Women ’ s experience of termination of a pregnancy

Tel: (011)489-2911 Fax:(011)489 2257 E-mail: cphm@edcur.rau.ac.za Abstract: Curationis 29(1): 3-9 In November 1996 the Act on the Termination of Pregnancies (no 92 of 1996) was promulgated. This Act enabled women from the age of twelve years old to decide to terminate their pregnancies before twelve weeks gestation without permission of anybody else. Since February 1997 almost 160 000 terminations of pregnancy have been carried out in South Africa. Little research has been conducted to explore and describe the effect of the termination of pregnancies on women Two aims were formulated for the research project described in this article: (1) the exploration and description of the women’s experience of terminating a pregnancy, and (2) the description of counselling guidelines for caring professionals to assist these women. Partic ipan ts were included in the sam ple through purposive sam pling. Phenomenological interviews were conducted individually. Data were analysed by means of Tesch’s descriptive approach. Counselling guidelines for educational psychologists and other caring professionals to empower the involved were being logically inferred from the results of the interviews. Measures to ensure trustworthiness have been applied in the research and ethical measures have been strictly adhered to during the research. One central theme was identified from the results of the interviews and naïve sketches, namely women’s experiences of a negative relationship with themselves and other persons as well as their focus on their terminated pregnancies.


Rationale and problem statement
In N ovem ber 1996 the Act on the Termination of Pregnancies (no. 92 of 1996) was promulgated.This Act enabled women from the age of 12 years old to decide to terminate their pregnancies before 12 w eeks gestation w ithout permission of their partners or parents.The reason for this Act was to enhance the health and quality life of women in South Africa by reducing and eradicating morbidity and mortality resulting from unsafe abortions and to enable women to exercise their sexual and reproductive rights (Potgieter & Andrews, 2004: 21).If, for any reason, a woman is of the opinion that the pregnancy is an obstacle to her health and quality life, she may request termination of pregnancy at an approved health service (clinics and hospitals) designated by the Department of Health.The Act made provision for non-com pulsory counselling before, during and after the termination of a pregnancy.The Act also created a context where back street abortions could be reduced.Since February 1997 more than 160 000 terminations of pregnancy have been carried out (Badenhorst, 1999: 13).National statistics indicate that in South A frica 17.4% of women requesting termination of pregnancy are below the age of 18 years (Barometer, 1997:1).

Research aims
From the research questions two aims were formulated: • to explore and describe women's experience of terminating a pregnancy; and • to describe counselling guidelines that can by utilised by caring professionals to support women who choose to terminate a pregnancy.

Research method
A qualitative research design was used because it deemed more effective than a quantitative approach in providing an understanding of how women experience the term in atio n o f a pregnancy.A qualitative, exploratory, descriptive design from a larger interdisciplinary study w asa used ands a secondary analysis was employed (Morse, 1994: 263).
The research was conducted in two phases.In phase 1 an exploration of wom en's experience of terminating a pregnancy was conducted.In phase 2 co u n sellin g g u idelines that can be utilised by caring p ro fessio n als to support women who choose to terminate a pregnancy were formulated.

Phase 1: Women's experience of terminating a pregnancy
In phase 1 atten tio n was given to sampling, data gathering, data analysis and lite ra tu re control.The issues regarding trustw orthiness and ethics were addressed.
Sampling: Participants were included by means of purposive sampling (Creswell, 1994:15).The criteria for inclusion were w om en who chose to term inate a pregnancy and who voluntarily agreed to participate in the research.Altogether 26 women participated in this research.Sixteen interviews were conducted and ten naïve sketches were written.These women were between 15 and 50 years of age.They came from all race groups, religions, socio-economic levels and educational levels and they were single as well as married.
Data collection: Data were gathered by means of phenomenological interviews, written personal stories (naïve sketches), o b serv atio n s and field notes.P henom enological interview s were conducted (Kvale, 1996: 81-107 et seq: Marshall & Rossman, 1995:80-83 et seq) were conducted with participants.These in terv iew s focused on the lived experience of each specific participant.One central question was posed, namely: "How did you experience the termination of pregnancy?"The interviewer created a context where the participants could speak freely and openly by utilising com m unication techniques such as clarification, paraphrasing, summarising, probing and minimal verbal as well as non-verbal responses (Wilson & Kneisl, 1996:110-131).During the interviews the interview er used bracketing (placing preconceived ideas aside) and intuiting (focusing on the lived experience of the participants regarding the termination of a pregnancy).The in terv iew s w ere conducted until the data were saturated as demonstrated by repeated themes.The interviewer wrote field notes based on observations during the interview s.T hese field notes ad d ressed the in terv iew er's observation, personal experience, methodological issues and theoretical notes (Wilson, 1989:436-438).
In instances where participants were not willing to be interviewed or where access was not readily available because of a variety of circumstances, the participants were requested to write their personal story (naïve sketches) regarding their experiences o f the term ination o f a pregnancy (Giorgi, 1985:10-19).
Data analysis: Data were descriptively analysed by using T esch 's m eth o d (Creswell, 1994: 154-156) of descriptive analysis.An independent coder analysed the data independently from the various researchers (Creswell, 1994:158;Krefting, 1990:216).Consensus discussions were held between the independent coder and the researchers and identified themes were refined.A literature control was done to verify the results.

Measures to ensure trustworthiness:
Measures to ensure trustworthiness were applied.G u b a's (L inco ln & G uba, 1985:290-327) strategies of credibility, tran sfera b ility , d e p e n d a b ility and confirmability were applied.Activities in achieving credibility were prolonged engagement in the field, keeping reflexive journals, the research ers' authority, triangulation, peer review and structural coherence.Transferability was achieved through a dense description of the data and purposive sampling.Dependability was achieved by a description of the method of data gathering, data analysis and interpretation.Finally, confirmability was achieved by ensuring an audit of the entire research process, reflexive analysis and triangulation.
Ethical m easures: Ethical measures (Democratic Nurses Association of South Africa, 1998:5) were adhered to during the research regarding this sensitive issue.These include ensuring quality of the research in fo rm ed co n sen t of participants, providing feedback on the project to the participants, ensuring co n fid e n tia lity and anonym ity and protection from harm.The participants were told that they were free to withdraw 4

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Table 1: Women's experience of changed relationships resulting from a termination of their pregnancies EXPERIENCING A CHANGED RELATIONSHIP WITH:

Themselves Physical pain and fatigue:
-Experience of pain and discomfort during the termination of pregnancy -The presence of fatigue

Psychological discomfort:
-Initial uncertainty and confusion about the decision-The experience of being stuck -"roller coaster effect" -Fear that secrets will be exposed -Emotional responses: regret, self-blame, anger, guilt feelings, emptiness

Psychological defense mechanisms -Rationalisation -Denial
Relief resulting from termination of pregnancy

Their partners Do not want to intrude into their partners' lives:
Anger after termination of the pregnancy -Do not like the partner anymore -Breaking up of the relationship -Experiences that partner does not understand

Their terminated babies Annual commemoration of date of presumed birth
Attraction to objects related to babies Personalises baby, for example, gender is accepted ss male

4, Their mothers Blaming them for the decision of termination
Feelings of hatred towards their mothers

Their friends Wear a mask in relationships
-Isolation -Not able to/not want to share pain from the study at any stage if they so desired.They were also told that if certain emotional issues might arise, they would be referred to a professional if necessary.Furrthermore the participants were given the assurance that all taped interviews would be destroyed once they had been transcribed.

Results and discussion
A central theme identified within the data was the women's experience of changed re la tio n sh ip s re su ltin g from the termination of their pregnancies.Their relationships with them selves, their partners, their terminated babies, their m others and their friends changed.Changed relationships within the context of this research refer to the women who had a termination of pregnancy reviewing th eir re la tio n sh ip s based on th eir experiences and the implications of their ex p e rien ce o f th eir term in ated pregnancies.The discussion will be based on the schematic condensation of the data in Table 1.This d iscu ssio n w ill be highlighted by direct quotations from the participants and accompanying literature control.

Subtheme 1: Experience of a changed relationship with themselves as a result of the termination of a pregnancy
The participants not only experienced physical effects from the termination of th eir p reg n an cies but som e also experienced psychological discomfort.They tried to address the psychological d isco m fo rt by u tilisin g defen ce mechanisms and some participants also experienced relief after their termination of pregnancy (see Table 1).

Experience of physical pain and fatigue:
The women verbalised the experience of pain and disco m fo rt du rin g the termination of pregnancy.The following direct quotations highlight this aspect: "Die pyn was die seerste wat ek nag gehad het.D it het gevoel a s o f my ingewande uitgesuig w ord".(The pain was the worst that I ever experienced.It felt as if my insides were being sucked out)."Verskriklik!Ek sal dit vir niemand aanraai n ie ". (Terrible!I would not recommend it for anybody).
The women explained that the pain did not end with the term ination o f the pregnancy itself, but they all experienced stomach aches or bleeding for some time after completion of the procedure: "Ek het vir d rie weke daarna nog maagkrampe gehad, niemand het vir my gesê dit gaan gebeurnie ". (I had stomach cram ps for th ree w eeks afte r the termination, nobody told me that it would happen).This experience is supported by the data in Fact Sheet: What is surgical abortion?(1997) namely that the pain did not end with the termination of the pregnancy itself.The wom en also experienced fatigue after the termination of pregnancy (see Table 1).The women's everyday lives was influenced by this, but they had to co n tin u e. T his is reflected by the following quotation: "OK,fisies was ek moeg.Ek was siek".(Okay, physically I was tired.I was ill).
Experience of psychological discomfort: Som e o f the som en who chose to terminate their pregnancies experienced psychological discomfort.

Initial uncertainty and confusion about the d ecisio n :
The w o m en 's psychological discomfort included initial uncertainty and confusion about the decision to terminate the pregnancy.".../ sat there fo r about 20 minutes thinking all sorts o f things like why am / here and why am I doing this.You know I can V blam e anybody.W hat am I supposed to do ?" A ccordin g to research done by Myburgh, et al (1998: 16) these women also ex p e rien ce fear before the termination of their pregnancies.The following direct quotation of one of the p a rtic ip a n ts in the current study demonstrated this: "... senuweeagtig, angstig en ook bang.Ek het nie geweet hoe hulle dit gaan doen nie.Ek wou dit net oorkry".(... nervous, anxious and also scared.I did not know how they would do it.I just wanted to get it over and done with).Thom pson and Rudolph (1992:523) support this by stating that most anxiety is caused by fears of the unknown -in this case the term in atio n o f the pregnancy.Another fear that the women experienced is related to the fear that the secret o f th e ir term in atio n o f the p regnancy co u ld be exposed.A quotation in this regard was: "Sjuutmaar net oor alles w a te k sê ". (Be silent, about everything I say).

Experience of being "stuck" :
Although the freedom of choice to terminate a pregnancy has been legalised, most women experienced limited freedom in making this choice.They seemed to exp erien ce being " stu ck " w ith the term in atio n o f a pregnancy but experienced it as being the only option available.One woman said that she was forced by her m other to have a termination of her pregnancy: "...because the decision wasn't left up to me and I think if it had been left to me, I would have had the baby...I said for me that wouldn't have been my first choice I m ean ...".
For other women the experience of being stuck had almost a "roller coaster" effect as d em o n strate d by the follow ing quotation: "Die verantwoordelikheid en op 'n manier dié dat dit so vinnig moet gebeur, jy weet uhm ek weet nie eers of dit so vinnig hoef te gebeur het nie maar in my kop het ek net geweet ek het min tyd, ek m oet vinnig d in k " .(The responsibility and in a way the fact that it has to take place so quickly.You know uhm I do not even know if it had to take place so quickly, but in my mind I knew I had little time and had to think fast).
Women also experienced being stuck after the term ination o f pregnancy because they felt guilty and wondered whether God would forgive them.
Em otional responses: These women experienced several negative emotional responses like regret, self-blame, anger, guilt feelings and emptiness.One woman referred to her self-blame and feelings of guilt after the termination of pregnancy, as caused by moral values and education which resulted in internal conflict: Gilles (1992:27) states that self-blame is present because people set c e rta in standards for themselves.If something like the termination of pregnancy takes place, they experience negative feelings towards themselves.The stronger the religious conviction, the greater the guilt feelings will be after the termination of a preg n an cy ( F a ct Sheet.P lanned Parenthood 1997:1 -6).Researchers (Britz, 1997: 42-44;Myburgh, et al, 1998: 18) found in their research conducted with adolescents who had term ination of pregnancies found that they experience self-blame and guilt feelings.
One woman described her self-blame as follows: "... ek dink dit was 'n bietjie van 'n selffoltering en op 'n manier het ek gedink dit as boetedoening gesien.Ja, ek verdien darem nou om bietjie swaar te kry, so dit was een manier wat ek amper my skuld aan my kind kon betaal".(I think it was self-blame and in a way I thought I deserve to suffer as it would be one way in which I can pay my debt to my child).She further remarked: "...ek sit nou en dink aan die hele naweek wat ek in die bed gelê het en uhm my wonde gelê en lek het".(I am sitting now and thinking about the whole weekend I spent in bed, licking my wounds).
Women also refer to their regret in terminating a pregnancy: "Well, I was lying there .. A n o th er way in w hich a w om an ra tio n a lised the term in atio n o f her pregnancy was to describe an unrealistic perspective regarding her relationship with possible children in the future by saying that they would be the center of her universe: "I f l had children one day they're going to be the absolute core o f my universe, that' s one thing fo r sure".

Denial resulting from the termination of a pregnancy:
The women denied that their pregnancies and/or the termination of pregnancies would have an effect on them: "In die begin wou ek niks daarvan weet nie, glad nie".(At the beginning I did not want to know anything about it, not at all)."... het ek in 'denial' gegaan...gemaak o f dit nie gebeur het n ie".(I went into denial...I pretend that it did not happen).Orenstein (1994:54) is of the opinion that the termination of a pregnancy has an influence on women; they are emotionally tom after the termination of a pregnancy and it has a social and mental impact on them.In the above cases the women denied that they had terminated their pregnancies.

Subtheme 2: Women's experience of a changed relationship with their partners
In the data tw o dim ensions o f the w om en's changed relationships with their partners were identified, namely some did not want to intrude into their partners' lives, while other experienced anger towards their partners.

Women do not want to intrude into their partners' lives
The following quotation demonstrates a woman's decision not to intrude into her partner's life: "....ek wou nie inbreuk maak op sy lewe nie, ek het gevoel uhm jy weet hy moet voortgaan met sy lew e..." (I did not want to interfere with his life.I felt uhm you know, that he should continue with his life).In this instance her partner was a married man with children.
In another situation the woman's partner was busy with post-graduate studies and she did not want to interfere with his dreams for his life: ".../ think I would have resented myself fo r jeopardising his academic future ''.

Women's anger towards their partners a fter the term in ation o f th eir pregnancies:
The other dimension of experienced changed relationships with a partner was the women's anger after 7

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the termination of their pregnancies.This anger was verbalised as not liking a partner anymore, breaking up of the re la tio n sh ip w ith the p artn e r and experiencing that the partner does not understand their em otional turm oil re g ard in g the term in atio n o f th eir pregnancies.From a naïve sketch written by a w om an it was clear th at she experienced that her relationship with her partner broke up after the termination of her pregnancy.She experienced that her partner did not love her, nor understood or sup p o rted her and that th eir relationship had become destructive.

Subtheme 3: Women's experience of a changed relationship with their terminated babies
The experience of a changed relationship w ith th eir term in ated bab ies was expressed in the following ways by the interviewed women: • commemoration of the presumed date of the babies' births; • personalisation of the terminated babies, for example, the gender is most often male; and • avoidance of contact with other babies.
Commemoration of the presumed date of the baby's birth: Women said that they were feeling down at the same time each year and have id en tified it as the presumed birth day of their terminated babies.One participant remarked: "... on the sixth o f September every year I just just break down I don' t know why ...it just happen to be the six o f September when this was happening and uhm I just burst into tears.It is difficult to say how I 'm fe e lin g , I f e l t like there w as something missing there should have been something there on that day".

Attraction to objects related to babies:
Several of the participants told the researchers that after the termination of their pregnancies they were attracted to objects related to babies, such as baby clothes, toys and foods: Cote and Reisser (1997:5) found that w om en d ep erso n alise th eir babies probably to protect themselves from the painful memories of their termination.

Avoidance of contact with other babies:
One woman told the researchers that she avoided contact with babies because she was afraid that she could hurt them: ".../ ca n ' t really discuss it.It is nothing it is ju st the fea r o f babies... she said: 'You were pregnant and you terminate' and I said: 'But how do you know?' and then she said: 'Because I did as well ' ''.
Subtheme 4: Women's experience of a changed relationship with their mothers Some of the participants voiced their experience of a changed relationship with their mothers.They often blamed their mothers for their decision to terminate their pregnancies.Some even voiced feelings of hatred towards their mothers.One participant said: "I shudder when my mother comes near me, I avoid her".
Another participant experienced that her m o th er av o id ed any discussion regarding the termination of pregnancy.So she did not receive any support: "...it properly will be better fo r me to talk about it sometime I felt it but so I do n ' t know the walls didn' t listen so well as they use to but uhm my mother never really expect me to talk about it".
Subtheme 5: The women's experience of a changed relationship with their friends Most of the women expressed a change in their relationship with their friends after the termination of their pregnancies.They wore a mask in their interaction with their friends, they showed a happy face, but inside they experienced em ptiness, loneliness, sadness and isolation.

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The participants reckoned that friends do not really understand what they went through and that results in the women feeling lonely and isolated.
The women are not able to share their pain and exp erien ce regarding the term ination o f pregnancy with their friends and they are not able to maintain their relationships with their friends.The participants remarked the following in this regard: "I haven' t really spoken to anybody else about it very much "."...I d o n ' t see her anymore and uhm that' s basically what happened with a couple o f my friends they just drifted", "...people that people do grow apart so its fully understandable".This quite Often contributes to their expressions of feelings of isolation and loneliness.

Conclusion
The wom en's experience of changed re la tio n sh ip s re su ltin g from th eir termination of pregnancy is evident on d iffe ren t levels nam ely th eir relationships with them selves, their partners, their terminated babies, their mothers and their friends.Their reactions to these changed relationships are to withdraw themselves from other people and to focus on themselves.They often break their relatio n sh ip s with their partners and friends.They also break their relationships with their mothers on a psychological level.In the process they are isolating themselves.These women should be assisted to deal with their changed relationships and to regain trust in themselves and others.
Phase 2: The description of counselling guidelines that can be utilised by caring professionals to support women who chose to terminate a pregnancy P rereq u isites for cou n sellin g these w om en are carin g attitu d e s and facilitative communication.These caring attitudes include empathy, unconditional acceptance, no judgement, sincerity and congruence.Facilitative communication includes m inim al verbal responses, clarification, reflection, paraphrasing and summarising (Wilson & Kneisl, 1996: 110-131;Myburgh, et al, 1998:19).
The focus of the counselling after the w om en's term ination o f pregnancy should be focused on the re-evaluation and reconstruction of their relationships.The caring professional should create a context where the women who had a termination of pregnancy could verbalise their thoughts and feelings (Hanley, 1994:31).They should be supported to forgive themselves.Support should also be given by the caring professionals to the women to grieve the loss of their babies.They should be assisted to accept their decision to terminate their pregnancies.
The women's experience of a termination o f p reg n an cy has ch an g ed th eir relationship with themselves and others -they are no longer novices regarding a termination and this make them wiser, but often sadder.After this life-changing experience, they should be assisted to ev a lu a te the co n stru c tiv e and destructive aspects of their relationships w ith o th ers and d ecid e w hich relationships would be worthwhile to continue.
In feren c e(C opi,  1986:57)  was used to identify counselling guidelines from the results of phase 1.Data analysis:This was discussed with ca rin g p ro fe ssio n a ls to ensure trustworthiness.Thereafter a literature control was done.
"E k ' s baie kw aad vir m yself hoe ek myself verwyt".(I am very angry with myself, how I blame myself)."Ek meen, ek weet nou ek het nie die regte keuse gemaak nie.Ek meen, ek het 'n lewe geneem".( I mean, I know now that I did not make the right choice.I mean, I took a life).Another woman said: "...thinking to 6 Curationis March 2006 myself what I mean how did things turn out if I could do it a bit differently".