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Women choosing not to have children : implications for social work practice and policy on reproductive… McCarthy, Claire Louise 1989

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WOMEN CHOOSING NOT TO HAVE CHILDREN: IMPLICATIONS FOR SOCIAL WORK PRACTICE AND POLICY ON REPRODUCTIVE CHOICE by CLAIRE LOUISE MCCARTHY B.Ed., The U n i v e r s i t y of B r i t i s h Columbia, 1982 B.S.W., The U n i v e r s i t y of B r i t i s h Columbia, 1986 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK i n THE FACULTY OF GRADUATE STUDIES ( S c h o o l of S o c i a l Work) We a c c e p t t h i s t h e s i s as co n f o r m i n g to the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA August, 1989 c o p y r i g h t C l a i r e L o u i s e McCarthy, 1989 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia Vancouver, Canada DE-6 (2/88) ABSTRACT The purpose of t h i s research study was to explore the re l a t i o n s h i p between women who have chosen not to have children and one s p e c i f i c area of s o c i a l p o l i c y , that of reproductive choice. Attitudes toward and access to voluntary s t e r i l i z a t i o n and abortion were emphasized. A feminist q u a l i t a t i v e research approach was used in t h i s study. Based on interviews with ten c h i l d f r e e women and fi v e community agency representatives/professionals, t h i s research explored the experiences and attitudes of c h i l d f r e e women and community representatives toward voluntary s t e r i l i z a t i o n and abortion. A substantive and t h e o r e t i c a l coding process was used for data a n a l y s i s . The r e s u l t s of t h i s research indicate a discrepancy between what these c h i l d f r e e women expected from the process of obtaining a tubal l i g a t i o n or abortion versus what a c t u a l l y happened to many of them in the i r contact with the medical profession. In p a r t i c u l a r , access to more information and the right to make an autonomous decision became poignant concerns in the study. Balancing the ri g h t s of women to v o l u n t a r i l y access abortion and s t e r i l i z a t i o n against the rig h t s of other women to not be coerced to have an abortion or tubal l i g a t i o n i s a challenge for our society. Social i i i workers have a s i g n i f i c a n t role to play both in terms of c l i n i c a l work in,the health f i e l d and at the s o c i a l p o l i c y l e v e l to ensure that a l l women have the opportunity to make autonomous reproductive choices. T A B L E OF CONTENTS Page ABSTRACT . i i TABLE OF CONTENTS i v ACKNOWLEDGEMENTS . .... . . v i INTRODUCTION. . . '.... . 1 PURPOSE OF THESIS .... 5 IMPLICATIONS FOR SOCIAL WORK 7 LANGUAGE USAGE . . . . 10 REVIEW OF THE LITERATURE H i s t o r i c a l P e r s p e c t i v e 11 The C h o i c e To Be C h i l d f r e e . 14 I m p l i c a t i o n s F o r S o c i a l P o l i c y 16 S o c i a l P o l i c y On R e p r o d u c t i v e C h o i c e 17 A b o r t i o n 18 V o l u n t a r y S t e r i l i z a t i o n 23 C o n c l u s i o n 30 RESEARCH DESIGN 32 SAMPLE . .. 34 IMPLEMENTATION I n t e r v i e w s W i t h C h i l d f r e e Women 35 I n t e r v i e w s W i t h Community A g e n c i e s / P r o f e s s i o n a l s . . . 39 VALIDITY AND RELIABILITY 40 RESULTS S t r a t e g y of A n a l y s i s 41 I n t e r v i e w s W i t h C h i l d f r e e Women Demographics . 43 Reasons F o r C h o o s i n g Not To Have C h i l d r e n 44 C o n t r a c e p t i o n 46 Pregnancy .. 48 A b o r t i o n 49 V o l u n t a r y S t e r i l i z a t i o n . . . . . . . 53 V I n t e r v i e w s W i t h Community A g e n c i e s / P r o f e s s i o n a l s S e r v i c e D e s c r i p t i o n s 60 A t t i t u d e s Toward Women C h o o s i n g Not To Have C h i l d r e n 62 H e a l t h - r e l a t e d I n f o r m a t i o n S h a r i n g W i t h C h i l d f r e e Women 65 D e c i s i o n - m a k i n g P r o c e s s e s . . . . . . . 69 Consent. 72 Ac c e s s To T u b a l L i g a t i o n and A b o r t i o n 74 DISCUSSION OF FINDINGS I n t r o d u c t i o n 78 I n t e r v i e w s W i t h C h i l d f r e e Women 79 I n t e r v i e w s W i t h Community A g e n c i e s / P r o f e s s i o n a l s . . . 82 I n t e g r a t i n g The I n d i v i d u a l and Community P e r s p e c t i v e s . . . . . 84 I m p l i c a t i o n s F o r S o c i a l Work P r a c t i c e and P o l i c y . . . 86 C o n c l u s i o n 96 CONCLUSION 98 BIBLIOGRAPHY.. 100 Appendix A R e s e a r c h A d v e r t i s e m e n t . . 107 Appendix B I n t e r v i e w S c h e d u l e F o r C h i l d f r e e Women.... 109 Appendix C I n t e r v i e w S c h e d u l e F o r Community A g e n c i e s . 113 ACKNOWLEDGEMENTS T h i s r e s e a r c h p r o j e c t would n ot have been p o s s i b l e w i t h o u t t h e a s s i s t a n c e o f t h o s e c h i l d f r e e women and community p r o f e s s i o n a l s who s h a r e d t h e i r t i m e and t h e i r t h o u g h t s w i t h me. My warm a p p r e c i a t i o n and t h a n k s t o each o f them. My t h a n k s t o J a c k MacDonald f o r h i s i n s i g h t on s o c i a l p o l i c y i s s u e s ; I v e r y much b e n e f i t t e d from h i s e x t e n s i v e e x p e r i e n c e and i n - d e p t h knowledge. My t h a n k s t o K a t h r y n M c C a n n e l l f o r t h e commitment she has g i v e n me t h i s p a s t y e a r . She has encouraged me t o t h i n k about a l l a s p e c t s of f e m i n i s m and has v a l u e d my work w h i l e c h a l l e n g i n g me t o go beyond. B e i n g a f e m i n i s t can sometimes b r i n g f r u s t r a t i n g moments; y e t K a t h r y n has p r o v i d e d me w i t h a r o l e model t h a t I have and w i l l a l w a y s v a l u e d e e p l y . F i n a l l y , my h e a r t f e l t t h a n k s t o my l i f e t i m e p a r t n e r , Tom, w i t h o u t whom my p r o f e s s i o n a l and p e r s o n a l g o a l s would have been l e s s a t t a i n a b l e . Words cannot do j u s t i c e t o t h e n e v e r e n d i n g s u p p o r t , encouragement, and a s s i s t a n c e he has g i v e n me. INTRODUCTION For the most part, the phenomenon of women making the decision of whether or not to have childre n is a recent one. In the past twenty years, a growing amount of research and l i t e r a t u r e has focussed on thi s decision and there is greater recognition of the s o c i a l legitimacy of such a choice. The a v a i l a b i l i t y of a v a r i e t y of kinds of contraception has had a s i g n i f i c a n t impact on a l l aspects of sexuality and procreation. It. has made sex more fe a s i b l e without the consequences of conception and i t has also made marriage without procreation an al t e r n a t i v e (Veevers, 1983). Prior to the recent i n t e r e s t in understanding why women choose not to have chi l d r e n , the prevalent attitude was that women who chose not to have ch i l d r e n had psychological, sexual or mental health problems (Veevers in Callan, 1987). Some of the ear l y l i t e r a t u r e on the subject of c h i l d f r e e women li n k s having c h i l d r e n with the feminine r o l e , " . . . f o r some [women] there is a r e j e c t i o n of the feminine role [by choosing not to have c h i l d r e n ] , based in turn on childhood and other experiences" (Pohlman, 1970, p. 6). Only recently has choosing not to have children been viewed as a proactive decision made by women who are aware of the i r choices and 2 s e r i o u s about the de c i s i o n - m a k i n g process r e l a t e d to having c h i l d r e n . With the onset of the r e c o g n i t i o n t h a t parenthood i s a c h o i c e , came the q u e s t i o n i n g by some of the b a s i c v a l u e s and p r i n c i p l e s w i t h i n our s o c i e t y . At the r o o t of t h i s i s the commonly h e l d assumption t h a t a l l women want to be mothers and t h a t women are not com p l e t e l y f u l f i l l e d u n t i l they have experie n c e d motherhood. However, C a l l a n (1987) concluded i n h i s study of 149 married women, 36 of whom were v o l u n t a r i l y c h i l d l e s s , 53 who were unable to have c h i l d r e n and 60 who had c h i l d r e n ; t h a t a c r o s s s e v e r a l measures a s s e s s i n g p s y c h o l o g i c a l w e l l - b e i n g and m a r i t a l adjustment, l i t t l e d i f f e r e n c e was found among the women. Furthermore, C a l l a n notes t h a t c h i l d f r e e women were "more pl e a s e d than mothers with the amount of freedom and f l e x i b i l i t y i n t h e i r l i v e s e s p e c i a l l y how they c o u l d spend t h e i r time and t h e i r l e v e l s of p e r s o n a l p r i v a c y , r e l a x a t i o n , and independence" (p. 847). Ri c h (1986) f u r t h e r p o i n t s out t h a t f o r the most p a r t "motherhood as [an] i n s t i t u t i o n has g h e t t o i z e d and degraded female p o t e n t i a l i t i e s " a lthough there have been a few p e r i o d s i n h i s t o r y when "the idea of woman-as-mother has worked to endow a l l women with r e s p e c t , even with awe" (p. 13). S o c i e t y p r o j e c t s a mixed message about the importance of mothering. Levine & E s t a b l e (1981) suggest t h a t "the romantic p e d e s t a l of motherhood i n f a c t i s used to mask the double standard that operates in favour of men and chi l d r e n . Hiding behind the mystique of motherlove and family, society forces women to accept a less than human l i f e contract" (p. 49). In addition, they suggest that "when expedient, the ideology of motherhood i s used as a subtle and not so subtle pressure to force women out of paid employment" (p. 10). From the above i t seems clear that both women with and women without childr e n have had and s t i l l have poor s o c i e t a l images. In addition to evaluating the decision women make with respect to whether or not they have chi l d r e n , i t i s also necessary to consider t h i s personal decision within a more expansive dimension. Two s i g n i f i c a n t factors of a woman's i n a b i l i t y to have complete control over whether or not to have childre n have been: access to and a v a i l a b i l i t y of methods of contraception, and p o l i t i c a l expectations and pressures on women to have c h i l d r e n . Medical research in recent decades has increased the number of a l t e r n a t i v e s women have with respect to short term, long term and permanent methods of contraception. U n t i l these choices were a v a i l a b l e , women had to r e l y on a v a r i e t y of primitive methods to prevent pregnancy and when these methods f a i l e d , unsafe and/or i l l e g a l abortions were needed to end an unwanted pregnancy. Today, women are in a better p o s i t i o n to choose i f and when they want to have c h i l d r e n . However, for women who choose not to have c h i l d r e n , safe and r e l i a b l e abortion and permanent methods of b i r t h control continue to be e r r a t i c a l l y a v a i l a b l e . A woman's access to contraception, abortion, and s t e r i l i z a t i o n very much depends on the supportiveness of her in d i v i d u a l physician and the general climate of support for women's autonomy. In addition, access has varied for women depending on th e i r race, age, and c l a s s . Poor women and women of colour may be coerced into having an abortion or tubal l i g a t i o n while white, middle class women are pressured to not have either procedure (Rich, 1986; Boston Women's Health Book C o l l e c t i v e , 1984). The 1967 United Nations Tehran Declaration recognizes that family planning and a free choice among the various methods of contraception, including s t e r i l i z a t i o n , are basic human r i g h t s . However, "formal declarations and the actual provision of services to a l l people are frequently separated by p o l i t i c a l , s o c i o c u l t u r a l , psychological, and r e l i g i o u s resistance to such services" (Report of the F i f t h International Conference on Voluntary Surgical Contraception, 1985, p. 7). H i s t o r i c a l l y , governments have focussed much attention on the family and p a r t i c u l a r l y , women's role in the family. As Penfold & Walker (1983) note, 5 Changes in the family may be prescribed by p o l i t i c a l leaders to meet the needs of the state. In Nazi Germany, a l l women, married or otherwise, were urged to have as many children as possible. H i t l e r promised that he would personally become the godfather of any woman's seventh son. Similar pleas for more children were contained in Winston C h u r c h i l l ' s s t i r r i n g speeches to war-time England. In Japan, in 1974, b i r t h - c o n t r o l p i l l s became v i r t u a l l y unavailable, and a l i b e r a l abortion law was rescinded when the b i r t h rate began to decline and the supply of cheap labour was threatened, (p. 120) The overwhelming pressure from society and government on women to have childre n has meant, to a c e r t a i n extent, that women choosing not to have children, can f e e l isolated in t h e i r decision. It has also affected the a v a i l a b i l i t y of contraception which during various periods in h i s t o r y has r e f l e c t e d the state's i n t e r e s t in the s i z e of the family. Thus, the p o l i c y implications associated with reproductive choice have s i g n i f i c a n t impact on the l i v e s of women who have chosen not to have c h i l d r e n . PURPOSE OF THESIS Most of the a v a i l a b l e research and l i t e r a t u r e on being c h i l d f r e e relates to the decision-making process and reasons why women decide not to have c h i l d r e n . Suggestions for 6 further research in the area of s o c i a l p o l i c y implications are often made in these e x i s t i n g studies. Of p a r t i c u l a r relevance are s o c i a l p o l i c i e s related to reproductive choice, population c o n t r o l , the e l d e r l y population, and optional parenthood. Veevers (1980) states, four goals in s o c i a l p o l i c y would be desirable: f i r s t , increasing consciousness of parenthood as optional rather than compulsory; second, increasing r a t i o n a l debate of the pros and cons of parenthood; t h i r d , maintaining f a c i l i t i e s whereby couples can e f f e c t i v e l y achieve t h e i r desire to have or not to have child r e n ; and fourth, providing support for those people who do opt for chi l d l e s s n e s s , (p. 165) Currently, a v a r i e t y of s o c i a l p o l i c i e s focus on support for women who have c h i l d r e n . For example, in 1988, Quebec introduced a p o l i c y of paying families a s p e c i f i c amount of money when they had a c h i l d . This was designed as an incentive for families with the goal of s t a b i l i z i n g or increasing the population of Quebec. Another s o c i a l p o l i c y i s that of the 'baby bonus' which provides f i n a n c i a l support to women for having c h i l d r e n . S o c i a l p o l i c y needs to address the growing trend of women choosing not to have childre n and ensure that t h i s population is recognized in terms of i t s p a r t i c u l a r needs. As Sapiro (1986) states, "most s o c i a l p o l i c y aimed at women has been designed e x p l i c i t l y to benefit them in th e i r capacity as wives and mothers and more p a r t i c u l a r l y , to benefit those who depend upon them for nurturance and domestic service: husbands, ch i l d r e n , and e l d e r l y r e l a t i v e s " (p. 231) . The purpose of t h i s research study is to explore the rel a t i o n s h i p between women who have chosen not to have chi l d r e n and one s p e c i f i c area of s o c i a l p o l i c y , that of reproductive choice. The intention of focussing on t h i s s p e c i f i c realm of s o c i a l p o l i c y i s to i d e n t i f y to what extent complete access to reproductive choice impacts women who have chosen not to have ch i l d r e n . Access to voluntary s t e r i l i z a t i o n and abortion w i l l be emphasized. More generally, the research w i l l also examine s o c i e t a l and p o l i t i c a l attitudes toward women and mothering and how these attitudes may impact s o c i a l p o l i c y i n i t i a t i v e s on reproductive choice which a f f e c t women who have chosen not to have c h i l d r e n . IMPLICATIONS FOR SOCIAL WORK This issue has relevance to s o c i a l work as i t bears on the development of s o c i a l programs and p o l i c i e s which w i l l take into account a wide v a r i e t y of family structures as well as women's right s with respect to the decisions they make. Assumptions are often made that families include c h i l d r e n or w i l l eventually include children when t h i s i s not always the case. Generally, more information i s needed in s o c i a l work which recognizes the legitimacy of the choice to not have chi l d r e n , p a r t i c u l a r l y as more and more women make t h i s d ecision. Social work l i t e r a t u r e often portrays c h i l d f r e e women in a very negative l i g h t . Levine & Estable (1981) describe three categories used in s o c i a l work to c l a s s i f y women according to the type of mothering role they have. A "good/normal/adequate mother" (p. 27) i s for example, part of a two-parent nuclear family. A "bad/deviant/inadequate mother" might be a lesbian mother. The category between these two i s the "grey area - danger" category of s o c i a l work l i t e r a t u r e and organizations which c h i l d f r e e women find themselves within. "Grey area" women are not conforming to the t r a d i t i o n a l expectations of women but have also not challenged the p a t r i a r c h a l ideology to the extent that lesbian mothers, for example, have challenged the pa t r i a r c h a l perspective. Furthermore, t h i s research is relevant to s o c i a l work c l i n i c a l practice and how c l i n i c i a n s respond to c h i l d f r e e women. Bernard (1975) states, "no one describes the women who prefer non-motherhood as strong, autonomous women able to r e s i s t coercive pressures. No one emphasizes th e i r strengths. It is always something verging on the pathological" (p. 46). Levine & Estable (1981) also state, " i f motherhood is to be f r e e l y chosen by women, we w i l l have to a c t i v e l y develop a l t e r n a t i v e ways for women to l i v e other than in the t r a d i t i o n a l family...and the assumptions of normalcy ascribed to the two parent, i n t a c t , t r a d i t i o n a l family must be destroyed" (p. 62). Thus for s o c i a l workers, there needs to be a recognition that some women may choose to remain c h i l d f r e e because of the lack of support given to women when they become mothers. Social workers need to support the acceptance of a v a r i e t y of l i f e s t y l e s for women. This research w i l l also have relevance to s o c i a l p o l i c y i n i t i a t i v e s related to reproductive choice. The rights of women choosing not to have children appear to be ignored by p o l i c y makers, the medical community and anti-abortion groups when i t comes to access to abortion, s t e r i l i z a t i o n and contraception. This study w i l l hopefully indicate the extent to which these issues are important to c h i l d f r e e women. Soc i a l workers have important roles as members of m u l t i d i s c i p l i n a r y health teams in advocacy for a woman's ri g h t to choose how she w i l l handle her reproductive choices. While other health d i s c i p l i n e s may consider the woman within a more narrow perspective of health care, s o c i a l workers must consider her within her s o c i a l context and support her decision-making r i g h t s through a process of empowerment. LANGUAGE USAGE The choice of language, in t h i s thesis proposal requires explanation. The majority of availa b l e l i t e r a t u r e on the subject of women choosing to have or not to have childre n refers to t h i s population as c h i l d l e s s . This term can imply a negative c h a r a c t e r i s t i c in terms of lacking something. The word c h i l d f r e e has been used because some consider i t a more p o s i t i v e term (Cooper, Cumber, & Hartner, 1978). However, for individ u a l s with strong p r o n a t a l i s t values, t h i s term may also be considered negative. The medical term for a woman who has not borne a c h i l d i s nulliparous and t h i s term has also been used in the l i t e r a t u r e (Kaltreider & Margolis, 1977). In addition, there are two terms avai l a b l e with respect to a partnered woman and man who have chosen not to have ch i l d r e n : c h i l d f r e e family or couple (Whelan, 1975). The rationale related to c h i l d f r e e family is that there are a va r i e t y of family compositions, not a l l of which require the presence of c h i l d r e n . 11 There are d i f f e r e n t dimensions to families including economic, emotional, and caregiving ( E i c h l e r , 1983). Procreation i s but one possible dimension of a family. For the purposes of t h i s t h e s i s , the terms c h i l d f r e e and c h i l d f r e e family w i l l be used when appropriate. The assumption i s made that the decision not to have childre n i s a p o s i t i v e one for the i n d i v i d u a l ( s ) involved and t h i s terminology r e f l e c t s that a t t i t u d e . This study w i l l not address the issues of relevance to women who are ' i n v o l u n t a r i l y ' c h i l d f r e e . REVIEW OF THE LITERATURE HISTORICAL PERSPECTIVE In the late nineteenth century, some public attention was directed towards the idea of women choosing not to have chil d r e n , although, at that time, the i n t e r e s t was founded on d i f f e r e n t premises from those of today. In part, the focus related to women's reproductive r e s p o n s i b i l i t i e s in general and encouragement for women to l i m i t the number of children they had, as opposed to not having any ch i l d r e n at a l l . Between 1869 and 1873, Elizabeth Cady Stanton toured the United States and encouraged women to l i m i t the number of c h i l d r e n they had. In a late nineteenth century book, Relations of the Sexes (Duffey in Faux, 1984), the author t e l l s women that they do not have to have childre n unless they want to. It was f e l t that pressuring a woman to have a c h i l d would be as detrimental to the c h i l d as to the mother. However, although there was an apparent l e v e l of support for parental choice, there s t i l l existed an underlying attitude that women who did not have children were maladjusted. The main focus for both Stanton and Duffey was b i r t h c o n t r o l , not support for the c h i l d f r e e a l t e r n a t i v e (Faux, 1984). A d i s t i n c t i o n was also made between b i r t h control (abstention, delayed marriage, and so forth) and contraception (the use of a s p e c i f i c method to prevent conception); the former was supported by most feminists, the l a t t e r was not (Degler, 1980) In an a r t i c l e of the weekly journal, The Independent (1905), an anonymous writer, "a c h i l d l e s s wife" (p. 654), described why she did not want to have c h i l d r e n . She stated, "we believe that to have ch i l d r e n would be detrimental to our usefulness as members of society, detract from the happiness of our marr iage.... I say "we" because t h i s story concerns my husband almost as much as myself" (p.654). She continues, "Whenever I learned the reason of the woman's submission i t was always based upon the fact that she had children and no money, the existence of the one precluding the obtaining of the other" (p. 656). For th i s woman, the r i s k s of pregnancy and c h i l d b i r t h along with the loss of independence for women with chil d r e n were strong enough reasons to compel her not to have c h i l d r e n . " . . . I t i s true that the woman who has a c h i l d r i s k s her l i f e and doubly r i s k s her health. I love my l i f e and I enjoy my good health. I fear to r i s k such precious possessions" (p. 658). "I decided that freedom, equality and self-ownership would come to the wife with her own pocketbook" (p. 656). This woman's comments Indicate her courageous commitment to make her own choices about family at a time when the overwhelming majority of married women had children (unless the couple was unable to conceive). Generally l i t t l e a ttention was given to the c h i l d f r e e a l t e r n a t i v e during t h i s f i r s t feminist movement. Much of the pressure and strength of the movement came from the association of women to motherhood. The ear l y feminists attempted to gain t h e i r rights on the basis of t h e i r contribution and value as mothers. It was the one role that separated women from men and the movement wanted to build t h e i r p o l i t i c a l strength from t h i s d i f f e r e n c e . In addition, there was the recognition that many women depended on th e i r role as mother for th e i r economic s u r v i v a l (Faux, 1984). In spite of some discussion on the choice have children, the overwhelming consensus should have ch i l d r e n . A prominent psycho for women not to was that women l o g i s t of the time believed that i t was the "weakness or self-indulgence of women ...(that) c u r t a i l e d t h e i r f e r t i l i t y " (Degler, 1980, p. 206). The second wave of feminism in the 1960's focussed on the rig h t s of women to leave the home and p a r t i c i p a t e outside of the home in a meaningful way. However, i n i t i a l l y , i t was not advocated that women ignore home r e s p o n s i b i l i t i e s , only that they add t h e i r new r e s p o n s i b i l i t i e s to t h e i r e x i s t i n g ones (Friedan, 1963). In another two decades, t h i s change would lead to the 'Superwoman Syndrome', in which women would t r y to combine the i r overwhelming v a r i e t y of roles and r e s p o n s i b i l i t i e s : career/job, wife, mother, volunteer, daughter, and so fo r t h . THE CHOICE TO BE CHILDFREE Procreation as a fundamental aspect of marriage continues to be a basic p r i n c i p l e of most major r e l i g i o n s . For example, within the Catholic church, a marriage contracted with the intention of remaining c h i l d f r e e is not v a l i d in the eyes of God (Veevers, 1980). Pohlman (1970) suggests that "the worship of parenthood and the horror of childlessness rest squarely on the Judaeo-Christian t r a d i t i o n " (p. 8). The underlying premise related to the decision of whether or not to have childre n i s the option or rig h t to choice. Choice i s considered a fundamental aspect of happiness and posi t i v e mental health (Bombardieri, 1981). Feldman (1981) states that choice may be one of the most s i g n i f i c a n t factors of one's l e v e l of s a t i s f a c t i o n with a l i f e s t y l e d ecision and that t h i s s a t i s f a c t i o n i s evident i n both groups of people who have chosen to have or not to have ch i l d r e n . The key i s that these people chose the l i f e s t y l e they wanted. The decision not to have children i s appealing to a growing minority of i n d i v i d u a l s . This choice gives people the freedom of an adult-oriented l i f e s t y l e as opposed to a child-centered one. U n t i l recently, the decision to be ch i l d f r e e was generally applicable only to married women and men because for the most part, single people did not v o l u n t a r i l y choose to parent (Veevers, 1979). However, more recently, single i n d i v i d u a l s and individuals in non-married re l a t i o n s h i p s have had greater options to adopt childre n and have t h e i r own ch i l d r e n . Two decision making patterns on how women decide to have children have been suggested (Whelan, 1975). The f i r s t pattern outlines two processes women may follow. One process i s by making a conscious decision to not have chi l d r e n ; t h i s decision i s often made early and may be a c r i t e r i o n for r e l a t i o n s h i p s and marriage. The second process i s more of a non-decision when a woman believes she w i l l have childre n but re g u l a r l y postpones pregnancy. Eventually, these women reach a time when i t i s either too late from a b i o l o g i c a l perspective or other p r i o r i t i e s have been established that make motherhood a less r e a l i s t i c or a t t r a c t i v e choice. The second pattern often involves four phases of dec i s i o n -making. The f i r s t phase is the postponement of the decision; the next phase i s a vague plan to have children eventually but probably only one; the t h i r d phase is the growing h e s i t a t i o n about having chil d r e n ; and the f i n a l phase is the decision not to have c h i l d r e n . IMPLICATIONS FOR SOCIAL POLICY It i s suggested that s o c i a l p o l i c y i n i t i a t i v e s have not adequately responded to the s p e c i f i c needs of women as in d i v i d u a l s . Instead the focus has been a response to women's needs in r e l a t i o n to others, p a r t i c u l a r l y family members. Sapiro (1986) states, " s o c i a l p o l i c y has supported individualism, independence, and s e l f - r e l i a n c e for some people (primarily men) and dependence and reliance on paternalism for others (primarily women). This i s l a r g e l y because indivi d u a l s have been viewed in terms of functional r o l e s depending upon gender" (p. 227). For women choosing not to have children, the t r a d i t i o n a l focus of s o c i a l p o l i c y directed at women may be i r r e l e v a n t . As the trend to not have childre n continues, t h i s w i l l have a s i g n i f i c a n t impact on s p e c i f i c p o l i c i e s such as those related to reproductive choice. SOCIAL POLICY ON REPRODUCTIVE CHOICE The issue of reproductive choice h i t s at the very core of basic issues a f f e c t i n g women who have chosen not to have ch i l d r e n . F i r s t is the question of safe and r e l i a b l e b i r t h c o n t r o l . Those forms of b i r t h control which are the most e f f e c t i v e , also carry the greatest health r i s k s . These health r i s k s prevent many women from choosing or being able to use these contraceptive methods. Other, less e f f e c t i v e but less harmful methods of contraception are available such as the diaphragm and condom, but they increase the r i s k of pregnancy. With the f a i l u r e of any type of b i r t h c o n t r o l , abortion as a back up method of contraception becomes important (Rich, 1986). Therefore, p o l i c i e s on a c c e s s i b i l i t y to and safe methods of contraception and abortion are important, p a r t i c u l a r l y for sexually active women who do not want to have ch i l d r e n . Acknowledging a woman's rig h t to choose whether or not she wants to have children requires an acceptance of the view that women's primary purpose does not involve being a mother. H i s t o r i c a l l y , women's primary function has been to bear and care for c h i l d r e n and recognizing a woman's rig h t to pursue other, more 'non-traditional' goals also means questioning the very foundation of p a t r i a r c h a l ideology. Many women involved with the feminist movement believe that the oppression of women stems from t h e i r lack of control over t h e i r own bodies, s e x u a l i t y and reproductive powers (Ashton & Whitting, 1987). Choosing not to have children i s but one aspect of women having control over t h e i r own bodies. Complete choice with respect to children requires complete access to r e l i a b l e and safe methods of contraception and to abortion. ABORTION In Canada, in 1969, the government l e g a l i z e d abortion for the f i r s t time under three conditions. The government required that an abortion be performed in an accredited hospital and by a licensed physician. The t h i r d condition required that an abortion be approved by a Therapeutic Abortion Committee, composed of a minimum of three physicians, which could approve the request i f the pregnancy was l i k e l y to endanger the l i f e and health of the woman (Dubinsky, 1985 & Rapp, 1981). This law (Section 251 of the Canadian Criminal Code) allowing access to abortion under c e r t a i n circumstances gave r i s e to the abortion movement which has seen two di a m e t r i c a l l y opposed groups attempting to change the law. McDonnell (1984) summarizes the problem: It became grimly clear in the succeeding years that women in Canada did not win the rig h t to abortion in 1969. The government's own Badgley Commission, set up in 1976 to examine the workings of the abortion law found i t to be unworkable, a bureaucratic obstacle course that endangered women's health by prolonging the approval process and increasing t h e i r anxiety about the outcome. By the late 1970's, due to growing pressure from the anti-abortion movement and a p o l i t i c a l climate generally less favourable to women's ri g h t s , access to abortion had a c t u a l l y dropped a l l across the country, (p. 19) In 1969, the Canadian law on abortion resulted In the problem of delayed abortions so that u n t i l 1988, Canada had the second highest rate of second trimester abortions in the world, second only to India (Singer, 1984). Greer (1984) explains why delayed abortions became more frequent by st a t i n g : The e f f e c t of a l l controls on the number of abortions car r i e d out...is to lengthen unwanted pregnancies and to make t h e i r termination more problematic than i t need be....In any other case the muddle and delay which r e s u l t in second trimester terminations would be considered highly unethical. Any p r a c t i t i o n e r who refuses a minor operation in the f u l l knowledge that as a r e s u l t a few weeks l a t e r a major operation with general anesthesia w i l l be necessary is not acting in the patient's best i n t e r e s t , (p. 219) The high rate of second trimester abortions suggests that society in general, and the medical profession in p a r t i c u l a r , has a great deal of d i f f i c u l t y allowing women to make t h e i r own decisions related to pregnancy. Underlying the delay t a c t i c s may be the idea that women w i l l change t h e i r minds about having an abortion. This implies a lack of respect for the decision-making process a woman w i l l have already undergone. In addition, the increased r i s k in delaying an abortion indicates a diminished regard for the health and safety of Canadian women. In January, 1988, the Supreme Court of Canada struck down the abortion law of 1969 declaring i t unconstitutional with respect to the Canadian Charter of Rights and Freedoms. This decision was in response to Dr. Henry Morgentaler's appeal of a lower Court's decision that found him g u i l t y of performing abortions outside the regulations set in Section 251 of the Criminal Code. The Court, in t h e i r f i v e to two decision, found that Section 251 of the Criminal Code was "unconstitutional because i t v i o l a t e d a woman's ri g h t to ' l i f e , l i b e r t y and s e c u r i t y of the person" 1 (Day & Persky, 1987, p. 13). This decision, and the abortion issue as a whole, raises the question of whether "women are autonomous, independent persons or, as Madame Justice Wilson says, 'passive recepients of a decision made by others as to whether [their bodies are to be used to nurture new l i f e ] ' " (Day & Persky, 1987, p. 180). Since that time, access to abortion has been haphazard depending on where in the country a woman l i v e s as well as on her a b i l i t y to pay for an abortion. Attempts to bring in new l e g i s l a t i o n to address the abortion question have subsequently f a i l e d and at t h i s time, abortion i s le g a l but inc o n s i s t e n t l y accessible both economically and geographically. Currently in B r i t i s h Columbia, abortions are performed at some hospita l s , such as the Vancouver General Hospital, and at the freestanding abortion c l i n i c , Everywoman's Health Centre, in Vancouver. Access to abortion continues to be a problem for women in r u r a l areas of the province. Sumner (1985) outlines three possible s o c i a l p o l i c i e s with respect to abortion. A permissive p o l i c y would place no r e s t r i c t i o n s on a woman's access to abortion and would treat i t as a s u r g i c a l procedure with relevant guidelines. A r e s t r i c t i v e p o l i c y would view abortion as an act of homocide with perhaps the only exception being when a woman's l i f e was in danger. However, t h i s exception i s not always supported by a l l who would l i k e the r e s t r i c t i v e p o l i c y adopted. A moderate p o l i c y would attempt to fin d some middleground between the permissive and r e s t r i c t i v e guidelines by permitting abortion under s p e c i f i c circumstances. The most commonly considered conditions are the length of pregnancy and the reasons for wanting an abortion. U n t i l January, 1988, Canada had a moderate p o l i c y on abortion. From a feminist perspective, decisions related to reproductive choice represent a woman's ri g h t to s e l f -determination and autonomy. Women have had too few opportunities to make t h e i r own decisions with respect to th e i r bodies. Access to abortion may be the ultimate step of women's autonomy when male permission i s not required (Degler, 1980). However, because of the involvement of the medical community in the abortion decision-making process, male involvement s t i l l e x i s t s . For example, "a pro-feminist male doctor who works with pregnant teenagers has said...he believes [ b i r t h control] p i l l s should be f r e e l y available over the counter, with [information] printed on the container, [but] that p i l l s remain a p r e s c r i p t i v e substance because doctors hate to r e l i n q u i s h control over t h e i r female patients* bodies" (Morgan, 1970, p. 251). Perhaps the same viewpoint can be stated with respect to male doctors' involvement in the decisions concerning abortion. VOLUNTARY STERILIZATION S t e r i l i z a t i o n , in the form of tubal l i g a t i o n for women, i s also of relevance to c h i l d f r e e women. Rather than deal with the health and r e l i a b i l i t y r i s k s associated with many methods of contraception, some women may choose to be s t e r i l i z e d . However, a v a r i e t y of p o l i c i e s and decision-making bodies have made i t d i f f i c u l t for women to make an autonomous decision about having a tubal l i g a t i o n . In what is c l e a r l y an example of p a t e r n a l i s t i c and possibly p a t r i a r c h a l p o l i c y a f f e c t i n g women who choose not to have chi l d r e n , Burgwyn (1981) describes the s i t u a t i o n of a thirty-one year old woman in North Carolina in the 1970's who not only needed her husband's consent but also her parents' consent to be s t e r i l i z e d . The question of tubal l i g a t i o n for c h i l d f r e e women raises the problem of how we ensure that c h i l d f r e e women have complete access to and decision-making power about tubal l i g a t i o n while also ensuring that other women, p a r t i c u l a r l y disabled women, poor women, and women of colour are not coerced or manipulated to have a tubal l i g a t i o n against t h e i r w i l l . In 1981, s t a t i s t i c s on the involuntary s t e r i l i z a t i o n of minority women indicated that 54% of teaching hospitals in North America continued to require that a woman consent to be s t e r i l i z e d in order to obtain an abortion (Rich, 1986). This i s further supported by the Boston Women's Health Book C o l l e c t i v e (1984), "since 1974, women have revealed and studies have documented a t e r r i b l e pattern of s t e r i l i z a t i o n abuse. Victims of s t e r i l i z a t i o n abuse are usually poor or black, Puerto Rican, Chicanb or Native American..." (p. 257). Therefore, the challenge for society, and p a r t i c u l a r l y for women, is to bring about a greater l e v e l of freedom of choice for a l l women with respect to a l l aspects of reproductive choice. Unfortunately, some dissension has grown within the feminist movement in t h i s struggle. Rich (19 86) states, many white feminists (have not understood) that the f a c i l i t i e s for ' s t e r i l i z a t i o n on demand' with no waiting period, could and did e a s i l y turn into s t e r i l i z a t i o n abuse i f a woman was dark-skinned, was a welfare c l i e n t , l i v e d on a reservation, spoke l i t t l e or no English, was a woman whose i n t e l l i g e n c e and capacity to judge for herself were assumed to be below par for any of the above reasons, (p. xxi) It i s important to be aware that s t e r i l i z a t i o n abuse i s not a new development. "Beginning in the nineteenth century, people known as 'eugenicists' t r i e d to popularize the idea that s o c i a l problems such as crime and poverty could be eliminated by preventing c e r t a i n 'u n f i t ' people from having children....Eugenicists urged the passage of laws empowering the state to s t e r i l i z e such individuals against t h e i r w i l l " (Boston Women's Health Book C o l l e c t i v e , 1984, p. 256). Veevers (1980) notes that while l e g a l l y a l l adults have the ri g h t to s t e r i l i z a t i o n , many physicians are a c t u a l l y reluctant to s t e r i l i z e women who are c h i l d f r e e , p a r t i c u l a r l y those who are white and middle c l a s s . This i s in part due to the fact that there is more acceptance for a temporary decision not to have childre n than for a permanent decision and, s t e r i l i z a t i o n , of course, i s , for the most part, permanent. However, when one considers the length of time a woman needs to take precautions with respect to contraception and the r i s k s associated with a v a r i e t y of contraceptive methods, i t is understandable that some women would choose a more permanent method. The problem as Veevers (1980) describes i t , is that in practice the control of f e r t i l i t y seems to be subject to u n i l a t e r a l decisions made by a physician rather than by the i n d i v i d u a l . Roberts (1985) in her extensive study of interviews with women patients and th e i r physicians found s i g n i f i c a n t evidence of a power imbalance i n th e i r r e l a t i o n s h i p . Doctors and patients a l i k e might be shocked at the suggestion that the doctor-patient r e l a t i o n s h i p i s a power r e l a t i o n s h i p . It is only when confronted as a patient with the a b i l i t y of the doctor to define, to make decisions, to reveal or not to reveal information about health matters which intimately a f f e c t ourselves ...that t h i s power becomes c l e a r , (p. 2) She further notes that "the power of reproduction...is as much in the doctor's province as in the (woman's)" (p. 5). Kaltr e i d e r & Margolis (1977) in th e i r study of th i r t y - t h r e e c h i l d f r e e women, f i f t e e n of whom chose tubal l i g a t i o n state that, "the p s y c h i a t r i s t i s often c a l l e d on to be a s o c i a l decision maker in the case of a young woman seeking s t e r i l i z a t i o n . Our follow-up study suggests that the decision of our sample of women not to bear children was based on an acute and responsible awareness of an i n a b i l i t y to mother" (p. 182). These comments rais e two points. The f i r s t i s that the decision-making power is removed from the woman and placed with a p s y c h i a t r i s t . The second point r e l a t i n g to the authors' use of the word ' i n a b i l i t y ' i s that there i s an implication that women choose not to have children because they are unable to be a mother as opposed to not wishing to be a mother (Veevers, 1980). Physicians have not escaped the h i s t o r i c a l l y s o c i e t a l view that women's primary role i s to mother. For example, a r e l a t i v e l y recent medical textbook used in t r a i n i n g physicians states, "the vast majority of women have a basic need to have a home and children of the i r own." (Craddock, 1976). As b i o l o g i c a l context. Roberts (1985) notes, t h i s assumption confuses information about women with t h e i r s o c i a l Two research studies have documented the images of women found in gynecology textbooks. The f i r s t analyzed the sex i s t content in 27 textbooks published between 1943 and 1972 (Scully & Bart, 1973). The authors concluded that these books continued to uphold the image of women of the la s t 125 years, that of pr i m a r i l y a c h i l d producer, homemaker, and husband pleaser. The second research study (Elder, Humphreys, Laskowski, 1988) evaluated 28 gynecology textbooks from 1978 to 1983. The authors concluded that, "although there have been e f f o r t s on the part of some authors to move to an e g a l i t a r i a n and non-sexist stance, approximately one quarte (one t h i r d of the more basic generalized texts) s t i l l have sections r e f l e c t i n g t r a d i t i o n a l sex-role stereotypes, paternalism, or misogynist a t t i t u d e s . " (p. 1) These two research studies on the images of women found in gynecological textbooks have s i g n i f i c a n c e for c h i l d f r e e women who seek medical a l t e r n a t i v e s to support t h i s d e c i s i o n . Considering that many present day gynecologists have had some of these negative stereotypes reinforced for them in th e i r medical t r a i n i n g , i t does not bode well for c h i l d f r e e women who want to make autonomous decisions about contraception, abortion, and tubal l i g a t i o n . Furthermore, S c u l l y & Bart (1973) found that there was greater concern for the patient's husband than the patient herself in many of the texts, creating the d i f f i c u l t y which women experience in making independent decisions which w i l l be accepted and respected by th e i r physicians. Such independent decision-making is p a r t i c u l a r l y relevant to the issue of tubal l i g a t i o n because of the general permanency of the procedure and the f i n a l i t y for c h i l d f r e e women to not have c h i l d r e n . This may be a more uncomfortable prospect for the medical professionals involved with the woman than for the woman who i s committed to her choice to not have ch i l d r e n . This may also explain why many physicians have h i s t o r i c a l l y involved a p s y c h i a t r i s t in the decision-making process for c h i l d f r e e women requesting a tubal l i g a t i o n . Lindenmayer, Steinberg, Bjork, and Pardes (1977) studied seven c h i l d f r e e women in th e i r twenties who had requested s u r g i c a l s t e r i l i z a t i o n . They note that the women "were also made aware that the p s y c h i a t r i s t ' s recommendation for or against the procedure would not necessarily have to be followed by the gynecologist, in whose hands the ultimate decision lay" (p. 88). It is important to note that i t was stated that the f i n a l decision would be made by the gynecologist as opposed to the woman involved. H i s t o r i c a l l y , women have been assessed for s t e r i l i z a t i o n s u i t a b i l i t y based on a formula of using the number of chil d r e n they have and th e i r age (Lieberman et a l , 1979). For example, a woman under the age of f o r t y , requesting a tubal l i g a t i o n , could be required to have at least three c h i l d r e n to be considered for the surgery. However, such an assessment is not without c r i t i c i s m . A woman who t o t a l l y r e j e c t s motherhood i s thought by society to be t r u l y deviant. I think i t is presumptuous of us as health care professionals to determine who may or may not opt for control of reproductive p o t e n t i a l , even i f the control i s by s t e r i l i z a t i o n , when we are not the ones who must deal with the consequences of not having that c o n t r o l . (Lieberman et a l , 1979, p. 183) Cer t a i n l y , the physician-patient r e l a t i o n s h i p and the power within that r e l a t i o n s h i p i s viewed as the source of much of the d i f f i c u l t i e s women have with respect to making decisions a f f e c t i n g t h e i r reproductive choices. Some suggest that the root of the problem l i e s with the attitudes of physicians and the t r a i n i n g and influence within t h e i r own profession. S c u l l y states, "the t r a i n i n g process prepares the surgeon to gain the patient's t r u s t and confidence p r i m a r i l y for the purpose of c o n t r o l l i n g or 'managing' her, and. then to manipulate her into doing something the physician wants her to do - undergoing surgery, for example" (p. 78). In the example of c h i l d f r e e women seeking a tubal l i g a t i o n , t h i s may work in reverse. Neale (1981) suggests why i t is important for women to f u l l y p a r t i c i p a t e in the medical decision-making process. " F i r s t , p a r t i c i p a t i o n r e f l e c t s and respects (a patient's) autonomy, i . e . , a b i l i t y to i d e n t i f y and to pursue goals and objectives they have set for themselves. Decisions about medical care, e s p e c i a l l y about surgery, a f f e c t not only the physical i n t e g r i t y , but also the well-being of the whole person" (p. 45). Furthermore, a second important reason for, patient p a r t i c i p a t i o n i s that "decisions are based on more than b i o l o g i c a l information and laboratory values. They also involve important considerations of the patient's own l i f e plan" (p. 45). This l a t t e r reason has p a r t i c u l a r s i g n i f i c a n c e for c h i l d f r e e women who want a tubal l i g a t i o n because the decision they have made i s very much in the context of t h e i r l i f e goals and experiences. CONCLUSION The issue of access to contraception, abortion, and voluntary s t e r i l i z a t i o n for c h i l d f r e e women is important at a c l i n i c a l l e v e l , an i n s t i t u t i o n a l l e v e l , and at a s o c i e t a l l e v e l . Attitudes, experiences, and t r a i n i n g a l l impact the p o l i c i e s found at each of these l e v e l s . Few issues have had the l e v e l of attention given to them as the issue concerning women and th e i r reproductive r e s p o n s i b i l i t i e s . Any attempt to change what has been h i s t o r i c a l l y expected of women i s , as the l i t e r a t u r e suggests, a challenge for a society that has only begun to acknowledge that not a l l women want to have ch i l d r e n . RESEARCH DESIGN This research study has incorporated elements of t r a d i t i o n a l q u a l i t a t i v e research methodology with elements of feminist research methodology. A q u a l i t a t i v e research approach i s an approach that allows the researcher to gain insight and "understand the r e a l i t y of people's l i v e s " (Lord, Schnarr, & Hutchinson, 1987, p. 26). Furthermore, "an individual's perceptions, b e l i e f s , f e e l i n g s , experience, and behaviours constitute the most important unit of analysis and understanding in any contemporary s o c i a l s c i e n t i f i c endeavour" ( E s t r o f f , 1981, p. 37). The n a t u r a l i s t model of research has been used and is one in which the research r e s u l t s decide the theory as opposed to the theory deciding the research (Stanley & Wise, 1983). This approach allows for greater p a r t i c i p a t i o n on the part of the interviewer (Bernard, 1973). In addition, t h i s model can f a c i l i t a t e a more relaxed r e l a t i o n s h i p between the interviewer and interviewee and strengthens the v a l i d i t y of the study (Patton, 1980). Feminist research methodology respects and values the experiences of women and "uses these experiences as a s i g n i f i c a n t indicator of the ' r e a l i t y ' against which hypotheses are tested" (Harding, 1987, p. 5). Feminist research requires that the researcher consider both feminist theory and methodology and how these can be applied to feminist practice with i n d i v i d u a l s , organizations and p o l i c y i n i t i a t i v e s . Roberts (1981) states that "feminist research,... is concerned not only with making women v i s i b l e , but with t h e o r e t i c a l and methodological issues, with problems of sexual d i v i s i o n s in the research team and the research process, and with the language of research findings and the way in which these may be used when they are : published" (p. 26). This research topic was chosen by the researcher, in part, because of a personal interest in the subject matter. As a woman who has chosen not to have children, I have experienced some of the pressures from others related to the decision as well as d i f f i c u l t i e s in accessing information about health issues important to the decision. As a r e s u l t , I was interested in discovering to what extent other women had had si m i l a r experiences. A feminist approach has been chosen for t h i s research because of the relevance of feminist theory to reproductive health issues and because of the appeal to the interviewer of a feminist interviewing s t y l e . The data obtained from c h i l d f r e e women and community groups/professionals was analyzed from a feminist perspective in terms of women's choices and what i s needed for women to be able to make these choices. Feminist research methodology, l i k e feminist theory, involves a wide range of perspectives, not a l l of which are mutually exclusive. Therefore, in thi s research study, the methodology has incorporated appropriate elements of d i f f e r e n t feminist research perspectives. For example, i t was e s s e n t i a l that the interviews be conducted in such a manner as to encourage a natural dialogue within the framework of the interview. SAMPLE The population studied was women, partnered or unpartnered, who had made the decision not to have c h i l d r e n . Only women who had made a decision not to parent were included. Therefore, the following populations were excluded: women who are b i o l o g i c a l l y unable to have chil d r e n ; women who are parenting c h i l d r e n who are not b i o l o g i c a l l y t h e i r own; and women who are s t i l l uncertain about whether or not they want to have c h i l d r e n . These exceptions were assessed prior to a parti c i p a n t ' s commitment to the research process. The sample of c h i l d f r e e women was drawn through a non-random se l e c t i v e approach by advertising, word of mouth, use of professional women's organizations, community agencies and through the interviewer's s o c i a l work f i e l d placement, the U.B.C. Women's Resources Centre. S p e c i f i c a l l y , 35 advertisements were placed with the Mature Women's Network and the U.B.C. Academic Women's Association. An advertisement example i s found in Appendix A. In addition, No Kidding, a group for indivi d u a l s without children was approached for p a r t i c i p a n t s . The sample of community agency representatives and professionals was drawn through a non-random s e l e c t i v e approach. The following participants were included: a representative of an anti-abortion organization, a member of the Women's Health C o l l e c t i v e , a s t a f f member of Planned Parenthood of B.C., a physician in general practice, and a lawyer f a m i l i a r with the leg a l issues pertaining to medical consent. I M P L E M E N T A T I O N INTERVIEWS WITH CHILDFREE WOMEN In t h i s study, the interviewer engaged in a structured interview with each of ten women who had made the decision not to have children, and examined th e i r experiences as they r e l a t e to s o c i a l p o l i c y on abortion and voluntary s t e r i l i z a t i o n . "A feminist interviewing women is by d e f i n i t i o n , both 'inside' the culture and p a r t i c i p a t i n g in that which she is observing" (Oakley, 1981, p. 57). Although the interviews had some structure to them, the interviewer attempted to encourage as informal a dialogue as possible. A nonscheduled, standardized interview approach was u t i l i z e d - s p e c i f i c questions c o n s i s t e n t l y used, with the interviewer being able to rephrase, follow-up or change the order (Monette, S u l l i v a n & Dejong, 1986). Some structure was u t i l i z e d in order to ensure that key issues of importance were addressed during the interview. The complete interview schedule can be found in Appendix B. However, i t was also important to ensure f l e x i b i l i t y in order that the interviewer was able to further explore other unexpected topics which surfaced during the interview (Patton, 1980). Questions focussed on the subjects' experiences, a t t i t u d e s , and feelings as c h i l d f r e e women as they related to reproductive choice access and p o l i c y issues. Closed-ended and open-ended questions were used for these questions as well as for obtaining demographic data (Reid & Smith, 1981). The interviewer added observational data to the responses. This type of interview allowed for a general systematic approach to the data c o l l e c t i o n process while s t i l l allowing the interview to be conversational and natural rather than r i g i d . However, the l e v e l of structure may have decreased opportunities for the interviewee to share spontaneous information which otherwise might not have come up in the interview (Patton, 1980). Furthermore, a v a r i e t y of other relevant issues e x i s t for c h i l d f r e e women but i t was thought that in order to focus on those issues of relevance to the research, some structure was needed in the interview questions. Two pre-test interviews with c h i l d f r e e women were completed prior to the formal data c o l l e c t i o n . From these interview experiences, minor changes were made to questions. However, more importantly, practice at introducing the research topic to the p a r t i c i p a n t as well as prefacing some of the more s i g n i f i c a n t questions was gained. In addition, the interview questions were presented to several peers in a q u a l i t a t i v e research class and some changes were made based on t h e i r feedback. Oakley (1981) emphasizes the importance of a non-h i e r a r c h i c a l r e l a t i o n s h i p between the interviewer and interviewee in order to approach the interview with as much care and respect as possible. "If the interviewee doesn't believe s/he i s being kindly and sympathetically treated by the interviewer, then s/he w i l l not consent to be studied and w i l l not come up with the desired information" (p. 33). Therefore, It becomes es s e n t i a l for the Interviewer to be aware of her power as the 'expert' on the subject matter and as the i n f o r m a t i o n seeker. In order to balance t h i s power d i f f e r e n t i a l , i t i s important f o r the i n t e r v i e w e r to share i n f o r m a t i o n about h e r s e l f so t h a t the r e l a t i o n s h i p i s not com p l e t e l y one-sided (Oakley, 1981). During the i n t e r v i e w s with c h i l d f r e e women, the i n t e r v i e w e r e x p l a i n e d her p e r s o n a l reasons f o r doing t h i s r e s e a r c h and her own d e c i s i o n r e l a t e d to having c h i l d r e n . In a d d i t i o n , the i n t e r v i e w e r answered any q u e s t i o n s asked by the p a r t i c i p a n t s . A l l of the i n t e r v i e w s were conducted i n one of thr e e s e t t i n g s : the i n t e r v i e w e r ' s home, the i n t e r v i e w e e ' s home, or the i n t e r v i e w e e ' s p l a c e of work. The i n t e r v i e w s with c h i l d f r e e women l a s t e d on average, one hour and a l l were audi o t a p e d . Each i n t e r v i e w was t r a n s c r i b e d and checked f o r acc u r a c y . A l l i n t e r v i e w s were coded by the i n t e r v i e w e r with some input from the t h e s i s a d v i s o r . L o r d , Schnarr, & Hutchinson (1987) suggest t h a t t h i s approach broadens the scope of a n a l y s i s of the i n t e r v i e w s . At the end of each i n t e r v i e w , the i n t e r v i e w e r summarized s i g n i f i c a n t a s p e c t s of the i n t e r v i e w , both in,terms of what was s a i d and o b s e r v a t i o n a l data noted. T h i s i n f o r m a t i o n was a supplement to the t r a n s c r i p t i o n s of each i n t e r v i e w . INTERVIEWS WITH COMMUNITY AGENCIES/PROFESSIONALS The i n t e r v i e w s with community o r g a n i z a t i o n r e p r e s e n t a t i v e s and p r o f e s s i o n a l s were l e s s s t r u c t u r e d because of the range of knowledge of the p a r t i c i p a n t s . A s e r i e s of q u e s t i o n s was formulated, not a l l of which were asked of a l l p a r t i c i p a n t s . The i n t e r v i e w schedule can be found i n Appendix C. These i n t e r v i e w s f o l l o w e d a s i m i l a r p a t t e r n to those done with c h i l d f r e e women i n terms of having some s t r u c t u r e to the i n t e r v i e w but s t i l l a l l o w i n g f o r enough f l e x i b i l i t y t h a t the i n t e r v i e w e r was abl e to e x p l o r e other unexpected t o p i c s which s u r f a c e d d u r i n g the i n t e r v i e w . Questions were g e n e r a l l y open-ended and focussed on those areas of the r e s e a r c h q u e s t i o n s a p p r o p r i a t e to the p a r t i c i p a n t . For example, the lawyer addressed q u e s t i o n s r e l a t e d t o the l e g a l a s p e c t s of o b t a i n i n g consent f o r a medical procedure and the r e p r e s e n t a t i v e of Planned Parenthood addressed q u e s t i o n s about access and a t t i t u d e s to c o n t r a c e p t i o n , a b o r t i o n , and v o l u n t a r y s t e r i l i z a t i o n , from a community agency p e r s p e c t i v e . Four of the i n t e r v i e w s were completed i n the workplace of the p a r t i c i p a n t s ; the f i f t h i n t e r v i e w was completed on the telephone. The i n t e r v i e w s l a s t e d on average, ap p r o x i m a t e l y f o r t y - f i v e minutes, and three of the f i v e i n t e r v i e w s were aud i o t a p e d . V A L I D I T Y AND R E L I A B I L I T Y The degree of v a l i d i t y in q u a l i t a t i v e research i s the extent to which the interview captures the part i c i p a n t ' s frame of reference. Patton (1980) states that t h i s i s most c l e a r l y done with the most open-ended questions possible. Therefore, i t i s c r i t i c a l that the respondent f e e l able to answer the questions in what ever way s/he pleases. The s p e c i f i c questions on reproductive choice issues and ch i l d f r e e women were open-ended. Questions were asked of ch i l d f r e e women about t h e i r personal experiences with contraception, s t e r i l i z a t i o n , pregnancy, and abortion. No assumptions were made in the questions and the respondent had complete freedom to answer how she chose; according to Patton (1980) t h i s would provide greater v a l i d i t y . Patton (1980) also recommends that demographic questions be scattered throughout the interview as opposed to being asked a l l at once in order to prevent the interviewee from forming the habit of answering questions b r i e f l y . Only a few demographic questions were asked in interviews with c h i l d f r e e women and these were placed at the beginning, the middle, and the end of the interview as appropriate. V a l i d i t y may also be affected in terms of the interviewer's influence on the interviews and subject matter in general. As a woman who has also chosen not to have chi l d r e n , my opinions and value judgements could enter into the interview. In addition, interviewing women in a feminist context also meant that the interview became more of a dialogue and that i t was appropriate and encouraged #for the interviewer to share of her s e l f . However, i t i s s t i l l possible to share of oneself and also ask questions in such a way that the respondent i s encouraged to f r e e l y answer. R e l i a b i l i t y considers the consistency of the interviewer(s) in terms of the ef f e c t s an interviewer has on the process. Only one interviewer was used for t h i s research and the same format of questioning was followed. However, some d i f f e r e n t questions were asked of d i f f e r e n t respondents and these were based on the information a respondent gave to a previous question. R e l i a b i l i t y was affected in the sense that these questions varied by interview but the same interviewer was involved which afforded greater consistency. R E S U L T S STRATEGY OF ANALYSIS Based on the l i t e r a t u r e review, a v a r i e t y of research questions (noted e a r l i e r ) were formulated with the goal of exploring relevant issues, not adequately addressed in ex i s t i n g research, with the women and representatives of community groups and professionals interviewed. The focus of t h i s research was to ascertain what aspects of access to contraception, abortion, and tubal l i g a t i o n were important to c h i l d f r e e women and relate t h i s information to the information obtained from selected individuals in the community. While the research brought out some of the dimensions important to access to reproductive choice, i t also considered the process of decision-making from the perspective of the women themselves and from the perspective of the ind i v i d u a l s in the community. The data analysis of the interviews with c h i l d f r e e women was done with a system of coding that considered the data from each woman as a whole as well as analyzing a l l of the pa r t i c i p a n t s ' responses to one question. Thus, answers to each question were grouped according to whose information i t was. Substantive coding was completed with each question of each Interview with primary codes defined in t h i s manner (Glaser, 1978). Substantive codes were coded with t h e o r e t i c a l codes defined for f i n a l a n a l y s i s . Data from interviews with individuals from community groups and professionals was coded in a si m i l a r manner to that from the interviews with c h i l d f r e e women. Substantive and th e o r e t i c a l codes were defined for an a l y s i s . INTERVIEWS WITH CHILDFREE WOMEN Demographics The ten par t i c i p a n t s in t h i s study ranged in age from 32 to 59; two were married, three were in a common-law re l a t i o n s h i p having been married before, one was in a common-law r e l a t i o n s h i p and had never been married, two were single having been divorced, one was single and one did not want her marital status noted because she does not "approve of r e l a t i n g women to marriage because . . . i t c a r r i e s much more weight for women than for men". Five of the women had had a tubal l i g a t i o n , four women considered s t e r i l i z a t i o n and discussed i t with t h e i r physician, and one woman's partner had a vasectomy. Two women had had an abortion. A l l of the women had completed a minimum of grade twelve education with seven of the ten having completed an undergraduate u n i v e r s i t y degree and three of these seven possessing a post-graduate u n i v e r s i t y degree. Paid employment varied among the group with three women teachers or r e t i r e d teachers, two women who are s e l f -employed as consultants in d i f f e r e n t f i e l d s , one woman who Is a s o c i a l worker, one a dental hyglenist, and one who is f i n i s h i n g a Master of Business Administration degree and is employed in the occupational health f i e l d . Two of the women are employed in c l e r i c a l p o s i t i o n s . The average i n d i v i d u a l income was $29,000 with the highest at $50,000 and the lowest at $16,000. For those women who described themselves as partnered, j o i n t income ranged from $40,000 to $100,000. Two of the women had made a recent commitment to formalized r e l i g i o n . Another woman was seeking a s p i r i t u a l path in her l i f e . A l l of the women were able-bodied, heterosexual, and Caucasian. Reasons For Choosing Not To Have Children Although the primary focus of t h i s research was on the issue of reproductive choice as i t relates to c h i l d f r e e women, information was also obtained from the women about th e i r decision-making process of whether or not they wanted to have c h i l d r e n . It was f e l t that t h i s data was important in order to e s t a b l i s h some background information about the women and provide a context for the more s p e c i f i c research questions related to attitudes toward and experiences with contraception, abortion, and s t e r i l i z a t i o n as c h i l d f r e e women. For many of the women, the decision to not have childre n evolved over a long period of time. It was not a question of when they would have childre n but ii_ they would have chil d r e n , depending upon a va r i e t y of circumstances in th e i r l i v e s . One woman stated, "I'm not sure i f i t was a decision. I think I could always have examined i t , year by year. But i t was something, perhaps given the circumstances, that I just did not want to do." Another woman commented on the process as something that evolved, "I don't think that there was a point where I a c t u a l l y decided, no, I would not....But i t just was sort of there a l l the time that i t wouldn't happen for me." A t h i r d woman commented that having children was something that she and her partner "kept putting o f f " u n t i l i t reached a time when they both f e l t r e a l l y comfortable with not having children and the f i n a l decision was made. Several of the women could r e c a l l the approximate time when they began to wonder whether or not they would have childre n and t h i s time varied from teenage years, through to the i r late twenties and ear l y t h i r t i e s . Half of the women chose to make a f i n a l decision in t h e i r late twenties or ear l y t h i r t i e s by e l e c t i n g to have a tubal l i g a t i o n . Some of the women made th e i r decision about childr e n during a time when they were not in a re l a t i o n s h i p while others included t h e i r partner in the decision. One woman stated, "It's the sort of thing you discuss before you get married." For one woman, her decision to not have ch i l d r e n was a major reason that her marriage subsequently ended. Contraception A l l of the women had some experience with at least one pharmaceutical method of contraception. Seven of the ten women had used oral contraception with varying degrees of success. Other methods of contraception used by one or more women included condoms, diaphragms, abstinence, the dalkon s h i e l d , and intrauterine devices. Six women expressed concerns about being on the p i l l or reasons why they could not use that method of contraception. One woman, who used the p i l l during the ear l y 1960's, described her experience, "I couldn't climb s t a i r s except one at a time. They refused to admit that i t had anything to do with the p i l l and wanted me to see a p s y c h i a t r i s t . " Other women expressed concern that there was s t i l l too l i t t l e known about the p i l l and the long term consequences of using i t , "I always f e l t there wasn't enough known about (the p i l l ) . . . a n d the impact of i t . I think that they are researched very poorly." For other women, using the p i l l for an extended period of time was not a problem. Four women stated that they could not r e c a l l any negative side e f f e c t s from the p i l l and one woman was a c t u a l l y reluctant to stop using the p i l l when she and her partner decided on s t e r i l i z a t i o n . The experience of being on the p i l l had been a pos i t i v e one for her and she was concerned that i f she stopped using the p i l l , new problems might surface, "I was a l i t t l e nervous because I f e l t so good and everything seemed ri g h t to me. I was worried about not being on the p i l l . My periods were good -I didn't experience pain or cramps." Four women made s p e c i f i c comments about t h e i r experiences with and expectations of using contraception. When asked about her sexual o r i e n t a t i o n , one woman commented that being heterosexual meant b i r t h control was that much more of an issue in her l i f e . Another woman had had enough of being the primary person to assume r e s p o n s i b i l i t y for b i r t h control in a r e l a t i o n s h i p and now f e l t that when she was in a r e l a t i o n s h i p , "I want the man to take some r e s p o n s i b i l i t y . " A t h i r d woman In speaking about her experiences accessing contraception during the 1960's believed that being married at that time made i t much easier for her to obtain b i r t h c o n t r o l . "I never had any trouble but then my f i r s t sexual experience was when I got married, i f that makes i t easier. It might have been more d i f f i c u l t i f I wasn't married or I might have been more self-conscious about I t . " F i n a l l y , a fourth woman commented that she did not believe she was able to make f u l l y informed decisions about which types of contraception she would use. Her experiences with her physician were such that she was not comfortable exploring her concerns about contraception with him and he never asked. Pregnancy Two women had been pregnant: one at the age of nineteen and one at the age of twenty-three. For one woman, the pregnancy was the r e s u l t of f a i l e d contraception and for the other woman, sexual intercourse occurred without her consent. One of the women experienced a great deal of trauma from the experience of being pregnant. In spit e of the fact that she did not consent to sexual intercourse, she blamed herself for what had happened. " I t seemed l i k e such a stupid thing that I had done." Being pregnant was very frightening for her p a r t i c u l a r l y because there was not a l o t of family support for her circumstances. While her father became aware of the pregnancy, they both agreed to keep the information from her mother and t h i s secrecy was very s t r e s s f u l for t h i s woman. Abortion A l l of the women were asked about t h e i r attitudes toward abortion and both of the women who had been pregnant shared t h e i r experiences with abortion. One of the women already knew at nineteen that she did not want to ever have ch i l d r e n and the unexpected pregnancy was p a r t i c u l a r l y d i f f i c u l t for her. The decision to have an abortion was straightforward in the sense that she was not aware of having other appropriate a l t e r n a t i v e s . The second woman who was pregnant decided to have an abortion because having a baby at that time was for her, out of the question. " I t was something I couldn't do. I was teaching; I knew I didn't want to stay with t h i s man or bring up a c h i l d by myself." Both women had t h e i r abortions within an atmosphere of secrecy. For one woman, sharing her s i t u a t i o n with other family members, other than her father, was out of the question. Her family, p a r t i c u l a r l y her mother, was unsupportive of abortion and t e l l i n g her about the abortion would have caused more emotional trauma for t h i s woman. Instead, she had the abortion with the support of her father and a physician who was "notoriously known for his poor bedside manner, which didn't help. He didn't say a word to me." The second woman had her abortion soon a f t e r the introduction of the Therapeutic Abortion Committee process. However, unaware of th i s option, she sought out a gynecologist who she paid to perform the abortion p r i v a t e l y . She was aware of a need to maintain secrecy about her choice because "I didn't want anyone to know. I f e l t so g u i l t y . " However, in retrospect, she would have preferred that the s i t u a t i o n be handled in a d i f f e r e n t way. "If I'd been supported through a s t a f f of people and gone to a h o s p i t a l . Not had i t in secret or as secret as I wanted i t . (But) had i t regarded as a normal procedure (that) women choose to do sometimes." The overwhelming pressure on women to prevent pregnancy was also evident in t h i s woman's experience. She commented, "I've made a mistake. I'm pregnant." Although she was using contraception at the time, she s t i l l i d e n t i f i e d the unwanted pregnancy as her mistake. A l l of the women interviewed supported the right of a woman to have an abortion i f that was her choice. However, not a l l of the women would necessarily have chosen that option for themselves i f they had had an unwanted pregnancy. One woman stated, "I thought I was against i t u n t i l my best f r i e n d was pregnant and had an abortion. I could understand her and so I can accept an abortion for someone else. I can say to you that that was her decision and that was a decision she needed to make. So I supported her in her choice to have an abortion. But for me, I don't know how I would f e e l about that. What I believe about abortion i s that a woman should have a choice." For another woman, the ri g h t for women to be able to have an abortion existed 'almost at an i n s t i n c t i v e l e v e l . She stated, "I also believe in l i f e and I don't r e a l l y know how to j u s t i f y i t other than i t just has to be the woman's deci s i o n . " Concern was expressed by some women that counselling needs to be an i n t e g r a l part of any woman's decision-making process with respect to an unwanted p r e g n a n c y T h i s i s equally important to ensure that a woman i s either choosing for herself to have the baby or i s choosing to have an abortion as opposed to being pressured from someone else to make a s p e c i f i c decision. One woman stated, "I'm pro-choice. I think . . . i t ' s a woman's choice. Although I c e r t a i n l y think there should be ca r e f u l counselling so she is n ' t being pressured to have (an abortion)." Several women commented on abortion being used as a means of b i r t h control and considered t h i s to be less than acceptable. " I t seems too bad that abortion has become a means of b i r t h c o n t r o l . " A second woman who knew of another woman who had had three abortions stated, "does she r e a l l y think that she's going to want to have childre n some day?" Reference was also made to the current anti-abortion movement and i t s e f f o r t s to prevent women from obtaining abortions. While one woman was able to t h e o r e t i c a l l y understand t h e i r motivation, she stated, " i t would be much better i f they would look a f t e r themselves only. Prevent yourself from having an abortion but l e t your neighbour do as she wants." These comments rais e the whole question of access to abortion and t h i s group of c h i l d f r e e women were quite clear in t h e i r expectations of obtaining an abortion. A l l of the women believed that abortions should be completely funded through one's government medical plan. In addition, abortion services need to be normalized as much as possible to decrease the secrecy and stigma attached to having an abortion. Several women f e l t that t h i s was best accomplished by having abortion procedures performed in both c l i n i c s and ho s p i t a l s . There was support for the c l i n i c s e t t i n g because of i t s s p e c i a l i z a t i o n and the b e l i e f that the s t a f f would be p a r t i c u l a r l y supportive of women having abortions. Hospitals were viewed as more fa m i l i a r to women and more anonymous. One woman stated that "Ever'ywoman's Health C l i n i c i s ideal....Or through a hos p i t a l where i t doesn't have to be secret..., where i t ' s just a matter of course and women decide." The anonymity of the hospital was viewed as more important by one woman who commented, "(with a l l of the anti-abortion protesters), maybe a c l i n i c i s n ' t a good idea because people don't have to know why someone i s going to the h o s p i t a l . " Voluntary S t e r i l i z a t i o n A l l of the women interviewed expressed the view that s t e r i l i z a t i o n should be ava i l a b l e to c h i l d f r e e women, regardless of th e i r age or marital status. One woman emphasized the importance of being sure about one's decision not to have childre n p r i o r to having a tubal l i g a t i o n — "I would recommend i t to anyone who was sure, but I've talked to so many women who aren't r e a l l y sure." Another pa r t i c i p a n t also supported a woman's rig h t to choose s t e r i l i z a t i o n but was cautious about i t s permanency— "I see no reason why we should not be allowed to choose that method, but I think we should r e a l i z e too that i t ' s permanent." The permanency of the procedure was also a factor for another woman who supported the choice but q u a l i f i e d her response with "(don't do i t ) unless you're 100% sure you're not going to have c h i l d r e n . " The emphasis on a woman's right to make a personal choice with respect to having a tubal l i g a t i o n was evident in several responses. One woman stated, "personally I believe that i£ someone's going to choose s t e r i l i z a t i o n , they are choosing that and that's an option. And you have to have options and choices." Another woman stated, "we own our own bodies." Yet another woman's opinion was that, " i t ' s her body, she should be able to do as she pleases." As one woman emphasized, "I think i t ' s an absolute personal choice." Tubal l i g a t i o n was c l e a r l y seen as a personal decision not to be interfered with by anyone else. The majority of women had some experience either in considering a tubal l i g a t i o n or in having the procedure done. However, very few f e l t p o s i t i v e about the process because of the lack of information a v a i l a b l e and the sense of limited control in the decision-making process. One woman, who chose not to have childre n because of medical reasons due to a genetic abnormality, received d i f f e r i n g opinions from the physicians f a m i l i a r with her circumstances. Although her s i t u a t i o n occurred many years ago, she had thought at the time that obtaining a tubal l i g a t i o n would s t i l l be straightforward because of her medical circumstances. However, t h i s was not the case. "My ( s p e c i a l i s t ) had said to me, don't have c h i l d r e n . But my own family doctor, when I discussed a tubal l i g a t i o n with him, refused, whether i t was on r e l i g i o u s grounds, I don't know." Generally, many of the women were quite clear about t h e i r expectations of the role of the physician with respect to obtaining a tubal l i g a t i o n . But, as w i l l be discussed l a t e r , the women's expectations and what a c t u a l l y happened were often quite d i f f e r e n t . Many of the women wanted the i r physicians to be more informative about a l l aspects of the procedure. One woman stated, "I believe that i t ' s the doctor's role to educate and to point out to me (information I need)." Another woman also summarized her expectations of the physician, "(the doctor) needs to point out the r i s k s involved." Support from the physician could have included, according to one woman "paperwork and some information to read." This concern about a lack o£ information was p a r t i c u l a r l y important to two women. One woman experienced a delay immediately prior to the surgery. There was "a big dispute about whether I was going to have clamps or was going to be cauterized. Nobody ever t o l d me about t h i s . " A second woman was concerned about the c l i p s used in a tubal l i g a t i o n . "I don't l i k e the idea of t h i s foreign thing -can i t get infected or does i t move?....I'd never a c t u a l l y seen one so I didn't know what they looked l i k e . (My doctor) described i t but never showed i t to me and I never asked." Several women commented on the decision-making process in terms of th e i r general f e e l i n g s , contact with th e i r physician, and the involvement of partners and/or family members in the decis i o n . One woman, who did not have much d i f f i c u l t y obtaining a tubal l i g a t i o n , was more troubled with the number of times she was asked i f she was d e f i n i t e about the decision. "I didn't have d i f f i c u l t y personally, nor did my s i s t e r , i t was just people asking a l l the way along, are you sure?" Another woman f e l t that the process of finding out information and discussing the decision with a physician was not very empowering for her as a woman. Instead, she would have f e l t much more validated i f she had received support for her decision. The d i f f i c u l t i e s experienced because of a lack of support were stated by one par t i c i p a n t , "I almost f e l t l i k e my choice wasn't believed, so I began to doubt my choice." For s t i l l others, wanting tubal l i g a t i o n related to their decision of not wanting to r e l y on contraceptives any longer, and p a r t i c u l a r l y oral contraception-- "what's the point of going through t h i s b i r t h control business, forever and ever, and ruining my body that way?" The issue that brought forth the largest amount of information was that of the women's contact with the medica profession in the course of th e i r decision-making process around tubal l i g a t i o n . While two of the women had straightforward experiences in accessing s t e r i l i z a t i o n , the other seven women who had a tubal l i g a t i o n or considered having one, had greater d i f f i c u l t i e s in accessing the procedure. One gynecologist, according to one woman, "was quite shocked, and he said 'oh', you had better talk to your family doctor. He said, 'I want a l e t t e r from your family doctor.'...He wanted to be sure that I knew what I was doing...and he thought my doctor would t r y to talk me out of i t . " Such a response conveyed a re a l lack- of respect on the gynecologist's part for the woman's a b i l i t y to make her own decision related to s t e r i l i z a t i o n . Another woman, who had a tubal l i g a t i o n done approximately ten years ago, had to obtain the approval of a p s y c h i a t r i s t and a hospital panel for the procedure. "I remember thinking that i t was r e a l l y unfair that anybody should be subjected to that kind of s i t t i n g in a chair with t h i s bright l i g h t shining at you....it was an ordeal, i t r e a l l y was, and then i t was waiting to see i f you'd won the p r i z e . Whether they would l e t you do i t or not." This experience focussed on the lack of control t h i s woman had with respect to the decision she wanted to make. By involving a p s y c h i a t r i s t , i t raised the question of whether or not choosing to not have childre n was seen as a mental health issue. As the l i t e r a t u r e indicates, t h i s has been a problem h i s t o r i c a l l y . Some of the women also described the extent to which they supported the involvement of a partner/family member in the decision-making process. A l l of the women believed that the f i n a l decision belonged only to the woman although many could see si t u a t i o n s where a woman would want to involve her partner. However, such involvement would not include having to give formal consent. One woman commented, " i t ' s the woman's decision and i f she decides to include her mate, then i t ' s his decision too." Another woman's opinion was, "she'd (discuss i t with her husband) out of courtesy." One woman mentioned the importance of having family support for her d e c i s i o n — "my family thought that i t was probably a l o g i c a l thing to do." Another woman f e l t that i t was her r e s p o n s i b i l i t y to be s t e r i l i z e d as opposed to her partner's r e s p o n s i b i l i t y because-- "regardless of whether I was married I did not want to have childre n — I mean I was the one with the physical d i s a b i l i t y and the r e s p o n s i b i l i t y came with me, to make sure that was not reproduced." Another area of concern for some of the women involved issues related to the procedure of tubal l i g a t i o n i t s e l f . One woman who had a tubal l i g a t i o n done many years ago was conscious of the stigma attached to the operation. As a re s u l t , she was discouraged from being open about the decision she had made. "Of course, i t would have been much better to have just handled i t on a normal basis l i k e having your t o n s i l s removed, where the doctor would make the arrangements and check into the general h o s p i t a l , have the proper care and go home. But...this operation was performed in a l i t t l e private h o s p i t a l . " This aura of secrecy was reinforced for thi s woman by having to pay for the surgery herself and by having to refer to i t as having her appendix removed. One woman commented on the intrusiveness of the procedure prior to usage of c l i p s ; previously, women had to have f u l l surgery in order to have a tubal l i g a t i o n and now the procedure can be done as day surgery. Another woman was uncomfortable about having a foreign object in her body and preferred to have the tubal l i g a t i o n done through ca u t e r i z a t i o n of the f a l l o p i a n tubes. This same woman commented on a lack of control over how the surgery would be done. "I always f e l t (that) maybe he wanted to put c l i p s in as many women as possible to see how they went and i f they were good. I f e l t afterwards that maybe t h i s was a guinea pig s i t u a t i o n . " This woman had to have the tubal l i g a t i o n done twice because the f i r s t procedure was done using c l i p s which later did not work. She then had her f a l l o p i a n tubes cauterized. Two women expressed concerns related to the s t e r i l i z a t i o n of ph y s i c a l l y and/or mentally disabled women. Both were aware of women who had been s t e r i l i z e d against t h e i r choice because of a d i s a b i l i t y . T h e r e f o r e , i n t h e i r opinion;, i t i s e s s e n t i a l t h a t a l l women have complete c h o i c e about whether or n o t t h e y w i l l have a t u b a l l i g a t i o n . One woman s t a t e d , " I have worked w i t h m e n t a l l y d i s a b l e d and e m o t i o n a l l y d i s a b l e d p e o p l e and t h o s e have n ot been c a s e s o f c h o i c e . That goes t o t h e o t h e r extreme." Two women no t e d t h a t , i n t h e i r o p i n i o n , i t was r e l a t i v e l y e a s y f o r men t o o b t a i n a vasectomy, i n s i m i l a r c i r c u m s t a n c e s . One woman commented, " I don't t h i n k a man w a n t i n g t o be s t e r i l i z e d would have as much t r o u b l e o r (be) ask e d as many q u e s t i o n s (as a woman)." INTERVIEWS WITH COMMUNITY AGENCIES/PROFESSIONALS S e r v i c e D e s c r i p t i o n s F our o f t h e f i v e community r e p r e s e n t a t i v e s a r e i n v o l v e d w i t h some t y p e o f s e r v i c e s t h a t c o u l d have a d i r e c t impact on women who have chosen n o t t o have c h i l d r e n . The f i v e chosen were P l a n n e d P a r e n t h o o d of B.C., t h e Women's H e a l t h C o l l e c t i v e , t h e R i g h t To L i f e S o c i e t y , a g e n e r a l p r a c t i t i o n e r , and a l a w y e r . The Women's H e a l t h C o l l e c t i v e o f f e r s r e s o u r c e i n f o r m a t i o n and s u p p o r t s e r v i c e s . Resource i n f o r m a t i o n i n c l u d e s a l i b r a r y , workshops, p u b l i c a t i o n s , and h e a l t h p r a c t i t i o n e r l i s t s and evaluations while support services include support groups and counselling. The general p r a c t i t i o n e r interviewed indicated that the majority of her practice was made up of women and that the greatest amount of contact with patients related to issues of reproduction. This included menstrual disorders, pap t e s t s , b i r t h c o n t r o l , pregnancy, abortion, and s t e r i l i z a t i o n . A small percentage of her female patients were c h i l d f r e e and had opted for tubal l i g a t i o n . Planned Parenthood of B r i t i s h Columbia offers both educational and c l i n i c a l services. Information services include programs on human reproduction, decision-making, b i r t h c o n t r o l , sexuality, and voluntary s t e r i l i z a t i o n . C l i n i c a l services are focussed on b i r t h c o n t r o l , pregnancy t e s t s , and counselling on reproduction including abortion and s t e r i l i z a t i o n . Many of the c l i e n t s served by Planned Parenthood are in t h e i r e arly twenties and have not yet i d e n t i f i e d s i g n i f i c a n t questions about whether or not to have chil d r e n ; however, for those women c l i e n t s between 25 and 40, questions about voluntary s t e r i l i z a t i o n were more often asked. The anti-abortion group member interviewed defined her organization as a human rights one dedicated to promoting the r i g h t to l i f e of every human being from conception to natural death. The primary focus of the organization i s education and while they may receive some enquiries from women about being c h i l d f r e e and abortion implications, t h i s organization generally refers such enquiries to other agencies of a supportive nature. However, because t h e i r focus is one of education and p o l i c y issues, t h e i r perspective w i l l have an i n d i r e c t e f f e c t on women who have chosen not to have childre n in terms of women having access to a l l aspects of reproductive choice. The lawyer interviewed was fa m i l i a r with legal issues related to patient consent for medical procedures. In p a r t i c u l a r , he had knowledge of the components necessary for informed consent. Attitudes Toward Women Choosing Not To Have Children The general p r a c t i t i o n e r , Planned Parenthood, and the Women's Health C o l l e c t i v e a l l supported a woman's right to choose whether or not she would have ch i l d r e n . One parti c i p a n t viewed the choice as completely legitimate p a r t i c u l a r l y because of the "overwhelming task of being a parent." Another stated, " i f you are up for i t , i t ' s a joy in l i f e ; i t ' s there, i t ' s unparalleled.... You can't have i t any other way but to experience i t . It's not always that way for people. There are a l o t of burdens that go with i t . " The t h i r d p a r t i c i p a n t emphasized the need for people to make autonomous decisions relevant to th e i r l i v e s , " i n d i v i d u a l s have the r i g h t to choose t h e i r own pattern of reproduction." Furthermore, she emphasized that having childre n i s but one option toward l i f e f u l f i l l m e n t - - "people who choose not to bear t h e i r own children can c e r t a i n l y f i n d other ways of having that c r e a t i v i t y . . . . I don't look at women who don't have children as d e f i c i e n t or missing something. I see them as people who have a d i f f e r e n t kind of l i f e that they have led for d i f f e r e n t reasons." For the anti-abortion group representative, a woman's motivation toward choosing not to have children was s i g n i f i c a n t . For example, " i f i t ' s a woman who has a motivation to serve society in a way that r e a l l y rules out having children and she's denying herself that joy, then you could admire her." This would include "Mother Theresa and other nuns l i k e her who decide they w i l l serve society in that role...or an o b s t e t r i c i a n (who does) aid work in t h i r d world countries." The emphasis here i s that women need to serve other people either through t h e i r roles as wife and mother or, by serving other people in the community. However, aside from these exceptional circumstances, t h i s p a r t i c i p a n t stated, "I f e e l sorry for women who do not have a family," therefore, defining family only as ch i l d r e n . There continues to be a bias that suggests that women who choose not to have childre n are doing so for reasons that c o u l d be d e s c r i b e d as n e g a t i v e ones. The p h y s i c i a n s t a t e d , "we a l l know f a m i l i e s where c h i l d r e n a r e n ' t welcome and r e a l l y d i d n ' t make anybody happy." The a n t i - a b o r t i o n i s t s u g g e s t e d t h a t many women c h o o s i n g n o t t o have c h i l d r e n do so f o r r e a s o n s r e l a t e d t o a need f o r m a t e r i a l i s t i c s u c c e s s . The c h i l d f r e e women i n t e r v i e w e d i n t h i s s t u d y , however, have s u g g e s t e d t h a t t h e i r r e a s o n s a r e not n e c e s s a r i l y based on unhappy c h i l d h o o d s or h i g h l e v e l c a r e e r a s p i r a t i o n s . The r e a s o n s go much deeper t h a n t h a t as no t e d e a r l i e r and do not alw a y s stem from a b e l i e f t h a t one w i l l make a poor p a r e n t . Some o f t h e p a r t i c i p a n t s a l s o acknowledged t h e p r e s s u r e from s o c i e t y i n g e n e r a l , and the m e d i c a l p r o f e s s i o n more s p e c i f i c a l l y , t h a t women a r e supposed t o have c h i l d r e n . Such p r e s s u r e comes from b o t h men and women. One p a r t i c i p a n t ' s o b s e r v a t i o n was t h a t , "our s o c i e t y has h i s t o r i c a l l y p r e s s u r e d and depended on women t o bear and r a i s e c h i l d r e n . . . a n d makes i t v e r y d i f f i c u l t f o r women t o have a sense of w e l l - b e i n g (as i n d i v i d u a l s ) . " The p h y s i c i a n commented t h a t , " ( n o t b e i n g t a k e n s e r i o u s l y by d o c t o r s stems from) a s e x i s t a t t i t u d e and women may have i t t o o . You don't have t o be male t o have t h e s e x i s t a t t i t u d e t h a t women s h o u l d have c h i l d r e n . " A n o t h e r ' s o b s e r v a t i o n was t h a t " i f a woman went t o her p h y s i c i a n c o m p l a i n i n g about s t r e s s , headaches, e t c e t e r a , t h e d o c t o r would s a y - what you need i s a c h i l d . . . . T h e r e ' s a c e r t a i n i n s e c u r i t y from s e e i n g an a d u l t who has chosen not t o have c h i l d r e n . " An a d d i t i o n a l consideration i s the b e l i e f that, as stated by the a n t i -abortion group representative, "one of the most basic things about being a woman...is having c h i l d r e n . . . something women are designed to do." This attitude s l o t s women into one s p e c i f i c role and makes i t very d i f f i c u l t for them to pursue other goals or to choose not to have c h i l d r e n . Health-related Information Sharing With Childfree Women One concern expressed by several of the c h i l d f r e e women interviewed related to th e i r a b i l i t y to access information about a l l aspects of reproductive choice. Some of these experiences and concerns were shared with the representatives of community agencies and professionals in order to ascertain t h e i r perspective on t h i s issue. In terms of contraception, the anti-abortion group representative stated, "the only way you can absolutely be sure that you are never going to be a parent i s to t o t a l l y abstain from sexual intercourse." In her view, those women choosing not to have childre n therefore, also had to choose not to have sexual intercourse. This b e l i e f stems, in part, from the knowledge that no method of contraception, including tubal l i g a t i o n , i s 1 0 0 percent r e l i a b l e . It also r e l a t e s to the anti-abortion perspective that once one has conceived, one has become a parent. Therefore, conception must be prevented. However, t h i s viewpoint also overlooks the human ph y s i o l o g i c a l need of sexuality. The Women's Health C o l l e c t i v e considers information dissemination on contraception a fundamental aspect of i t s program. Information i s availa b l e both in written form and from paid and unpaid s t a f f members. Their approach considers "the safety of the woman (as a) high p r i o r i t y along with the effectiveness of the method." Information sharing on contraception is also a high p r i o r i t y for Planned Parenthood. Their emphasis i s on women making independent decisions most suited to th e i r l i f e s t y l e and l i f e goals. "Whatever b i r t h control method she selects would be the one that she sees as the most appropriate for herself rather than somebody saying to her, 'I think you should go on the p i l l ' . " Information on obtaining an abortion i s available from the physician interviewed, Planned Parenthood, and the Women's Health C o l l e c t i v e . A l l three attempt to ascertain why a woman wants to have an abortion to ensure that that is a decision she i s making for herself as opposed to being pressured by someone else to have an abortion. Supportive counselling i s availa b l e to women who are undecided and resource information is availa b l e to those women who have made t h e i r decision and do not want to discuss i t further. A l l three respect a woman's ri g h t to make her own decision with respect to abortion, although i t is hoped that i f the woman i s in a supportive r e l a t i o n s h i p , her partner w i l l p a r t i c i p a t e in the decision-making process. For the anti-abortion group, information on obtaining an abortion is not forthcoming. Instead, the information given w i l l r elate to the development of the fetus and the abortion procedure. For example, "the woman has to f i r s t r e a l i z e that she has a c h i l d so the humanity and development of her c h i l d would be explained to her so she could appreciate the need to do what she could for that c h i l d . " It would also be ascertained whether or not someone else was pressuring the woman to have an abortion. Furthermore, "... they need to recognize that they are now pregnant and there i s a c h i l d and make a plan for t h e i r l i f e that doesn't involve doing violence to the c h i l d . So you educate them to appreciate the humanity of the c h i l d and the need to care for the c h i l d for at least nine months." For the anti-abortion group, there are no circumstances under which abortion would be the alt e r n a t i v e " i n a c i v i l i z e d society" and women are informed of t h i s . General information on tubal l i g a t i o n i s also a v a i l a b l e ; however, a d i s t i n c t i o n can be made between obtaining information about the procedure i t s e l f and accessing the procedure. Access to tubal l i g a t i o n w i l l be discussed at a lat e r point. The anti-abortion group has l i t t l e opportunity to discuss tubal l i g a t i o n with women, although the representative interviewed offered an opinion about the procedure and p a r t i c u l a r l y the fact that i t is not 100 percent r e l i a b l e . Therefore, a woman who has a tubal l i g a t i o n may s t i l l f i nd herself pregnant at a la t e r time and needing to assess her al t e r n a t i v e s . The physician, Planned Parenthood representative, and the Women's Health C o l l e c t i v e representative a l l offer information on tubal l i g a t i o n . This may include d e t a i l s of the procedure i t s e l f , i t s effectiveness, and how to access the procedure. A l l three indicated that there would be a desire to discuss t h i s a l t e r n a t i v e in d e t a i l with women who had chosen not to have ch i l d r e n . For example, the Women's Health C o l l e c t i v e f a c i l i t a t e s an information gathering process for women. This includes, "reading on the subject...going through l i t e r a t u r e where there are ch e c k l i s t s for checking out feelings...and checking out the d i r e c t o r y for appropriate doctors and ther a p i s t s . " Another element of focus, p a r t i c u l a r l y for unpartnered women, is that "while having a tubal l i g a t i o n would help with contraception, i t doesn't prevent sexually transmittable diseases. In a non-monogamous s i t u a t i o n , condoms and foam would s t i l l be important." The physician stressed the importance for women to be able to make as an informed a decision as possible. "Some people aren't aware that i t may be i r r e v e r s i b l e . They come for a tubal l i g a t i o n and are t o l d i t ' s only 60 or 70 percent r e v e r s i b l e . " Therefore, while she respects a woman's ri g h t to make her own decision, t h i s physician wants the decision to be based on as much accurate information as possible. Planned Parenthood provides information about the procedure i t s e l f as well as names of resource people who perform a tubal l i g a t i o n . Some women go to Planned Parenthood because they have been unable to access t h i s information from t h e i r personal physician. Part of the information they w i l l provide to women who have chosen not to have children and want to have a tubal l i g a t i o n relates to how to be assertive with a physician in order to be able to have the procedure done. Decision-making Processes The decision-making process i s viewed as a c r i t i c a l aspect of obtaining an abortion or tubal l i g a t i o n . Some of the considerations about choosing to have an abortion have been previously discussed in the context of information sharing. The respondents emphasized that making a decision about whether or not to have a tubal l i g a t i o n needed to be done c a r e f u l l y . A frequently mentioned concern was that each of the par t i c i p a n t s had known women, who at one time chose not to have childre n and had a tubal l i g a t i o n , but then several years l a t e r , changed t h e i r minds and wanted the procedure reversed. As a r e s u l t , the observation was made that physicians continue to be reluctant about performing tubal l i g a t i o n s , p a r t i c u l a r l y on women who have chosen not to have ch i l d r e n . The physician stated, "I've known a l o t of women who have changed t h e i r minds. I see them f i v e or ten years l a t e r and th e i r circumstances have completely changed t h e i r minds." This physician also pointed out that i t was "important to recognize my own biases." She has a c h i l d and very much supports that decision but recognizes that i t is not up to her to persuade another woman to have a c h i l d . Part of what women face when making the decision to have a tubal l i g a t i o n and then approaching a physician about the procedure, i s a va r i e t y of attitudes held by physicians which influence t h e i r l e v e l of cooperation. One respondent stated, " i t has to do with respect....A l o t of male doctors talk down to t h e i r female patients on any subject, not just (tubal l i g a t i o n ) . But i f you r e a l l y respect a woman's freedom to choose and have that control over her l i f e , that's the most important." The physician noted that the extent to which women are empowered within t h e i r r e l a t i o n s h i p with t h e i r physician varies greatly. "Some doctors take a l o t of r e s p o n s i b i l i t y for t h e i r patients....and in that case, t h e i r attitudes would be p r e v a i l i n g . They would f e e l maybe more r e s p o n s i b i l i t y than I would." The representative of Planned Parenthood expanded on t h i s perspective further. "Some doctors l i k e t h e i r patients to be independent. Others l i k e t h e i r patients to be phoning them every four hours to ask 'what do I do now?'." A woman's circumstances were viewed as an i n t e g r a l part of the decision-making process, both for abortion and tubal l i g a t i o n . The physician commented, " ( i t ' s important) to make sure that the reasons are not circumstantial - having to do with her s i t u a t i o n or with finances. Something might change more e a s i l y in the environment, l i k e a crummy re l a t i o n s h i p or being influenced by a partner." Planned Parenthood provides general support and can f a c i l i t a t e the decision-making process for women who are undecided about having a tubal l i g a t i o n . An important goal for t h i s organization, according to i t s representative, i s to determine whether or not pressure to have a tubal l i g a t i o n stems from another person. This exploration process would focus on the woman's feelings as being an important indicator of the a l t e r n a t i v e with which she is most comfortable. Planned Parenthood summarizes t h e i r approach to the decision-making process on tubal l i g a t i o n and the support available as follows: "If there are s i g n i f i c a n t people in t h e i r l i v e s who they l i k e and t r u s t , we suggest they discuss t h i s with them. If they have any doubts, think about adoption as a choice down the road i f they decide to have a tubal l i g a t i o n or to (postpone) having a tubal l i g a t i o n and think about b i r t h control more s e r i o u s l y . Where there's doubt, i t ' s quite often because you aren't ready to make that de c i s i o n . . . . there's usually a c r i t i c a l time for a l l of us when we know t h i s i s the time to act and make the decision." Consent Consent for a tubal l i g a t i o n or abortion was thought to be required only of the woman for those who supported a woman's righ t to have either procedure. However, the Women's Health C o l l e c t i v e , Planned Parenthood, and the physician a l l hoped that i f a woman was in a posi t i v e r e l a t i o n s h i p , she would consider the perspective of her partner, prior to making her decision. The other issue related to consent and p a r t i c u l a r l y that of tubal l i g a t i o n was a concern on the part of some physicians that a woman might la t e r sue the physician for performing the procedure, whether or not i t was done with her consent. The e a r l i e r discussed l i t e r a t u r e that addresses the issue of poor women, disabled women, and women of colour who receive a tubal l i g a t i o n without th e i r consent or under coercion, i s not necessarily the issue of concern for these physicians. It i s white, middle class women who have more d i f f i c u l t i e s obtaining a tubal l i g a t i o n who physicians fear may sue them and as a r e s u l t , ensuring that proper consent has been obtained has become important to the medical profession. This l a t t e r group of women have the economic resources and the s o c i e t a l power to use legal channels — a n a l t e r n a t i v e not as accessible to women of colour, poor women, disabled women, or lesbian women. Planned Parenthood stated, "there i s an extensive informed consent procedure for both women and men. Some of the doctors use videotape and others have an audiotape for the woman which goes through the whole procedure." This has replaced the previously used c r i t e r i a of "multiplying a woman's age by the number of children she has and i f the t o t a l i s over 120, she i s permitted to have a tubal l i g a t i o n . " From a legal perspective, the lawyer interviewed summarized the e s s e n t i a l elements of" medical consent, in that "the nature and consequences of the treatment be covered and discussed to the extent that i t i s reasonable to know." Therefore, "consent i s n u l l and void i f i t is demonstrated a person did not understand the consequences." To ensure that a physician meets the requirement to provide the best possible explanation of the treatment and consequences, a standard explanation i s often used for consistency and thoroughness. Because of previous law s u i t s and the pot e n t i a l for future ones, physicians are encouraged to "keep very thorough f i l e s and when possible, to have other s t a f f present during consent discussions." With t h i s type of pressure on physicians, i t becomes quite apparent why many women have a d i f f i c u l t time finding doctors who w i l l perform a tubal l i g a t i o n , p a r t i c u l a r l y i f they are c h i l d f r e e . Access To Tubal Ligation and Abortion Currently, abortions are availa b l e at Vancouver General Hospital and the Everywoman's Health C l i n i c . The three p a r t i c i p a n t s who refer women for abortions u t i l i z e both resources. In addition, they each believe that i t i s a medical service that should be covered under the government medical plan. In B r i t i s h Columbia, abortions are covered under the Medical Services Plan. However, the present p r o v i n c i a l government t r i e d to change th i s coverage in 1988 through an Order In Council in the p r o v i n c i a l Cabinet. When the government was taken to Court for making t h i s change, the Supreme Court of B.C. disallowed t h i s a l t e r a t i o n . Abortions obtained in B.C. hospitals are completely free to women; however, women obtaining an abortion at the Everywoman's Health Centre pay on a s l i d i n g scale up to $150 for an abortion to help cover the operating costs of the C l i n i c . The p r o v i n c i a l government refuses to fund community-based women's health c l i n i c s . In the physician's experience, "most women want a fast abortion and that's a big factor. As long as the person i s reasonably sympathetic, they don't care who they see. It doesn't seem to matter even i f they have a doctor who i s obnoxious, i t ' s not a big part of the issue....Waiting is hard; abortion c l i n i c s are good because they are f a s t e r . " From the Women's Health C o l l e c t i v e ' s perspective, access to abortion i s e s s e n t i a l in part, because access to safe and r e l i a b l e forms of contraception continues to be a problem. Thus although the decision to have an abortion.is a d i f f i c u l t one, i t needs to be availa b l e as a back-up method of contraception. The Planned Parenthood representative stated, "abortion i s a health issue and a medical necessity. Funded, accessible, safe, and ear l y are a l l important." The anti-abortion group, as i t s fundamental purpose, lobbies against access to abortion for women. Therefore, t h e i r p o s i t i o n i s quite c l e a r l y against any woman having an abortion. A c c e s s i b i l i t y to tubal l i g a t i o n i s dependent on a v a r i e t y of vari a b l e s : the physician, the age of the woman, the maturity and assertiveness of the woman, and whether or not the woman is in a r e l a t i o n s h i p or married. In addition, the past experiences of the physician in terms of her or his contact with women who have wanted a tubal l i g a t i o n and remained s a t i s f i e d with the decision may have an e f f e c t . One par t i c i p a n t noted, "a l o t of doctors w i l l respond to ind i v i d u a l cases and depending on the s i n c e r i t y that the person can project and how convincing they are in th e i r arguments.... But you can see where the problems are... someone who is not assertive or in great awe of physicians i s n ' t going to be able to say, 'I want t h i s done'." The physician summarized how she works with the problem, "I choose c e r t a i n gynecologists e s p e c i a l l y i f i t ' s a young woman who has never had children. There are cer t a i n gynecologists that I know -who are- open-minded about that and others who aren't." This selectiveness becomes important in cer t a i n circumstances as one part i c i p a n t noted, "the 23 year old who i s healthy and has no reason other than that she never wants to have childre n — she w i l l probably get a f a i r amount of questioning and pressure from just about every gynecologist." It may s t a r t to change as a woman reaches 30 but i f she is unpartnered, there w i l l s t i l l be a l o t of pressure. While the physician was able to respect a woman's ri g h t to make the f i n a l decision with respect to tubal l i g a t i o n , she also commented on the role of the physician doing the procedure and the r e s p o n s i b i l i t y that that brings. As a r e s u l t , she had mixed feelings about the issue. "When you are a doctor and s u r g i c a l l y rearranging someone's body, with the i r consent, but you are a c t u a l l y p h y s i c a l l y changing them, then you are p a r t l y responsible. I would fe e l p a r t l y responsible. It is n ' t that you are saying that's a good decision and t h i s i s how you go about i t and you can do i t yourself. If you could do i t to yourself, I'd f e e l better about i t . (But) you're taking a piece out that they can never have put back i n . If they wish that part of the i r body to work again, i t won't. You are part of that." Therefore, in some respects, two opposing concerns may become the Issue between a woman wanting a tubal l i g a t i o n and the physician she has approached to perform the procedure. DISCUSSION OF FINDINGS INTRODUCTION Reproductive choice continues to be one of the cornerstones of women's equality. Women who have chosen not to have children are p a r t i c u l a r l y affected by these, choices. In th i s research project, nine out of the ten women considered or chose s t e r i l i z a t i o n suggesting that for t h i s non-randomly selected group of women, s t e r i l i z a t i o n was an important a l t e r n a t i v e . ._._, In addition, t h i s research has shown that these women did not l i g h t l y make th e i r decision to not have ch i l d r e n . For some, i t was evolving circumstances and for others, a consciousness reached at an early age. A l l of the women were, for the most part, comfortable with t h e i r c h i l d f r e e decision and in th e i r view, the pos i t i v e aspects c e r t a i n l y outweighed the negative ones. Childfree women are impacted by a number of issues as noted in e a r l i e r comments. Access to reproductive choice is but one element of a s o c i e t a l process that continues to equate womanhood with motherhood and attempts not only to regulate how women w i l l have childre n but indeed, if_ they w i l l have children at a l l . These interviews with c h i l d f r e e women have focussed on the p a r t i c u l a r impact of the medical profession on t h i s choice. As Roberts (1985) notes, "the power of reproduction...is as much in the doctor's province as in the (woman's)" (p. 5). INTERVIEWS WITH CHILDFREE WOMEN When thi s research was begun, i t was an expectation of the researcher that the women interviewed would share t h e i r general b e l i e f s about access to contraception, abortion, and tubal l i g a t i o n . It was believed that because a l l of these are generally assumed to be e a s i l y a v a i l a b l e to women, that the data obtained would merely reinforce the importance of th i s access. However, the re s u l t s of the interviews with c h i l d f r e e women have been more s t a r t l i n g and disturbing. A l l of the women have shared t h e i r personal experiences about th e i r decisions related to having c h i l d r e n and the subsequent impact of contraception, abortion, and tubal l i g a t i o n . What has become apparent is the discrepancy between what is t h e o r e t i c a l l y a v a i l a b l e to women and what, women are a c t u a l l y able to access. Of p a r t i c u l a r relevance to these women has been t h e i r contact with members of the medical community and how the women believe they have been perceived as c h i l d f r e e women. One area of concern with respect to t h i s issue i s that of the decision-making processes that take place with respect to reproductive choice and p a r t i c u l a r l y , tubal l i g a t i o n . This is compounded with concern about the amount of information a v a i l a b l e to them about the tubal l i g a t i o n procedure. Waitzkin (1985) researched the question of information giving in health care. Based on 336 encounters recorded from several outpatient s e t t i n g s , i t was found that doctors spent l i t t l e time informing t h e i r patients, overestimated the time they did spend, and underestimated patients' desire for information. The re s u l t s supported the hypothesis that doctors may withhold information and maintain uncertainty to preserve power in the doctor-patient r e l a t i o n s h i p . Much concern was expressed that the information about s t e r i l i z a t i o n received from the physician was inadequate considering the seriousness of the surgery i t s e l f and the consequences. In addition, t h i s lack of information resulted in some l a s t minute decisions related to the surgery which were p a r t i c u l a r l y f r u s t r a t i n g for the women involved. Elston (1981) comments on the patient-physician r e l a t i o n s h i p , "one of the things which makes women patients - perhaps a l l patients - so powerless when they go to the doctor's i s the fact that the doctor is assumed to hold a l l the knowledge about the patient's body, what symptoms can mean, what treatment would be appropriate" (p. 117). Most of the women were able to describe how they would have li k e d the process handled with t h e i r physician. The focus would have been more on the dissemination of information and less on the physician's opinion of what she or he thought the woman should do with respect to having a tubal l i g a t i o n . The concern with the l a t t e r role for the physician was that she or he may bring stereotypic attitudes to the s i t u a t i o n which may a f f e c t the opinion offered. Issues a f f e c t i n g the general decision-making process were of pa r t i c u l a r i n t e r e s t to t h i s group of women. Both partnered and unpartnered women very much supported a woman's ri g h t to make an autonomous decision with respect to tubal l i g a t i o n but they could also see value in the involvement of others in terms of consultation. A partner's or physician's consent should not be needed in order to obtain a tubal l i g a t i o n in the opinion of the women interviewed; however, discussing the implications of the surgery with a partner and/or physician was encouraged. Perhaps the d i s t i n c t i o n i s between support and information being given in a positi v e way versus t e l l i n g someone what to do or what would be best for them, as was described by some women. A l l of the women were pro-choice with respect to abortion. It was p a r t i c u l a r l y noteworthy that several women saw value in abortions being performed in both hospital and c l i n i c s e t t ings. P o s i t i v e and negative factors were attr i b u t e d to both settings and by having both a v a i l a b l e , i t would allow women to choose what they were most comfortable with. INTERVIEWS WITH COMMUNITY AGENCIES/PROFESSIONALS Two of the fi v e community representatives were from agencies whose c l i e n t population was predominantly women. Therefore, t h e i r opinions may not r e f l e c t other mainstream health professionals' opinions. As well, the physician interviewed was fam i l i a r with and supportive of some aspects of feminist issues. As a r e s u l t , these three respondents work from a perspective of respect for women and trust in the i r a b i l i t y , to make autonomous decisions about t h e i r own l i v e s . Three of the fi v e respondents expressed some reluctancy about c h i l d f r e e women having a tubal l i g a t i o n even though from a t h e o r e t i c a l perspective, they supported any woman's rig h t to voluntary s t e r i l i z a t i o n . This reluctancy stemmed from t h e i r personal experiences with women who had changed th e i r minds about having children. The challenge for professionals continues to be finding the balance between th e i r personal expectations of women and th e i r professional r e l a t i o n s h i p with women who consider a l t e r n a t i v e s other than those t r a d i t i o n a l l y expected of them. Because the issue of reproductive choice i s , in part, a health issue, the role of the medical community was an important consideration in t h i s research. Three of the respondents shared examples of what has already been noted in the l i t e r a t u r e review, that of women having limited control over th e i r reproduction as a r e s u l t of continued male dominance within the medical community. Ehrenreich & English (1974) note that, "medical science has been one of the most powerful sources of sex i s t ideology in our cult u r e " (p. 5) . Three of the fi v e community respondents supported a woman's rig h t to have an abortion and believed that i t should be availab l e in hospitals and c l i n i c s . It was expected that the anti-abortion group would not consider the c h i l d f r e e choice to be s u f f i c i e n t enough reason to warrant an abortion for a woman with an unwanted pregnancy. Indeed, t h i s representative had d i f f i c u l t y understanding why a woman who was not completely devoting herself to others in the community would not instead choose to devote herself to a family of ch i l d r e n . Planned Parenthood, the Women's Health C o l l e c t i v e , and the general p r a c t i t i o n e r a l l offer support and resource information to women around the issue of reproductive choice. However, the sample of women interviewed had had l i t t l e contact with either resource information or a feminist general p r a c t i t i o n e r . This raises the question of the need to bridge the gap between those resources supportive of women's autonomy and the women themselves who can benefit from these resources. INTEGRATING THE INDIVIDUAL AND COMMUNITY PERSPECTIVES A l l of the c h i l d f r e e women and most of the community individuals interviewed agreed that a woman's i d e n t i t y i s not s o l e l y defined by motherhood and that there i s growing recognition of t h i s . However, most of the respondents also recognized that choosing to be c h i l d f r e e was far from being a completely acceptable choice. It was apparent in many of the interviews with c h i l d f r e e women that finding health professionals who supported t h i s decision was not very easy. Many comments were made by various women about the lack of respect on the part of some physicians for a woman's a b i l i t y to make a decision regarding tubal l i g a t i o n . As the l i t e r a t u r e has shown, physicians have had some d i f f i c u l t y respecting a woman's ri g h t and a b i l i t y to make her own health-related decisions, p a r t i c u l a r l y those a f f e c t i n g reproduction. However, the consequences of not respecting a woman's decision-making a b i l i t y are great, as Huntingford (1975) notes: "the worst (sort of doctor-patient re l a t i o n s h i p ) i s no doubt where the doctor r e a l l y believes that he knows what i s right for those who seek his help" (p. 815). While i t i s true that some physicians express reluctancy about a c h i l d f r e e woman having a tubal l i g a t i o n because of th e i r concern that the woman might change her mind about children, the more fundamental issue here is whether or not women are to be free to make th e i r own decisions and also accept the po s i t i v e and negative consequences of that decision. One study in the l i t e r a t u r e points out that a patient's r i g h t to make a mistake is greater than the ri g h t of a physician to make that person remain f e r t i l e by refusing to perform s u r g i c a l s t e r i l i z a t i o n (Lieberman et a l , 1979). Furthermore, Brody (1987) suggests that such interference on the part of a physician i s unethical. When doctors decide on who has access to family planning, pregnancy termination, or the noncoital reproductive technologies, or when they recommend s t e r i l i z a t i o n or l i m i t i n g family s i z e , the decisions are often based on unacknowledged moral or s o c i a l grounds. When they are based on whether a patient i s r i c h or poor, married or unmarried, heterosexual or homosexual, c l i n i c i a n s are making decisions that are not t h e i r s to make and that have, so far , received only benign neglect from committees, (p. 284) These comments perhaps refer more to the coercion of women to be s t e r i l i z e d but are equally applicable to those women choosing not to have childre n who are pressured to do so because they are members of the more 'powerful' groups of society, those of white, middle class i n d i v i d u a l s . Brody (1987) further comments that, "the best -interests observed in the c l i n i c a l s o c i a l contract are those of the patient, not of the doctor, the nurse, the profession, society, the state or necessarily even of the family" (p. 278). However, judging from the re s u l t s of t h i s research project, when the patient i s a woman, her right s can be superseded by those of another. IMPLICATIONS FOR SOCIAL WORK PRACTICE AND POLICY Within the limi t e d context of t h i s research come suggestions for s o c i a l work p o l i c y and practice which r e f l e c t a respect for the choices women make in our society. Such choices range from the decision to remain c h i l d f r e e to the choice to have a permanent method of contraception as a means to achieve one's c h i l d f r e e choice. For some women, the choice to be c h i l d f r e e i s a deep and personal one based on one's own l i f e experiences and expectations. For others, i t may be the r e s u l t of st r u c t u r a l circumstances which never seemed quite right to consider having c h i l d r e n . Some of the women indicated that they were never with the rig h t partner to consider having a c h i l d . The physician in t h i s research study expressed concern about c h i l d f r e e women choosing to have a tubal l i g a t i o n when the decision not to have childre n was influenced by s i t u a t i o n a l circumstances such as the absence of an appropriate partner. It was thought by the physician that these circumstances could change thereby changing the woman's decision about having c h i l d r e n . However, t h i s suggestion minimizes the extent to which such circumstances a f f e c t women in a s i g n i f i c a n t way. The Boston Women's Health C o l l e c t i v e (1984) summarizes the problems: "the lack of employment opportunities, education, day care, decent housing, adequate medical care; safe, e f f e c t i v e contraception and access to abortion a l l create an atmosphere of subtle coercion" (p. 256). Overcoming these b a r r i e r s continues to be a challenge for society in general and s o c i a l workers in p a r t i c u l a r . If women are to f r e e l y choose whether or not they w i l l have ch i l d r e n , an equal amount of; support needs to be ava i l a b l e to women regardless of the choice made. Raising childr e n requires greater access to s o c i e t a l resources such as housing, day care, and an adequate income; however, for many women with ch i l d r e n , and p a r t i c u l a r l y those who are single parents, s u f f i c i e n t resources continue to elude them. Therefore, u n t i l systematic changes have been made, some women w i l l continue to choose not to have children because of the circumstances in the i r l i v e s . The need for safer, more r e l i a b l e methods of contraception from which women are free to choose continues to be a concern for many women. Several women in t h i s study c i t e d concerns with current contraceptive methods as one reason for wanting to have a tubal l i g a t i o n . The need for a va r i e t y of choices continues to be the key underlying theme related to contraception. However, Michaelson (1981) states a problem, "even as contraceptive technology has developed, i t has been applied not to give women greater control over t h e i r own reproductive l i v e s , but to give others control over women's entire l i f e circumstances" (p. 25). A l l of the women and the majority of the community individ u a l s supported t o t a l access to abortion. Currently, the Canadian government i s considering the question of to what extent abortion should be availa b l e to a woman with an unwanted pregnancy. At the same time, p r o v i n c i a l Supreme Courts and the Supreme Court of Canada continue to be centre stage of the abortion debate where women wanting to have an abortion are forced to explain, j u s t i f y , and defend th e i r reasons for and rig h t to an abortion in a public forum. The rights women have gained in recent years in the i r quest f o r complete a c c e s s t o a b o r t i o n a r e b e i n g usurped by men demanding t h a t a pr e g n a n t woman be c o m p e l l e d t o complete t h e pregnancy, r e g a r d l e s s of her own d e c i s i o n , and by t h e a n t i -c h o i c e i n d i v i d u a l s who b e l i e v e t h e y have t h e r i g h t t o impose t h e i r b e l i e f s and p e r s p e c t i v e on o t h e r s . The r e s u l t s of t h i s r e s e a r c h o v e r w h e l m i n g l y s u p p o r t t h e vi e w t h a t t h e r e s h o u l d be no l e g a l , s o c i a l , p o l i t i c a l , f i n a n c i a l , or g e o g r a p h i c b a r r i e r s t o a b o r t i o n i n Canada. A b o r t i o n s h o u l d not be c o v e r e d i n t h e C r i m i n a l Code of Canada but does need t o be c o v e r e d under a l l p r o v i n c i a l and t e r r i t o r i a l m e d i c a l p l a n s . I n a d d i t i o n , a b o r t i o n s e r v i c e s need t o be a c c e s s i b l e t o women b o t h i n urban and r u r a l s e t t i n g s . The o p t i o n of h a v i n g an a b o r t i o n i n e i t h e r a h o s p i t a l or a c l i n i c s e t t i n g was seen as i m p o r t a n t i n t h e s e r e s e a r c h f i n d i n g s . S o c i a l w o r k e r s have a major r o l e t o p l a y i n t h e a b o r t i o n q u e s t i o n b o t h i n terms of c l i n i c a l p r a c t i c e and a t the s o c i a l p o l i c y l e v e l . R e g a r d l e s s of one's own p e r s o n a l b e l i e f s , f a c i l i t a t i n g t he r i g h t s of women t o have c o n t r o l o v e r a l l a s p e c t s of t h e r e p r o d u c t i v e p r o c e s s i s a r e s p o n s i b i l i t y f o r a l l s o c i a l w o r k e r s . E n s u r i n g t h a t women have a c c e s s t o s a f e a b o r t i o n s i n s e t t i n g s where c o u n s e l l i n g and d e c i s i o n - m a k i n g s u p p o r t i s a v a i l a b l e i s but one avenue f o r s o c i a l w o r k ers t o p u r s u e . In a d d i t i o n , a d v o c a t i n g f o r complete access to these s e r v i c e s a t both the p r o v i n c i a l and f e d e r a l l e v e l s i s another r o l e f o r s o c i a l workers. For s t e r i l i z a t i o n t o be a v i a b l e o p t i o n , i t must be a v a i l a b l e t o those groups of i n d i v i d u a l s who f r e e l y choose and consent to the procedure while not being used as a t o o l of o p p r e s s i o n of other groups of i n d i v i d u a l s who are coerced i n t o a g r e e i n g to be s t e r i l i z e d . The Report of the F i f t h  I n t e r n a t i o n a l Conference on V o l u n t a r y S u r g i c a l C o n t r a c e p t i o n (1985) d e s c r i b e s the components of a s t e r i l i z a t i o n program t h a t need to be c o n s i d e r e d : Because v o l u n t a r y s u r g i c a l c o n t r a c e p t i o n i s permanent, and because ending one's f e r t i l i t y has s e r i o u s p s y c h o l o g i c a l and s o c i o c u l t u r a l i m p l i c a t i o n s , programs must e s t a b l i s h safeguards to ensure t h a t a c l i e n t ' s c h o i c e i s informed. A l l who r e q u e s t the procedure should r e c e i v e thorough p r e o p e r a t i v e c o u n s e l i n g , to guarantee t h a t the d e c i s i o n f o r v o l u n t a r y s u r g i c a l c o n t r a c e p t i o n i s based on complete, a c c u r a t e , and unbiased i n f o r m a t i o n . C o u n s e l i n g i s a p r e r e q u i s i t e to informed consent, (p. 43) The emphasis on making a d e c i s i o n based on a c c u r a t e and unbiased i n f o r m a t i o n i s s i g n i f i c a n t , p a r t i c u l a r l y i n l i g h t of the r e s u l t s of t h i s r e s e a r c h which i n d i c a t e d t h a t the m a j o r i t y of women who c o n s i d e r e d a t u b a l l i g a t i o n d i d not f e e l they were w e l l enough informed or were t r e a t e d i n an unbiased manner. Outside Canada, t h e r e are a v a r i e t y of b a r r i e r s i n c l u d i n g l e g a l , r e l i g i o u s , c u l t u r a l , and economic ones which prevent v o l u n t a r y s t e r i l i z a t i o n from being a c c e s s i b l e t o i n d i v i d u a l s . For example, v o l u n t a r y s t e r i l i z a t i o n , except f o r t h e r a p e u t i c reasons, i s i l l e g a l i n Saudi A r a b i a , Peru, and C h i l e . In other c o u n t r i e s , the procedure i s c o m p l e t e l y f o r b i d d e n , such as S y r i a . W i t h i n the past two decades, v o l u n t a r y s t e r i l i z a t i o n i n many European c o u n t r i e s has gone from being t o t a l l y i l l e g a l t o an i n t e g r a l and r e s p e c t e d element of f a m i l y p l a n n i n g . S t i l l , i n many areas of the world, v o l u n t a r y s t e r i l i z a t i o n f a l l s i n t o a grey area of u n c e r t a i n t y i n terms of acc e s s and r e s t r i c t i o n s (Report of the F i f t h I n t e r n a t i o n a l Conference on V o l u n t a r y S u r g i c a l C o n t r a c e p t i o n , 1985). O v e r a l l , a ccess t o i n f o r m a t i o n , support systems, and medical treatment r e l a t e d t o a l l a s p e c t s of r e p r o d u c t i v e c h o i c e has been i d e n t i f i e d as c r i t i c a l f o r a l l women and c e r t a i n l y f o r those women choo s i n g not to have c h i l d r e n . One means of a c h i e v i n g t h i s g o a l would be to s e t up e a s i l y a c c e s s i b l e women's community h e a l t h c e n t r e s where a v a r i e t y of h e a l t h p r o f e s s i o n a l s , i n c l u d i n g s o c i a l workers, c o u l d be l o c a t e d . S e r v i c e s c o u l d i n c l u d e c o u n s e l l i n g on c o n t r a c e p t i o n , a b o r t i o n , and s t e r i l i z a t i o n as w e l l as p r o v i d i n g these l a t t e r two procedures to women. In a d d i t i o n , i n f o r m a t i o n -s h a r i n g s e s s i o n s c o u l d be r e g u l a r l y scheduled which would te a c h women about t h e i r bodies and t h e i r medical needs, s i m i l a r l y to t h a t of the Boston Women's He a l t h C o l l e c t i v e r e s o u r c e , The New Ourbodles, Ourselves (1984). As a r e s u l t , when women are c o n s u l t i n g with p h y s i c i a n s they can f e e l more c o n f i d e n t about t h e i r own l e v e l of knowledge r e s u l t i n g i n a more equal p a t i e n t - p h y s i c i a n r e l a t i o n s h i p . Women have unique h e a l t h care needs and by p r o v i d i n g women's h e a l t h c e n t r e s , women can meet these needs i n a s e t t i n g of r e s p e c t and s u p p o r t . While many p h y s i c i a n s c o n s u l t with t h e i r p a t i e n t s on an i n d i v i d u a l b a s i s , t h e r e i s a need f o r d o c t o r s to become more aware of how best t o respond t o t h e i r women p a t i e n t s . A woman's h e a l t h c e n t r e would h o p e f u l l y a f f o r d women the o p p o r t u n i t y to seek but medical p r o f e s s i o n a l s who c o m p l e t e l y r e s p e c t women and t h e i r a b i l i t y to make d e c i s i o n s t h a t govern t h e i r l i v e s . In a d d i t i o n , as more women enter the medical p r o f e s s i o n , there w i l l h o p e f u l l y be a g r e a t e r l e v e l of empathy f o r the needs of women p a t i e n t s as w e l l as a g r e a t e r l e v e l of r e s p e c t f o r the a b i l i t y of women to make d e c i s i o n s a f f e c t i n g t h e i r h e a l t h care needs. Women's h e a l t h c e n t r e s would need to be government funded and g e o g r a p h i c a l l y a c c e s s i b l e t o ensure t h a t a l l women r e g a r d l e s s of f i n a n c i a l c i r c u m s t a n c e s or where they l i v e have a c c e s s t o t h e s e s e r v i c e s . I n a d d i t i o n , s e r v i c e s would need t o be p r o v i d e d i n a manner r e s p e c t f u l t o t h e needs of d i s a b l e d women, women of c o l o u r , l e s b i a n women, poor women, and o l d e r women. T h i s would perhaps be b e s t a c c o m p l i s h e d by i n c l u d i n g members of t h e s e groups i n a l l a s p e c t s of program p l a n n i n g , d e c i s i o n - m a k i n g and s t a f f i n g of such a C e n t r e . At t h e p r e s e n t t i m e , women's h e a l t h s e r v i c e s i n B r i t i s h C o l u m b i a a r e o f f e r e d i n a v e r y fragmented way and as e v i d e n c e d from t h e r e s u l t s of t h i s r e s e a r c h p r o j e c t , many women miss t h e o p p o r t u n i t y t o become more i n f o r m e d about t h e i r h e a l t h c a r e c h o i c e s . W h i l e women's h e a l t h c a r e c e n t r e s a r e one o p t i o n t o re s p o n d t o t h e r e p r o d u c t i v e h e a l t h c a r e needs of Cana d i a n women, t h e br o a d e r o b j e c t i v e must s t i l l be t o change t h e s o c i e t a l v i e w t h a t women cannot and s h o u l d not be a b l e t o make t h e i r own d e c i s i o n s r e l a t e d t o h a v i n g c h i l d r e n . As s o c i a l w o r k e r s , some of the r e s p o n s i b i l i t y r e s t s w i t h u s . As s o c i a l w o r k e r s d e v e l o p a g r e a t e r r o l e w i t h i n t h e m e d i c a l community, i t may be p o s s i b l e f o r them t o f u r t h e r a d v o c a t e f o r t h e needs of women p a t i e n t s w i t h r e s p e c t t o r e p r o d u c t i v e c h o i c e . B a r r e t t & R o b e r t s (1978) s u g g e s t more of an i n t e g r a t i o n between p h y s i c i a n s and s o c i a l w o r k e r s , I t seems p o s s i b l e t h a t i f c l o s e r l i n k s e x i s t e d between g e n e r a l p r a c t i t i o n e r s and t h e s o c i a l work system and i f t h e l a t t e r had e x t e n s i v e c o u n s e l l i n g f a c i l i t i e s f o r women, t h e n g e n e r a l p r a c t i t i o n e r s would r e f e r many women t o them i n s t e a d of t o a p s y c h i a t r i s t . A l t h o u g h t h e s o c i a l work system may l i k e w i s e o p e r a t e as an agency of s o c i a l c o n t r o l , i t does not d e f i n e t h e i n d i v i d u a l so a c u t e l y as a s i c k p e r s o n , (p. 46) F u r t h e r m o r e , t h e Cana d i a n A s s o c i a t i o n of S o c i a l Workers - Code of E t h i c s (1983) " p r o v i d e s a p r a c t i c a l g u i d e f o r p r o f e s s i o n a l b e h a v i o u r and t h e maintenance of a r e a s o n a b l e s t a n d a r d of p r a c t i c e w i t h i n a g i v e n c u l t u r a l c o n t e x t " ( p. 2 ) . W i t h i n t h i s g u i d e come recommendations f o r t h e s o c i a l w o r k er's r e s p o n s i b i l i t y t o s o c i e t y . Some of t h e r e s p o n s i b i l i t i e s have d i r e c t r e l e v a n c e t o t h e needs of c h i l d f r e e women and t h e i r g u e s t f o r complete a c c e s s t o r e p r o d u c t i v e c h o i c e . F o r example, t h r e e r e s p o n s i b i l i t i e s a r e t h a t , The s o c i a l worker w i l l make r e a s o n a b l e e f f o r t s t o ad v o c a t e f o r the e q u i t a b l e d i s t r i b u t i o n of s o c i e t a l r e s o u r c e s and a c t t o ensure t h a t a l l p e r s o n s have r e a s o n a b l e a c c e s s t o t h e r e s o u r c e s , s e r v i c e s and o p p o r t u n i t i e s w h i c h t h e y r e q u i r e ( 1 0 . 2 ) . The s o c i a l worker w i l l t a k e r e a s o n a b l e a c t i o n s t o expand c h o i c e and o p p o r t u n i t y f o r a l l p e r s o n s , w i t h s p e c i a l r e g a r d t o d i s a d v a n t a g e d or o p p r e s s e d groups and p e r s o n s ( 1 0 . 3 ) . The s o c i a l worker w i l l make r e a s o n a b l e e f f o r t s t o ad v o c a t e f o r changes i n p o l i c y and l e g i s l a t i o n t o improve s o c i a l c o n d i t i o n s and t o promote s o c i a l j u s t i c e (10.6) (CASW - Code of E t h i c s , p. 8 ) . The r e s p o n s i b i l i t i e s o f s o c i a l w o r k e r s need t o be e s t a b l i s h e d a t t h e e a r l i e s t s t a g e p o s s i b l e - d u r i n g f o r m a l s o c i a l work e d u c a t i o n . I t i s w i t h i n t h i s c o n t e x t t h a t s o c i a l work s t u d e n t s must become aware of t h e d i v e r s e needs of women and the systems which e x i s t t o p r e v e n t women from h a v i n g complete e q u a l i t y and d e c i s i o n - m a k i n g power. F u r t h e r m o r e , m e d i c a l s c h o o l t r a i n i n g programs can do more t o edu c a t e t h e i r s t u d e n t s about women's h e a l t h c a r e needs i n a manner t h a t provokes r e s p e c t . As the r e s e a r c h o f E l d e r , Humphreys, & L a s k o w s k i (1988) a t t e s t s t o , m e d i c a l s c h o o l t e x t b o o k s a r e moving toward an e g a l i t a r i a n and n o n - s e x i s t a p p r o a c h of g y n e c o l o g y , but t h e r e i s s t i l l room f o r f u r t h e r change. F i n a l l y , s o c i a l w o r k e r s , w i t h i n t h e i r r o l e as c a t a l y s t s f o r s o c i a l change, can a l s o b e g i n t o r a i s e t he c o n s c i o u s n e s s of women w i t h r e s p e c t t o t h e i r r i g h t s . S o c i a l w o r k ers o r g a n i z i n g f o r the empowerment of women can b r i n g f u r t h e r a t t e n t i o n t o one of t h e most fundamental i s s u e s f o r women, t h a t of r e p r o d u c t i v e c h o i c e . CONCLUSION T h i s r e s e a r c h has been e x p l o r a t o r y i n n a t u r e and i s a f i r s t s t e p i n i d e n t i f y i n g some o f the i s s u e s f o r c h i l d f r e e women w i t h r e s p e c t t o t u b a l l i g a t i o n . L i t t l e q u a l i t a t i v e r e s e a r c h i s t o be found t h a t examines the i s s u e s from t h e woman's p e r s p e c t i v e and i d e n t i f i e s t h o s e a s p e c t s of t h e p r o c e s s t h a t a r e b o t h empowering and/or f r u s t r a t i n g . T h i s r e s e a r c h has had l i m i t a t i o n s i n i t s i m p l e m e n t a t i o n i n terms of t h e r e s e a r c h e r ' s i n a b i l i t y t o have p a r t i c i p a n t s from a number o f s p e c i f i c p o p u l a t i o n s of women. These i n c l u d e women o f c o l o u r , l e s b i a n women, and d i s a b l e d women. The sample was o b t a i n e d t h r o u g h word of mouth and a d v e r t i s i n g and w h i l e no a t t e m p t was made t o e x c l u d e t h e s e women, none of t h e r e s p o n d e n t s were members of t h e s e groups of women. T h e r e f o r e , t h e r e s u l t s of t h i s r e s e a r c h can o n l y be d i s c u s s e d i n t h e c o n t e x t of h e t e r o s e x u a l , w h i t e , a b l e -b o d i e d women. A f u r t h e r l i m i t a t i o n t o t h i s r e s e a r c h i s t h a t a number of o t h e r h e a l t h p r o f e s s i o n a l s c o u l d have been i n t e r v i e w e d so as t o g i v e a b r o a d e r p e r s p e c t i v e o f t h e m e d i c a l community's a p p r o a c h t o t h e i s s u e o f r e p r o d u c t i v e c h o i c e ; p a r t i c u l a r l y as i t r e l a t e s t o women who have chosen n ot t o have c h i l d r e n . F u r t h e r r e s e a r c h t h a t examines t h e imp o r t a n c e o£ a c c e s s t o t u b a l l i g a t i o n f o r c h i l d f r e e women would be i m p o r t a n t w i t h an emphasis on a l a r g e r number of r e s p o n d e n t s and a more w i d e - r a n g i n g c r o s s - s e c t i o n of t h e p o p u l a t i o n . F o r example, t h e i n c l u s i o n o f women o f c o l o u r and l e s b i a n women would be i m p o r t a n t as w e l l as more women who a r e m e n t a l l y and/or p h y s i c a l l y c h a l l e n g e d . The l a t t e r group might i n c l u d e d i s a b l e d women who, as a d u l t s , were u n d e c i d e d about h a v i n g c h i l d r e n , but found t h e m s e l v e s i n a s i t u a t i o n where t h e y had been s t e r i l i z e d w i t h o u t c o n s e n t . The whole i s s u e of women making autonomous d e c i s i o n s w i t h r e s p e c t t o s t e r i l i z a t i o n i s i m p o r t a n t f o r women who have chosen not t o have c h i l d r e n , but i s perhaps even more i m p o r t a n t f o r t h o s e women who a r e l e s s a b l e , f o r whatever r e a s o n , t o f u l l y a d v o c a t e f o r t h e i r own needs. I n a d d i t i o n , f u r t h e r r e s e a r c h i s w a r r a n t e d w h i c h examines the a l t e r n a t i v e methods o f p r o v i d i n g women's h e a l t h c a r e . George (1986) s u g g e s t s t h a t t h e B o s t o n Women's H e a l t h C o l l e c t i v e model i s a v a l u a b l e one but t h a t more r e s e a r c h i s needed t o a s c e r t a i n t h e needs of l e s s a r t i c u l a t e women who might n o r m a l l y be mi s s e d i n the c o u r s e of our r e s e a r c h . A l t h o u g h many groups of women have n ot p a r t i c i p a t e d i n t h i s r e s e a r c h s t u d y , e f f o r t s have been made by t h e r e s e a r c h e r t o i d e n t i f y some of t h e i r unique needs and t o ensure t h a t t h e s e c o n c e r n s a r e i n c o r p o r a t e d i n t o t h e r e s e a r c h recommendations. C O N C L U S I O N S t a n l e y & Wise (1983) s t a t e t h a t "the p r o d u c t of f e m i n i s t r e s e a r c h s h o u l d be d i r e c t l y used by women i n o r d e r t o f o r m u l a t e p o l i c i e s and p r o v i s i o n s n e c e s s a r y f o r f e m i n i s t a c t i v i t i e s " (p. 1 8 ) . I t i s hoped t h a t t h i s r e s e a r c h w i l l g i v e a group o f women t h e i r ' v o i c e ' i n d e f i n i n g as c h i l d f r e e women t h e i r e x p e c t a t i o n s o f p o l i c i e s and t h e d e c i s i o n - m a k i n g p r o c e s s r e l a t e d t o t h e i s s u e o f r e p r o d u c t i v e c h o i c e . A c c o r d i n g t o 1981 S t a t i s t i c s Canada f i g u r e s , 19.8 p e r c e n t of m a r r i e d women, 36 y e a r s o l d or younger, had no c h i l d r e n ( R e b a l s k i , 1989). Wh i l e a g r o w i n g number of women i n t h e i r l a t e t h i r t i e s have t h e i r f i r s t c h i l d , t h i s f i g u r e s t i l l r e p r e s e n t s a s i g n i f i c a n t i n c r e a s e from a decade ago when t h e p e r c e n t a g e was l e s s t h a n t e n . Not i n c l u d e d i n t h i s f i g u r e a r e t h o s e women not m a r r i e d who a r e s t i l l making the c h o i c e t o be c h i l d f r e e . These f i g u r e s s u g g e s t s t h a t c h i l d f r e e women a r e a g r o w i n g p o p u l a t i o n whose needs must b e g i n t o be a d d r e s s e d i n a more comprehensive manner. Many gaps c o n t i n u e t o e x i s t between what c h i l d f r e e women have i d e n t i f i e d as i m p o r t a n t s e r v i c e s and o p p o r t u n i t i e s v e r s u s what i s a v a i l a b l e and a c c e s s i b l e . The c h a l l e n g e c o n t i n u e s t o e x i s t f o r women, h e a l t h c a r e p r o f e s s i o n a l s , and 99 s o c i a l w o r k e r s t o e n s u r e t h a t w o m e n g a i n c o m p l e t e e q u a l i t y i n o u r s o c i e t y . B I B L I O G R A P H Y A s h t o n , F., & W h i t t i n g , G. ( E d s . ) . ( 1 9 8 7 ) . F e m i n i s t t h e o r y  and p r a c t i c a l p o l i c i e s . D o r c h e s t e r : D o r s e t P r e s s . B a l a k r i s h n a n , T., A l l i n g h a m , J . , & K a n t n e r , J . (1 9 7 2 ) . A t t i t u d e s toward a b o r t i o n o f m a r r i e d women i n M e t r o p o l i t a n T o r o n t o . S o c i a l B i o l o g y , 19, 35-42. B a r r e t t , M. & R o b e r t s , H. (1 9 7 8 ) . D o c t o r s and t h e i r p a t i e n t s : The s o c i a l c o n t r o l o f women i n g e n e r a l p r a c t i c e . I n Smart, C. & B. Smart ( E d s . ) , Women,  s e x u a l i t y and s o c i a l c o n t r o l (pp. 41-52). London: R o u t l e d g e and Kegan P a u l . B e l e n k y , M., C l i n c h y , B., G o l d b e r g e r , N., & T a r u l e , J . (198 6 ) . Women's ways o f knowing. New Yo r k : B a s i c Books. B e r n a r d , J . ( 1 9 7 3 ) . My f o u r r e v o l u t i o n s : An a u t o b i o g r a p h i c a l h i s t o r y of t h e ASA. I n Huber, J . ( E d . ) , Changing women i n a c h a n g i n g s o c i e t y (pp. 68-87). C h i c a g o , I L : U n i v e r s i t y of C h i c a g o P r e s s . B e r n a r d , J . ( 1 9 7 5 ) . The f u t u r e of motherhood. Harmondsworth: P e n g u i n . B o m b a r d i e r i , M. ( 1 9 8 1 ) . The baby d e c i s i o n . New York: Rawson, Wade. Bo s t o n Women's H e a l t h Book C o l l e c t i v e . ( 1 9 8 4 ) . The new our b o d i e s , o u r s e l v e s . New York: Simon & S c h u s t e r . B r o d y , E. (1 9 8 7 ) . New r e p r o d u c t i v e t e c h n o l o g i e s and women's r i g h t s : F r a ming the e t h i c a l q u e s t i o n s . H e a l t h Care F o r  Women I n t e r n a t i o n a l , 8_, 277-286. Burgwyn, D. ( 1 9 8 1 ) . M a r r i a g e w i t h o u t c h i l d r e n . New York: Harper & Row. C a l l a n , V. J . (19 8 6 ) . The impact of t h e f i r s t b i r t h : M a r r i e d and s i n g l e women p r e f e r r i n g c h i l d l e s s n e s s , one c h i l d , or two c h i l d r e n . J o u r n a l o f M a r r i a g e and t h e F a m i l y , 48, 261-269. C a l l a n , V. J . ( 1 9 8 7 ) . P e r s o n a l and m a r i t a l a d j u s t m e n t o f mothers and o f v o l u n t a r i l y and i n v o l u n t a r i l y c h i l d l e s s w i v e s . J o u r n a l o f M a r r i a g e and t h e F a m i l y , 49, 847-856. Ca n a d i a n A s s o c i a t i o n o f S o c i a l Workers. ( 1 9 8 3 ) . Code of e t h i c s . Ottawa, ONT: The A s s o c i a t i o n . 101 Conover, P . J . & Gray, V. (19 8 3 ) . Feminism and t h e new  r i g h t : C o n f l i c t over the American f a m i l y . New York: P r a e g e r P u b l i s h i n g . C raddock, D. (19 7 6 ) . A s h o r t t e x t b o o k of g e n e r a l p r a c t i c e . London: L e w i s & Co. D a l y , M. (19 7 8 ) . Gyn/ecoloqy. B o s t o n : Beacon P r e s s . Day, S. & P e r s k y , S. (Eds.) ( 1 9 8 8 ) . The Supreme C o u r t of  Canada d e c i s i o n on a b o r t i o n . Vancouver: New S t a r Books. D e g l e r , C. (19 8 0 ) . At odds. Women and t h e f a m i l y i n Am e r i c a  from the r e v o l u t i o n t o the p r e s e n t . New York: O x f o r d U n i v e r s i t y P r e s s . Denes, M. (19 7 6 ) . I n n e c e s s i t y and s o r r o w : L i f e and d e a t h  i n an a b o r t i o n h o s p i t a l . New Yo r k : P e n g u i n . 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Gordon, L. ( 1 9 7 6 ) . Woman's body, woman's r i g h t . New Yo r k : Grossman P u b l i s h i n g . G r e e r , G. (1 9 8 4 ) . Sex and d e s t i n y . New Yo r k : Harper & Row. Guberman, N. (1 9 8 6 ) . Who's a t home t o p i c k up t h e p i e c e s ? The e f f e c t s of c h a n g i n g s o c i a l p o l i c y on women i n Quebec. Canadian S o c i a l Work Review '86. 219-227. Hammersley, M. & A t k i n s o n , P. ( 1 9 8 3 ) . E t h n o g r a p h y :  P r i n c i p l e s i n p r a c t i c e . New York: T a v i s t o c k . H a r d i n g , S. (Ed.) (1987). Feminism and methodology. B l o o m i n g t o n , IN: I n d i a n a U n i v e r s i t y P r e s s . H a r e - M u s t i n , R. & Hare, S. (1 9 8 6 ) . F a m i l y change and t h e co n c e p t of motherhood i n C h i n a . J o u r n a l of F a m i l y I s s u e s , 7, 67-82. H e r r i n g e r , B. (1 9 8 8 ) . 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F a m i l y and c l a s s i n conte m p o r a r y A m e r i c a : n o t e s toward an u n d e r s t a n d i n g o f i d e o l o g y . I n Thorne, B. & M. Yalom ( E d s . ) , R e t h i n k i n g t h e f a m i l y (pp. 168-88). New York: Longman. R e b a l s k i , N. (1989, May 1 9 ) . No k i d d i n g . The Vancouver Sun, p. C6. R e i d , W. & S m i t h , A. (1 9 8 1 ) . R e s e a r c h i n s o c i a l work. New York: C o l u m b i a U n i v e r s i t y P r e s s . R e p o r t of t h e f i f t h i n t e r n a t i o n a l c o n f e r e n c e on v o l u n t a r y  s u r g i c a l c o n t r a c e p t i o n . ( 1 9 8 5 ) . New Yo r k : World F e d e r a t i o n o f H e a l t h A g e n c i e s f o r t h e Advancement of V o l u n t a r y S u r g i c a l C o n t r a c e p t i o n . R i c h , A. (1986). Of woman born - Motherhood as e x p e r i e n c e  and i n s t i t u t i o n . New York: W.W. N o r t o n . R o b e r t s , H. (Ed.) (198 1 a ) . Doing f e m i n i s t r e s e a r c h . London: R o u t l e d g e & Kegan P a u l . R o b e r t s , H. (Ed.) ( 1981b). Women, h e a l t h , and r e p r o d u c t i o n . London: R o u t l e d g e & Kegan P a u l . R o b e r t s , H. (19 8 5 ) . The p a t i e n t p a t i e n t s : Women and t h e i r  d o c t o r s . London: Pandora P r e s s . R o s e n t h a l , T. (1 9 8 0 ) . V o l u n t a r y c h i l d l e s s n e s s and t h e n u r s e ' s r o l e . American J o u r n a l of M a t e r n a l C h i l d N u r s i n g , 5, 398-402. S a p i r o , V. (1 9 8 6 ) . The gender b a s i s o f American s o c i a l p o l i c y . P o l i t i c a l S c i e n c e Q u a r t e r l y , 101, 221-238. S c o t t , H. (1 9 7 8 ) . E a s t e r n European women i n t h e o r y and p r a c t i c e . Women's S t u d i e s I n t e r n a t i o n a l Q u a r t e r l y . 1, 189-199. S c u l l y , D. (1 9 8 0 ) . Men who c o n t r o l women's h e a l t h : The  m i s e d u c a t i o n o f o b s t e t r i c i a n - g y n e c o l o g i s t s . B o s t o n : H o u g h t o n - M i f f l e r . S c u l l y , D. & B a r t , P. (19 7 3 ) . A fu n n y t h i n g happened on t h e way t o t h e o r i f i c e : Women i n g y n e c o l o g y t e x t b o o k s . A m e r i c a l J o u r n a l o f S o c i o l o g y , 7 8 ( 4 ) , 283-287. S h a p i r o , T. (19 8 5 ) . P o p u l a t i o n c o n t r o l p o l i t i c s : Women, s t e r i l i z a t i o n , and r e p r o d u c t i v e c h o i c e . P h i l a d e l p h i a : Temple U n i v e r s i t y P r e s s . S i n g e r , G. ( D i r e c t o r , W r i t e r , C o - P r o d u c e r ) . ( 1 9 8 4 ) . A b o r t i o n : S t o r i e s from n o r t h and s o u t h . [ F i l m ] . N a t i o n a l F i l m Board o f Canada: S t u d i o D P r o d u c t i o n . S t a n l e y , L. & Wise, S. (19 7 9 ) . F e m i n i s t r e s e a r c h , f e m i n i s t c o n s c i o u s n e s s and e x p e r i e n c e s of s e x i s m . Women's S t u d i e s  I n t e r n a t i o n a l Q u a r t e r l y , 2., 359-374 . S t a n l e y , L. & Wise, S. (1 9 8 3 ) . B r e a k i n g o u t : F e m i n i s t c o n s c i o u s n e s s and f e m i n i s t r e s e a r c h . London: R o u t l e d g e & Kegan P a u l . S t r a u s s , A. (1 9 8 6 ) . Q u a l i t a t i v e a n a l y s i s f o r s o c i a l s c i e n t i s t s . Cambridge: U n i v e r s i t y o f Cambridge P r e s s . Sumner, L. W. (1 9 8 5 ) . A b o r t i o n p o l i c i e s : The v i e w from t h e m i d d l e . I n P. Sachdev ( E d . ) , P e r s p e c t i v e s on a b o r t i o n (pp. 59-69). Metuchen, NJ: Sc a r e c r o w P r e s s . Thomas, W. (1 9 7 0 ) . A b o r t i o n d e a t h s i n B r i t i s h Columbia -1955-1968. B.C. M e d i c a l J o u r n a l , 1 2 ( 5 ) , 111-112. V e e v e r s , J . E. (19 7 4 ) . V o l u n t a r y c h i l d l e s s n e s s and s o c i a l p o l i c y : An a l t e r n a t i v e v i e w . The F a m i l y C o o r d i n a t o r , 23, ( O c t o b e r ) , 397-406. V e e v e r s , J . E. (1979) V o l u n t a r y c h i l d l e s s n e s s : A r e v i e w o f i s s u e s and e v i d e n c e . M a r r i a g e and F a m i l y Review, 2.(2), 2-26. V e e v e r s , J . E. ( 1 9 8 0 ) . C h i l d l e s s by c h o i c e . T o r o n t o : B u t t e r w o r t h . V e e v e r s , J . E. ( 1 9 8 3 ) . V o l u n t a r y c h i l d l e s s n e s s : A c r i t i c a l a ssessment of the r e s e a r c h . I n E. D. M a c k l i n & R. H. R u b i n ( E d s . ) , Contemporary f a m i l i e s & a l t e r n a t i v e  l i f e s t y l e s (pp. 75-96). B e v e r l y H i l l s : Sage P u b l i s h i n g . W a i t z k i n , H. ( 1 9 8 5 ) . I n f o r m a t i o n g i v i n g i n m e d i c a l c a r e . J o u r n a l of H e a l t h and S o c i a l B e h a v i o u r , 26.(2), 81-101. W a l k e r , R. ( E d . ) . ( 1 9 8 5 ) . A p p l i e d q u a l i t a t i v e r e s e a r c h . E n g l a n d : Gower P u b l i s h i n g . Whelan, E. M. ( 1 9 7 5 ) . A b a b y ? — M a y b e . A g u i d e t o making t h e  most f a t e f u l d e c i s i o n o f your l i f e . New York: Bobbs-M e r r i l l . Why I have no f a m i l y . (1905, March 2 3 ) . The Independent. 654-659. Z o l a , I . ( 1 9 7 2 ) . M e d i c i n e as an i n s t i t u t i o n o f s o c i a l c o n t r o l . S o c i o l o g i c a l Review, 20, 487-504. A P P E N D I X A R E S E A R C H A D V E R T I S E M E N T 109 APPENDIX B INTERVIEW SCHEDULE FOR CHILDFREE WOMEN WOMEN CHOOSING NOT TO HAVE CHILDREN: IMPLICATIONS FOR  SOCIAL WORK PRACTICE AND POLICY ON REPRODUCTIVE CHOICE INTERVIEW QUESTIONS: CHILDFREE WOMEN Demographic I n f o r m a t i o n A l . Hov o l d a r e you? A2. What i s your m a r i t a l s t a t u s ? A3. What l e v e l of e d u c a t i o n have you comple t e d ? A4. I f you a r e c u r r e n t l y i n t h e p a i d work f o r c e , d e s c r i b e your work. L i f e s t y l e B l . D e s c r i b e your c u r r e n t l i f e s t y l e . B2. What impact has not h a v i n g c h i l d r e n had on your l i f e s t y l e , i n terms of c a r e e r , r e l a t i o n s h i p s , and l e i s u r e p u r s u i t s ? Gender C I . What does b e i n g a woman mean t o you? C2. What, i f any, i n your o p i n i o n , i m p o r t a n t d i f f e r e n c e s e x i s t between men and women? C3. How has your sense o f s e l f as a woman been c h a n g i n g ? C4. What i s your s e x u a l o r i e n t a t i o n ? C5. What i m p a c t , i f any, has your s e x u a l o r i e n t a t i o n had on your d e c i s i o n not t o have c h i l d r e n ? B e i n g C h i l d f r e e T e l l me about your d e c i s i o n not t o have c h i l d r e n . P r o b e s : DI. When d i d you f i r s t f e e l aware t h a t you might not want t o have c h i l d r e n ? D2. Hov d i d you r e a c h t h e d e c i s i o n t o not have c h i l d r e n ? D3. Who and/or v h a t h e l p e d you t o make t h e d e c i s i o n ? D4. What r e s o u r c e s o r s u p p o r t systems v o u l d you have b e n e f i t t e d from? D5. When d i d you d e c i d e t h a t you v o u l d d e f i n i t e l y n o t have c h i l d r e n ? D6. What a r e your r e a s o n s f o r not v a n t i n g c h i l d r e n ? D7. Hov has your d e c i s i o n t o not have c h i l d r e n a f f e c t e d i n t i m a t e r e l a t i o n s h i p s ? D8. Hov do you f e e l nov about your d e c i s i o n not t o have c h i l d r e n ? R e p r o d u c t i v e C h o i c e E l . What method(s) o f c o n t r a c e p t i o n have you used over t h e y e a r s ? E2. Which method(s) have you f e l t m o s t / l e a s t c o m f o r t a b l e w i t h ? E3. How a c c e s s i b l e t o you has c o n t r a c e p t i o n been over t h e y e a r s ? E4. Have you e v e r e x p e r i e n c e d s i d e e f f e c t s from any method of c o n t r a c e p t i o n ? I f s o , what were t h e y ? E5. How do you f e e l about s t e r i l i z a t i o n as a permanent method of c o n t r a c e p t i o n ? E6. To what e x t e n t do you b e l i e v e s t e r i l i z a t i o n s h o u l d be a v a i l a b l e t o women who have chosen n ot t o have c h i l d r e n ? E7. Who do you f e e l s h o u l d be i n v o l v e d i n t h e d e c i s i o n -making p r o c e s s when a c h i l d f r e e woman wants t o be s t e r i l i z e d ? Ed. To what e x t e n t do you s u p p o r t s o c i a l i z e d m e d i c a r e ? E8. To what e x t e n t do you b e l i e v e t h a t v o l u n t a r y s t e r i l i z a t i o n f o r women s h o u l d be c o v e r e d under a government m e d i c a l p l a n ? E9. Have you c o n s i d e r e d s t e r i l i z a t i o n ? I f s o , have you d i s c u s s e d t h i s o p t i o n w i t h anyone? Who? What was t h e i r r e s p o n s e ? E10. Have you e v e r been p r e g n a n t ? I f s o , what d i d you do? E l l . Had you made t h e d e c i s i o n t o not have c h i l d r e n when you became p r e g n a n t ? E12. How d i d you f e e l about t h e pregnancy? E13. How do you f e e l about a b o r t i o n ? E14. To what e x t e n t do you b e l i e v e a b o r t i o n s h o u l d be a v a i l a b l e t o women who have chosen n ot t o have c h i l d r e n ? E15. To what e x t e n t do you b e l i e v e t h a t a b o r t i o n f o r women c h o o s i n g n o t t o have c h i l d r e n s h o u l d be c o v e r e d under a government m e d i c a l p l a n ? E16. Have you ev e r had an a b o r t i o n ? E17. I f s o , what d i d h a v i n g an a b o r t i o n mean t o you? A t t i t u d e s F l . I f you have e v e r been u n d e c i d e d about h a v i n g c h i l d r e n and e x p r e s s e d t h i s t o p e o p l e , how have t h e y responded? F2. What amount o f p r e s s u r e t o have c h i l d r e n , i f any, have you been aware of from o t h e r p e o p l e ? F 3 . How has your f a m i l y responded t o your d e c i s i o n n o t t o have c h i l d r e n ? F4. How have male and female f r i e n d s / c o w o r k e r s responded t o your d e c i s i o n not t o have c h i l d r e n ? F 5 . To what e x t e n t a r e you aware o f media p r e s s u r e s on women t o have c h i l d r e n ? C o n c l u d i n g Demographic I n f o r m a t i o n 112 G l . What i s your e t h n i c background? G2. What a r e your c u r r e n t r e l i g i o u s b e l i e f s ? G3. What i s your r e l i g i o u s background? G4. What e f f e c t , i f any, d i d your r e l i g i o u s b e l i e f s have on your d e c i s i o n not t o have c h i l d r e n ? G5. What i s your i n d i v i d u a l and f a m i l y income? G6. Any f i n a l comments? APPENDIX C INTERVIEW SCHEDULE FOR COMMUNITY AGENCIES WOMEN CHOOSING NOT TO HAVE CHILDREN: IMPLICATIONS FOR  SOCIAL WORK PRACTICE AND POLICY ON REPRODUCTIVE CHOICE INTERVIEW QUESTIONS: COMMUNITY AGENCIES 1. What services for women do you provide? 2. To what extent are your c l i e n t s women who have chosen not to have children? 3. What are your professional attitudes toward women who choose not to have children? 4. How important do you think i t i s for a woman's mental health and f u l f i l l m e n t i n l i f e , that she have a ch i l d ? 5. What vould you i d e n t i f y as the s o c i a l p o l i c y and community practice needs of t h i s population? Depending on agency appropriateness, a s e l e c t i o n of the following questions w i l l be asked. If a woman vere to approach t h i s agency for counselling on vhether or not to have c h i l d r e n , hov vould i t be handled? What information on methods of contraception do you provide to vomen? If a woman who didn't want ch i l d r e n , but was pregnant, came to you to discuss having an abortion, how would you respond? If a woman of any age, vho didn't vant c h i l d r e n , came to you to discuss tubal l i g a t i o n , hov vould you respond? What choices should vomen vho have chosen not to have chi l d r e n have v i t h respect to abortion and s t e r i l i z a t i o n ? In your opinion, vho should be involved i n the d e c i s i o n -making v i t h respect to abortion and s t e r i l i z a t i o n ? Who should fund abortions and voluntary s t e r i l i z a t i o n for vomen choosing not to have children? If a woman who had decided not to have childre n and was past the age b i o l o g i c a l l y for having c h i l d r e n came to you to discuss her regrets about the decision, hov vould you respond? 

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