Reflections on Post Abortion Care
Dawn de Witt
Beginnings
Around 2000 I joined a small group of women to explore the merits of the Victims of Choice post abortion recovery programme from the United States. At the time, it struck me that I had very little knowledge of abortion issues despite my professional studies. In New Zealand, a termination of pregnancy is available through the public health system and is promoted as a safe medical option for those who do not wish to continue a pregnancy to term. The experience of the group was that there existed a real need for healing and reconciliation after abortion - and we wanted to make that possible.
The literature confounds
My interest in the issue prompted me to do a literature survey. This opened a Pandora's box for me. There were conflicting findings, heated debate, fierce criticism of unsound methodologies, vehement argument and counter argument. I was disappointed. The scholarly articles and debates seemed to be immersed in the politics and polarities surrounding abortion that were prevalent in American society, unable to transcend them. The title of the 1998 monograph of the American Psychological Association, The New Civil War: The Psychology, Culture, and Politics of Abortion1 appears to confirm that.
There was no consensus on the impact of abortion. In some reports, it was construed as just another stressful event. For others, it was a significant trauma associated with mental health issues and symptoms similar to Post Traumatic Stress Disorder (PTSD). The notion of Post Abortion Syndrome (PAS) was raised and rejected.
The American Psychological Association (APA) consistently asserted that the incidence of negative responses after abortion was low (19902, 19923). In 2006, a task force was assigned to evaluate the evidence.
The American Psychological Association Report on Abortion and Mental Health
In 2009, in their Report on Abortion and Mental Health4, the APA concluded that:
1. Most adult women who terminate a pregnancy do not experience mental health problems. Some women do, however.
2. The evidence regarding the relative mental health risks associated with multiple abortions is more uncertain.
3. Some women experience sadness, grief and feelings of loss following an abortion, and some may experience "clinically significant disorders, including depression and anxiety." 5
4. No evidence sufficient to support the claim that an observed association between abortion history and mental health was caused by the abortion per se, as opposed to other factors." 6
The results related to the experience of a single abortion as opposed to multiple abortions. The Report noted factors that may be predictive of more negative psychological responses following first-trimester abortion among women in the United States:
• perceptions of stigma
• need for secrecy
• low or anticipated low social support for the abortion decision
• a prior history of mental health problems
• personality factors such as low self-esteem and the use of avoidance and denial coping strategies
• characteristics of the particular pregnancy, and the extent to which the woman wanted and felt committed to it.
Here was clear acknowledgement that some women were experiencing grief and mental health issues after an abortion. Yet, despite the report warning about the dangers of making globalising statements, the message disseminated was: Abortion Has No Impact On Women's Mental Health. This message persists today.
To better understand the impact of abortion, I undertook to listen to those who were seeking help after abortion.
Impressions from the field
The deepest of sorrows
The most poignant learning has been the depth of grief and sorrow I encountered. This is no ordinary grief. It is complex and complicated. There are multiple losses; complex personal and social narratives; intense emotions; and some level of responsibility in the death. The grief is disenfranchised. It is socially unrecognised, unacknowledged and unsanctioned. There are no socially accepted rituals for mourning. At its heart is a death of a baby.
In those seeking help, this sorrow seems universal. It has presented in men and women; in relationships that are secure or in more tenuous, uncommitted or even undesirable relationships; whether there had been full responsibility or coercion; where there is faith and where there is no faith; where there have been pre-existing mental health issues and where there has not; in cases of secure attachment histories and in those with histories of insecure attachments; whether the pregnancy was unwanted or wanted; and whether there was a sense of connection with the foetus or not.
Anger is a part of grieving. Coupled with bitterness and resentments, it can become intense. It may be directed towards God, oneself or others. At times, we see that anger directed at 'the State', the 'system', or society at large; this anger is about unrealistic societal expectations, mixed messages from society, insensitive processes and a lack of information about the risks.
Four areas of wounding have emerged from my own listening and reading: the wound to the child; the wound to self (primarily for being implicated in the termination, intentionally or by default); wounded relationships (with others involved in the abortion) and wounded spirituality. Healing entails reconciliation(s) in each of these areas.
The feminine face of coercion
The incidence of coercion is high, consistent with that reported by the Elliot Institute.7 The classic picture of threats, intimidation, ultimatums, stand-over tactics and/or violence is seldom reported. More prevalent is the subtle psychological pressure applied by others, usually female, to compel a woman to terminate a pregnancy against her will.
Younger women, not yet fully individuated, still dependent on their parents and lacking the confidence to challenge parental authority, tend to fall victim to the female face of coercion - a mother, sister, or grandmother may persuade, cajole or harass, the subtle use of a position of trust, power and influence in a close relationship. Youth, obedience to parents and respect for authority add to the pressure to comply.
The message 'I know what's best for you' masquerades as care and may go unnoticed by the professionals involved. Reports include not being listened to by medical personnel; not being given an opportunity to be seen alone; and being sidelined while the dominating figure conducts the conversation. Passivity is easily misconstrued as consent and the process quickly moves to completion. Powerlessness, isolation and a sense of abandonment ensue. Violated boundaries, betrayals of trust and the losses of abortion give rise to anger and rage which, if internalised, may trigger depression.
Family narratives
Family stories underpin decisions to terminate a pregnancy.
Fathers shape their daughters' perceptions and expectations of men. A daughter observes her father's care for her, for her mother and how he relates to his wife/partner in pregnancy. The absence of a father may prompt a daughter to exchange sex for love. In my experience father narratives have been less prominent than mother-daughter narratives.
A woman's relationship with her mother is seen as central and ambivalence in the mother-daughter relationship is significant. Themes and patterns of behaviour are noted over three generations of women as they respond to trauma, life events, societal and familial attitudes to women and sociocultural trends.
Narratives passed down inform womanhood and produce powerful, often subconscious, beliefs about motherhood, for example, 'Once you're a mother, your life is not your own'. Injunctions like 'be successful' and 'do something with your life' subtly undermine the value of motherhood. Mothers who have been disappointed or who have struggled with motherhood subtly communicate this to their daughters.
Presence of historical sexual abuse was not surprising and is well documented in the literature.8 What is surprising is the high incidence I've noticed in peer support groups with whom I have been involved – over 80% on one occasion.
Lack of information
It is surprising that reports of insufficient information are regularly heard. With some dismay, women say: 'Nobody told me'; 'I didn't know'; or 'I never expected this'.
The Code of Ethics for Psychologists 9 states that obtaining informed consent from those with whom they are working is "a fundamental expression of respect for the dignity of persons and peoples."
A psychologist needs to:
1. provide "as much information as a reasonable or prudent person, family, whānau, or community would want to know before making a decision or consenting to an activity" (para. 1.7.6)
2. take reasonable steps to ensure that the information is understood (1.7.7)
3. take all reasonable steps to ensure that consent is not given under conditions of coercion or undue pressure from them (1.7.4)
4. "have an increased responsibility to protect and promote the rights of those who were vulnerable because they have lesser power" (1.7.1)
5. give sufficient time for the recipients to respond to the information (1.7.7).
The omission of informed consent in the protocols around abortion may, in part, reflect the fact that the Contraception, Sterilisation, and Abortion Act 1977 was promulgated before there was any developed notion of informed consent.
The fact that other health care professionals operate under equivalent codes of ethics regarding information and consent is not borne out in the stories I have consistently heard from women.
Conclusion
Experience confirms that abortion is a significant life event that can cause considerable loss and grief. The circumstances of the decision and the factors that influence the decision are diverse and complex. Simplistic restatements of research findings, without elaboration, do women a disservice.
Full and accurate information about risks and effective screening for coercion by way of independent and neutral counselling, and enough time to consider her response to an unwanted pregnancy, is every woman's basic right. As psychologists and healthcare professionals, it is our responsibility to ensure that.
I am deeply grateful to those men and women who have shared their stories with me and I thank them for enabling me to grow in this field.
Dawn de Witt is a Counselling Psychologist with a background in general practice, relationship counselling and family therapy. She presently co-ordinates Project Rachel in the Catholic Diocese of Hamilton, New Zealand and is on the retreat team of Rachel's Vineyard Retreats.
Endnotes
1. http://www.apa.org/search.aspx?query=the new civil war retrieved on 2 February 2017
2. Adler, et al. 'Psychological responses after abortion'. Science 06 Apr 1990: Vol. 248, Issue 4951, pp. 41-44. http://science.sciencemag.org/content/248/4951/41 accessed on 21 March 2017
3. Adler, et al. 'Psychological factors in abortion: A review'. American Psychologist, Vol 47(10), Oct 1992, 1194-1204. http://dx.doi.org/10.1037/0003-066X.47.10.1194 accessed on 2 February 2017
4. http://www.apa.org/pi/wpo/mental-health-abortion-report.pdf accessed on 2 February 2017
5. APA Press Release. http://www.apa.org/news/press/releases/2008/08/single-abortion.aspx accessed on 20 March 2017
6. Ibid.
7. http://www.theunchoice.com/articles/howcommoniscoercion.htm accessed on 20 March 2017
8. Boden, Joseph M; Fergusson, David M; & Horwood, L. John. 'Experience of sexual abuse in childhood and abortion in adolescence and early adulthood'. Child Abuse & Neglect, Volume 33, Issue 12, December 2009, pp. 870–876
9. Code of Ethics for Psychologists. Para 1.7 http://psychologistsboard.org.nz/cms_show_download.php?id=235 accessed on 6 March 2017.