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Abortion in adolescence: a four-country comparison
Article Abortion in Adolescence: A Four-Country Comparison Patricia Welsh, MD Department of Obstetrics and Gynecology University Hospitals Ohio State University College of Medicine and Public Health Columbus, Ohio
Maureen McCarthy, PhD Department of Community Health State University of New York Potsdam Potsdam, New York
Barbara Cromer, MD Department of Pediatrics Case Western Reserve University School of Medicine Cleveland, Ohio
Abstract The purpose of this study was to conduct a comparison, using qualitative analytic methodology, of perceptions concerning abortion among health care providers and administrators, along with politicians and anti-abortion activists (total n ⫽ 75) in Great Britain, Sweden, The Netherlands, and the United States. In none of these countries was there consensus about abortion prior to legalization, and, in all countries, public discussion continues to be present. In general, after legalization of abortion has no longer made it a volatile issue European countries have refocused their energy into providing family planning services, education, and more straightforward access to abortion compared with similar activities in the United States.
INTRODUCTION
D
ata in 1997 demonstrated that the adolescent birth rate in the United States had fallen since 1992.1 However, the United States still has by far the highest adolescent pregnancy and birth rates of all the industrialized countries; these rates are sharply contrasted especially with those of The Netherlands and of Sweden.2,3 The rates are also higher than those found in Great Britain, a country that more politically and socially similar to the United States but geographically located closer to the aforementioned countries.4 In 1986, the Alan Guttmacher Institute published the first comprehensive comparison of issues salient to adolescent pregnancy among industrialized countries.5 In our study we aimed to update some of that information; however, we chose to use a qualitative analysis method as opposed to the mixed descriptive approach used in the Guttmacher Report.6 This report focuses on findings specifically related to abortion in the United States, Great Britain, Sweden, and The Netherlands.
The United States has the highest adolescent pregnancy rates
© 2001 by the Jacobs Institute of Women’s Health Published by Elsevier Science Inc. 1049-3867/01/$20.00 PII S1049-3867(01)00078-5
WELSH ET AL: ABORTION IN ADOLESCENCE
73
Our hypothesis was that abortion services would be viewed as more accessible, and personal and societal attitudes toward abortion would appear more accepting, among interviewees in Sweden and The Netherlands compared with views expressed by interviewees in Great Britain and the United States.
METHODS Study Population The study population consisted of professionals who, from either a personal or public health perspective, had expertise in the field of adolescent pregnancy. Initially there was a contact person in each country who compiled a list of other professionals in that country. Each group was then expanded based on information given from the individuals comprising the original sample. An attempt was made to ensure that half the sample had a physical or mental health background, and that the remainder included a mix of professional backgrounds, including those with opposing views on contraception and abortion. After the group of interviewees from Sweden was established (n ⫽ 20), an attempt was made to match the samples in the other countries with professionals of similar backgrounds (The Netherlands ⫽ 18; United States ⫽ 18; Great Britain ⫽ 19). The ages of respondents ranged from 31 to 76 years; gender breakdown was 58% female, 42% male. Description of the professional backgrounds of interviewees is included in Table 1.
Procedure One of the authors (BC) conducted all of the interviews in English; each lasted approximately one-half to one hour. The interviews followed a semistructured format, as described by Britten,7 which involved coverage of certain issues but which allowed the interviewee to lead the interview into other pertinent topics. The following issues were covered with each interviewee: definition of the problem of teen pregnancy in that country, risk factors for pregnancy, the most and least successful approaches to its prevention, impact of recent health care reforms on adolescent health care, the current status of contraception and abortion services, plus what changes that interviewee would institute to lower the incidence of teen pregnancy. Because the study sample was composed of adult professionals, signed informed consent was not mandated as approved by the Human Subjects Research Committee, Columbus Children’s Hospital, Columbus, Ohio. The interviews were audiotaped, transcribed, and then analyzed to identify themes. First, the interviews were broken down into individual pieces of data called data bits, a frequently used approach to separating and reorganizing the qualitative data.8 An attempt was made to ensure that each bit included one discrete piece of information. The transcripts were color-coded according to country and letter coded according to professional background of interviewee. Two of the authors (BC and MM) reviewed the transcripts and decided what would comprise each of the data bits. The bits were then transferred to index cards and shuffled to achieve random order. From the first two interviews a list of categories was developed; this list was expanded and further developed as data from the remaining interviews were examined. One of these categories was entitled Abortion Services. By discussion regarding various themes within this particular category, the authors identified four further subcategories. These were Decision-making Process, Access, Society, and Strategies for Change. Finally, through more discussion among the authors, themes emerged from the data bits further 74
WOMEN’S HEALTH ISSUES VOL. 11, NO. 2 MARCH/APRIL 2001
Table 1. NUMBER OF INTERVIEWEES, BY PROFESSIONAL BACKGROUND, ACCORDING TO COUNTRY
Health care provider Physician Nurse Psychologist Social worker Nonclinicians Public health administrator Politician Antiabortion activist Health educator Anthropologist Sociologist Sexologist Total
Great Britain
United States
The Netherlands
Sweden
11 7 1 1 2 8 3 2 2 1 0 0 0 19
10 9 0 0 1 8 5 1 2 0 0 0 0 18
9 6 2 1 0 9 5 0 1 1 1 0 1 18
12 7 4 0 1 8 4 3 0 0 0 1 0 20
representing and describing each subcategory. This iterative process was modeled after that described by Chenitz and Swanson.9
RESULTS Decision-Making Process A universal theme among interviewees, with the exception of anti-abortion activists, was that the decision to have an abortion is ultimately the teen’s own. The issue of parental involvement was addressed by interviewees in all four countries; however, in the United States the focus of comments was on parental notification laws, whereas in The Netherlands and Sweden, focus was more on parental support and involvement with teens seeking abortion. In Sweden, providers legally cannot talk to parents about the teen’s consent; however, in 99% of the cases providers help teens to talk to their parent. Counseling for pregnant teens was also addressed by interviewees in all countries; the consistent and firm impression of interviewees was that counseling was a crucial element of a clinical visit involving a teen’s request for pregnancy termination. A Swedish interviewee stated, “We always demand that a woman thinks twice.” This counseling appeared to be individualized in most countries; as an interviewee in The Netherlands said, “We listen—that’s most important—to listen to her problems at that moment . . . .” In the United States, once again counseling was intertwined with the issue of parental notification. Antiabortion activists emphasized the need for postabortion counseling as well. The attitude of the boyfriend also appeared to be a strong influence in the teen’s decision-making process. Anti-abortion activists in United States addressed the issue of disappointment a girl may feel about the boyfriend’s lack of support for pregnancy continuation as a motivating factor for choosing abortion. An interviewee in Great Britain reiterated the strong influence of the boyfriend: “The difference between those who deliver and those who don’t.” However, in Sweden and Great Britain, interviewees emphasized the need for the girl ultimately to make the decision without the influences of boyfriend, or parents, for that matter.
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The teen’s attitude toward abortion, which in turn is influenced by society, also appeared to be important in her decision-making process. Many interviewees felt that the termination group perceived themselves as goal-oriented, having a future: “They know where they are going.” In some sectors of society, however, pregnancy was viewed as much more acceptable and therefore abortion was not chosen. As an interviewee in The Netherlands states: “I think there are two groups of young women. There is a group [whose] expectations of themselves means that the pregnancy is a disaster, and many of those [choose to] terminate. In certain ways it is less acceptable and in other sectors of society, it is becoming more acceptable, even though unchosen.”
Access First, information appeared to be more readily available in the European countries, compared with the United States, where comments were made regarding knowledge barriers about available abortion services. In The Netherlands, information about abortion was given in the schools: “We find abortion clinics, prices, make appointments, make sure they have support for the visit.” The procedure for obtaining an abortion was also an issue: Great Britain appeared to have an exceptionally streamlined referral system, and interviewees in all the European countries described reasonably straightforward systems. In contrast, in the United States, there appeared to be a less organized system for obtaining an abortion. In addition, respondents described legal issues that might make obtaining an abortion more difficult; for example, in Ohio a 24-hour waiting period is required. Geographic availability was recognized as a significant issue in the United States, with rural areas in particular lacking abortion providers. In fact, in the United States barriers to abortion access appeared to be more an issue of geographical location than of the cost of the procedure. In contrast, in Sweden, “ . . . a doctor can say ‘No, I won’t do this abortion’ . . . but it’s not a problem. . . because you can get an abortion in every clinic.” In Great Britain a situation in which there were not enough abortion providers in a certain area “would not be allowed to exist.” The cost of abortion was also addressed as an important factor in accessing abortion: In Sweden it was described as less expensive than birth control pills; in The Netherlands it was stated as free, and in the United States and Great Britain the cost was described as reasonable, depending on the provider, the geographic location, and the involvement of the parents.
Society Consensus among interviewees in the four countries was that long-term debate and discussion had preceded the legalization of abortion in all of the countries. There was not current, complete public agreement about abortion in any of the countries; debate and discussion have continued to the present. Legalization appeared to be a watershed event that spawned public policy reevaluation, anti-abortion response, and a change in public acceptance. The style of conflict resolution appeared to differ between the European countries and the United States. Dialogue and mutual tolerance between abortion and anti-abortion activists was emphasized in The Netherlands and Sweden. For example, in The Netherlands an anti-abortion activist described working with Stimezo on the abortion issue; she was also invited by the Ministry of Welfare to a conflict resolution panel. An interviewee in Sweden described using “mild words” and “the Swedish way” regarding conflict resolution. In contrast, interviewees in the United States described a more polarized relationship 76
WOMEN’S HEALTH ISSUES VOL. 11, NO. 2 MARCH/APRIL 2001
Information appeared to be more readily available in the European countries
between abortion and antiabortion activists. This was also noted by an interviewee in Sweden: “The American debate is harsh and we suppose it is polarizing the society.” Concurrent with legalization was the development of public policy leading to the expansion of contraceptive services, which was most apparent in Sweden and The Netherlands. Anti-abortion activists in all four countries viewed legalization of abortion as an instigator of moral deterioration. In Sweden it was observed, “When the law said it is okay, people thought it is okay.” An interviewee in Great Britain was quoted as saying, “We won’t have peace in the world till we have peace in the womb.” Several interviewees noted the general increased acceptance of abortion since legalization. In the United States, “kids grew up with Roe vs. Wade,” referring to the fact that teens today do not recognize an era when abortion was considered illegal and immoral. In the European countries there was reference to the religious community and its attitude toward abortion. Catholics and Protestants were generally united concerning their anti-abortion views, “but not as strict as America,” according to an interviewee in The Netherlands. The church “can speak loudly,” according to one Swede.
Strategies for Change Strategies for change followed along similar lines for the countries sampled; differences were more apparent when comparing views of abortion and anti-abortion activists across the countries. Informing teens regarding the development of the fetus and the abortion procedure itself was the education strategy promoted by several anti-abortion activists. In The Netherlands, anti-abortion activists were allowed to go to the schools to educate the students on “the other side.” Among abortion activists comprehensive sex education was favored: “When abortion became legal in 1974 [in Great Britain], it was free, but information increased in schools as well. This led to no increase in abortions or pregnancies.” Legislation was proposed by anti-abortion activists in all the countries: for example, “I believe that the protection of life should be enshrined in the law.” In Great Britain, another antiabortion activist discussed legislative reform to protect unborn children, as well as the initiation of a massive educational program. Availability of contraceptives was also generally viewed as important in preventing abortions; interestingly, anti-abortion activists in Great Britain claimed that this has led to an increase in abortions, whereas those in The Netherlands and Sweden believed that prevention of pregnancy was a logical strategy toward preventing abortion. In Sweden an interviewee stated, “But I never believed you could persuade anyone from sex if they set their minds to having sex, so instead, I think it is better to offer the services.” An anti-abortion activist in The Netherlands echoed that sentiment with the following statement, “Of course, if you had to make a choice between having the contraceptive pill or abortion, then I say please take the pill because it is not a human being then.” In Sweden, as mentioned earlier, the legalization of abortion was accompanied by an expansion in contraceptive services. When it was noted that an island called Gottland had a high abortion rate, a program was begun that offered free birth control pills along with a large parent and teen education program. This led to a dramatic decrease in the abortion rates and solidified the Swedish view that easily available and affordable contraceptive services were an important public health strategy to achieve abortion prevention.
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DISCUSSION Abortion was legalized at around the same time in all four countries, ranging from 1968 in Great Britain, to 1973 in the United States, 1975 in Sweden, and 1984 in The Netherlands. Debate and dissent have continued to affect the implementation of the law. For example, in the early 1980s the U.S. Supreme Court upheld several cases that allowed states to require parental consent or notification. Judicial bypass remains an option in some states, but a young women must be familiar with the legal system to pursue this path. As recorded by Stotland, “legal provisions for ‘judicial bypass’ of parental involvement laws are only a cosmetic solution; they require that the young woman know about the law, identify and arrive at the correct courthouse when the judge is sitting, and present painful accounts of parental neglect and abuse.”10 These restrictions reflect a different approach from that taken in European countries, where streamlined access to abortion and confidentiality is more prevalent. The importance of counseling for teens seeking abortion was emphasized by interviewees in all the countries in our study. In the United States some states have mandated certain waiting periods so that a woman can further think through her decision or undergo counseling if she chooses. However, these kinds of laws do not take into consideration that many teens, especially younger ones, wait until the pregnancy is far advanced before seeking abortion services.11 This could potentially lead to a more difficult procedure or the inability to legally perform the procedure at all. The European countries have a more streamlined system, which includes counseling. Soderberg describes a system in Sweden in which women are given a counseling appointment after a positive pregnancy test. The recommended time interval is 1 week after the pregnancy test so that the woman has time to consider her situation. The counseling is free, and women are also offered an appointment with a social worker during that period. If she decides on an abortion she is placed on a waiting list and the procedure is done within a week.12 A recent study in Sweden went so far as to investigate the decision-making process that young men undergo when confronted with the pregnancy of their girlfriends.13 In our study, interviewees in the four countries viewed provision of contraception as one of the most important factors in the prevention of abortion. In the United States, contraceptive services have undergone much review and legislation. By the 1970s it was recognized that teens did have the legal right to privacy and confidentiality with a physician in terms of contraception. The funding for these services, however, are continually at risk. As pointed out by Luker, cuts in federal funding can be attributed to “a resurgence in political opposition to publicly funded contraception, opposition based to some extent on the fact that federal programs have slowed but not reversed the acceleration in the pregnancy rates of teenagers, leading people to see these programs as a failure rather than the considerable success that they are.”14 In The Netherlands in the 1970s and 1980s, the government made a vast investment in pregnancy prevention, which led to massive public education and service availability. Even after abortion was legalized in 1984, it was considered by most of the Dutch people as a last resort, although also as an option that should be available to all women. The low rate of abortion has always been maintained, and contraceptive services remain a top priority. In addition, there appear to be few barriers to contraception, especially for teenagers. The services are described as strictly confidential, even if they go to the family doctor who is often viewed as a friend of the family. Doctors do not maintain a minimum age limit for prescribing pills, a pelvic examination is not necessarily standard procedure, pills are free, and if a teen does not want to go to the family doctor, she can easily go to a local family planning clinic.15 78
WOMEN’S HEALTH ISSUES VOL. 11, NO. 2 MARCH/APRIL 2001
In European countries, streamlined access to abortion and confidentiality are more prevalent
Conclusion An interesting finding was that in none of the four countries was there public consensus about abortion before legalization, and that, in all four, public discussion continues today. From information gleaned from interviews with professionals with expertise in adolescent health, there appears to be a more streamlined, straightforward access to abortion services in Great Britain, The Netherlands, and Sweden, compared with that in the United States. Cost of abortion, which varied among countries, appeared to be an important factor in accessing abortion. Prevalent views among interviewees were that counseling was a crucial part of a pretermination office visit and that the decision to have an abortion is ultimately the teen’s own. Consensus among interviewees was that, since legalization of abortion in all four countries, public debate still continues. A consistent theme expressed by anti-abortion activists in Northern Europe was a mutual tolerance between abortion and anti-abortion activists for their beliefs, as opposed to more polarized attitudes in the United States. Suggested strategies for change among anti-abortion advocates in all four countries included legislation for protection of the unborn and extensive public health education. Other strategies endorsed by other respondents also included public health education, albeit with different subject content, along with public policies that increased access to contraception, and universal, mandatory sex education in schools.
The decision to have an abortion is ultimately the teen’s own
REFERENCES 1. U.S. Department of Health and Human Services. HHS News. Hyattsville, MD: National Center for Health Statistics, May 1997. 2. Singh S, Darroch J. Adolescent pregnancy and childbearing: levels and trends in developed countries. Fam Plann Perspect 2000;32:14 –23. 3. Ghebrehewet A. A review of induced abortion rates in England and Wales, 1969 –1994. Br J Fam Plann 1998;23:120 – 6. 4. Alan Guttmacher Institute. Facts in brief: teen sex and pregnancy. New York: Author, 1996. 5. Jones F, de Forrest J, et al. Teenage pregnancy in industrialized countries: a study sponsored by the Alan Guttmacher Institute, New Haven, CT: Yale University Press, 1986. 6. Cromer B, McCarthy M. Family planning services in adolescent pregnancy prevention: a four country comparison. Fam Plann Perspect 1999;31:287–93. 7. Britten N. Qualitative interviews in medical research. BMJ 1995;311:251–3. 8. Strauss A. Introduction. In: Strauss A, editor. Qualitative analysis for social scientists. England: Cambridge University Press, 1987:1–319. 9. Chenitz W, Swanson J. From practice to grounded theory: qualitative research in nursing. Menlo Park, CA: Addison-Wesley, 1986. 10. Stotland N. Conceptions and misconceptions decisions about pregnancy. Gen Hosp Psychiatry 1995;18:238 – 43. 11. Bromham D, Oloto E. Trying to prevent abortion. Eur J Contracept Reprod Health 1997;2:81–7. 12. Soderberg H. Abortions in Malmo—problems and prevention. Acta Obstet Gynecol Can 1997;76:60 –2. 13. Holmberg L, Wahlberg M. The process of decision-making on abortion: a grounded theory study of young men in Sweden. J Adolesc Health 2000;26:230 – 4. 14. Luker K. Dubious conceptions, the politics of teenage pregnancy. Cambridge, MA: Harvard University Press, 1996. 15. Ketting E, Visser A. Contraception in the Netherlands: the low abortion rate explained. Patient Educ Counsel 1994;23:161–71.
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Maureen McCarthy, PhD Department of Community Health State University of New York Potsdam Potsdam, New York
Barbara Cromer, MD Department of Pediatrics Case Western Reserve University School of Medicine Cleveland, Ohio
Abstract The purpose of this study was to conduct a comparison, using qualitative analytic methodology, of perceptions concerning abortion among health care providers and administrators, along with politicians and anti-abortion activists (total n ⫽ 75) in Great Britain, Sweden, The Netherlands, and the United States. In none of these countries was there consensus about abortion prior to legalization, and, in all countries, public discussion continues to be present. In general, after legalization of abortion has no longer made it a volatile issue European countries have refocused their energy into providing family planning services, education, and more straightforward access to abortion compared with similar activities in the United States.
INTRODUCTION
D
ata in 1997 demonstrated that the adolescent birth rate in the United States had fallen since 1992.1 However, the United States still has by far the highest adolescent pregnancy and birth rates of all the industrialized countries; these rates are sharply contrasted especially with those of The Netherlands and of Sweden.2,3 The rates are also higher than those found in Great Britain, a country that more politically and socially similar to the United States but geographically located closer to the aforementioned countries.4 In 1986, the Alan Guttmacher Institute published the first comprehensive comparison of issues salient to adolescent pregnancy among industrialized countries.5 In our study we aimed to update some of that information; however, we chose to use a qualitative analysis method as opposed to the mixed descriptive approach used in the Guttmacher Report.6 This report focuses on findings specifically related to abortion in the United States, Great Britain, Sweden, and The Netherlands.
The United States has the highest adolescent pregnancy rates
© 2001 by the Jacobs Institute of Women’s Health Published by Elsevier Science Inc. 1049-3867/01/$20.00 PII S1049-3867(01)00078-5
WELSH ET AL: ABORTION IN ADOLESCENCE
73
Our hypothesis was that abortion services would be viewed as more accessible, and personal and societal attitudes toward abortion would appear more accepting, among interviewees in Sweden and The Netherlands compared with views expressed by interviewees in Great Britain and the United States.
METHODS Study Population The study population consisted of professionals who, from either a personal or public health perspective, had expertise in the field of adolescent pregnancy. Initially there was a contact person in each country who compiled a list of other professionals in that country. Each group was then expanded based on information given from the individuals comprising the original sample. An attempt was made to ensure that half the sample had a physical or mental health background, and that the remainder included a mix of professional backgrounds, including those with opposing views on contraception and abortion. After the group of interviewees from Sweden was established (n ⫽ 20), an attempt was made to match the samples in the other countries with professionals of similar backgrounds (The Netherlands ⫽ 18; United States ⫽ 18; Great Britain ⫽ 19). The ages of respondents ranged from 31 to 76 years; gender breakdown was 58% female, 42% male. Description of the professional backgrounds of interviewees is included in Table 1.
Procedure One of the authors (BC) conducted all of the interviews in English; each lasted approximately one-half to one hour. The interviews followed a semistructured format, as described by Britten,7 which involved coverage of certain issues but which allowed the interviewee to lead the interview into other pertinent topics. The following issues were covered with each interviewee: definition of the problem of teen pregnancy in that country, risk factors for pregnancy, the most and least successful approaches to its prevention, impact of recent health care reforms on adolescent health care, the current status of contraception and abortion services, plus what changes that interviewee would institute to lower the incidence of teen pregnancy. Because the study sample was composed of adult professionals, signed informed consent was not mandated as approved by the Human Subjects Research Committee, Columbus Children’s Hospital, Columbus, Ohio. The interviews were audiotaped, transcribed, and then analyzed to identify themes. First, the interviews were broken down into individual pieces of data called data bits, a frequently used approach to separating and reorganizing the qualitative data.8 An attempt was made to ensure that each bit included one discrete piece of information. The transcripts were color-coded according to country and letter coded according to professional background of interviewee. Two of the authors (BC and MM) reviewed the transcripts and decided what would comprise each of the data bits. The bits were then transferred to index cards and shuffled to achieve random order. From the first two interviews a list of categories was developed; this list was expanded and further developed as data from the remaining interviews were examined. One of these categories was entitled Abortion Services. By discussion regarding various themes within this particular category, the authors identified four further subcategories. These were Decision-making Process, Access, Society, and Strategies for Change. Finally, through more discussion among the authors, themes emerged from the data bits further 74
WOMEN’S HEALTH ISSUES VOL. 11, NO. 2 MARCH/APRIL 2001
Table 1. NUMBER OF INTERVIEWEES, BY PROFESSIONAL BACKGROUND, ACCORDING TO COUNTRY
Health care provider Physician Nurse Psychologist Social worker Nonclinicians Public health administrator Politician Antiabortion activist Health educator Anthropologist Sociologist Sexologist Total
Great Britain
United States
The Netherlands
Sweden
11 7 1 1 2 8 3 2 2 1 0 0 0 19
10 9 0 0 1 8 5 1 2 0 0 0 0 18
9 6 2 1 0 9 5 0 1 1 1 0 1 18
12 7 4 0 1 8 4 3 0 0 0 1 0 20
representing and describing each subcategory. This iterative process was modeled after that described by Chenitz and Swanson.9
RESULTS Decision-Making Process A universal theme among interviewees, with the exception of anti-abortion activists, was that the decision to have an abortion is ultimately the teen’s own. The issue of parental involvement was addressed by interviewees in all four countries; however, in the United States the focus of comments was on parental notification laws, whereas in The Netherlands and Sweden, focus was more on parental support and involvement with teens seeking abortion. In Sweden, providers legally cannot talk to parents about the teen’s consent; however, in 99% of the cases providers help teens to talk to their parent. Counseling for pregnant teens was also addressed by interviewees in all countries; the consistent and firm impression of interviewees was that counseling was a crucial element of a clinical visit involving a teen’s request for pregnancy termination. A Swedish interviewee stated, “We always demand that a woman thinks twice.” This counseling appeared to be individualized in most countries; as an interviewee in The Netherlands said, “We listen—that’s most important—to listen to her problems at that moment . . . .” In the United States, once again counseling was intertwined with the issue of parental notification. Antiabortion activists emphasized the need for postabortion counseling as well. The attitude of the boyfriend also appeared to be a strong influence in the teen’s decision-making process. Anti-abortion activists in United States addressed the issue of disappointment a girl may feel about the boyfriend’s lack of support for pregnancy continuation as a motivating factor for choosing abortion. An interviewee in Great Britain reiterated the strong influence of the boyfriend: “The difference between those who deliver and those who don’t.” However, in Sweden and Great Britain, interviewees emphasized the need for the girl ultimately to make the decision without the influences of boyfriend, or parents, for that matter.
WELSH ET AL: ABORTION IN ADOLESCENCE
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The teen’s attitude toward abortion, which in turn is influenced by society, also appeared to be important in her decision-making process. Many interviewees felt that the termination group perceived themselves as goal-oriented, having a future: “They know where they are going.” In some sectors of society, however, pregnancy was viewed as much more acceptable and therefore abortion was not chosen. As an interviewee in The Netherlands states: “I think there are two groups of young women. There is a group [whose] expectations of themselves means that the pregnancy is a disaster, and many of those [choose to] terminate. In certain ways it is less acceptable and in other sectors of society, it is becoming more acceptable, even though unchosen.”
Access First, information appeared to be more readily available in the European countries, compared with the United States, where comments were made regarding knowledge barriers about available abortion services. In The Netherlands, information about abortion was given in the schools: “We find abortion clinics, prices, make appointments, make sure they have support for the visit.” The procedure for obtaining an abortion was also an issue: Great Britain appeared to have an exceptionally streamlined referral system, and interviewees in all the European countries described reasonably straightforward systems. In contrast, in the United States, there appeared to be a less organized system for obtaining an abortion. In addition, respondents described legal issues that might make obtaining an abortion more difficult; for example, in Ohio a 24-hour waiting period is required. Geographic availability was recognized as a significant issue in the United States, with rural areas in particular lacking abortion providers. In fact, in the United States barriers to abortion access appeared to be more an issue of geographical location than of the cost of the procedure. In contrast, in Sweden, “ . . . a doctor can say ‘No, I won’t do this abortion’ . . . but it’s not a problem. . . because you can get an abortion in every clinic.” In Great Britain a situation in which there were not enough abortion providers in a certain area “would not be allowed to exist.” The cost of abortion was also addressed as an important factor in accessing abortion: In Sweden it was described as less expensive than birth control pills; in The Netherlands it was stated as free, and in the United States and Great Britain the cost was described as reasonable, depending on the provider, the geographic location, and the involvement of the parents.
Society Consensus among interviewees in the four countries was that long-term debate and discussion had preceded the legalization of abortion in all of the countries. There was not current, complete public agreement about abortion in any of the countries; debate and discussion have continued to the present. Legalization appeared to be a watershed event that spawned public policy reevaluation, anti-abortion response, and a change in public acceptance. The style of conflict resolution appeared to differ between the European countries and the United States. Dialogue and mutual tolerance between abortion and anti-abortion activists was emphasized in The Netherlands and Sweden. For example, in The Netherlands an anti-abortion activist described working with Stimezo on the abortion issue; she was also invited by the Ministry of Welfare to a conflict resolution panel. An interviewee in Sweden described using “mild words” and “the Swedish way” regarding conflict resolution. In contrast, interviewees in the United States described a more polarized relationship 76
WOMEN’S HEALTH ISSUES VOL. 11, NO. 2 MARCH/APRIL 2001
Information appeared to be more readily available in the European countries
between abortion and antiabortion activists. This was also noted by an interviewee in Sweden: “The American debate is harsh and we suppose it is polarizing the society.” Concurrent with legalization was the development of public policy leading to the expansion of contraceptive services, which was most apparent in Sweden and The Netherlands. Anti-abortion activists in all four countries viewed legalization of abortion as an instigator of moral deterioration. In Sweden it was observed, “When the law said it is okay, people thought it is okay.” An interviewee in Great Britain was quoted as saying, “We won’t have peace in the world till we have peace in the womb.” Several interviewees noted the general increased acceptance of abortion since legalization. In the United States, “kids grew up with Roe vs. Wade,” referring to the fact that teens today do not recognize an era when abortion was considered illegal and immoral. In the European countries there was reference to the religious community and its attitude toward abortion. Catholics and Protestants were generally united concerning their anti-abortion views, “but not as strict as America,” according to an interviewee in The Netherlands. The church “can speak loudly,” according to one Swede.
Strategies for Change Strategies for change followed along similar lines for the countries sampled; differences were more apparent when comparing views of abortion and anti-abortion activists across the countries. Informing teens regarding the development of the fetus and the abortion procedure itself was the education strategy promoted by several anti-abortion activists. In The Netherlands, anti-abortion activists were allowed to go to the schools to educate the students on “the other side.” Among abortion activists comprehensive sex education was favored: “When abortion became legal in 1974 [in Great Britain], it was free, but information increased in schools as well. This led to no increase in abortions or pregnancies.” Legislation was proposed by anti-abortion activists in all the countries: for example, “I believe that the protection of life should be enshrined in the law.” In Great Britain, another antiabortion activist discussed legislative reform to protect unborn children, as well as the initiation of a massive educational program. Availability of contraceptives was also generally viewed as important in preventing abortions; interestingly, anti-abortion activists in Great Britain claimed that this has led to an increase in abortions, whereas those in The Netherlands and Sweden believed that prevention of pregnancy was a logical strategy toward preventing abortion. In Sweden an interviewee stated, “But I never believed you could persuade anyone from sex if they set their minds to having sex, so instead, I think it is better to offer the services.” An anti-abortion activist in The Netherlands echoed that sentiment with the following statement, “Of course, if you had to make a choice between having the contraceptive pill or abortion, then I say please take the pill because it is not a human being then.” In Sweden, as mentioned earlier, the legalization of abortion was accompanied by an expansion in contraceptive services. When it was noted that an island called Gottland had a high abortion rate, a program was begun that offered free birth control pills along with a large parent and teen education program. This led to a dramatic decrease in the abortion rates and solidified the Swedish view that easily available and affordable contraceptive services were an important public health strategy to achieve abortion prevention.
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DISCUSSION Abortion was legalized at around the same time in all four countries, ranging from 1968 in Great Britain, to 1973 in the United States, 1975 in Sweden, and 1984 in The Netherlands. Debate and dissent have continued to affect the implementation of the law. For example, in the early 1980s the U.S. Supreme Court upheld several cases that allowed states to require parental consent or notification. Judicial bypass remains an option in some states, but a young women must be familiar with the legal system to pursue this path. As recorded by Stotland, “legal provisions for ‘judicial bypass’ of parental involvement laws are only a cosmetic solution; they require that the young woman know about the law, identify and arrive at the correct courthouse when the judge is sitting, and present painful accounts of parental neglect and abuse.”10 These restrictions reflect a different approach from that taken in European countries, where streamlined access to abortion and confidentiality is more prevalent. The importance of counseling for teens seeking abortion was emphasized by interviewees in all the countries in our study. In the United States some states have mandated certain waiting periods so that a woman can further think through her decision or undergo counseling if she chooses. However, these kinds of laws do not take into consideration that many teens, especially younger ones, wait until the pregnancy is far advanced before seeking abortion services.11 This could potentially lead to a more difficult procedure or the inability to legally perform the procedure at all. The European countries have a more streamlined system, which includes counseling. Soderberg describes a system in Sweden in which women are given a counseling appointment after a positive pregnancy test. The recommended time interval is 1 week after the pregnancy test so that the woman has time to consider her situation. The counseling is free, and women are also offered an appointment with a social worker during that period. If she decides on an abortion she is placed on a waiting list and the procedure is done within a week.12 A recent study in Sweden went so far as to investigate the decision-making process that young men undergo when confronted with the pregnancy of their girlfriends.13 In our study, interviewees in the four countries viewed provision of contraception as one of the most important factors in the prevention of abortion. In the United States, contraceptive services have undergone much review and legislation. By the 1970s it was recognized that teens did have the legal right to privacy and confidentiality with a physician in terms of contraception. The funding for these services, however, are continually at risk. As pointed out by Luker, cuts in federal funding can be attributed to “a resurgence in political opposition to publicly funded contraception, opposition based to some extent on the fact that federal programs have slowed but not reversed the acceleration in the pregnancy rates of teenagers, leading people to see these programs as a failure rather than the considerable success that they are.”14 In The Netherlands in the 1970s and 1980s, the government made a vast investment in pregnancy prevention, which led to massive public education and service availability. Even after abortion was legalized in 1984, it was considered by most of the Dutch people as a last resort, although also as an option that should be available to all women. The low rate of abortion has always been maintained, and contraceptive services remain a top priority. In addition, there appear to be few barriers to contraception, especially for teenagers. The services are described as strictly confidential, even if they go to the family doctor who is often viewed as a friend of the family. Doctors do not maintain a minimum age limit for prescribing pills, a pelvic examination is not necessarily standard procedure, pills are free, and if a teen does not want to go to the family doctor, she can easily go to a local family planning clinic.15 78
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In European countries, streamlined access to abortion and confidentiality are more prevalent
Conclusion An interesting finding was that in none of the four countries was there public consensus about abortion before legalization, and that, in all four, public discussion continues today. From information gleaned from interviews with professionals with expertise in adolescent health, there appears to be a more streamlined, straightforward access to abortion services in Great Britain, The Netherlands, and Sweden, compared with that in the United States. Cost of abortion, which varied among countries, appeared to be an important factor in accessing abortion. Prevalent views among interviewees were that counseling was a crucial part of a pretermination office visit and that the decision to have an abortion is ultimately the teen’s own. Consensus among interviewees was that, since legalization of abortion in all four countries, public debate still continues. A consistent theme expressed by anti-abortion activists in Northern Europe was a mutual tolerance between abortion and anti-abortion activists for their beliefs, as opposed to more polarized attitudes in the United States. Suggested strategies for change among anti-abortion advocates in all four countries included legislation for protection of the unborn and extensive public health education. Other strategies endorsed by other respondents also included public health education, albeit with different subject content, along with public policies that increased access to contraception, and universal, mandatory sex education in schools.
The decision to have an abortion is ultimately the teen’s own
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