Abortions in a hospital setting: hidden realities in Dar es Salaam, Tanzania

This study investigates the extent of unwanted pregnancy, the use of illegally induced abortion, and the attitudes toward and practice of contraception among women admitted to a hospital with the diagnosis of abortion in Dar es Salaam, Tanzania. (In Tanzania, induced abortion is permitted only to save the mother's life.) A random sample of 300 women with early pregnancy loss admitted to Muhimbili Medical Centre, the teaching hospital in Dar es Salaam, were interviewed between September and November 1987, using a structured questionnaire. Among the 300 respondents, 155 said that their pregnancy had been unwanted: 94 of them presented with an illegally induced abortion and 61 with a spontaneous abortion. The number of spontaneous abortions of unwanted pregnancies increased with age and stability in a relationship. Having a small child to look after and having completed the family were the most common reasons for the pregnancy to be unwanted in this group. Induced abortion was more a problem of the young, unmarried woman. The 61 women with spontaneous abortion but unwanted pregnancy suggest that a much larger group of pregnant women continue to term with what are, at least initially, unwanted pregnancies--precisely the group of women family planning programs want to reach. The low prevalence of contraceptive use in this group indicates the failure of family planning clinics to motivate their target group. Recommendations are made for improved functioning of family planning clinics.

Medically indigent women seeking abortion prior to legalization: New York City, 1969-1970

If the efforts now underway to limit access to abortion services in the United States are successful, their greatest impact will be on women who lack the funds to obtain abortions elsewhere. There is little published information, however, about the experience of medically indigent women who sought abortions under the old, restrictive state laws. This article details the psychiatric evaluation of 199 women requesting a therapeutic abortion at a large municipal hospital in New York City under a restrictive abortion law. Thirty-nine percent had tried to abort the pregnancy. Fifty-seven percent had concrete evidence of serious psychiatric disorder. Forty-eight percent had been traumatized by severe family disruption, gross emotional deprivation or abuse during childhood. Seventy-nine percent lacked emotional support from the man responsible for the pregnancy, and the majority were experiencing overwhelming stress from the interplay of multiple problems exacerbated by their unwanted pregnancy.

Abortion: its contribution to maternal mortality

Every year between 100,000 and 200,000 women die from illicit abortion. In this paper the magnitude of the problem is described, those most at risk are identified and methods of preventing unwanted pregnancy are suggested. It is argued that midwives have a major role to play in family planning counselling and the provision of contraceptive services. Midwives can also reduce maternal mortality by resuscitating women when emergencies arise from incomplete abortion. This paper is based on one originally given at the ICM/WHO/UNICEF pre-congress workshop is Kobe, Japan, October 1990.

Outcome and management of crisis pregnancy counselling

Between October 1989 and April 1991, 215 women were seen in the pregnancy centre. Of these women, 139 were in crisis pregnancy situations. Of the remaining 76 women, 42 attended for pregnancy education, 10 for counselling regarding adoption options, eight for postabortion counselling, and 10 for other reasons. All 139 women in crisis pregnancy situations received counselling and assistance with the resolution of the specific life crises that the pregnancy precipitated and were informed about the physical and emotional effects of pregnancy, normal fetal development, and the options that were available to them. These 139 women were divided into three groups at the start of their initial interview, according to whether they planned to continue with the pregnancy (18), seek termination of pregnancy (72), or were ambivalent (49). The outcome for each of these groups has been evaluated separately. Overall 65 (47%) of the women changed an initial decision or reached their final decision regarding the future of their pregnancy during the time of counselling, and 64 (46%) ultimately continued with their pregnancies. These outcomes support the need for a specific approach to crisis pregnancy situations such as that provided at the pregnancy centre and provide support for considering the crisis pregnancy an obstetric emergency.

The psychological sequelae of therapeutic abortion--denied and completed

OBJECTIVE

The purpose of this article is to review the available literature on the psychological sequelae of therapeutic abortion, addressing both the issue of the effects of the abortion on the woman involved and the effects on the woman and on the child born when abortion is denied.

METHOD

Papers reviewed were initially selected by using a Medline search. This procedure resulted in 225 papers being reviewed, which were further selected by limiting the papers to those reporting original research. Finally, studies were assessed as to whether or not they used control groups or objective, validated symptom measures.

RESULTS

Adverse sequelae occur in a minority of women, and when such symptoms occur, they usually seem to be the continuation of symptoms that appeared before the abortion and are on the wane immediately after the abortion. Many women denied abortion show ongoing resentment that may last for years, while children born when the abortion is denied have numerous, broadly based difficulties in social, interpersonal, and occupational functions that last at least into early adulthood.

CONCLUSIONS

With increasing pressure on access to abortion services in North America, nonpsychiatrist physicians and mental health professionals need to keep in mind the effects of both performing and denying therapeutic abortion. Increased research into these areas, focusing in particular on why some women are adversely affected by the procedure and clarifying the relationship issues involved, continues to be important.

Symptom reporting in wanted and unwanted pregnancies

This study examined the association between unwanted pregnancy and the reporting of pregnancy symptoms in a sample of 99 pregnant women drawn from an urban, medical school based family practice residency. Of these women, 51 had unwanted pregnancies, and 48 had wanted pregnancies. Women with wanted pregnancies were more likely than women with unwanted pregnancies to report three pregnancy symptoms (amenorrhea, breast tenderness, and morning sickness). This association of symptoms with a wanted pregnancy persisted after controlling for age, race, marital status, contraceptive use, menstrual irregularity, and days since last menses through multiple logistic regression. Findings suggest that symptoms may be underreported by women with unwanted pregnancies.

Effects of reviewing risk-relevant behavior on perceived vulnerability among women marines

People generally underestimate their own vulnerability to negative events such as illness or accidents. It has been suggested that this illusion of "unique invulnerability" is due to selective focus on one's own risk-reducing behaviors, to the exclusion of others' risk-reducing behaviors and one's own risk-increasing behaviors. The current study examined the effects of reviewing sexual and contraceptive behavior on perceived vulnerability to unplanned pregnancy. Our results indicated that review of pregnancy-related behaviors decreased perceived vulnerability among two groups of subjects: those who considered unplanned pregnancy to be most undesirable and those who had the most confidence in the efficacy of their contraceptive behavior. The data also support the hypothesis that selective focus is a source of the illusion of invulnerability.

Prenatal stress and childhood psychopathology

The documentation of levels of prenatal maternal stress and anxiety of four populations of severely emotionally disturbed children and adolescents was retrospectively reviewed to examine their relationship to the later development of childhood psychopathology. Significantly more of those children were born to unmarried mothers who had not planned to become pregnant, felt unhappy about being pregnant, lived in family discord, emotionally rejected being pregnant, and experienced significantly more physical problems than would be expected by chance. This study supports the hypothesis that chronic prenatal stress adds both physiological and psychological risk factors to the later development of childhood psychopathology.

The incidence of unplanned and unwanted pregnancies among live births from health visitor records

A survey of health visitor records has indicated that approximately one-third of pregnancies resulting in live births are unplanned. The data further revealed an association between planning of pregnancies and socio-demographic variables and use of preventive health care for infants.

Pregnancy wantedness and the early initiation of prenatal care

The study examines the impact of the wantedness of a pregnancy on the demand for early prenatal care. Using a cohort of pregnant women in New York City, we estimate a prenatal care demand function in which we control for the probability of giving birth, given a woman is pregnant. We interpret this control as a measure of wantedness. The results indicate that if the black and Hispanic women who aborted had instead given birth, they would have delayed the initiation of prenatal care, on average, more than three-quarters of a month longer than the mean number of months of delay that were actually observed for the women who gave birth. By allowing women to terminate an unwanted pregnancy, induced abortion increases the average use of prenatal care among black and Hispanic women relative to what would have been observed if the women who aborted had instead given birth.

[Background information on contraception behavior of patients undergoing abortion as an indication of the psychosocial origin of unwanted pregnancies]

269 patients were interviewed in a private abortion clinic in Lindenfels, Hessen, West Germany on aspects of contraception and abortion. The results indicated three crucial points, which influence contraceptive behaviour: social barriers, which affect indirectly the access to and the handling of contraceptives; psychic, mainly unconscious barriers, which counteract contraception; an increasing distrust and rejection of modern medical contraception, especially in highly educated women. These barriers are evident in lack of information, differing in the various social groups; partly irrational and exaggerated fear of side effects, and lack of success of factual information. Furthermore, poor co-operation is evident on the part of the husband or partner together with considerable shortcomings in medical counselling.

Abortion counseling: attention to the whole woman

Women's experience of pregnancy and abortion are examined and redefined. Abortion may be undertaken for a variety of reasons, and involves not only physical and emotional health, but also a woman's basic identity. Under restrictive norms and laws set by men, women's decision to abort is a subversive act. Recommendations are made for comprehensive services, including psychosocial counseling to help women cope with social pressures and experience abortion as an act of self-affirmation.