Authors

1. Nyboe, Mille Petersen
2. Fandt, Christl Hansen

Abstract

Review question/objective: The objective of this review is to investigate Scandinavian women's experiences in connection with "abortion on request".

Background: In Scandinavia, the main issues in the abortion-debate up until now have been centred around Scandinavian women's legal rights around induced abortion, or an "abortion on request". To a lesser extent, the questions of how women experience an induced abortion" and how society could and should support her also exist. In this systematic review Scandinavian women are defined as women living in (but not necessarily have citizenship of) Sweden, Norway or Denmark.

"Abortion on request" is the woman's formal right to abort a fetus without any medical indication for mother or child. In Scandinavia the woman's right to abortion was adopted when the law on Induced Abortion on Request was promulgated in 1973 in Denmark, in 1974 in Sweden and in 1975 in Norway. The deadline for the right to request abortion was set to 18 weeks of pregnancy in Sweden1 and 12 weeks of pregnancy in Denmark2 and in Norway.3 According to figures from the national abortion records from 2009, 15,774 abortions were performed in Norway, or 255 abortions per 1000 live births,4 in Sweden there were 335 abortions per 1000 live births,4 and in Denmark there were a total of 16,205 abortions, or 258 abortions per 1000 live births.4

Up to the late 90s, induced abortions were performed as surgical abortions, but from 1988 to 1998 medical abortion was introduced in Europe. The latter can be done up till the eighth week of pregnancy.5 A medical abortion is initiated with an antiprogesteron (mifepristone) that interrupts normal development of the pregnancy, followed by a prostaglandin analogue to initiate contractions of the uterus.6

In 2011 the question of how society can provide support and care for women before and after an induced abortion was debated among priests, midwives, nurses and intellectuals as a result of a formal proposal for the so-called fetus-funeral (cremation or burial of the miscarried foetus regardless of whether it was a product of an induced or a spontaneous abortion).7,8 The question was also debated in the Danish Ethics Council,9 and it was argued among some members of the Danish Ethics Council that this burial of a fetus from an induced abortion could be firstly society's tribute to what these members of the Council called "the incipient human life" (translated, MNP) and secondly a help to the women who had an abortion on request, to support them through their possible guilt and feelings of shame.10

A reasonable question to ask after this debate is how do Scandinavian women who have had an abortion on request feel and react in connection with the intervention - do they indeed suffer from shame, guilt or other emotions?

How has this question about women's experiences in connection with an abortion on request and without a medical indication been investigated in international and Scandinavian contexts? An initial search for studies, articles and reviews from 1990 until 2013 on CINAHL, PubMed and SweMed+ provided some answers. This question has been explored differently, in an international setting, with the use of different perspectives, methods and focus.

In an American context, the initial search resulted in two American reviews, both with the aim to explore a possible connection between induced abortion and mental or psychological health consequences for the woman, but with slightly different conclusions. Charles, Polis, Sridhara & Blum's systematic review from 2008,11 which aimed to challenge the claim that women who have induced abortions will experience psychological distress. The systematic review shows that the highest quality studies had findings that were mostly neutral, suggesting few, if any, differences between women who had abortions and their respective comparison groups in terms of mental health sequelae.11 Conversely, Thorp, Hartmann & Shadigian's review from 2003 which investigated the "long-term physical and psychological health consequences of induced abortion", showed that induced abortion increased the risks for both a subsequent pre-term delivery and mood disorders substantial enough to provoke attempts of self-harm.12 The question for this systematic review is to uncover if Scandinavian women indeed report experiences and health consequences similar to those described by Thorp, Hartmann & Shadigian,12 or if the mental or psychological health consequences are experienced as less or none, as uncovered by Charles, Polis, Sridhara & Blum.11

In an older third American study, Turell, Armstrong & Gaa's critical review of the literature from 1990, it is stated that although research on the long-term effects of induced abortion is marred by methodological errors, most studies have found no adverse psychological sequelae; rather there appears to be a sense of relief and opportunity for personal growth.13 However there is an exception of a small group of women who do experience emotional distress after abortion; this group is characterized by a demographic of young women with little or no support from significant others, and Catholics.13 The point that negative psychological effects in connection with an abortion are more likely in certain "high risk" groups of women is also found in Lipp's review from Wales in 2009.14 As a consequence of their findings, Lipp et al. suggest some implications for practice with a focus on the following: firstly, the need for psychological support to some women after a termination of pregnancy, and this support should be targeted towards those who are most at risk of experiencing negative psychological consequences; second, that nurses should establish the presence of risk factors for adverse psychological impact before termination to determine whether support is likely to be necessary.14 The four studies mentioned above provide relevant and interesting perspectives on the research question, but as far as uncovering women's own experiences, it is appropriate to pursue studies seeking the woman's self-reported experience. One example of this is Lie, Robson and May's narrative review of qualitative studies from England from 2008. This review identified 18 qualitative studies on women's experiences of abortion, and revealed three main themes: experiential factors that promote or inhibit the choice to seek TOP (termination of pregnancy), experiences of TOP, and experiential aspects of the environment in which TOP takes place.15

In the initial search, there were no findings of a systematic review in a Scandinavian context, and because the existing reviews have conflicting results, this systematic review will investigate Scandinavian women's experiences in connection with an abortion on request - meaning before, during and after the intervention - including the women's possible and self-reported psychosocial or psychological health consequences.

Also this systematic review will suggest some implications for practice with focus on the pre- and postoperative care and information related to abortion.