d o r r e l u c t a n t to take the neces-sary steps. They may have h a l f - h e a r t e d l y been u s i n g foam, withdrawal, or rhythm i n t h i s i n t e r v a l of i n d e c i s i o n . The remaining three women had i n t r a u t e r i n e devices i n place at the time of conception. One, a Dalkon s h i e l d , had been i n s i t u f o r one year. The other two, both Lippes Loops, had been i n place f o r two and one-half and s i x and one-half years r e s p e c t i v e l y . More women i n the o l d e r group have had some experience with a r e l i a b l e method of b i r t h c o n t r o l . However, there s t i l l remain areas of need concerning a woman's c o n t r a -ce p t i v e p r o t e c t i o n and her sexual l i f e . The data c o n s i s t e n t l y r e v ealed t h a t when a woman experienced some problem o r d i f f i c u l t y w i t h her b i r t h c o n t r o l method, she had l i t t l e or no access to p a t i e n t and concerned guidance which could a s s i s t her In s o r t i n g out her f e e l i n g s and preferences and In making a d e c i s i o n . S e v e r a l women mentioned t h a t they had not been informed of the p o s s i b i l i t y of side e f f e c t s from the p i l l . When symptoms d i d develop, these women, not r e c o g n i z i n g t h e i r s i g n i f i c a n c e , f e l t r e l u c t a n t to "bother" an "already busy 44 d o c t o r " w i t h a " s m a l l q u e s t i o n . " One woman, who d i d complain to her p h y s i c i a n about troublesome side e f f e c t s , was t o l d , " Y o u ' l l have to l e a r n to l i v e w i t h them." Other women had been reassured by t h e i r p h y s i c i a n s of the e f f e c t i v e n e s s of foam used alone. Two married women mentioned that t h e i r p h y s i c i a n s had i m p l i e d i t was time they had a c h i l d , and would only suggest foam f o r contracep-t i o n . Some women, i n d i s c o v e r i n g t h e i r use of an u n r e l i a b l e method, blamed themselves, sa y i n g , " I should have known b e t t e r , " or " I f only I had t r i e d to f i n d a b e t t e r method," o r " I guess I d i d n ' t want to admit to myself what I was doing and r e a l l y p l a n my b i r t h c o n t r o l . " DECISION-MAKING PROCESS Once a woman suspected t h a t she was pregnant, she had to make a d e c i s i o n regarding the outcome. There was a wide range of r e a c t i o n s to t h i s s i t u a t i o n . Two women had p r e v i o u s l y been s t r o n g l y opposed to a b o r t i o n and had regarded i t as " k i l l i n g ; " one other person had been opposed to a b o r t i o n u n t i l two years p r e v i o u s l y when she came to b e l i e v e t h a t " a l l c h i l d r e n should be wanted." Comments i n favour of a b o r t i o n were v a r i e d : "I've seen too many 'forc e d ' marriages end unhappily"; " I couldn't bear to have a c h i l d and g i v e i t up"; "Women should be able to choose whether o r not they want to keep a c h i l d " ; " I b e l i e v e i n a b o r t i o n on demand." 45 W i t h i n these d i f f e r i n g p h i l o s o p h i c a l frameworks, the women worked out s o l u t i o n s to t h e i r s i t u a t i o n s . Those who had p r e v i o u s l y opposed a b o r t i o n s t a t e d t h a t " I t i s d i f f e r e n t when i t happens to you and you are not able to keep the c h i l d (because you l a c k f i n a n c i a l resources and are not s e t t l e d down)." The o b v i o u s l y d i f f i c u l t d e c i s i o n to have an a b o r t i o n was i n f l u e n c e d by a number of f a c t o r s ; some were expressed i n such comments ass "I'm not ready y e t " ; " I don't have the economic resources to support a c h i l d " ; "I'm u n c e r t a i n about the d i r e c t i o n of my own l i f e " ; "I'm not i n a s t a b l e r e l a t i o n -s h i p w i t h a man at present." For .some women, the presence of one o r more of these f a c t o r s seemed to d i c t a t e the d e c i s i o n . Another group of women, who were i n s t a b l e r e l a t i o n s h i p s w i t h men, had p r e v i o u s l y discussed what they would do i n t h i s e v e n t u a l i t y ; f o r them, the present d e c i s i o n was a r e a f f i r m a t i o n of an e a r l i e r agreement. Four women, who were mothers, d i s c u s s e d the a n x i e t y they experienced i n making the d e c i s i o n . Three were s i n g l e women, one of whom des c r i b e d i n some d e t a i l the s t r u g g l e she had gone through to provide f o r her two c h i l d r e n , now teen-agers. She was r e l u c t a n t to a l t e r her c u r r e n t l y s t a b l e s i t u a t i o n , economically and s o c i a l l y , w i t h the a d d i t i o n of a new f a m i l y member. Another s i n g l e mother was e x p e r i e n c i n g h e a l t h problems h e r s e l f and simply d i d not f e e l she c o u l d cope wi t h a pregnancy. The t h i r d s i n g l e parent would have 46 l i k e d to keep the pregnancy, but economically i t was a l l she could manage to keep h e r s e l f and a s i x year o l d daughter going. I f she had had male support i n her l i v i n g s i t u a t i o n , she s a i d , that would have made a great d i f f e r e n c e . The f o u r t h mother had had toxemia d u r i n g a very d i f f i c u l t pregnancy w i t h her daughter (now two and one-half years o l d ) . This woman and her husband had considered adopting i n the f u t u r e and now found themselves i n an awk-ward s i t u a t i o n . The d e c i s i o n to have the a b o r t i o n was made on the b a s i s of the mother's h e a l t h and the t i m i n g of the pregnancy. Before having another c h i l d , she wanted to r e j o i n the world of g a i n f u l employment, having given up an enjoyable career before the f i r s t c h i l d ' s b i r t h . Some found the s i t u a t i o n p a r t i c u l a r l y d i s t r e s s i n g because they could not accept that they were pregnant. One woman f e l t t hat she had transgressed an important moral law and f e a r e d excommunication from her church i f she spoke w i t h her p r i e s t . Another wanted the a b o r t i o n immediately and d i d not want to t h i n k about I t as she was s t i l l u n s e t t l e d from the b i r t h of a daughter f i v e months p r e v i o u s l y . While the daughter was given up at b i r t h f o r adoption, and the mother had accepted the s i t u a t i o n i n t e l l e c t u a l l y , she s t i l l woke up i n the middle of the n i g h t hearing her c h i l d c r y . Yet another woman, who had fo r m e r l y been opposed to a b o r t i o n , s a i d she s t i l l f e l t l i k e a c h i l d h e r s e l f and could not cope w i t h a baby at t h i s p o i n t i n her l i f e . The women who had s e r i o u s l y considered keeping the 47 pregnancy were the same ones who s a i d they experienced the gr e a t e s t d i f f i c u l t y i n making the d e c i s i o n to have the ab o r t i o n . The ot h e r s , who had never considered keeping the c h i l d , seemed to have somewhat l e s s d i f f i c u l t y i n a r r i v i n g a t the d e c i s i o n . . F i v e women s t a t e d t h a t they had had help (from a husband o r boyfriend) i n reaching the d e c i s i o n ; the remaining fourteen made the d e c i s i o n on t h e i r own, although f r e q u e n t l y supported i n t h e i r d e c i s i o n by a f r i e n d o r r e l a t i v e once i t was made. C l e a r l y , then, many of the women examined t h i s s i t u a t i o n from s e v e r a l angles before making a d e c i s i o n . THE SEARCH FOR HELP By f o l l o w i n g the course of a c t i o n of these women a f t e r they suspected t h e i r pregnancy, I t i s p o s s i b l e to determine other areas of need. Three of the women i n t h i s study had an ongoing, t r u s t i n g r e l a t i o n s h i p w i t h a doctor i n t h i s c i t y , and went d i r e c t l y to t h e i r r e s p e c t i v e p h y s i c i a n s to seek help. Three were new to the c i t y and were not estab-l i s h e d w i t h a p h y s i c i a n . Others were a f r a i d t h e i r doctor would t e l l t h e i r parents or would refuse because of h i s b e l i e f s . S t i l l o t h e r s , on the b a s i s of past experiences w i t h the medical p r o f e s s i o n , f e l t unable o r u n w i l l i n g to approach a p h y s i c i a n . Most women, then, d i d not have a place to turn to at t h i s Important p o i n t i n t h e i r l i v e s . Many women d e s c r i b e d the complete desperation and f e a r they 48 experienced as they t r i e d to deal w i t h the f a c t of an unwanted pregnancy, not knowing where to go f o r a s s i s t a n c e . They mentioned t h a t the h e a l t h care system does not openly provide p o i n t s of entry f o r women i n such a s i t u a t i o n . One young woman had t r i e d a vin e g a r douche i n an attempt to abort. No other r e p o r t s of attempts at s e l f -induced a b o r t i o n s were given. Some women had the support of a husband or f r i e n d to a s s i s t them i n t h e i r search f o r h e l p . Agencies which were approached f o r help i n c l u d e d the Family P l a n n i n g A s s o c i a t i o n (where the woman was t o l d , "You're a l i t t l e l a t e f o r u s . " ) , the C r i s i s Centre, a Community. Information S e r v i c e , a women's h e a l t h r e f e r r a l s e r v i c e , f r e e c l i n i c s , as w e l l as underground newspapers and the Yellow Pages. Someone new to the c i t y had approached the B r i t i s h Columbia Medical A s s o c i a t i o n f o r h e l p ; she d e s c r i b e d to the researcher her f r u s t r a t i o n i n having to make at l e a s t f i v e telephone c a l l s before she r e c e i v e d any i n d i c a t i o n of p o s s i b l e a s s i s t a n c e . Most people made two o r three contacts w i t h d i f f e r e n t s e r v i c e s before they r e c e i v e d the necessary i n f o r m a t i o n . C l e a r l y , when women needed i n f o r m a t i o n regarding the a v a i l a b i l i t y of a b o r t i o n , there was no e a s i l y a c c e s s i b l e , w e l l - p u b l i c i z e d way of o b t a i n i n g i t . Rather, the network which l i n k e d the person w i t h the needed resource was made up of f r i e n d s , sometimes u n f a m i l i a r newspapers, and unknown people. For many, t h i s "undercover" q u a l i t y of the experience r e i n f o r c e d the shame they already f e l t . They were f o r c e d to approach resources which p r e v i o u s l y would have been out of the question due to d i f f e r e n c e i n l i f e s t y l e ( f o r i n s t a n c e , the underground newspaper or the f r e e c l i n i c ) . Some mentioned a stigma they f e l t simply because they needed to c a l l the C r i s i s Centre o r an Information Centre and s t a t e a problem. Only one woman s t a t e d that what she wanted was an impersonal, e f f i c i e n t s e r v i c e . Many others s a i d i t was d i f f i c u l t f o r them to t a l k w i t h a complete s t r a n g e r about something so important to themselves, although they d i d a p p r e c i a t e the help given by the d i f f e r e n t s e r v i c e s i n r e f e r r i n g them to a g y n e c o l o g i s t . Once a woman was i n s i d e the network of a b o r t i o n r e f e r r a l , she f e l t r e l i e v e d and reassured, but i t d i d take an e f f o r t to d i s c o v e r t h a t network. IMPLICATIONS OF DECISION IN LIFE SITUATION The i m p l i c a t i o n s i n the woman's f a m i l y l i f e of t h i s d e c i s i o n were explored to determine i f any r e l a t e d needs arose. A l l of the sexual p a r t n e r s except f o r t h r e e were aware of the pregnancy. Of those t h r e e , one was not t o l d because he s t i l l harboured g u i l t f e e l i n g s over having made another woman pregnant; t h a t woman had been unable to ob t a i n an a b o r t i o n and had experienced problems i n r a i s i n g the c h i l d on her own. The p r e s e n t l y pregnant woman d i d not want to upset her f r i e n d f u r t h e r , so she c a r r i e d out her plans on her own. 50 Another woman was not sure which of two men was the f a t h e r , so she s a i d nothing to e i t h e r man. The t h i r d woman had ended her r e l a t i o n s h i p with the p u t a t i v e f a t h e r and saw no purpose being served by informing him of t h i s event. The remaining s i x t e e n women r e c e i v e d d i f f e r i n g degrees of support from the men i n v o l v e d . I t i s worth remarking how o f t e n the young women, whose f a m i l i e s were f o r the most p a r t near by, d i d not share the experience o r the plans w i t h t h e i r f a m i l i e s . The most commonly given reason f o r not t e l l i n g parents was, " I t would hurt them too much," o r "They couldn't accept my d e c i s i o n . " S e v e r a l of these women e x p l a i n e d t h a t sex was not a subject d i s c u s s e d w i t h i n the f a m i l y . A couple of young women s a i d t h a t they wanted to t a l k w i t h t h e i r mothers but d i d not know how to b r i n g up the su b j e c t . They mentioned t h e i r own f e e l i n g s of awkwardness and embarrassment. These f i n d i n g s are s i m i l a r to those of Monsour and Stewart who de s c r i b e d a "conspiracy of s i l e n c e " i n f a m i l i e s where human s e x u a l i t y i s a for b i d d e n subject.3 In one s i t u a t i o n , the mother i n a d v e r t e n t l y d i s c o v e r e d t h a t her daughter had had an a b o r t i o n . The i n i t i a l r e a c t i o n was anger and dismay, which d i d not, however, l a s t l o n g ; r a t h e r , the mother and daughter began t a l k i n g together more and seemed to reach some new understandings. However, even 3see Chapter 2, p. 20. 51 though d i s c u s s i o n opened up, the daughter s t i l l c o u ld not b r i n g h e r s e l f to confide i n her mother about her ongoing b i r t h c o n t r o l plans. Of the three women who had p r e v i o u s l y given a c h i l d up f o r adoption, one had experienced a nig h t m a r i s h s i t u a t i o n where, when pregnant that time, she had been kept indoors a t home ("so t h a t the neighbours won't see the di s g r a c e , " ) and then had been sent i n t o a l a r g e c i t y , alone, f o r the d e l i v e r y . Only now, s i x years l a t e r , was her r e l a t i o n s h i p w i t h her f a m i l y developing w e l l , and she was r e l u c t a n t to jeopa r d i z e i t . Another woman i n t h i s category f e l t t hat her parents would urge her to keep the c h i l d as she i s now married. The t h i r d woman d i d not r e a l l y have any f a m i l y to r e l a t e to as she had been r a i s e d as a f o s t e r c h i l d i n many homes. Only r e c e n t l y had she had the op p o r t u n i t y to meet her n a t u r a l brothers and s i s t e r s , and had co n f i d e d i n a bro t h e r who had supported her d e c i s i o n . J u s t one woman i n the study who was alr e a d y a mother chose to t e l l her c h i l d about the a b o r t i o n . The s i x year o l d r e a c t e d a n g r i l y and t e a r f u l l y ; the mother t r i e d to give her reasons as to why t h i s was not an ap p r o p r i a t e time f o r another baby. G e n e r a l l y , then, the woman dis c u s s e d t h i s s i t u a t i o n w i t h her b o y f r i e n d o r husband, and r e c e i v e d support from t h i s r e l a t i o n s h i p . F a m i l i e s ( e s p e c i a l l y of younger women) were seldom Included i n the event at a l l , even i f the woman may have d e s i r e d i t . There seemad. to be so great an expect-52 a t i o n of c o r r e c t behaviour w i t h i n f a m i l i e s that these women f e l t i t impossible to d i s c u s s t h e i r s i t u a t i o n s . NEEDS FOR INFORMATION Concerning the Law Women s t a t e d t h a t they needed knowledge r e g a r d i n g the l e g a l i t y of a b o r t i o n . Four women thought that they would have to o b t a i n an i l l e g a l a b o r t i o n . Three were d i s t r e s s e d to th i n k they would need to prove themselves mentally i l l i n order to o b t a i n approval f o r an a b o r t i o n . Another three were f r i g h t e n e d that they would be refu s e d f o r being under-age. A l l of these concerns and others r e l a t i n g to residency and payment were answered once the woman was In touch w i t h someone knowledgeable about the a b o r t i o n procedure—whether the g y n e c o l o g i s t , the women's r e f e r r a l s e r v i c e , o r the researcher. While some women had adequate knowledge about the l e g a l s i t u a t i o n , others mentioned th a t t h e i r Ignorance of the law gave r i s e to overwhelming f e a r of even c o n s i d e r i n g a b o r t i o n . Concerning the H o s p i t a l Experience The researcher was i n t e r e s t e d i n knowing i f the women had needs concerning the op e r a t i o n i t s e l f . The areas mentioned were t y p i f i e d by such comments as these: " I don't know what i s a c t u a l l y going to happen d u r i n g the o p e r a t i o n " ; "I've heard there are two ways of doing an e a r l y a b o r t i o n ; what i s the d i f f e r e n c e ? " "Why can't I eat o r d r i n k on the day of the 53 o p e r a t i o n ? " "I've never been: i n a h o s p i t a l and I'm a f r a i d because I don't know what to expect." When questioned by the researcher, the m a j o r i t y of the women (fourteen) could e x p l a i n the b a s i c procedure of the op e r a t i o n . They had been prepared by the women's . r e f e r r a l s e r v i c e o r by the g y n e c o l o g i s t . ( I n a d d i t i o n , one woman was a nurse.) The researcher answered any questions and prepared those who d i d not seem to understand the pro-cedure. Concerning P o s t - o p e r a t i v e E x p e c t a t i o n s None of the women expected any major p h y s i c a l problems o r co m p l i c a t i o n s f o l l o w i n g the a b o r t i o n , although two were t r u l y a f r a i d t h a t they might d i e during anaesthesia. The a n t i c i p a t e d minor problems were cramps, b l e e d i n g , f a t i g u e , hormonal changes, and i n f e c t i o n . The res e a r c h e r d i s c u s s e d p o s t - a b o r t i o n care w i t h each of the women, d e a l i n g w i t h , among ot h e r t o p i c s , hygiene, hormonal changes, and resumption of sexual r e l a t i o n s . Concerning the p o s t - o p e r a t i v e p e r i o d , some women wanted to know whether they would f e e l extreme g u i l t , r e g r e t , o r depression; whether the r e l a t i o n s h i p w i t h the male p a r t n e r would undergo s e r i o u s change; or whether they would f e e l d i f f e r e n t l y about themselves ( i n the sense, f o r i n s t a n c e , of "having a f r e s h s t a r t . " ) . While only one woman s a i d she had no one (whether husband, b o y f r i e n d , g i r l f r i e n d , t h e r a p i s t , o r p s y c h i a t r i s t ) to t a l k w i t h about her r e a c t i o n s to t h i s experience, s e v e r a l women mentioned t h e i r a p p r e c i a t i o n i n being able to s i t down wi t h the researcher and r e f l e c t aloud on what the experience meant to them. Concerning Future Contraception The f i r s t v i s i t to the women i n t h i s study i n c l u d e d d i s c u s s i o n at l e n g t h about b i r t h c o n t r o l plans and sexual e x p e c t a t i o n s . Of the nineteen women, s i x t e e n had decided what method they wanted to use. These were: B i r t h C o n t r o l P i l l 6 I n t r a u t e r i n e Device 8 Diaphragm and J e l l y 1 Tubal L i g a t i o n 1 Unsure 3 Other Needs The women were asked to de s c r i b e any other areas of need which they had experienced. Topics mentioned here Included: (a) "We need more b i r t h c o n t r o l Information i n s c h o o l s . M (b) "We need more i n f o r m a t i o n , r e a d i l y a v a i l a b l e , r e g a r d i n g vasectomy and b i r t h c o n t r o l i n g e n e r a l . " (c) A s i n g l e woman mentioned her need f o r t r a n s -p o r t a t i o n home from the h o s p i t a l (she was very poor and the h o s p i t a l d i d not a l l o w women to leave from the evening o u t p a t i e n t o p e r a t i o n unaccompanied). The women's h e a l t h education and r e f e r r a l group provided t h i s s e r v i c e f o r her. (d) Another s i n g l e woman mentioned her f e a r t h a t , unless she had the op e r a t i o n i n the evening, she would miss work and be f i r e d from her newly a c q u i r e d job. (e) An o l d e r woman (37 years) w i t h two c h i l d r e n s t a t e d that she f e l t a d i s c r i m i n a t o r y a t t i t u d e on the pa r t of her doctor, who s u b t l y i m p l i e d that she should have known b e t t e r than to get pregnant (even though she had had an IUD i n p l a c e ) . She d e s c r i b e d the impression she r e c e i v e d as r e l a t i n g to her ob s e r v a t i o n t h a t s o c i e t y seems to s a n c t i o n a b o r t i o n f o r the younger woman, a l l o w i n g her to make a mis-take, but i s not so generous w i t h the o l d e r , presumably more r e s p o n s i b l e woman. FIRST FOLLOW-UP VISIT The two week p o s t - a b o r t i o n f o l l o w - u p i n t e r v i e w focused on the h o s p i t a l experience, the p h y s i c a l r e a c t i o n , b i r t h c o n t r o l implementation, the r e l a t i o n s h i p w i t h the sexual p a r t n e r , and general f e e l i n g s £n response to a l l of t h i s . H o s p i t a l Experience Regarding the h o s p i t a l experience, three of the seven overnight p a t i e n t s questioned the n e c e s s i t y of t h i s e a r l y h o s p i t a l i z a t i o n . One woman suggested that t h i s time might w e l l have been spent i n a group d i s c u s s i o n w i t h the nurse about b i r t h c o n t r o l . 56 The most frequent c r i t i c i s m of the h o s p i t a l experience (from e i g h t women) was that I t wns "Impersonal," " f e l t l i k e a f a c t o r y , " and was r o u t i n e - o r i e n t e d . T h i s a t t i t u d e was summed up f o r one woman i n a remark she over-heard j u s t before she was given the a n a e s t h e t i c : one of two op e r a t i n g room nurses a w a i t i n g the a r r i v a l of the gyne-c o l o g i s t s a i d to the other, " I sure don't l i k e being on the a b o r t i o n run." The only contact that the m a j o r i t y of the women had w i t h a nurse was around t a s k - o r i e n t e d procedures; i t was an unusual s i t u a t i o n indeed when a nurse stopped at the bedside " j u s t to t a l k . " Three women f e l t that they had been t r e a t e d w i t h condescension by nurses who d i s p l a y e d a m o r a l i s t i c a t t i t u d e to the p a t i e n t s . S e v e r a l p a t i e n t s mentioned t h e i r bafflement a t r e c e i v i n g such f e e l i n g s from nurses who were approximately t h e i r own age. Contrasted w i t h t h i s was a sense of under-s t a n d i n g and support given by a couple of o l d e r nurses, which was warmly r e c e i v e d by the women i n v o l v e d . One source of emotional support f o r the women l a y i n t a l k i n g w i t h other p a t i e n t s . Women r e l a t e d how they shared s t o r i e s and advice i n t h e i r h o s p i t a l rooms. Fre q u e n t l y , o l d e r women assumed a supportive r o l e w i t h younger, apprehensive women. Nonetheless, such a s i t u a t i o n d i d not always occur. One woman s t a t e d that when she went i n , none of the a b o r t i o n p a t i e n t s acknowledged the reason f o r t h e i r presence i n the h o s p i t a l . She would have p r e f e r r e d a more open atmosphere 57 so that p a t i e n t s might f r e e l y d i s c u s s t h e i r s i t u a t i o n . An o l d e r woman observed that the younger p a t i e n t s seemed to be the ones who wanted most to t a l k , "as i f they had more working out to do." The women who p r e f e r r e d not to t a l k w i t h others kept to themselves and read. The husband of one woman d e s c r i b e d h i s f e e l i n g s while w a i t i n g f o r h i s wife i n the h o s p i t a l s he s a i d he f e l t " l e f t out" a t a time when he wanted to be i n v o l v e d i n order to reassure and comfort. He desc r i b e d himself as having a s i m i l a r emotional involvement as an expectant f a t h e r , and wondered whether there was any way that men could be given a more a c t i v e r o l e i n the h o s p i t a l when t h e i r wives o r f r i e n d s were having a b o r t i o n s . P h y s i c a l Response Most of the p h y s i c a l r e a c t i o n s to the a b o r t i o n were s e l f - l i m i t i n g and w i t h i n the "normal" category. T h i s i n c l u d e d r e p o r t s of some cramping, b l e e d i n g , and nausea. One woman remained very nauseated and i t was di s c o v e r e d , a f t e r two more months, th a t her pregnancy had, i n f a c t , not been terminated. One woman r e q u i r e d treatment w i t h a n t i b i o t i c s f o r a p e l v i c i n f e c t i o n . C ontraception The f o l l o w i n g t a b l e (TABLE X) shows the c o n t r a c e p t i v e choices at the two week follow- u p . 58 TABLE X Contraceptive Choices Two Weeks . F o l l o w i n g A b o r t i o n Method . Number . . B i r t h C o n t r o l P i l l 9 I n t r a u t e r i n e Device 5 Diaphragm wi t h J e l l y 1 Condoms 1 Foam 1 None 1 T o t a l 18 R e l a t i o n s h i p w i t h Sexual P a r t n e r At the time of the second i n t e r v i e w , e i g h t of the women s a i d t h a t they b e l i e v e d t h e i r sexual f e e l i n g s towards t h e i r p a r t n e r had not changed, and that they expected t h e i r f u t u r e sexual p r a c t i c e would not be n e g a t i v e l y i n f l u e n c e d by the a b o r t i o n experience'. Three women s t a t e d t h a t they f e l t much c l o s e r to t h e i r p a r t n e r now than before the a b o r t i o n , and r e l a t e d t h i s f e e l i n g to having shared an important d e c i s i o n . Two of these women mentioned t h a t , because of t h i s experience, t h e i r r e l a t i o n s h i p s had moved onto a deeper l e v e l of understanding. Two women had d i s c o n t i n u e d w i t h the sexual p a r t n e r 59 and f i v e expressed v a r i o u s degrees of anger, resentment, and h o s t i l i t y towards the sexual p a r t n e r while c o n t i n u i n g i n the r e l a t i o n s h i p . S e v e r a l women made note of the f a c t t h a t t h e i r p a r t n e r t r i e d to be sup p o r t i v e , "but i t j u s t d i d n ' t always come o f f . " I t was e v i d e n t l y d i f f i c u l t f o r the men to know how to be of a s s i s t a n c e . F e e l i n g s Related to the A b o r t i o n The women discussed the i n f l u e n c e of the a b o r t i o n on t h e i r t o t a l l i v e s . For s e v e r a l , questions of independence and autonomy were r a i s e d when they were faced w i t h t h i s s i t u a t i o n . A couple of women mentioned t h a t they f e l t "important" when they found out they were pregnant. One very young person s a i d t h a t she f e l t " f o r c e d to be o l d e r than I am," and tha t she experienced c o n s i d e r a b l e d i f f i c u l t y i n coping w i t h the pressure which the s i t u a t i o n generated. Three women mentioned f e e l i n g depressed a f t e r the oper a t i o n . One married woman s a i d t h a t she had not wanted to get out of bed i n the morning and l a c k e d energy. She de s c r i b e d her r e l a t i o n s h i p w i t h her husband as "shaky," and s a i d t h a t while i n h o s p i t a l , she had not wanted to t a l k w i t h anyone. She was f e e l i n g hopeful now about l o o k i n g f o r a job, being p r e s e n t l y " s a t i a t e d with the joys of housework a f t e r three s o l i d y e a r s . " Another woman f e l t the peak of her depression about one week a f t e r the o p e r a t i o n , when she c r i e d a great d e a l ; t e l l i n g her b o y f r i e n d what was t r o u b l i n g her provid e d some 6 0 emotional r e l i e f . The t h i r d woman who s t a t e d t h a t she had f e l t de-pressed s a i d she had not r e a l i z e d how "down" she had been throughout the pregnancy, u n t i l i t was over and she began to f e e l more e n e r g e t i c . Each of these three women mentioned s p e c i f i c a l l y that i t was h e l p f u l to be able to t a l k to an o u t s i d e r who, they f e l t , would not be judging them. Another woman expressed f e e l i n g s of sorrow t h a t the pregnancy was over. She had enjoyed her maternal f e e l i n g s , and was now t r y i n g to r e - a d j u s t to a non-pregnant s t a t e . Yet another person (who had had an IUD i n place at the time of conception) s a i d t h a t i f she became pregnant again, she would attempt to f i n d the economic resources which would enable her to keep the c h i l d . She s t a t e d e m p h a t i c a l l y t h a t she would not choose to experience an a b o r t i o n again. A mother of two teenagers, having her t h i r d a b o r t i o n , d e s p i t e an i n t r a u t e r i n e device In s i t u , s t a t e d t h a t she f e l t compelled to consider permanent b i r t h c o n t r o l , i n the form of a t u b a l l i g a t i o n . She was knowledgeable about the procedure and had r a i s e d the question w i t h her p h y s i c i a n at her recent check-up. Plans f o r the op e r a t i o n were underway. This same woman r e l a t e d to the res e a r c h e r an ex-perience she had had at the time of the second a b o r t i o n . Because she had found the f i r s t so tr a u m a t i c , she had post-poned going to her doctor with the next pregnancy u n t i l I t was so l a t e t h a t s a l i n e a b o r t i o n was needed. " I f e l t very 61 shaken a f t e r the s a l i n e ; i t was a very, very unpleasant experience. Once i t was over, I heard one nurse say to another, 'This i s a good specimen; l e t ' s keep i t . ' I f e l t t h at they were t a l k i n g about a part of me. I t was depressing to t h i n k about. E v e r y t h i n g was bad enough. That was the c l i m a x . M Thus, at the tlmej of the two week follow-up i n t e r -view, the m a j o r i t y of the women d i d not have s p e c i f i c knowledge needs. Rather, t h e i r comments focused p r i m a r i l y on the need f o r emotional support both i n the h o s p i t a l and i n t h e i r own homes, as they coped w i t h t h i s a l t e r a t i o n i n t h e i r l i v e s . SECOND FOLLOW-UP VISIT F e e l i n g s In Response to t h i s Event At the time of the t h i r d v i s i t , a l l of the women f e l t t hat the d e c i s i o n to have the a b o r t i o n had been the best one, given the circumstances; however, s e v e r a l s a i d they d i d not t h i n k they could make the same d e c i s i o n again. I t would simply be "too d i f f i c u l t . " Some had since " f o r g o t t e n about i t " o r "regarded i t as a dead i s s u e . " Others expressed an overwhelming sense of r e l i e f t hat they were not pregnant, r e a l i z i n g that at the time of the In t e r v i e w they c o u l d have been s i x months pregnant. One woman had been making e n q u i r i e s about adopting i n these i n t e r v e n i n g f o u r months. She d e s c r i b e d how d i f f i c u l t i t was to f i n d a worker i n an agency who would take the time to l i s t e n to her concerns. Mostly, she f e l t , she was "given the run-around.". In f a c t , she was not a b s o l u t e l y sure t h a t adoption was a path she wanted to f o l l o w . Her marriage was expe r i e n c i n g unsure times, and she thought a great d e a l about r e t u r n i n g to work. However, she f e l t s t r o n g l y that the fragmentation of s o c i a l s e r v i c e s (one person to t a l k to regarding adoption; another f o r marriage c o u n s e l l i n g ; yet another f o r r e a c t i o n s to the ab o r t i o n ) made i t extremely d i f f i c u l t f o r her to s t a t e her needs repeatedly to unknown people. A couple of women st a t e d t h a t they now f e l t more con f i d e n t i n themselves. The experience of being pregnant and not wanting a c h i l d seemed to be a t u r n i n g p o i n t f o r some women. I t compelled them to r e a l i z e t h a t they d i d , i n f a c t , have some c o n t r o l over the d i r e c t i o n of t h e i r l i v e s . S e v e r a l people mentioned f e e l i n g s t ronger now i n terms of a c t i n g on t h e i r own b e l i e f s . By r a i s i n g the question of motherhood as a r e a l p o s s i b i l i t y , some of the women had to a r t i c u l a t e to them-s e l v e s , perhaps f o r the f i r s t time, what e x p e c t a t i o n s they had of themselves. I n doing so, some women experienced a major r e o r g a n i z a t i o n i n l i f e s t y l e . S e v e r a l sought more meaningful work, two became engaged o r married, and at l e a s t two ended l o n g term r e l a t i o n s h i p s . One woman d e s c r i b e d a change In her self-image t h i s way: "When you're pregnant and you r e a l i z e you can't keep the baby, i t k i n d of k i l l s 63 the v i s i o n of how th i n g s should be: that i s , that you get married and have c h i l d r e n . " A l l but the woman who was arra n g i n g f o r a t u b a l l i g a t i o n were s t i l l open to the p o s s i b i l i t y of someday having a c h i l d , and looked forward to p r o v i d i n g adequately f o r a d e s i r e d c h i l d . S e x u a l i t y and Related Needs One woman had f e l t l i t t l e or no sexual d e s i r e d u r i n g these f o u r months. She had had an i n t r a u t e r i n e device i n place f o r two months, and had found the a s s o c i a t e d d i s -comfort and p a i n unbearable. She was s u f f e r i n g from a p e l v i c i n f e c t i o n at the time of the two week f o l l o w - u p , and had since had c y s t i t i s . She wondered i f a l l the pa i n she had experienced was "punishment" f o r her " s i n " and speculated t h a t by not having sexual d e s i r e s , she was attempting to re g a i n her " v i r g i n a l s e l f . " Two ot h e r women, s t i l l i n s t a b l e r e l a t i o n s h i p s , d e s c r i b e d changes i n t h e i r sexual a c t i v i t y . One found i n t e r -course p a i n f u l because of l a c k of l u b r i c a t i o n , and the other was very f r i g h t e n e d about becoming pregnant again. A theme repeated by many women was t h a t they had experienced some change i n t h e i r f e e l i n g s about t h e i r sex-u a l i t y . G e n e r a l l y , there was more awareness shown i n t h i s , s e r i e s of i n t e r v i e w s about a r e l a t i o n s h i p between s e x u a l i t y and c o n t r a c e p t i o n . I t appeared to the researcher t h a t many women had Integ r a t e d the need f o r b i r t h c o n t r o l i n t o t h e i r s e x u a l i t y and f e l t more comfortable about that aspect of t h e i r l i v e s . This was p a r t i c u l a r l y e vident i n the younger women who i n i t i a l l y were b a r e l y w i l l i n g to recognize the f a c t that they were s e x u a l l y a c t i v e . At the f o u r month Interv i e w , s e v e r a l of them d i s p l a y e d confidence i n t h e i r changing r o l e s w i t h t h e i r sexual p a r t n e r s . They no l o n g e r seemed to f e e l o b l i g e d to p a r t i c i p a t e i n sexual i n t e r c o u r s e unless they too d e s i r e d the experience. Two admitted t h a t they were prepared to l e t t h e i r b o y f r i e n d s go i f t h i s new s i t u a t i o n was not acceptable to them. S u r p r i s i n g l y , these women s a i d , t h i s d i d not happen, but i n s t e a d more d i s c u s s i o n about a l l aspects of t h e i r r e l a t i o n s h i p s developed. Contr a c e p t i o n This c o n t i n u i n g r e s p o n s i b i l i t y f o r b i r t h c o n t r o l was shown i n the c o n t r a c e p t i v e p r a c t i c e s at the time of the t h i r d i n t e r v i e w . (TABLE XI.) Three of the women on the p i l l had had yeast i n f e c t i o n s since the a b o r t i o n . One woman had developed b r e a s t lumps and was r e f e r r e d to a s p e c i a l i s t f o r I n v e s t i g a t i o n . As mentioned, one woman had had an IUD i n place f o r two months, but the unbearable p a i n n e c e s s i t a t e d removal. 6 5 TABLE XI Contraceptive P r a c t i c e s Pour Months F o l l o w i n g A b o r t i o n . Type . Number . B i r t h C o n t r o l P i l l 8 I n t r a u t e r i n e Device 4 Condoms 2 None 1 Unknown ( l o s t to follow-up) . . . . 4 T o t a l 19 Other Areas of Expressed Need Two women at t h i s t h i r d i n t e r v i e w seemed predomi-n a n t l y concerned about f i n d i n g employment. One s t a t e d she would l i k e a job where she could be w i t h women having abor-t i o n s , so she could share what she l e a r n e d from her own experience. Four women mentioned t h e i r need f o r more b i r t h con-t r o l a l t e r n a t i v e s , as they had experienced problems w i t h the most r e l i a b l e methods ( p i l l , IUD). Seven women s t r e s s e d the importance and n e c e s s i t y of having c o n t r a c e p t i v e i n f o r m a t i o n e a s i l y a v a i l a b l e and a c c e s s i b l e . One woman expressed a need f o r adoption i n f o r m a t i o n . In t h i s study, ten women spoke of the need f o r a combined a b o r t i o n and c o u n s e l l i n g s e r v i c e , p r e f e r a b l y l o c a t e d In a separate c l i n i c , away from a h o s p i t a l . .Nurses were f r e q u e n t l y mentioned as "being a p p r o p r i a t e people f o r these women to t u r n to i f such a s e r v i c e e x i s t e d . At present, according to these women, nurses i n the h o s p i t a l c o n s i s t e n t l y seem to be o r i e n t e d towards e f f i c i e n c y r a t h e r than towards the p a t i e n t , and consequently were not viewed as p o t e n t i a l c o u n s e l l o r s w i t h i n the h o s p i t a l . Most people had not had experience w i t h a P u b l i c H ealth Nurse and were not aware of t h e i r a v a i l a b i l i t y . Many women agreed t h a t nurses working i n the community would be a va l u a b l e resource i n terms of p r e p a r a t i o n f o r the experience of the a b o r t i o n i t s e l f and f o r f o l l o w - u p l a t e r . The women s t r e s s e d that "understanding" was an important q u a l i t y f o r such nurses to possess. SUMMARY In t h i s study, then, the i n i t i a l needs expressed by the women in t e r v i e w e d were f o r i n f o r m a t i o n concerning v a r i o u s aspects of the a b o r t i o n i t s e l f and f o r emotional support. The women showed I n t e r e s t i n l e a r n i n g about a s u i t a b l e b i r t h c o n t r o l method. At the time of the second i n t e r v i e w , some women dis c u s s e d t h e i r need f o r emotional support d u r i n g hos-p i t a l i z a t i o n and l a t e r a t home. The f i n a l i n t e r v i e w gave the women the oppo r t u n i t y to view the experience from a d i s t a n c e . Needs mentioned a t t h i s v i s i t had to do w i t h changes experienced In self-image and i n exp e c t a t i o n s concerning the f u t u r e . Suggestions were given f o r making the h o s p i t a l experience b e t t e r , or even unnecessary by p r o v i d i n g b e t t e r b i r t h c o n t r o l a l t e r n a t i v e s . Chapter 5 CONCLUSION The purpose of t h i s paper was to explore the abor-t i o n experience from the woman's po i n t of view, to d i s c o v e r any unmet needs. SUMMARY. The g r e a t e r p a r t of research done on women's needs a f t e r an a b o r t i o n has had a p a t h o l o g i c a l focus. There has been a search f o r the unusual. Only r e c e n t l y have s t u d i e s begun to de s c r i b e what t h i s experience has meant to the woman's ongoing l i f e , and whether i t has had a s i g n i f i c a n t e f f e c t on her f a m i l y r e l a t i o n s h i p s , her f e e l i n g s about her-s e l f , her m o t i v a t i o n f o r e f f e c t i v e c o n t r a c e p t i o n , and her ideas about c h i l d - r e a r i n g and mothering. The researcher was i n t e r e s t e d i n e x p l o r i n g these Ideas f u r t h e r , to add to n u r s i n g knowledge on the care of women undergoing a b o r t i o n . By studying how d i f f e r e n t women adapt to t h i s u n s e t t l i n g l i f e event, n u r s i n g can b e t t e r understand the dynamic i n f l u e n c e s which operate In t h i s s i t -u a t i o n . With t h i s knowledge, n u r s i n g i n t e r v e n t i o n can be planned, a p p r o p r i a t e , and o p e r a t i v e In the pr e v e n t i v e stages. The study Included Interviews w i t h n i n e t e e n women a t three d i f f e r e n t stages: before the o p e r a t i o n , two weeks 68 6 9 f o l l o w i n g , and f o u r months a f t e r the op e r a t i o n . A b a s i c a l l y u n s t r u c t u r e d , open-ended i n t e r v i e w method was used, a l l o w i n g f o r e x p l o r a t i o n of areas important to the women. R e f e r r a l s t o the study were made by (1) a l a y women's h e a l t h education and a b o r t i o n r e f e r r a l group, and (2) a p r i v a t e g y n e c o l o g i s t . The f i n d i n g s were de s c r i b e d by us i n g f r e q u e n c i e s of cate-g o r i e s a r i s i n g from the data. The r e s u l t s of t h i s study suggest that women having a b o r t i o n s do experience unmet needs. I n i t i a l l y these needs r e v o l v e around the a v a i l a b i l i t y of a b o r t i o n . Other areas of need f o r many women are: p r e p a r a t i o n f o r the p h y s i c a l experience of a b o r t i o n ; d i s c u s s i o n about what t h i s experience means to them i n terms of s e l f - p e r c e p t i o n and r e l a t i o n s h i p s w i t h o t h e r s ; d i s c u s s i o n about a v a i l a b l e b i r t h c o n t r o l op-t i o n s ; and d i s c u s s i o n of s e x u a l i t y i n r e l a t i o n to these v a r i o u s areas. Other needs di s c u s s e d by some of the women were: the need f o r a s t a b l e r e l a t i o n s h i p w i t h a man; the need f o r improved economic circumstances; and the need to share some of the emotional and p s y c h o l o g i c a l aspects of having an a b o r t i o n w i t h a non-judgmental person. The most f r e q u e n t l y mentioned area of need centred on questions about b i r t h c o n t r o l , i n p a r t i c u l a r , and s e x u a l i t y , i n g e n e r a l . The study suggests t h a t , i n the experience of many women having a b o r t i o n s , these two needs are not seen as r e l a t e d ; that i s , r e f u s i n g to recognize t h e i r s e x u a l i t y , they perceive no need f o r r e l i a b l e b i r t h c o n t r o l . Many young women expressed a d e s i r e to share t h e i r experiences w i t h t h e i r f a m i l i e s , but d i d not, l a c k i n g a 70 framework f o r d i s c u s s i n g s e x u a l i t y i n t h e i r homes. Se v e r a l women wondered about the f u t u r e of t h e i r sexual r e l a t i o n -s h i p s ; i n f a c t , some r e l a t i o n s h i p s ended a f t e r t h i s exper-ience while others developed i n t o a deeper l e v e l of under-standing. The l a c k of a v a i l a b i l i t y of a b o r t i o n i n f o r m a t i o n was commonly c i t e d as i n c r e a s i n g the woman's f e e l i n g s of f e a r and desperation. Some women expressed a need f o r help i n the decision-making process so tha t they c o u l d adequately consider a l l the f a c t o r s i n v o l v e d . At the two week follow-up i n t e r v i e w , many women s a i d t h a t they would have a p p r e c i a t e d more o p p o r t u n i t i e s to t a l k w i t h the h o s p i t a l nurses who f r e q u e n t l y seemed busy and u n i n t e r e s t e d i n them. A gr e a t e r sense of r e s p o n s i b i l i t y f o r s e x u a l i t y and consequently f o r b i r t h c o n t r o l was evident a t t h i s s e r i e s of i n t e r v i e w s , i n the m a j o r i t y of the women. A s e l f - l i m i t i n g depression was de s c r i b e d by three women du r i n g t h i s p e r i o d . At the time of the t h i r d i n t e r v i e w , many of the women de s c r i b e d changes i n t h e i r sexual r e l a t i o n s h i p s r e l a t e d to t h e i r increased f e e l i n g s of c o n t r o l and de t e r -mination. The consistency between r e c o g n i t i o n of s e x u a l i t y and u t i l i z a t i o n of r e l i a b l e c o n t r a c e p t i o n was evident i n twelve of the f i f t e e n women seen f o u r months l a t e r . Some women expressed a need f o r emotional support i n t h e i r d e v e l -opment of a new r o l e . A l a r g e number of those i n t e r v i e w e d (ten) mentioned the need f o r a combined a b o r t i o n and c o u n s e l l i n g c l i n i c , p r e f erably l o c a t e d apart from a l a r g e h o s p i t a l . The l a s t i n t e r v i e w r e v e a l e d that a l l of the women f e l t that they had made the best d e c i s i o n at that time; nevertheless, s e v e r a l s a i d they could not go through w i t h an abortion again. This event was profoundly d i s t u r b i n g to them and t h e i r p h i l o s o p h i c a l b e l i e f s . This aspect of the women's l i v e s does not give r i s e to a need of the same order as the ot h e r s ; r a t h e r , i t i s an area to be a p p r e c i a t e d and understood, but i t i s not subject to s p e c i f i c i n t e r v e n t i o n . I n summary, then, the main needs i d e n t i f i e d were: 1. the need f o r thorough d i s c u s s i o n of b i r t h c o n t r o l options coupled with d i s c u s s i o n of s e x u a l i t y ; 2 . the need f o r r e a d i l y a v a i l a b l e i n f o r m a t i o n regarding a l l aspects of a b o r t i o n ; 3. the need f o r a b o r t i o n c o u n s e l l i n g , i n c l u d i n g d i s c u s s i o n of a l t e r n a t i v e s to a b o r t i o n ; 4. the need f o r emotional support d u r i n g h o s p i t a l -i z a t i o n and, p o s s i b l y , afterward; 5 . the need to explore the meaning of t h i s event i n the context of the woman's l i f e i n terms of exp e c t a t i o n s of s e l f and r e l a t i o n s h i p s w i t h o t h e r s . 72 IMPLICATIONS The f i n d i n g s of t h i s study suggest t h a t there are s e v e r a l d i s c r e p a n c i e s both i n the way i n which h e a l t h care i s provided i n an area of s p e c i a l concern to women, and i n the way i n which women regard t h e i r own s e x u a l i t y . An i m p l i c a t i o n of the f i r s t discrepancy i s t h a t the present h e a l t h care system does not c o n s i s t e n t l y g i v e adequate c o n s i d e r a t i o n to the needs of women r e q u i r i n g an a b o r t i o n . This statement i s supported by the f a c t t h a t many women had to make s e v e r a l contacts before they obtained the r e q u i r e d a s s i s t a n c e w i t h i n the h e a l t h care system. Another discrepancy i s obvious i n the l a c k of emphasis on and a v a i l a b i l i t y of preventive s e r v i c e s and c o u n s e l l i n g . Women i n t h i s study o f t e n s t a t e d that they d i d not f e e l c o n f i d e n t about t h e i r b i r t h c o n t r o l p r a c t i c e s but they "do not know what t o do about i t . w That Imp l i e s t h a t h e a l t h care p r o f e s s i o n a l s have not been i n s t r u m e n t a l i n ensuring t h a t such s e r v i c e s are provided at an app r o p r i a t e time. Nursing, i n p a r t i c u l a r , stands i n an i d e a l p o s i t i o n to take an a c t i v e r o l e In changing t h i s s i t u a t i o n . The r e l a t i o n s h i p s which nurses have w i t h young people i n schools and women i n the community could w e l l be the foundations f o r b r i d g i n g an e x i s t i n g gap i n the d e l i v e r y of h e a l t h care between the woman and the g y n e c o l o g i s t . Yet another discrepancy i n the h e a l t h care system, which i s o s t e n s i b l y concerned about the h e a l t h of a l l I t s 73 members, has to flo with the way i n which women e x p e r i e n c i n g a b o r t i o n s i n a h o s p i t a l s e t t i n g are t r e a t e d . Many women mentioned, not tha t they had been t r e a t e d c r u e l l y or w i t h obvious p h y s i c a l n e g l e c t , but that they had not been regarded as i n d i v i d u a l s . I n the process of being h o s p i t a l i z e d they f e l t t hat they had become pa r t of a huge system which operated by schedules and r u l e s and which d i d not seem to consider them as d i f f e r e n t women w i t h d i f f e r e n t needs and f e a r s . Thus, i n t e r a c t i o n w i t h the h e a l t h workers was f o r -m a lized and o r i e n t e d towards a s p e c i f i c f u n c t i o n . Such h o s p i t a l experience suggests t h a t h e a l t h p r o f e s s i o n a l s are educated to de a l w i t h i l l n e s s o r pathology r a t h e r than w i t h i n d i v i d u a l s having p a r t i c u l a r needs and problems. The i m p l i -c a t i o n of t h i s f o r a l l h e a l t h workers, but p a r t i c u l a r l y f o r nurses, i s t h a t * l i k e o t her p a t i e n t s , the woman who i s having an a b o r t i o n a p p r e c i a t e s being t r e a t e d as a t h i n k i n g and f e e l i n g being who wants to be con s u l t e d about what i s being done to her and i n v o l v e d more d i r e c t l y i n her own care. The l a c k of i n t e g r a t i o n between s e x u a l i t y and c o n t r a -c e p t i o n i m p l i e s t h a t h e a l t h workers have not done enough comprehensive te a c h i n g . Some e f f o r t has indeed been made to dispense advice and in f o r m a t i o n about b i r t h c o n t r o l , but th a t does not seem to be enough. An i m p l i c a t i o n of these f i n d i n g s i s t h a t h e a l t h workers must understand human sex-u a l i t y , and must f e e l comfortable i n openly i n i t i a t i n g d i s -c u s s i o n about t h i s aspect of l i v i n g . 74 RECOMMENDATIONS The i m p l i c a t i o n s of t h i s study suggest s e v e r a l recommendations f o r change: 1. Access to a b o r t i o n s e r v i c e s and c o u n s e l l i n g should be made more r e a d i l y a v a i l a b l e by e s t a b l i s h i n g a network to c a r r y t h i s out. E x i s t i n g s e r v i c e s , such as those of the women's h e a l t h education and a b o r t i o n r e f e r r a l group, should be strengthened to enable them to f u n c t i o n w i t h i n a broader community. 2 . Health p r o f e s s i o n a l s must recognize and e s t a b l i s h as a p r i o r i t y the preventive aspects of c o n t r a c e p t i o n combined w i t h d i s c u s s i o n of s e x u a l i t y . In t h i s way, more meaningful i n t e g r a t i o n of the whole experience of s e x u a l i t y w i t h i n the woman's l i f e i s encouraged. Nurses working i n the community should t r y , whenever p o s s i b l e , t o f a c i l i t a t e d i s c u s s i o n between young people and t h e i r parents about human s e x u a l i t y . 3. Nurses should recognize the p o t e n t i a l psycho-s o c i a l d i f f i c u l t i e s experienced by women having a b o r t i o n s and intervene a c c o r d i n g l y . Some of these d i f f i c u l t i e s i n c l u d e g a i n i n g access to an a b o r t i o n s e r v i c e ; making the d e c i s i o n t o have the a b o r t i o n ; e x p e r i e n c i n g changes i n r e l a t i o n s h i p s w i t h s i g n i f i c a n t o t h e r s ; d e c i d i n g upon an app r o p r i a t e method of b i r t h c o n t r o l ; and working through f e e l i n g s i n r e l a t i o n to s e l f i n the context of t h i s experience. 4 . Health workers should recognize the value of i n c l u d i n g the p u t a t i v e f a t h e r as much as p o s s i b l e i n the c o u n s e l l i n g process. I n t h i s way, g r e a t e r understanding of a l l the i n t e r p e r s o n a l dynamics w i l l be a t t a i n e d , and so more b e n e f i c i a l l y acted upon. RECOMMENDATIONS FOR FUTURE RESEARCH This study has i d e n t i f i e d , from a s m a l l sample, c e r t a i n unmet needs experienced by a b o r t i o n p a t i e n t s . Areas which r e q u i r e f u r t h e r research are suggested by t h i s r e p o r t and centre around the f o l l o w i n g questions: 1. What are the most e f f e c t i v e ways to meet the i d e n t i f i e d needs? 2. What are the l o n g e r range e f f e c t s on a woman's a b i l i t y to cope w i t h the a b o r t i o n , and on her l i f e g e n e r a l l y , of meeting these needs? 3. How can the concepts of s e x u a l i t y and respon-s i b i l i t y be i n t e g r a t e d e f f e c t i v e l y i n t o sex education courses i n high schools? 4 . I f a woman has p r e v i o u s l y given a c h i l d up f o r adoption, what d i f f e r e n c e s does she experience i n her psycho-s o c i a l r e a c t i o n to an a b o r t i o n as opposed to her r e a c t i o n s to g i v i n g the c h i l d up? 5. I s there a s i g n i f i c a n t d i f f e r e n c e i n the way i n which a t h i r t y year o l d woman copes w i t h an a b o r t i o n as compared to a seventeen year old? 76 6. What proportion of pre-operative anxiety i s rel a t e d primarily to fear of the s u r g i c a l procedure as such and VThat proportion i s r e l a t e d to concern about the abortion i t s e l f ? BIBLIOGRAPHY 77 BIBLIOGRAPHY A. BOOKS Cal l a h a n , D a n i e l . A b o r t i o n ; Law, Choice and M o r a l i t y . London, The MacMillan Company, 1970. F e r r i s , P a u l . The Nameless: A b o r t i o n i n B r i t a i n Today. London: Hutchinson & Co. ( P u b l i s h e r s ) L t d . , 1 9 6 6 . H a l l , Robert E. (ed.). A b o r t i o n i n a Changing World. 2 v o l s . New York: Columbia U n i v e r s i t y P r e s s , 1970. Maloney, E. I n t e r p e r s o n a l R e l a t i o n s . Dubuque: C. Brown Co., 1960^ P e l r l n e , Eleanor Wright. A b o r t i o n In Canada. Toronto: new press, 1971. Schaefer, George (ed.). C l i n i c a l O b s t e t r i c s and Gynecology: L e g a l A b o r t i o n s i n New York S t a t e ; M e d i c a l , L e g a l , Nursing, S o c i a l Aspects ( J u l y 1-December 3 1 . 1970)• New York: Harper & Row, P u b l i s h e r s , 1971'. Shaw, R u s s e l l . A b o r t i o n on T r i a l . Ohio: Pflaum P r e s s , 1968. Smith, David T. (ed.). A b o r t i o n and the Law. Cle v e l a n d : The Press of Western Reserve U n i v e r s i t y , 19^7. T r i p o d i , Tony A. e t . a l . S o c i a l Program E v a l u a t i o n . I t a s c a : Peacock P u b l i s h e r s , 1971. Westoff, L e s l i e A l d r i d g e and Charle s F. Westoff. From Now  to Zero: F e r t i l i t y , C ontraception and A b o r t i o n i n  America. Toronto: L i t t l e , Brown and Company, 1971. B. PERIODICALS Athanasiou, Robert e t . a l . " P s y c h i a t r i c Sequelae to Term B i r t h and Induced E a r l y and Late A b o r t i o n : A Lo n g i -t u d i n a l Study," Family P l a n n i n g P e r s p e c t i v e s , 5 : 4 , F a l l , 1973, 227—231. 78 79 Brody, Harry, Stewart M e i k l e , and Ric h a r d G e r r i t s e , "Therapeutic A b o r t i o n : A Pr o s p e c t i v e Study. 1 . , " American J o u r n a l of O b s t e t r i c s and Gynecology, 1 0 9 : 3 , February 1, 1971, 347-353-Claman, David A., e t . a l . "Impact on H o s p i t a l P r a c t i c e of L i b e r a l i z i n g A b o r t i o n s and Female S t e r i l i z a t i o n s , " Canadian Medical A s s o c i a t i o n J o u r n a l , 105, J u l y 10, 1971, 3 5 - 4 1 . Danon,. A r d i s Hyland. "Organizing an A b o r t i o n S e r v i c e , " Nursing Outlook, 21:7, J u l y , 1973, 4 6 0 - 4 6 4 . David, Henry P. "Abo r t i o n : P u b l i c Health Concerns and Needed P s y c h o s o c i a l Research," American J o u r n a l of  P u b l i c Health, 6 l : 3 , March, 1971, 510-516. . "Abortion Trends i n European S o c i a l i s t C o u n t r i e s and i n the U n i t e d S t a t e s , " American J o u r n a l of Ortho- p s y c h i a t r y , 4 3 : 3 , A p r i l , 1973, 376-3«3. E h r l l c h , Paul and John P. Holdren. "Abortion and M o r a l i t y , " Canadian Nurse, 6 8 : 6 , June, 1972, 37« Ford, C h a r l e s V., P i e t r o Castelnuovo-Tedesco, and K a h l i l a D. Long. "Women Who Seek Therapeutic A b o r t i o n : A Comparison w i t h Women who Complete T h e i r Pregnancies," American J o u r n a l of P s y c h i a t r y , 1 2 9 : 5 , November, 1972, 58-64. Harper, W., Be t t y R. Marcom, and V i c t o r D. W a l l . " A b o r t i o n : Do A t t i t u d e s of Nursing Personnel A f f e c t the P a t i e n t ' s P e r c e p t i o n of Care?" Nursing Research, 21 :4 , August, 1972, 327-331. K e l l e r , C h r i s t a and Pamela Copeland. " C o u n s e l l i n g the A b o r t i o n P a t i e n t I s More Than Talk," American J o u r n a l of Nursing, 7 2 : 1 , January, 1972, 102-109. Marder, Leon. " P s y c h i a t r i c Ezperience w i t h a L i b e r a l i z e d . Ab o r t i o n Law," American J o u r n a l of P s y c h i a t r y , 1 2 6 : 9 , March, 1970, 64^75^ ~ Monsour, Karem J . and Barbara Stewart. "Abortion and Sexual Behavior i n College Women," American J o u r n a l of Ortho-p s y c h l a t r y , 4 3 : 5 , October, .1973, 804-814-. Rogers, Joan M. "Therapeutic A b o r t i o n : A M u l t i d i s c i p l i n e d Approach to P a t i e n t Care from a S o c i a l Work P e r s p e c t i v e , " Canadian J o u r n a l of P u b l i c Health, 6 4 : 3 , May/June, 1973, 254-259. ' ' 80 Ryder, Norman B. "Contraceptive F a i l u r e i n the U n i t e d S t a t e s , " Family Planning P e r s p e c t i v e s , 5 : 3 , Summer, 1973, 133-142. Schorr, Thelma M. "Issues of Conscience," American J o u r n a l  of Nursing, 7 2 : 1 , January, 1972, 6 l . Schwartz, Richard A. "The S o c i a l E f f e c t s of L e g a l A b o r t i o n , " 6 2 : 1 0 , October, 1972, 1331-1335-Schwenger, Cope W. "Abortion i n Canada as a P u b l i c Health Problem and as a Community Health Measure," Canadian  J o u r n a l of P u b l i c Health, 64 : 3 , May/June, 1973, 223-~2~29: Smith, E l i z a b e t h M. "A Follow-up Study of Women who Request A b o r t i o n , " American J o u r n a l of Or t h o p s y c h i a t r y , 4 3 : 4 , J u l y , 1973, .574-585-. "Counseling f o r Women who Seek A b o r t i o n , " S o c i a l Work, 17 :2 , March, 1972, 6 2 - 6 8 . T i e t z e , C h r i s t o p h e r and Sarah L e w i t t . " J o i n t Program f o r the Study of A b o r t i o n (JPSA): E a r l y Medical Complica-t i o n s of Legal A b o r t i o n , " Studies i n Family P l a n n i n g , 3 : 6 , June, 1972, 97-119-. Whittlngdon, H.G. " E v a l u a t i o n of Therapeutic A b o r t i o n as an Element of Prev e n t i v e P s y c h i a t r y , " American J o u r n a l  of P s y c h i a t r y . 1 2 6 : 9 , March, 1970, 5 8 - c ^ C . UNPUBLISHED MATERIALS Model f o r Nursing, U n i v e r s i t y of B r i t i s h Columbia School of Nursing, Vancouver, 1973- (Mimeographed.) "A Study to I d e n t i f y Problems Experienced by P a t i e n t s Having Therapeutic A b o r t i o n s on the One-Day S u r g i c a l S l a t e , " P r o j e c t D i r e c t o r : Mary L. Richmond-MacBean, N a t i o n a l Health Grant ( P r o j e c t No. 610-21-25) , June, 1972, Vancouver. 81 D. OTHER B a b i e s by C h o i c e Not by Chance. 2 v o l s . O u t r e a c h S e r v i c e s , S o c i a l P o l i c y and R e s e a r c h Department, U n i t e d Com-munity S e r v i c e s o f G r e a t e r Vancouver A r e a , J u n e , 1973. T i e t z e , C h r i s t o p h e r and Deborah A. Dawson. "Induced. A b o r t i o n s A F a c t b o o k , " R e p o r t s on P o p u l a t i o n / F a m i l y P l a n n i n g , 14, December, 1973, 1-55-APPENDIX A: THE PACE SHEET 82 THE FACE SHEET PLACE OF INTERVIEW: NAME: HOME ADDRESS: PHONE: DATE: AGE: NEXT OF KIN: NATIONALITY: RELIGIOUS OR CULTURAL BACKGROUND: STUDENT, WORKING, AT HOME: FAMILY.SIZE: LIVING ARRANGEMENT: LAST NORMAL MENSTRUAL PERIOD: WEEKS OF GESTATION: SCHEDULED FOR OPERATION: 83 APPENDIX Bs BROCHURE 84 BROCHURE ABORTION RESEARCH PROJECT I am i n t e r e s t e d i n t a l k i n g w i t h you about your r e a c t i o n s to haying an a b o r t i o n , because I b e l i e v e t h a t your experience could be v a l u a b l e i n p r e p a r i n g other women f o r t h i s experience. I t i s my p l a n to v i s i t w i t h you once before the oper a t i o n and twice f o l l o w i n g , to explore your f e e l i n g s , r e a c t i o n s , and needs r e g a r d i n g t h i s event. This research i s being done as one of the r e q u i r e -ments f o r a Master of Science i n Nursing program at the U n i v e r s i t y of B r i t i s h Columbia. A l l i n f o r m a t i o n w i l l be c o n f i d e n t i a l . I f you are i n t e r e s t e d , please i n d i c a t e so, and I w i l l contact you to e x p l a i n f u r t h e r . Looking forward to meeting and t a l k i n g w i t h you, Reta McKay, R.N. 85 APPENDIX C: CRIMINAL CODE OF CANADA, SECTION 251, SUBSECTIONS I TO 4 86 CRIMINAL CODE OF CANADA, SECTION 251. 251. (1) Every one who, w i t h i n t e n t to procure the mis-c a r r i a g e of a female person, whether or not she i s pregnant, uses any means f o r the purpose of c a r r y i n g out h i s i n t e n t i o n i s g u i l t y of an i n d i c t a b l e offence and i s l i a b l e f o r im-prisonment f o r l i f e . (2) Every female person who, being pregnant, w i t h i n t e n t to procure her own m i s c a r r i a g e , uses any means or permits any means to be used f o r the purpose of c a r r y i n g out her i n t e n t i o n i s g u i l t y of an i n d i c t a b l e offence and i s l i a b l e to Imprisonment f o r two years. (3) In t h i s s e c t i o n , "means" i n c l u d e s (a) the a d m i n i s t r a t i o n of a drug o r other noxious t h i n g , (b) the use of an instrument, and (c) manipulation of any k i n d . (4) Subsections (1) and (2) do not apply to (a) a q u a l i f i e d medical p r a c t i t i o n e r , o t h e r than a member of a t h e r a p e u t i c a b o r t i o n committee f o r any h o s p i t a l , who i n good f a i t h uses i n an a c c r e d i t e d o r approved h o s p i t a l any means f o r the purpose of c a r r y i n g out h i s i n t e n t i o n to procure the m i s c a r r i a g e of a female person, o r (b) a female person who, being pregnant, permits 87 88 a q u a l i f i e d medical p r a c t i t i o n e r to use i n an a c c r e d i t e d or approved h o s p i t a l any means de s c r i b e d i n paragraph (a) f o r the purpose of c a r r y i n g out her i n t e n t i o n to procure her own m i s c a r r i a g e , i f , before the use of those means, the t h e r a p e u t i c a b o r t i o n committee f o r that a c c r e d i t e d or approved h o s p i t a l , by a maj o r i t y of the members of the committee and at a meeting of the committee at which the case of such female person has been reviewed, (c) has by c e r t i f i c a t e i n w r i t i n g s t a t e d t h a t i n i t s o p i n i o n the c o n t i n u a t i o n of the preg-nancy of such female person would or would be l i k e l y to endanger her l i f e o r h e a l t h , and (d) has caused a copy of such c e r t i f i c a t e to be given to the q u a l i f i e d medical p r a c t i t i o n e r . 

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