Journal of Psychosomatic Obstetrics & Gynecology, December 2007; 28(4): 231–237

Midwives’ experiences of encountering women seeking an abortion

¨ M, LARS JACOBSSON, MARIANNE WULFF & ANN LALOS META LINDSTRO Department of Clinical Sciences, Obstetrics and Gynecology, University Hospital, Umea˚ University, Umea˚, Sweden and Department of Clinical Sciences, Psychiatric, Universtiy Hospital, Umea˚ University, Umea˚

(Received 22 May 2006; accepted 7 March 2007)

Abstract In order to gain knowledge about midwives’ clinical and emotional experiences of working with termination of pregnancy (TOP) and their perception of women’s motives for having an abortion questionnaires were mailed to a representative sample of Swedish midwives (n ¼ 258), and 84% responded. Responses to 17 statements were studied and interpreted. It was found that every third midwife had not at all worked with TOP, and every fifth had not done so in the preceding two years. Among those who had experienced this work, few midwives had considered changing their job or had had misgivings or feelings of inadequacy caused by encountering women seeking an abortion. Both working currently with TOP and for a longer period of time were found to evoke positive experiences in every other midwife. Midwives’ perception of motives for abortion corresponded very well to motives provided by women themselves. Half the midwives had had misgivings concerning late abortions and somewhat fewer regarding surgical abortions. In general, religious belief did not influence midwives’ views of TOP. Those midwives who had themselves had an abortion reported fewer misgivings about late abortions than those without personal experience of TOP.

Keywords: Abortion motive, emotion, midwife, misgivings, termination of pregnancy, working experience

Introduction Termination of pregnancy (TOP) is one aspect of reproductive healthcare within which midwives in Sweden work to a relatively large extent. The midwife is one of the first, if not the first, among the staff that women will meet doing a pregnancy test at maternity centers or after a positive test at home. During the abortion procedure, as well as at follow up after treatment including discussions about contraceptives, she will also usually meet a midwife. In addition, midwives work at youth centers specifically counseling young people in contraceptive use and partner relationship matters. Some midwives also work within specialist gyaecology healthcare where one of their tasks may be to assist in induced abortions. In general, midwives working on delivery wards do not have such assignments as meeting women seeking abortions. Thus, in Sweden midwifery is handling with reproductive health in the widest sense. The Swedish Abortion Law allows women to request TOP up to 18 gestational weeks without question [1]. The annual number of abortions in Sweden is 21.5 per 1000 women aged 15–44 [2]. Ninety-three percent are performed before 12

completed gestational weeks. Usually, a medical method is used for the period within 63 days after conception and surgical methods for up to 12 weeks. Abortions between 12 and 18 weeks (6%) are usually performed in a two-stage session. Requests for late terminations between 18 and 22 weeks have to be submitted to the National Board of Health and Welfare which decides upon these cases [1]. Such late abortions accounts for less than 1% of the annual number of abortions. Recently, women in early pregnancy have been given the opportunity to have a medical abortion in a home environment [3,4]. In the two latest years, 38% of all women having an abortion have already had one earlier (repeat abortion) [2]. Before TOP the woman is examined by a gynecologist who estimates the stage of pregnancy using ultrasound and considers her medical history as well as her physical and mental health. Thereafter, the woman and the gynecologist decide on the preferred abortion method. In addition, the women should always be offered psychosocial support from a social worker/counselor [1,3]. In a previous study we have found that midwives as well as gynecologists in Sweden support the current abortion legislation and believe that it is right that

Correspondence: Meta Lindstro¨m, Department of Clinical Sciences, Obstetrics and Gynecology, University Hospital, S-901 85 Umea˚, Sweden. Tel: þ46907853322. Fax: þ4690773905. E-mail: [email protected] ISSN 0167-482X print/ISSN 1743-8942 online Ó 2007 Informa UK Ltd. DOI: 10.1080/01674820701343505

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women themselves should decide about TOP [5]. It was also found that midwives in general were slightly more restrictive in their views about free abortion than gynecologists [5]. However, both midwives and gynecologists have become more liberal over time in Sweden [5]. In another study, focusing solely on gynecologists, we found that fewer female than male gynecologists agreed that staff should have the possibility of refusing to take part in TOP on personal grounds [6]. This study also showed that twice as many male as female gynecologists had felt inadequate in encounters with women seeking an abortion. However, both female and male gynecologists were united believing that continuing professional development and ongoing guidance are important for professionals involved in TOP. In order to optimize reproductive healthcare for women and men and to offer good working conditions for staff, it is of great importance that decision makers assess and are aware of staff experiences and attitudes to TOP. Previous studies on midwives’ experiences of TOP are often dated one to three decades back and mainly dealt with concerns about being in favor of or against legal abortion and the willingness to provide and take part in TOP [7–14]. In fact, there is a great lack of knowledge about midwives’ emotions and ideas involved in abortion care. The aim of the current study was, therefore, to describe Swedish midwives’ clinical and emotional experiences and to search for influencing factors on midwives’ views on working with TOP. A further aim was to study the midwives’ perceptions of women’s motives for having an abortion.

Methods Subject A questionnaire was sent to a randomly chosen sample of 258 midwives, who were active in their professions in 1997 and 1998. According to a power calculation of sample size every 14th midwife authorized to prescribe contraceptives (258 of 3695) was asked to participate in the study. At the time of collecting data there were about 6000 midwives totally working in health care in Sweden. Midwives now graduating will have the authority to prescribe contraceptives, however, the midwives included in our study had to have further education to achieve this competence. The authorized midwives were chosen because they were most probably the midwives who had experiences of working with TOP. Method Initially, a pilot participating observation and interview study was conducted based on women seeking an abortion in order, for example, to identify the

professionals who most frequently encounter such patients/women. In accordance with the result of the pilot study supplemented with a few questions from two previous studies [13,14], a questionnaire was designed and tested on staff. Apart from demographics and professional characteristics, participants were asked to respond to specific statements and give their views on these statements on a six-grade scale. Only one square could be marked. The first value ‘‘agree totally’’ was coded 1 and the last one ‘‘do not agree at all’’ was coded 6 in the analyses. As the participants who had no experience of TOP had no answers to give to the questions concerned with experience, they were asked to ignore that part of the questionnaire that dealt with these issues. The present paper, together with demographics and questions on women’s motives for having an abortion, is almost exclusively based on 17 statements concerning experiences of working with TOP. As the questions dealt with personal and private matters it was important to ensure that anonymity was preserved. Thus, respondents were asked not to reveal their identity and, one reminder was, therefore, sent to all the 258 midwives. Analysis The descriptive analyses included frequency and cross-tables including the Chi squared tests assisted by the SPSS data program (Statistical Package for the Social Sciences for Windows 8.0 and 11.5). Analyses have been conducted on all midwives excluding the male midwives (n ¼ 2) to avoid identification. The midwives were also divided into two and three subgroups respectively according to if and when they had worked with TOP. Non-parametric tests were used to test the difference between two groups. Due to the nature of the questions a six-grade scale was chosen which was dichotomized into ‘‘agree’’ (coded 1–3) and ‘‘disagree’’ (coded 4–6). At the end the midwives were invited to comment on the questionnaire itself. About 150 comments were given and some will be presented in Italics as a complement to the findings. The Ethics Committee of the Faculty of Medicine, Umea˚ University, Sweden approved the study.

Results Demographics A great majority (84%) of the 258 Swedish midwives answered the questionnaire. Of these 216 midwives, 75 (35%) had never worked with abortion clients and two (1%) were men. Thus, 139 (65%) female midwives were included in the analyses, 49 of these (35%) had not worked with abortion clients in the

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Midwives’ experiences of abortion care previous two years and 90 (65%) were currently active in abortion care. Demographics and professional characteristics regarding these three groups are shown in Table I. There was no difference in mean age between the groups and the majority (about 90%) had two children. Every fifth midwife had personally had an induced abortion. It found that among those who had never worked with abortion clients more were working on delivery wards than those who had worked with TOP. The majority of those with working experiences of TOP worked in out-patient clinics. Seventeen percent did not give any specific information in answer to the question ‘‘experience of abortion method’’ (Table I). The midwives, who had current experience of TOP worked to an estimated extent of 10% with TOP. These midwives also had larger experience of work with surgical than medical abortions. Furthermore, this group had worked almost double as many years with abortions than those who had not worked with TOP in the proceeding two years (Table I). Midwives’ perception of women’s motives for having an abortion About one third of all midwives ranked ‘‘Too young and immature’’ as the most common motive cited by women seeking an abortion (Table II). Nobody really wants to have an abortion but certain situations leave you no option. These women who chose abortion have very strong reasons (aged 45 yrs). There is never one reason for having an abortion there are several factors influencing the decision (aged 41 yrs). Some midwives recalled women’s motives out of the list and ranked these as most important, for instance earlier traumatic deliveries, earlier complicated pregnancies, malformations in the fetus, and women becoming pregnant due to contraceptive failure. Clinical and emotional experiences The key focus of the study was the clinical and emotional experiences of working with TOP (Table III). Two-thirds agreed that ‘‘It is good that Sweden is increasingly shifting from surgical to medical abortions’’ (Statement 1). I am very much in favor of medical abortion (aged 50 yrs). The majority of the midwives also supported the view that medical abortions should be managed by primary healthcare in the foreseeable future (Statement 2). In general, neither surgical, medical, nor repeat abortions had made the midwives consider changing their job (Statements 3–5) and the vast majority agreed that midwives should take part in TOP (Statement 7). Concerning midwives’ views about gynecologists’ participation, about 80% thought that they should perform and take part in TOP (Statement 6). I think

Table I. Demographic characteristics of Swedish female midwives in relation to working experience of TOP (n ¼ 214) (values in percentages).

Characteristics Age Range (yrs) Mean (yrs)

No No Current experience experience experience in previous at all (n ¼ 90) 2 yrs (n ¼ 49) (n ¼ 75)

32–65 46

32–65 48

34–64 48

14 85 1

22 74 4

19 80 1

Children No Yes, 1–2 children 3–4 children 5 children

8 92 58 40 2

12 88 60 35 5

11 89 62 36 1

Principally raised Sweden Scandinavia Outside Scandinavia

98 1 1

90 4 6

95 1 4

22

20

–

23

37

–

11 19 56 14

10 27 45 18

– – – –

79 12 5 4

67 4 18 11

36 12 37 15

Duration of work with TOP Mean years 51 1–3 4–10 11–20 21–30 430

17 5 17 34 31 10 2

9 17 23 29 19 12 0

– – – – – – –

Extent of work with TOP last year (%) 0 10 25 50 75 100

10 80 8 1 1 0

– – – – – –

– – – – – –

34 20 29

– – –

– – –

Civil status Single Co-habitant/married Stable relationship; not co-habiting

Private experiences Has had an abortion personally Relative/close person has had an abortion Religious belief as influencing factor Very important Important Not important Have no religious belief Working places Outpatient clinics Inpatient clinics Delivery awards Outside obstetrics and gynecology

Experience of abortion method (prev. 2 yrs)~ Surgical Medical Surgical and medical to same extent

~17% did not give information.

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Table II. Women’s most common motives for termination of pregnancy ranked by Swedish female midwives from a list of 12 given motives in relation to work period (n ¼ 139) (values in percentages).

Motives 1. Too young and immature 2. Do not want to have more children 3. Problems in partner relationship

No experience Current in previous Total experience 2 yrs (n ¼ 139) (n ¼ 90) (n ¼ 49) 33

30

39

18

21

12

16

15

16

8

9

8

3 3

5 2

0 4

7. Poor personal finances 8. Physical or psychic problems 9. Do not know paternity of child

1 1

1 0

2 2

1

0

2

10. Poor housing conditions 11. Difficult to find childcare 12. Lack of social support

0

0

0

0

0

0

0

0

0

Other motives

8

10

4

Did not rank the 12 motives

8

7

10

100

100

100

4. Incomplete education/ training 5. Too old 6. Unemployed or under threat of unemployment

that nobody should become a midwife or a gynecologist if she or he is not able to meet a woman seeking an abortion on personal grounds (aged 43 yrs). With regard to the right to refuse to work with TOP on personal grounds, more than half of the midwives thought that neither gynecologists nor they themselves should have this possibility (Statements 8 and 9). Gynecologists should have the right to refuse to perform and taking part in TOP. But if all doctors did that!! What would happen then?? . . . . . . . being in the situation where the autonomy of the staff is put before the patients’! (aged 45 yrs) It was found that the occurrence of surgical, medical and repeat abortions caused misgivings among a minority of those who were working with TOP at the time of the study. However, misgivings were twice as common among those who had not worked with it in the preceding two years (Statements 10, 11, 13). Concerning late abortions, it was found that they caused misgivings in every other midwife in both groups (Statement 12). I may think what ever I want concerning some abortions, but for me it is important to support the woman/girl in what she decides (aged 47 yrs). Not only misgivings were highlighted but also feelings of inadequacy when encountering women

seeking an abortion and it appeared that every third midwife had felt that (Statement 14). However, twothirds among those working with TOP thought that their work with women seeking an abortion brought them positive experiences (Statement 15). Furthermore, those who had not worked with TOP in the preceding two years reported less positive experiences (p 5 0.05). Nevertheless, 100% in both groups believed that development for professionals involved in TOP is important as well as ongoing guidance (Statements 16 and 17). The possibilities for staff to reflect and understand their own moral and ethical aspects are under-emphasized (aged 40 yrs). Influencing factors As regards late abortions, 62% of the midwives working within primary healthcare centers, where TOP does not take place, reported misgivings in working with abortions compared with 40% of the midwives who had not worked in primary healthcare (p ¼ 0.035). Furthermore, among midwives who had experience of late abortions, 35% had had misgivings compared with 61% among those who had no such experience (p ¼ 0.006). Feelings of inadequacy when encountering women seeking an abortion were more common among midwives within primary healthcare than among those working in other settings (p ¼ 0.002). Regarding personal experiences of TOP, it was found that those who had not personally had an abortion reported misgivings concerning late abortions more frequently than those who had had an abortion themselves (p ¼ 0.028). As to the statement dealing with medical abortions being managed within the primary healthcare system, more midwives who had personally had an abortion agreed than among those who had not had an abortion themselves (p ¼ 0.047). The midwives who were currently working with TOP (n ¼ 90) and those who had experienced it some time but not the preceding two years (n ¼ 49) were asked if religious belief might be an influencing factor on their views of abortion (Table I). A comparison of the outcome of the statements concerning misgivings about working with TOP showed that half of those who thought that religious belief was very important had had misgivings about surgical, medical, as well as repeat abortions compared with the 6–7% of those who had no belief. Among those with religious belief 82% and among those without belief 50% respectively agreed to having had misgivings about late abortions (p ¼ 0.018). Discussion The main focus in the present study was to describe midwives’ clinical and emotional experiences of working in abortion services. The participation rate

Midwives’ experiences of abortion care

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Table III. Swedish female midwives’ clinical and emotional experiences of work with TOP according to 17 statements in relation to work period (n ¼ 139) (values in percentages).

Statements 1. It is good that Sweden is increasingly shifting from medical to surgical abortions 2. In the foreseeable future medical abortions ought to be managed by primary health care 3. The occurrence of surgical abortions in my work has made me consider changing job* 4. The occurrence of medical abortions in my work has made me consider changing job 5. The occurrence of repeat abortions in my work has made me consider changing job* 6. Performing and taking part in legal abortions should be included in gynecologists’ tasks 7. Taking part in legal abortions should be a midwife’s task* 8. Gynecologists should have the right to refuse to participate in abortions on personal grounds 9. Midwives should have the right to refuse to participate in abortions on personal grounds 10. I have misgivings about carrying out surgical abortions 11. I have misgivings about carrying out medical abortions 12. I have misgivings about carrying out late abortions (418 gestational weeks) 13. I have misgivings about carrying out repeat abortions 14. I feel inadequate when encountering women seeking legal abortions 15. My work with women seeking legal abortion provides me with positive experiences* 16. Continuing professional development for professionals involved in abortions is important 17. Ongoing guidance on cases is important for people working in abortion care

Current experience (n ¼ 90) Agree

No experience in previous 2 yrs (n ¼ 49) Agree

73

63

66

63

5

18

5

10

6

24

77

81

97 44

88 37

44

37

13 13 46

26 27 51

20 32 65

36 31 42

100

100

100

100

*p 5 0.05.

was very high; thus, the findings could be regarded as representative of those of Swedish midwives. It was found that almost all the midwives believed involvement in abortions should be a part of their work. Another important finding was that one-third of the midwives had never worked in abortion services, and one-quarter had no experience of TOP in the preceding two years. In the latter group the reality could be that it was more, not less, than two years since they worked with abortion clients. Therefore, midwives’ experiences must be regarded both as experiences of and attitudes to working with TOP compared with gynecologists, among whom everyone had experience of working with TOP [6]. It was obvious that some midwives made use of the Swedish Abortion Law which allows staff to choose whether or not to work in abortion services and also that the Swedish healthcare is organized in the way that it makes it possible as a midwife to choose not to work with TOP. Among those who had chosen to work with abortion clients, two-thirds thought it gave them positive experiences compared to less than half of those who had not worked in the field for the previous two years.

This may be explained by the fact that taking care of patients in vulnerable life situations implies that the encounter will be both challenging and meaningful. Previous results among Swedish gynecologists have shown similar positive experiences [6]. The vast majority of all midwives thought that both gynecologists and midwives should take part in TOP, which was consistent with the midwives’ reluctance to accept the possibility of refusing to take part in it. The pattern is strikingly similar to a previous study among Swedish gynecologists where almost 100% of both female and male gynecologists believed that their own profession should take part in TOP [6]. Thus, both midwives and gynecologists have fewer expectations regarding one another. Obviously, the two main groups involved in abortion care seem to make high demands on themselves in supporting their patients, which reveals great empathy with the women. The same commitment to work with women seeking abortion was shown among nurse practitioners, physician assistants and nurse-midwives in the US (only women in the first trimester were studied). The conclusion was that they work to a ‘‘high level of passion’’ [15].

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Nowadays, a great many early abortions are performed medically [2], and even in a home environment and this shift from surgical to medical abortions was supported by the majority of the midwives in the present study. The trend to think in this way has also been found among gynecologists [6]. However, regarding managing abortions in the primary healthcare system, two-thirds of the midwives were in favour, whereas only 10% of the gynecologists supported it [6]. The greater restriction favored by gynecologists may be explained by the fact that the two professions have different medical backgrounds and fields of responsibility leading to a greater awareness among gynecologists of medical complications that can arise from induced abortions. Thoughts about changing job and feelings of misgivings or inadequacy in working with abortions do not seem to be common either in Swedish midwives or in gynecologists [6]. However, when it comes to late abortions, half of those in both groups had felt misgivings, probably due to the extraordinary circumstances surrounding these abortions. But it cannot be excluded that some already had changed job due to their previous experiences of TOP. The overall challenges in working with TOP were reflected by all the midwives in their demand for continued professional development and ongoing guidance regarding TOP. Factors influencing experiences and views Among the midwives who currently worked with TOP and had highest duration of working time, the majority reported that they had been provided positive experiences. This is in line with findings among Swedish gynecologists [6], and could be explained by the staff experiencing these encounters as characterized by confirming, supporting and caring for a woman in an exposed and vulnerable position. In other words, being able to carry out a professional and meaningful obligation induces positive feelings. Having had an abortion oneself occurred to almost an equal extent among those who were currently working with TOP compared to those who had not worked with TOP for the preceding two years. Furthermore, it corresponded to an equal extent among the average Swedish woman as well as among Swedish female gynecologists and the partners of the male gynecologists [2,6]. This indicates the challenging complexity of the reasons behind unplanned pregnancies; having the very best knowledge about contraceptives did not prevent an unplanned pregnancy. The finding that midwives who had experienced TOP themselves reported misgivings about late abortions less frequently than midwives without such personal experience could mirror a greater permissiveness toward and acceptance of women in this

situation. Those with personal experience were also more open to abortions being managed in the primary healthcare system. Midwives who thought that religious belief was important for their views on abortion were more concerned about late abortions than those who had no belief. Among gynecologists, religious belief did not prove to be an impacting factor on their opinions [6]. However, from other countries’ research we learn that religious beliefs are stated as an impacting factor on willingness to take part in TOP [16,17]. As regards midwives’ perception of women’s motives for abortion, it was found that they ranked ‘‘Too young and immature’’ first, with ‘‘Do not want to have more children’’ and ‘‘Problems in partner relationship’’, second and third respectively. This finding is in good agreement with current Swedish studies of women’s motives for abortion [18,19]. This is also in good agreement with the midwives’ opinion that women’s motives consist of multiple factors [19– 21]. In the earlier study of Swedish gynecologists the same three most common motives were also reported [6]. Thus, it seems that two of the most crucial professions involved in abortion care have a great awareness and understanding of the circumstances in which the women seeking an abortion are living. To summarize, this study indicates that there are few midwives who are considering changing their job, have misgivings, or feelings of inadequacy when encountering a woman seeking an abortion. On the contrary, one third of the midwives do not work, and one fifth has not in the preceding two years, worked with TOP. Having currently worked with TOP and for a longer period of time are factors which evoke positive experiences among every other midwife. Midwives’ perception of abortion motives corresponds very well to the motives given by women themselves. In general, religious belief does not impact on the midwives’ views of TOP. The midwives who have had an abortion themselves have fewer misgivings about late abortions than those without personal experience of TOP. Acknowledgements The authors would like to thank the Swedish National Board of Public Health and the Swedish Council for Life and Social Research for financial support.

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Current knowledge on this subject . Three decades ago staff in Swedish obs/gyn clinics were less in favor of free abortion than nowadays. . Generally, midwives have been found to be more restrictive about TOP than gynecologists. Midwives and gynecologists have, however, become more liberal in their views over time. . The later in pregnancy TOP is performed the less willing the midwives/nurses are to work with abortions. What this study adds . Every other midwife thinks that encounters with women seeking an abortion evoke positive working experiences in their work. However, all midwives asked for continuous guidance and education regarding TOP. Two-thirds support the shift from surgical to medical abortion. . Thoughts about changing jobs, misgivings or feelings of inadequacy due to TOP are not common among midwives. When misgivings occurred in midwives they are connected with late and surgical abortions. . Midwives conform to the average for Swedish women regarding personal experience of having had an abortion. Those midwives having had an abortion themselves reported fewer misgivings when working with late abortions than those who had not. . In general, religious belief was not an influencing factor on midwives’ views of TOP.