The impetus for this research (Faure & Loxton, 1999) grew out of a practical situation. When the Choice on Termination of Pregnancy Act, No 92 of 1996 was implemented in February 1997, I was serving my internship as a counselling psychologist at a provincial hospital in the Western Cape. It soon became evident that, although the decision to terminate an unwanted pregnancy was, for some women, a stressful and conflicted experience, the majority of women appeared to cope with the procedure, accept their decision and its consequences, and go on with their lives.

This awareness corresponded with prevailing opinion espoused in research literature pertaining to elective abortion. There was a general consensus among researchers that the termination of an unwanted or unplanned pregnancy, particularly in the first trimester, was unlikely to create psychological hazards for the majority of women undergoing the procedure (Adler et al., 1992).

It was therefore considered to be relevant to investigate if the findings of researchers in other countries could be extrapolated to the South African situation. In addition, as informative and sensitive counselling was deemed to be an essential component of an effective abortion service, it also seemed pertinent to identify the counselling needs of women undergoing a legal, elective abortion.

The study

The theoretical framework which underpinned the study was the transactional model of stress and coping (Lazarus & Folkman, 1984; Folkman & Lazarus, 1986,1988; Lazarus, 1993) and the theory of self-efficacy (Bandura, 1977, 1982). From this perspective, unwanted pregnancy and abortion are viewed as potentially stressful life events that pose challenges and difficulties but do not necessarily lead to long term negative sequelae (Adler et al., 1992). It is argued that although women may experience mixed emotions such as relief, happiness, guilt, regret, shame or anger shortly after an abortion, post-abortion anxiety and depression usually resolve within a few weeks after the event.

Emotional reactions themselves are not signs of emotional or mental disturbances. The literature on stress and coping suggests rather that it is the inability to cope with emotions that might lead to a clinical problem (Wilmot, de Alteriis, & Bussel, 1992). The two functions of coping are to regulate emotional reactions (emotion-focussed coping) and to alter the person-environment relationship causing the distress (problem-focussed coping). These dimensions may also be viewed as approach-avoidance coping behaviours.

It was reasoned that theoretical perspectives that focus on negative responses to abortion, (and postulate, for example, post-abortion syndrome), possibly misdirect or avoid the uncomfortable fact of personal responsibility. The importance of accepting responsibility for unwanted pregnancy and abortion, is believed to be a crucial factor in coping with the stress of such a major life event (Petchesky, 1990). It has also been shown that women experience a range of responses including positive responses such as growth and maturation (Adler, et al., 1992).

The aims of the study were:

1. to investigate the levels of anxiety, depression and perceived self-efficacy (coping) before and after termination of a first-trimester pregnancy
2. to explore the relationship between anxiety, depression and perceived self-efficacy (coping) in the short term adjustment to abortion
3. to explore the possibility that pre-abortion scores on measures of anxiety, depression and perceived self-efficacy (coping) may have the potential to predict a vulnerability to post-abortion distress which manifests as anxiety or depression
4. to explore the relationship between various biographical and psychological variables associated with coping and adjustment to abortion.

Seventy-six participants were recruited from three health facilities in the Western Cape during a two-month period in 1998. Only women in their first trimester of pregnancy, whose pregnancy was unintended and who were not terminating for medical reasons were approached to participate in the study.

Approximately one hour before the procedure, participants were requested to complete the short form of the Beck Depression Inventory (Beck & Beck, 1972), the State-Trait Anxiety Inventory (Spielberger, Gorsuch, Lushene, Vagg & Jacobs, 1983), and a self-efficacy scale developed by Major, Richards, Cooper, Cozzarelli & Zubeck (1998). All of these measuring instruments were employed in prior research on adjustment to abortion. A biographic form was completed for each participant by the researcher.

The forty-three participants who returned to the facilities approximately three weeks after the abortion for follow-up medical checks were asked to complete only the depression and anxiety inventories.

The Beck Depression Inventory was utilised to measure the presence and intensity of depression. The State-Trait Anxiety Inventory assessed levels of state anxiety (anxiety experienced in a specific situation) and trait anxiety (a person’s proneness to anxiety). The self-efficacy questionnaire asked participants to rate the extent to which they were sure they could: "think about children or babies comfortably"; "spend time around children or babies comfortably"; "have good sexual relations"; and "watch TV shows or read newspaper/magazine stories about abortion" in the next two months following their abortion.

Participants ranged in age from 17 to 39 years with a mean age of 26 years and a standard deviation of 5.5. Thirty-seven percent of the women were coloured, 34% White, 18% Black, and 11% Asian. Fifty-four percent of the women were single. Fifty-eight percent had received some form of tertiary education and 33% had completed standard ten. Fifty percent of the woman had never given birth and 92% had no previous abortion. The mean gestation age was 8 weeks with a standard deviation of 2.2. However, the highest frequency (42%) of terminations was between 6 and 7 weeks gestation.

Table 1 shows the presence of high levels of state anxiety and moderate levels of depression before the abortion. This suggests that the termination of a first trimester abortion is perceived as a stressful event. However, it is also shown that the levels of anxiety and depression of the majority of participants declined in the three-week period following the abortion. Only 7% of the sample reported high levels of depression, no participants reported high levels of state anxiety, and only 2% showed high trait anxiety.

With regard to participants’ perceived ability to cope with the experience, 55% of the participants expected to cope well with the experience, and no participants felt that they would be able to cope at all.

It is also shown that high levels of perceived self-efficacy (coping) before the abortion were related to lower levels of state anxiety and depression after the abortion.

Figure 1 represents the variables graphically and shows that one group of variables (age, births, state-anxiety, marital status and race) are almost perpendicularly projected to a second group of variables (depression, trait-anxiety, gestation and education). Thus, gestation, trait-anxiety and depression before abortion are mutually correlated and associated with education in such a way that higher levels of education are associated with low levels of trait-anxiety, depression and lower gestational age, and the other way around. High levels of trait-anxiety, however, are not strongly related to high levels of trait-anxiety and depression. Thus, with respect to abortion, high state-anxiety does not necessarily imply a high level of trait-anxiety. In fact, state-anxiety is more strongly related to race, marital status, age and number of children (births).

Figure 2 reveals more insight into how the variables are related. Low levels of depression are strongly associated with low levels of trait-anxiety and low gestational age but high levels of self-efficacy and vice versa. Participants who studied at college and university seem to be associated with lower levels of trait-anxiety and depression. Finally, participants who are older and have two or more children are mostly living together, whereas younger participants have one or no children and are mostly single. Age and the number of children, however, does not appear to be related to depression.

The study thus provided insight into the relatively complex relationship between anxiety, depression and coping in the context of a first trimester abortion. Depression, rather than anxiety, was shown to be the domination factor in post-abortion distress. However, a mixed anxiety-depression syndrome was also identified. Perceived self-efficacy (coping) was also strongly related to healthier post-abortion adjustment. It was therefore shown that women who, before the abortion, expected to cope well, experienced lower levels of anxiety and depression shortly before, and up to three weeks after an abortion.

These findings are consistent with prior studies which suggest that individuals who believe they can exercise control or choice over potential threats do not conjure up apprehensive thoughts. Furthermore, it is well documented that the presence of depression before a stressful event may limit an individual’s ability to cope.

It was also shown statistically that pre-abortion scores of depression and self-efficacy have the power to predict post-abortion depression. It was, however, not possible to validate these findings. Given the sensitive nature of unwanted pregnancy and abortion, all data in the study were coded to maintain privacy and confidentiality. As such it was not possible to follow up the 33 participants who did not complete the post-abortion measures. It was concluded that a level of construct validity had been reached, but criterion validity could not be tested. These two questionnaires may, however, provide the basis for a screening tool to distinguish between women who may require in-depth counselling from those who need only supportive counselling.

Although this study confirmed that only a small percentage of women experience severe levels of post-abortion anxiety and depression, it is important to recognise that the abortion experience is far more complex than a straightforward medical procedure.

No woman sets out to create, then terminate, a potential life. Choosing to terminate an unwanted pregnancy is often a painful decision and not an easy choice. It should engage emotions. It is crucial that the counsellor does not ignore or minimise the emotions that each individual woman experiences. Perhaps at no other time in her life is a woman more deserving of information, patience, respect and compassion.

During pre-abortion counselling, the circumstances under which the woman became pregnant should be discussed, and the meaning she attributes to her pregnancy should be explored. Her fears and concerns with regard to the procedure, pregnancy loss, and disapproval of others should be addressed. Furthermore, it may be useful to explore possible relationship difficulties and establish the strength of her social support. The counsellor should also be aware that anxiety, due to stress or conflict with personal beliefs, may make it difficult for a woman to process information immediately before the abortion.

Screening for high-risk factors that may compound post-abortion psychological distress is recommended. When a woman’s psychological state is already fragile, the stress of an abortion can more easily overwhelm her (Reardon, 1996). Factors such as the existence of emotional, social, or moral conflicts regarding the contemplated abortion, developmental limitations, a history of prior sexual abuse or trauma, prior psychological problems or feeling pressured by others to abort, may predispose a woman towards post-abortion adjustment difficulties.

What abortion evokes more than anything else is profound ambivalence. In confronting abortion women are forced to make a choice between the meaning and purpose of their own lives, as well as the meaning and value of the potential life of another being. This deep-rooted ambivalence raises awareness of the inherent paradoxical nature of the abortion experience. The stress of a continued unwanted pregnancy is contrasted with the potential relief of termination; the continued growth and development of the mother versus the prevention of the development of the fetus; freedom of choice versus religious and moral dogmatism; an intimate, personal issue and at the same time a sensational public debate; the experience of pain while exercising freedom; the vacillation between feelings of relief and regret.

The most important message for women choosing abortion is that ambivalence and distressed feelings are part of the experience. The fact that she is exercising her right to choose does not necessarily alleviate the anguish a woman may feel at ending a pregnancy. It also does not mean that it is not a regrettable decision. For many women it is often a hollow and empty decision, made in privacy and isolation, in order to protect herself.

The choice is ultimately the woman's, one for which she is responsible (Gilligan, 1977). If the decision has come about after careful consideration of all the options, then ambivalence and distress can be woven into the overall tapestry of her life. They become part of her decision. It is important that counsellors endeavour to raise women’s confidence in their own personal opinions and choices. Rarely is a woman unquestioningly secure in her decision to terminate a pregnancy. It is therefore essential that these emotions are dealt with in a safe and supportive environment. The woman needs to feel that she is in control, that she is being listened to, that her feelings of guilt, anger, sadness, fear, despair, helplessness and self-condemnation are validated and legitimized, and that her personal meaning of the experience is understood.

For some women, there is no choice but to terminate an unwanted pregnancy. They genuinely feel no need to mourn, and should be allowed to experience their relief. Feelings of being unburdened and released from an intolerable situation need to be respected.

With time, the majority of psychologically healthy women integrate the abortion experience and are able to live with the decision and consequences, knowing that it was the right decision at that time of her life. These women are generally able to cope with any complex feelings that have been evoked, grieve their losses and have a sense of a meaningful future.

However, a small percentage of women may be more sensitive to loss, and seek help with post-abortion grief and regret. These women require support in exploring and understanding feelings around their loss and any resonances to other losses they may have previously experienced. Knowledge in the form of advice has little meaning unless it is linked to a process of understanding. Additionally, prior unresolved trauma may exacerbate emotional stress and tension.

People often use denial or avoidance in order to prevent them from being exposed to intense, unbearable emotions. The need by some women to exclude such memories from a lived experience must be respected. However, a containing environment that acknowledges the depths and dimensions of abortion may facilitate the process of grieving. With sensitive counselling, the character and repetitive quality of disturbing dreams and nightmares may change and the woman may be able to make meaning from her losses. In moving through her grief and resolving feelings of anger and guilt, a woman may begin to feel emotional peace and growth.

As relationship difficulties are frequently exposed or arise out of the abortion experience, it may also be useful in abortion counselling to include discussions of the different ways in which men and women cope. Many women tend to turn to their partners for comfort and support, and are angry and hurt when their partners avoid talking about it. It may help women to recognise that this may possibly be the manner in which her partner distances himself from his own feelings of grief, helplessness, guilt, personal inadequacy or sense of impotence.

Finally, women may have expectations and perceptions as to the care they should receive from health professionals. These expectations may be unrealistic and exceed what the healthcare professional is willing or able to deliver. If a woman did not receive the respectful and sensitive care she expected, intense feelings of distress and anger may have been evoked. Thus it may be helpful to create awareness that there are times when doctors and nurses are not able to fully engage with their patients. Health professionals may themselves be experiencing stressful times or the reopening of old wounds and this may prevent them from being fully available to their patients. By creating this awareness, levels of anger, resentment and hostility that sometimes arise between patients and healthcare professionals may be reduced.

While conducting abortion values clarification workshops and discussion groups with nurses I became conscious that many of the nurses were experiencing significant psychological reactions that paralleled those experienced by their patients. Nurses were at times distressed and confused by their own ambivalence towards abortion and challenged by their own issues. Many of them struggled with this work. The job was done, but the anguish was left unrecognized. Low levels of empathy and judgmental attitudes were combined with high levels of care. The desire to care for and protect others conflicted with their desire to protect and care for themselves.

Some of the emotions and conflicts experienced and expressed at times by healthcare professionals include:

 Frustration when confronted by unreasonable expectations from demanding clients.

 Anger when dealing with irresponsible clients who do not make use of family planning services and return for repeat terminations, or clients who display indifference or callousness.

 Distress at the constant exposure to the hardship of other peoples' lives as well as the naivete or ignorance of very young girls with regard to the meaning of terminating a pregnancy.

 Guilt arising out of the conflict between their own moral values and beliefs, their commitment to preserve life and their role in relieving a client of an unwanted pregnancy.

 Resentment at having to cope with late terminations regardless of their protest. Strong resentment when their own feelings were disregarded, discounted, minimized or ignored by hospital management.

 Depression owing to cumulative stress or burnout as a consequence of constantly drawing on their own inner resources to help others.

 Fear and anxiety with regard to anti-abortionists’ protests, harassment from members of their communities or the threat of harm to themselves or their families.

 Inadequacy with regard to fulfilling client's needs.

 Failure with regard to raising client awareness around contraceptive compliance and responsibility.

 Sadness at all they hear during counselling sessions and witnessing clients’ grief and anguish.

 Doubt as to whether a client is making the right decision and constant self-reflection as to whether or not they are influencing a client's decision.

 Excessive pressure to meet the growing demand for terminations, and in so doing, loose sight of the person and see their work only as a production of labour.

 Overwhelmed by the need to educate men and women with regards to responsible sexual behaviour.

 Helplessness and hostility when confronted by the fear, anger and guilt that some client's and their partners project onto them.

1. Satisfied when they know that they have helped a woman in a difficult situation.

1. Appreciated when patients express how much their support and compassion has meant to them.

1. Deepened appreciation of life and human relationships.

From this it should become quite clear that healthcare professionals also require a supportive community in which to discuss the impact of this work on their lives. It is important that nurses are provided with the opportunity to express strong emotional reactions and feel that they are being listened to and heard. Healthcare professionals are equally deserving of understanding and empathy and it is essential that their humanity be affirmed.

While psychologists, social workers, hospital management and policy makers enjoy a degree of distance from the actual abortion procedure, doctors and nurses are at the cutting edge. It is therefore recommended that all institutions providing abortion services should endeavour to provide counselling and support for healthcare professionals who require it. Better client care will be ensured if the personal and psychological comfort of the service providers is improved.

Programmes which strengthen counselling skills may help nurses to manage distressed clients and minimize their feelings of inadequacy, guilt and helplessness. Stress management, conflict resolution and emotional regulation skills may further empower nurses. Care-for-the-caregiver programmes which create awareness to the subtle signs of burnout may help to prevent the development of a full-blown condition of emotional and physical exhaustion which is inherent in work of this nature.

In conclusion I would like to recommend that more resources be allocated to ‘soft issues’ such as counselling. The social and economic cost of anxiety and depression should not be overlooked.

Finally, I would like to pay tribute to the large number of women who had the courage and goodwill to participate in all this research. We are indebted to them for their contribution to research on abortion in South Africa.

Signed: Date: 7 June 2000

Sheila Faure

Correspondence concerning this research should be addressed to Helene Loxton, Department of Psychology, University of Stellenbosch, Private Bag X1, 7602 Matieland.

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