- Email: [email protected]
Anxiety in Japanese Women After Elective Abortion
Anxiety in Japanese Women After Elective Abortion Yasuko Kishida, RN, MPH, M A
=
Obiective: To examine women’s anxiety levels after elective abortion. Design and Setting: Women seeking elective abortion at six clinics in Japan were solicited to participate in a questionnaire survey. Participants: Sixty-six Japanese women requesting abortion participated in this survey. Main Outcome Measures: State anxiety was measured using Spielberger’s State Trait Anxiety Inventory before and after abortion. Results: Multiple regression analyses using predictor variables with a significant link to postabortion anxiety level showed that among potential predictors, a conservative attitude toward abortion was the most significant predictor of postabortion anxiety after controlling for the level of preabortion anxiety. Conclusion: These findings suggest that a woman’s attitude toward abortion and reproductive rights is an important but neglected factor influencing postelective abortion anxiety. Medical and nursing professionals should, therefore, take note of a woman’s attitude toward abortion as a part of her mental health care. JOGNN, 30,490-495;2001. Keywords: Abortion-Anxiety-Attitude toward abortion Accepted: April 2001
After World War 11, pregnancy termination became legal in Japan. National sentiment, however, was hostile toward women who had abortions. This sentiment was due in part to the economic boom in Japan that lasted for a few decades after World War 11; more manpower was needed than ever before. Abortion is not practiced at university or national hospitals, but only in private 490 JOGNN
clinics. Thus, abortion is not included under national medical insurance coverage. Follow-up care is poor (Suzui, 1997). Under these conditions, women have found it difficult to be assertive in their decision-making process with regard to their reproductive rights. It is, therefore, likely that women in Japan would experience psychologic maladjustment after elective abortion. The Japanese government has developed sexual education programs that are part of the health education of adolescents. The government also is interested in preventing unwanted pregnancy and sexually transmitted diseases. However, counseling and mental health care for women before and after abortion has been lacking, although its necessity has been advocated. Data on the psychologic reactions of women toward abortion may give more impetus to the implementation of this policy.
The Women’s Body Protection Law in Japan Abortion under 22 weeks of gestation has been universally available in Japan since 1996 when the Women’s Body Protection Law was enacted. The Women’s Body Protection Law legalizes abortion not only to protect the health and life of pregnant women but also to avoid economic difficulty. This provision makes women in Japan able to obtain abortion whenever they choose. Although the annual number of abortions in Japan has been decreasing, the number remains more than 300,000. One quarter of pregnancies in Japan end in abortion, and that number may reflect underreporting (Smith, Adler, & Tschann, 1999). Abortion is a matter of concern from medical, psychologic, social, legal, bioethical, and religious perspectives.
Volume 30, Number 5
Family planning has been successful in Japan, but Japanese society is concerned with the falling population. The most prevalent method of contraception in Japan is the condom. More than 70% of married Japanese women report having sex at their partner’s request, “even if they [the women] did not want it” (Ogino, 1995). It is likely that in such a situation, contraception is not considered an option for the woman. This conservative marital relationship (husband’s superiority and wife’s inferiority in the relationship) may in part influence the high rate of elective abortion. Although abortion is legal in Japan, it is socially unacceptable and not openly discussed. Obstetricians in Japan perform abortion without knowing the reason for the woman’s choice. Women may go to a Buddhist shrine to ask a priest to pray for the baby (mizuko, literally “fluid baby”), reflecting conservatism and conflict regarding abortion. At least a portion of Japanese women remains uncomfortable about choosing abortion.
Literature Review Researchers have found that abortion is preceded and followed by psychologic maladjustment (Adler et al., 1990; Belsey, Greer, Lal, Lewis, & Beard, 1977; Dagg, 1991; Greer, Lal, Lewis, Belsey, & Beard, 1976; Hamill & Ingram, 1974). Researchers and clinicians have noted the necessity of care for such women (Adler et al., 1990, 1992; David, 1992; Erikson, 1993; Speckhard & Rue, 1992, 1993). Speckhard and Rue (1992), in their literature review, noted that abortion can be a traumatic experience and suggested that postabortion maladjustment be viewed as a post-traumatic stress disorder. It has been recognized that women who seek to terminate a pregnancy without the support of their partner are at higher risk for negative psychologic responses (Adler et al., 1992; Bluestein & Rutledge, 1993). Nevertheless, few studies have been conducted in Japan to analyze women’s psychologic responses after abortion. Anxiety after elective abortion may develop into posttraumatic stress disorder; this progression is what Speckhard and Rue (1992)referred to as postabortion syndrome. Even 5 years after an abortion (Speckhard & Rue, 1992), postabortion syndrome may persist. The long-term effects of postabortion anxiety thus deserve investigation. Although women’s attitudes toward abortion have been well studied (Agostino & Wahlberg, 1991; Embree, 1998; Gold & Coupey, 1998; Norup, 1997), few studies have focused on the relationship between women’s attitudes and postabortion adjustment. Further studies are required to illuminate the relationship between attitude and adjustment. Because abortion carries a stigma in Japan, it was speculated in the current study that a woman’s negative attitude toward abortion in general would predict postabortion anxiety. SeptemberlOctober 2002
In the current study, the level of anxiety immediately after abortion was examined, as were factors that correlated with this anxiety among Japanese women. Previous researchers have focused on the psychologic adjustment of women at some point after an elective abortion. Few reports describe women’s adjustment on the day of the elective abortion. The current study
Rstabortion anxiety was correlated with three variables: marital status, duration
of marriage or partnership, and attitude toward abortion in general.
examined women’s anxiety just after the abortion. This time was chosen because it probably is the one time when midwives and other health care professionals are available to give psychologic support to the woman receiving an abortion. Anxiety was selected as the criterion variable because it is considered to be the most likely psychologic condition appearing after abortion.
Method Participants Women seeking elective abortion at six obstetric clinics in Japan were solicited to participate in a survey. Two of the clinics were located in Hyogo Prefecture, another two in Osaka Prefecture, one in Kyoto Prefecture, and the sixth clinic was in Tokyo. Except for the latter clinic in Tokyo, all of the clinics were in the Kansai area. A total of 66 women who elected to undergo abortion returned the questionnaires. The age distributions of participants were as follows: teenagers, 3%; ages 20 to 29,49%;ages 30 to 39, 46%; ages 40 and older, 2% (one woman’s age was unknown). Fifty-five percent of the participants were married, and 45% were single. Of the 66 initial participants, 5 failed to return usable questionnaires.
Procedures A representative population was desired; however, difficulties in approaching patients made this objective difficult. Not all the women who sought abortion participated in this investigation during the study period. Thus, this study represents a convenience sample. After the purpose and nature of the study were explained and consent was obtained, the preabortion questionnaire was given to the women. Participants completed the survey while waiting for medical examinaJOG”
491
tion or after returning home. Abortion usually was performed a few days after participants filled out their questionnaires. Immediately after the abortion, the postabortion questionnaires were distributed and returned. The procedure for the protection of human subjects was reviewed and approved by managers and staff of the clinics. Participants were informed that they could choose to participate or not and their privacy would be protected.
approving of. elective abortion: (a) economic reasons, such as the cost of the delivery and child care; (b) job difficulties, such as not being able to work because of lack of child care; (c) schoolwork difficulties; (d) contraceptive failure; and (e) complete disapproval. No points were given if “complete disapproval” was chosen. The number of reasons chosen for the approval of abortion was used as the scale score. Thus, the women’s attitude toward abortion score could range between 0 and 4.
Measures The Japanese version of the State Trait Anxiety Inventory (STAI) (Spielberger, Gorsuch, & Lushene, 1970) was used to measure pre- and postabortion state anxiety. The STAI consists of 40 items that measure both state and trait anxiety. In this study, only 20 items regarding state anxiety were used. The trait anxiety items were not used because the focus of the study was the change in anxiety levels before and after the abortion. Each item was rated on a 4-point scale: 1 (not at all) to 4 (verylikely).Total scores ranged from 20 to 80, with higher scores indicating greater state anxiety. The Cronbach alpha coefficient of the Japanese version of the STAI state score among this sample population was .99.
Demographic and Obstetric Variables. Participants were asked about their age and that of their partner, marital status (married or single), occupation (housewife or student = 1, employed = 2), number of past abortions and deliveries, weeks gestation of the current pregnancy, duration of the relationship (less than a month = 1, less than 6 months = 2, less than a year = 3, less than 3 years = 4, more than 3 years = 5 ) , and the main method of contraception (condom = 1, others = 2). Relationship With the Partner. As ad hoc items to match the situation of these women, the following questions were asked: (a) whether they had discussed contraception with their partners (definitely = 1, slightly = 2, no = 3), (b) whether the partner was cooperative in contraception (yes = 1, neither yes nor no = 2, no = 3), (c) whether the partner was the first person informed about the current pregnancy (no = 1,yes = 2), (d)whether they had chosen not to discuss the current abortion with the partner (no = 1, yes = 2), and (e) whether they had decided to have the abortion primarily because of the wishes of others (no = 1, yes = 2). Guilt Feelings About Abortion. The women were asked whether or not they felt guilty about the current abortion. A 3-point scale was used for this measurement (not at all = 1, ambivalent = 2, extremely = 3). Attitude Toward Abortion. Women were asked about their attitude toward abortion in general. As an ad hoc question, this item offered four reasons for 492 lOGNN
Statistical Analyses To examine the extent to which predictor factors contribute to state anxiety after abortion, the correlation coefficients between the postabortion STAI score and each of the predictor variables were calculated first, after controlling for preabortion state anxiety scores if the predictor variable was rank ordered. A strong correlation was discovered between the pre- and postabor-
Rstabortion anxiety was linked with a conservative attitude toward abortion.
tion state anxiety levels ( r = .743, p c .001). When the predictor variable was categorical, a one-way analysis of covariance (ANCOVA)was performed, with postabortion state anxiety as the dependent variable, each of the predictor variables as the independent variable, and the preabortion state anxiety score as a covariate. After predictor variables with significant links to the postabortion state anxiety in bivariate analyses were identified, a multiple regression analysis was performed. Preabortion state anxiety scores showed a strong correlation with postabortion anxiety. These analyses were conducted using SPSS-X (SPSS, Inc., 1988).
Results Descriptive statistics for all study variables are presented in Table 1, which also summarizes the correlations between postabortion state anxiety scores and other study variables. As stated above, a strong correlation was found between pre- and postabortion state anxiety. Apart from the preabortion state anxiety, the postabortion state anxiety scores were significantly correlated with marital status, duration of the marriage (duration of partnership for unmarried women), and a conservative attitude toward abortion in general. The postabortion state anxiety was significantly higher among married women than it was among unmarried
Volume 30, Number 5
TABLE 1
Bivariate Associations Between Predictor Variables and Postabovtion Anxiety
Variable Preabortion STAI score Age Age of partner Marital status
Possible Scores
Adual
20-80 1-4 1 4 1-2
26-76 1 4
scores
14
1-2
Scale Mean
Scale
55.77 2.46 2.73 1.42
8.75 0.59 0.85 0.50
SD
Correlation/Association With Postabortion STAI State Anxiety r = .743***
= .218 T = .073 F = 8.769**
I
1-5
1.63 1.70 2.13 8.35 4.05
0.49 0.91 1.25 2.84 1.22
1-2 1-3
1-2 1-3
1.42 1.42
0.50 0.67
married > single F = 0.033 r = .082 I = .181 T = .016 T = .328* longer > shorter F = 0.061 T = -A63
1-3
1-3
1.61
0.68
T
1-2
1-2
1.23
0.43
F = 1.377
1-2
1-2
1.11
0.32
F = 1.044
1-2
1-2
1.14
0.35
F = 1.047
1-3
1-3
2.40
0.92
T
0-4
0-4
2.08
1.05
r = -.499* * *
Occupation Number of abortions Number of deliveries Weeks of gestation Duration of relationship
1-2 1-5 1-5
1-2 1-4 1-5
1-5
Major method of contraception Discussed contraception with partner Partner is a confidant in contraception Partner was not the first person informed of the pregnancy Abortion was not discussed with partner Abortion was decided upon mainly due to others' wishes Feelings of guilt because of the abortion Liberal attitude toward abortion
= .036
= ,038
Note. F = ANOVA controlling for preabortion State Trait Anxiety Inventory (STAI). r = partial correlation coefficients controlling for pre. abortion STAI.
' p c .05. * * p < .01.* * * p < .001.
women ( p < .01). Postabortion state anxiety was significantly correlated with longer relationship duration ( p < .05). Postabortion state anxiety also was associated with a more conservative attitude toward abortion ( p c .001). Table 2 presents the results of a multiple regression analysis in which the postabortion STAI score was the dependent variable. A backward elimination method was used in which the control variables of preabortion STAI scores were entered as the first step. These were followed by the simultaneous entry of three variables: marital status, duration of marriage or parmership, and attitude toward abortion in general. Preabortion state anxiety scores exhibited the strongest significant association with postabortion state anxiety scores, R2 = S 6 5 , F(l, 45) = 58.4, p c .001. The three demographic and clinical variables contributed significantly to the prediction of the postabortion state anxiety scores, R2 increase = SeptemberlOctobey 2 001
-190, F(4, 42) = 32.4, p < .001, with only liberal attitudes toward abortion having a significant f3 value (-.295, p c .001). Thus, a conservative attitude toward abortion was a significant predictor of the postabortion state anxiety. Neither marital status nor the duration of the marriage or partnership was a significant predictor.
Discussion The current study showed that after controlling for preabortion state anxiety, oniy a conservative attitude toward abortion in general (not necessarily the current abortion) could predict postabortion state anxiety. One might conclude that a conservative attitude toward abortion in general induced feelings of guilt regarding the current pregnancy. These attitudes in turn resulted in high postabortion levels of anxiety. However, no sig-
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TABLE 2
STAI Predictors of Postabortion Trait Anxiety: Multiple Regression R2 Predictor
Preabortion state anxiety (STAI state) Demographic and clinical variables Liberal attitude toward abortion Marital status Duration of marriage or partnership
Rf
Increase
F
df
P
.565
.565 .190
58.4 32.4
1,45 4,42
c .001
.755
B
r
.752* * *
.752
-.295 * * * -.230 .065
-.237 -.069
c .001
-504
Note. R2 was adjusted.
***p < .001.
nificant link was found between preabortion feelings of guilt and postabortion state anxiety. The links between the participants’ attitudes toward abortion and their levels of postabortion anxiety were difficult to explain. Interpretations of this study are limited by the reliability and validity of the measures used. Some researchers (Blumenthal, 1991) have noted that abortion may exert some positive effect on women’s psychologic adjustment, such as emotional maturation. The current study indicates that in Japanese women seeking abortion, women with a conservative attitude toward abortion are at high risk of developing anxiety. These women may be the ones whose anxiety is least likely to subside after an abortion. The issue becomes more complicated when one considers fetal rights as well as women’s rights. Under Japanese law, no stipulations are made for the fetus. Some women choose abortion after prenatal tests reveal defects or possible genetically determined disorders in the fetus. Some of the participants may have had a conservative attitude toward abortion because of their feelings for the rights of the fetus. This topic has been rarely discussed or examined empirically. In the current study, the presence/absence and results of prenatal testing were not examined. If these data had been included, more insight about postabortion anxiety might have been obtained. Because this investigation was limited to Japanese women, the findings cannot be generalized to populations outside of Japan. Nor can the results be generalized to thegeneral public in Japan because this was a convenience sample. The participants were self-selected. They also may have responded with socially acceptable answers to the questionnaire. Furthermore, the use of the same questionnaire in a short interval may have distorted the findings on the second occasion (Knowles, Coker, Scott, Cook, & Neville, 1996). Because of the lack of appropriate measures, ad hoc items were used to measure interpersonal relationships 494 JOGNN
and attitude toward abortion. The use of researcherdeveloped measures with unknown reliability and validity significantly limits the current study. Future investigators should use measures with established reliability and validity. This study was limited to an investigation of women’s state anxiety as determined by a questionnaire immediately after having an abortion. Future researchers could examine the long-term outcomes of these women’s anxiety, as well as of their other psychologic symptoms. In addition, clinical levels of anxiety should be identified via interview. To further understand the mechanism of postabortion anxiety, information about the partner will be needed. Replication of the current study may shed more light on the psychologic issues related to elective abortion.
Nursing Implications In many countries, it is the midwives and nurses who offer emotional support to women undergoing elective abortion. Nurses should be encouraged to learn more about the psychologic and physical adjustment of such women. Because postabortion anxiety is significantly linked to a woman’s attitude toward abortion, midwives and nurses should be sensitive to the stigmatization of elective abortion (Prettyman & Cordle, 1992). Medical staff members need sufficient time to interview women seeking elective abortion-particularly women with conservative attitudes toward abortion. These women may need extra attention from nurses before and after abortion. It may be desirable to assign the same nurse/midwife as the attending staff. Care should be exercised to prevent further abortions. Counseling and education in contraceptive techniques should be offered to these women and, possibly, to their partners. A liaison with psychiatrists and psychologists may be recommended in some cases. Volume 30, Number 5
Not only should midwives and nurses be impartial toward the woman’s choice to have an abortion, but they also should be considerate about the woman’s life goals and value judgments. This is an issue not only for nursing but also for health care in general, public education, and policy making.
M i d w i v e s and nurses should be impartial toward women’s choice to have an abortion.
Graduate and postgraduate nursing and midwifery education should include the psychologic adjustment of women undergoing abortion in addition to the clinical, ethical, and legal aspects. In summary, the current study underscores the importance of studies of anxiety and interventions available to women seeking elective abortion. Women’s attitudes toward abortion may be a neglected factor related to postabortion anxiety. These issues could be considered in the wider context of Japanese women’s general health.
REFERENCES Adler, N. E., David, H. P., Major, B. N., Roth, S. H., RUSSO, N. F., & Wyatt, G. E. (1990). Psychological responses after abortion. Science, 248, 41-44. Adler, N. E., David, H. P., Major, B. N., Roth, S. H., RUSSO, N. F., & Wyatt, G. E. (1992). Psychological factors in abortion. American Psychologist, 47, 1194-1204. Agostino, M. B., & Wahlberg, V. (1991). Adolescents’ attitudes to abortion in samples from Italy and Sweden. Social Science and Medicine, 33, 77-82. Belsey, E. M., Greer, H. S., Lal, S., Lewis, S. C., & Beard, R. W. (1977). Predictive factors in emotional response to abortion: King’s termination study-IV. Social Science and Medicine, 11, 71-82. Bluestein, D., & Rutledge, C. M. (1993). Family relationships and depressive symptoms preceding induced abortion. Family Practice Research Journal, 13, 149-156. Blumenthal, S. J. (1991). Psychiatric consequences of abortion: Overview of research findings. In N. L. Stotland (Ed.), Psychiatric aspects of abortion (pp. 17-37). Washington, DC: American Psychiatric Press. Dagg, P. K. (1991). The psychological sequelae of therapeutic abortion-Denied and completed. American Journal of Psychiatry, 148, 578-585. David, H. P. (1992). Abortion in Europe, 1920-91: A public health perspective. Studies in Family Planning, 23, 1-22.
SeptemberlOctober 2001
Embree, R. A. (1998). Attitudes toward elective abortion: Preliminary evidence of validity for the Personal Beliefs Scale. Psychological Report, 82, 1267-1281. Erikson, R. C. (1993). Abortion trauma: Application of a conflict model. Pre- and Perinatal Psychology Journal, 8, 33-44. Gold, M. A., & Coupey, S. M. (1998).Attitudes of inner-city female adolescents toward medical and surgical abortion. Journal of Pediatric and Adolescent Gynecology, 11, 127-131. Greer, H. S., Lal, S., Lewis, S. C., Belsey, E. M., & Beard, R. W. (1976). Psychosocial consequences of therapeutic abortion King’s termination study 111. Social Science and Medicine, 128, 74-79. Hamill, E., & Ingram, I. M. (1974).Psychiatric and social factors in the abortion decision. British Medical Journal, 1, 229-232. Knowles, E. S., Coker, M. C., Scott, R. A., Cook, D. A., & Neville, J. W. (1996). Measurement-induced improvement in anxiety: Mean shifts with repeated assessment. Journal of Personality and Social Psychoiogy, 71,352363. Norup, M. (1997). Attitudes towards abortion in the Danish population. Bioethics, 11, 439-449. Ogino, M. (1995), Marriage and sex. In T. Inoue & Y. Ehara (Eds.), Women’s data book (pp. 74-75). Tokyo: Yuhikaku. Prettyman, R. J., & Cordle, C. (1992). Psychological aspects of miscarriage: Attitudes of the primary health care team. British Journal of Gynecology Practice, 42(356),97-99. Smith, L. B., Adler, N. E., & Tschann, J. M. (1999). Underreporting sensitive behaviours: The case of young women’s willingness to report abortion. Health Psychology, 18, 37-43. Speckhard, A., & Rue, V. (1992). Postabortion syndrome: An emerging public health concern. Journal of Social Issues, 48, 95-119. Speckhard, A., & Rue, V. (1993). Complicated mourning: Dynamics of impacted postabortion grief. Pre- and Perinatal Psychology Association of North America, 8,5-32. Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). Manual for the State-Trait Anxiety Inventory (self-evaluation questionnaire). Palo Alto, CA: Consulting Psychologists Press. SPSS, Inc. (1988). SPSS-X user’s guide (3rd ed.). Chicago: Author. Suzui, E. (1997). Abortion in Japanese society: Coping and need for a support system. Kawasaki Iryo-hukushigakkai-shi, 7, 237-248 (in Japanese).
Yasuko Kishida is a lecturer, School of Nursing, Shimane Medical University, Shimane, Japan. Address for cowespondence: Yasuko Kishida, RN, MPH, MA, 89-1 Enya-cho, Izumo, Shimane, 693-8501 Japan. E-mail: [email protected].
JOG”
495
=
Obiective: To examine women’s anxiety levels after elective abortion. Design and Setting: Women seeking elective abortion at six clinics in Japan were solicited to participate in a questionnaire survey. Participants: Sixty-six Japanese women requesting abortion participated in this survey. Main Outcome Measures: State anxiety was measured using Spielberger’s State Trait Anxiety Inventory before and after abortion. Results: Multiple regression analyses using predictor variables with a significant link to postabortion anxiety level showed that among potential predictors, a conservative attitude toward abortion was the most significant predictor of postabortion anxiety after controlling for the level of preabortion anxiety. Conclusion: These findings suggest that a woman’s attitude toward abortion and reproductive rights is an important but neglected factor influencing postelective abortion anxiety. Medical and nursing professionals should, therefore, take note of a woman’s attitude toward abortion as a part of her mental health care. JOGNN, 30,490-495;2001. Keywords: Abortion-Anxiety-Attitude toward abortion Accepted: April 2001
After World War 11, pregnancy termination became legal in Japan. National sentiment, however, was hostile toward women who had abortions. This sentiment was due in part to the economic boom in Japan that lasted for a few decades after World War 11; more manpower was needed than ever before. Abortion is not practiced at university or national hospitals, but only in private 490 JOGNN
clinics. Thus, abortion is not included under national medical insurance coverage. Follow-up care is poor (Suzui, 1997). Under these conditions, women have found it difficult to be assertive in their decision-making process with regard to their reproductive rights. It is, therefore, likely that women in Japan would experience psychologic maladjustment after elective abortion. The Japanese government has developed sexual education programs that are part of the health education of adolescents. The government also is interested in preventing unwanted pregnancy and sexually transmitted diseases. However, counseling and mental health care for women before and after abortion has been lacking, although its necessity has been advocated. Data on the psychologic reactions of women toward abortion may give more impetus to the implementation of this policy.
The Women’s Body Protection Law in Japan Abortion under 22 weeks of gestation has been universally available in Japan since 1996 when the Women’s Body Protection Law was enacted. The Women’s Body Protection Law legalizes abortion not only to protect the health and life of pregnant women but also to avoid economic difficulty. This provision makes women in Japan able to obtain abortion whenever they choose. Although the annual number of abortions in Japan has been decreasing, the number remains more than 300,000. One quarter of pregnancies in Japan end in abortion, and that number may reflect underreporting (Smith, Adler, & Tschann, 1999). Abortion is a matter of concern from medical, psychologic, social, legal, bioethical, and religious perspectives.
Volume 30, Number 5
Family planning has been successful in Japan, but Japanese society is concerned with the falling population. The most prevalent method of contraception in Japan is the condom. More than 70% of married Japanese women report having sex at their partner’s request, “even if they [the women] did not want it” (Ogino, 1995). It is likely that in such a situation, contraception is not considered an option for the woman. This conservative marital relationship (husband’s superiority and wife’s inferiority in the relationship) may in part influence the high rate of elective abortion. Although abortion is legal in Japan, it is socially unacceptable and not openly discussed. Obstetricians in Japan perform abortion without knowing the reason for the woman’s choice. Women may go to a Buddhist shrine to ask a priest to pray for the baby (mizuko, literally “fluid baby”), reflecting conservatism and conflict regarding abortion. At least a portion of Japanese women remains uncomfortable about choosing abortion.
Literature Review Researchers have found that abortion is preceded and followed by psychologic maladjustment (Adler et al., 1990; Belsey, Greer, Lal, Lewis, & Beard, 1977; Dagg, 1991; Greer, Lal, Lewis, Belsey, & Beard, 1976; Hamill & Ingram, 1974). Researchers and clinicians have noted the necessity of care for such women (Adler et al., 1990, 1992; David, 1992; Erikson, 1993; Speckhard & Rue, 1992, 1993). Speckhard and Rue (1992), in their literature review, noted that abortion can be a traumatic experience and suggested that postabortion maladjustment be viewed as a post-traumatic stress disorder. It has been recognized that women who seek to terminate a pregnancy without the support of their partner are at higher risk for negative psychologic responses (Adler et al., 1992; Bluestein & Rutledge, 1993). Nevertheless, few studies have been conducted in Japan to analyze women’s psychologic responses after abortion. Anxiety after elective abortion may develop into posttraumatic stress disorder; this progression is what Speckhard and Rue (1992)referred to as postabortion syndrome. Even 5 years after an abortion (Speckhard & Rue, 1992), postabortion syndrome may persist. The long-term effects of postabortion anxiety thus deserve investigation. Although women’s attitudes toward abortion have been well studied (Agostino & Wahlberg, 1991; Embree, 1998; Gold & Coupey, 1998; Norup, 1997), few studies have focused on the relationship between women’s attitudes and postabortion adjustment. Further studies are required to illuminate the relationship between attitude and adjustment. Because abortion carries a stigma in Japan, it was speculated in the current study that a woman’s negative attitude toward abortion in general would predict postabortion anxiety. SeptemberlOctober 2002
In the current study, the level of anxiety immediately after abortion was examined, as were factors that correlated with this anxiety among Japanese women. Previous researchers have focused on the psychologic adjustment of women at some point after an elective abortion. Few reports describe women’s adjustment on the day of the elective abortion. The current study
Rstabortion anxiety was correlated with three variables: marital status, duration
of marriage or partnership, and attitude toward abortion in general.
examined women’s anxiety just after the abortion. This time was chosen because it probably is the one time when midwives and other health care professionals are available to give psychologic support to the woman receiving an abortion. Anxiety was selected as the criterion variable because it is considered to be the most likely psychologic condition appearing after abortion.
Method Participants Women seeking elective abortion at six obstetric clinics in Japan were solicited to participate in a survey. Two of the clinics were located in Hyogo Prefecture, another two in Osaka Prefecture, one in Kyoto Prefecture, and the sixth clinic was in Tokyo. Except for the latter clinic in Tokyo, all of the clinics were in the Kansai area. A total of 66 women who elected to undergo abortion returned the questionnaires. The age distributions of participants were as follows: teenagers, 3%; ages 20 to 29,49%;ages 30 to 39, 46%; ages 40 and older, 2% (one woman’s age was unknown). Fifty-five percent of the participants were married, and 45% were single. Of the 66 initial participants, 5 failed to return usable questionnaires.
Procedures A representative population was desired; however, difficulties in approaching patients made this objective difficult. Not all the women who sought abortion participated in this investigation during the study period. Thus, this study represents a convenience sample. After the purpose and nature of the study were explained and consent was obtained, the preabortion questionnaire was given to the women. Participants completed the survey while waiting for medical examinaJOG”
491
tion or after returning home. Abortion usually was performed a few days after participants filled out their questionnaires. Immediately after the abortion, the postabortion questionnaires were distributed and returned. The procedure for the protection of human subjects was reviewed and approved by managers and staff of the clinics. Participants were informed that they could choose to participate or not and their privacy would be protected.
approving of. elective abortion: (a) economic reasons, such as the cost of the delivery and child care; (b) job difficulties, such as not being able to work because of lack of child care; (c) schoolwork difficulties; (d) contraceptive failure; and (e) complete disapproval. No points were given if “complete disapproval” was chosen. The number of reasons chosen for the approval of abortion was used as the scale score. Thus, the women’s attitude toward abortion score could range between 0 and 4.
Measures The Japanese version of the State Trait Anxiety Inventory (STAI) (Spielberger, Gorsuch, & Lushene, 1970) was used to measure pre- and postabortion state anxiety. The STAI consists of 40 items that measure both state and trait anxiety. In this study, only 20 items regarding state anxiety were used. The trait anxiety items were not used because the focus of the study was the change in anxiety levels before and after the abortion. Each item was rated on a 4-point scale: 1 (not at all) to 4 (verylikely).Total scores ranged from 20 to 80, with higher scores indicating greater state anxiety. The Cronbach alpha coefficient of the Japanese version of the STAI state score among this sample population was .99.
Demographic and Obstetric Variables. Participants were asked about their age and that of their partner, marital status (married or single), occupation (housewife or student = 1, employed = 2), number of past abortions and deliveries, weeks gestation of the current pregnancy, duration of the relationship (less than a month = 1, less than 6 months = 2, less than a year = 3, less than 3 years = 4, more than 3 years = 5 ) , and the main method of contraception (condom = 1, others = 2). Relationship With the Partner. As ad hoc items to match the situation of these women, the following questions were asked: (a) whether they had discussed contraception with their partners (definitely = 1, slightly = 2, no = 3), (b) whether the partner was cooperative in contraception (yes = 1, neither yes nor no = 2, no = 3), (c) whether the partner was the first person informed about the current pregnancy (no = 1,yes = 2), (d)whether they had chosen not to discuss the current abortion with the partner (no = 1, yes = 2), and (e) whether they had decided to have the abortion primarily because of the wishes of others (no = 1, yes = 2). Guilt Feelings About Abortion. The women were asked whether or not they felt guilty about the current abortion. A 3-point scale was used for this measurement (not at all = 1, ambivalent = 2, extremely = 3). Attitude Toward Abortion. Women were asked about their attitude toward abortion in general. As an ad hoc question, this item offered four reasons for 492 lOGNN
Statistical Analyses To examine the extent to which predictor factors contribute to state anxiety after abortion, the correlation coefficients between the postabortion STAI score and each of the predictor variables were calculated first, after controlling for preabortion state anxiety scores if the predictor variable was rank ordered. A strong correlation was discovered between the pre- and postabor-
Rstabortion anxiety was linked with a conservative attitude toward abortion.
tion state anxiety levels ( r = .743, p c .001). When the predictor variable was categorical, a one-way analysis of covariance (ANCOVA)was performed, with postabortion state anxiety as the dependent variable, each of the predictor variables as the independent variable, and the preabortion state anxiety score as a covariate. After predictor variables with significant links to the postabortion state anxiety in bivariate analyses were identified, a multiple regression analysis was performed. Preabortion state anxiety scores showed a strong correlation with postabortion anxiety. These analyses were conducted using SPSS-X (SPSS, Inc., 1988).
Results Descriptive statistics for all study variables are presented in Table 1, which also summarizes the correlations between postabortion state anxiety scores and other study variables. As stated above, a strong correlation was found between pre- and postabortion state anxiety. Apart from the preabortion state anxiety, the postabortion state anxiety scores were significantly correlated with marital status, duration of the marriage (duration of partnership for unmarried women), and a conservative attitude toward abortion in general. The postabortion state anxiety was significantly higher among married women than it was among unmarried
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TABLE 1
Bivariate Associations Between Predictor Variables and Postabovtion Anxiety
Variable Preabortion STAI score Age Age of partner Marital status
Possible Scores
Adual
20-80 1-4 1 4 1-2
26-76 1 4
scores
14
1-2
Scale Mean
Scale
55.77 2.46 2.73 1.42
8.75 0.59 0.85 0.50
SD
Correlation/Association With Postabortion STAI State Anxiety r = .743***
= .218 T = .073 F = 8.769**
I
1-5
1.63 1.70 2.13 8.35 4.05
0.49 0.91 1.25 2.84 1.22
1-2 1-3
1-2 1-3
1.42 1.42
0.50 0.67
married > single F = 0.033 r = .082 I = .181 T = .016 T = .328* longer > shorter F = 0.061 T = -A63
1-3
1-3
1.61
0.68
T
1-2
1-2
1.23
0.43
F = 1.377
1-2
1-2
1.11
0.32
F = 1.044
1-2
1-2
1.14
0.35
F = 1.047
1-3
1-3
2.40
0.92
T
0-4
0-4
2.08
1.05
r = -.499* * *
Occupation Number of abortions Number of deliveries Weeks of gestation Duration of relationship
1-2 1-5 1-5
1-2 1-4 1-5
1-5
Major method of contraception Discussed contraception with partner Partner is a confidant in contraception Partner was not the first person informed of the pregnancy Abortion was not discussed with partner Abortion was decided upon mainly due to others' wishes Feelings of guilt because of the abortion Liberal attitude toward abortion
= .036
= ,038
Note. F = ANOVA controlling for preabortion State Trait Anxiety Inventory (STAI). r = partial correlation coefficients controlling for pre. abortion STAI.
' p c .05. * * p < .01.* * * p < .001.
women ( p < .01). Postabortion state anxiety was significantly correlated with longer relationship duration ( p < .05). Postabortion state anxiety also was associated with a more conservative attitude toward abortion ( p c .001). Table 2 presents the results of a multiple regression analysis in which the postabortion STAI score was the dependent variable. A backward elimination method was used in which the control variables of preabortion STAI scores were entered as the first step. These were followed by the simultaneous entry of three variables: marital status, duration of marriage or parmership, and attitude toward abortion in general. Preabortion state anxiety scores exhibited the strongest significant association with postabortion state anxiety scores, R2 = S 6 5 , F(l, 45) = 58.4, p c .001. The three demographic and clinical variables contributed significantly to the prediction of the postabortion state anxiety scores, R2 increase = SeptemberlOctobey 2 001
-190, F(4, 42) = 32.4, p < .001, with only liberal attitudes toward abortion having a significant f3 value (-.295, p c .001). Thus, a conservative attitude toward abortion was a significant predictor of the postabortion state anxiety. Neither marital status nor the duration of the marriage or partnership was a significant predictor.
Discussion The current study showed that after controlling for preabortion state anxiety, oniy a conservative attitude toward abortion in general (not necessarily the current abortion) could predict postabortion state anxiety. One might conclude that a conservative attitude toward abortion in general induced feelings of guilt regarding the current pregnancy. These attitudes in turn resulted in high postabortion levels of anxiety. However, no sig-
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TABLE 2
STAI Predictors of Postabortion Trait Anxiety: Multiple Regression R2 Predictor
Preabortion state anxiety (STAI state) Demographic and clinical variables Liberal attitude toward abortion Marital status Duration of marriage or partnership
Rf
Increase
F
df
P
.565
.565 .190
58.4 32.4
1,45 4,42
c .001
.755
B
r
.752* * *
.752
-.295 * * * -.230 .065
-.237 -.069
c .001
-504
Note. R2 was adjusted.
***p < .001.
nificant link was found between preabortion feelings of guilt and postabortion state anxiety. The links between the participants’ attitudes toward abortion and their levels of postabortion anxiety were difficult to explain. Interpretations of this study are limited by the reliability and validity of the measures used. Some researchers (Blumenthal, 1991) have noted that abortion may exert some positive effect on women’s psychologic adjustment, such as emotional maturation. The current study indicates that in Japanese women seeking abortion, women with a conservative attitude toward abortion are at high risk of developing anxiety. These women may be the ones whose anxiety is least likely to subside after an abortion. The issue becomes more complicated when one considers fetal rights as well as women’s rights. Under Japanese law, no stipulations are made for the fetus. Some women choose abortion after prenatal tests reveal defects or possible genetically determined disorders in the fetus. Some of the participants may have had a conservative attitude toward abortion because of their feelings for the rights of the fetus. This topic has been rarely discussed or examined empirically. In the current study, the presence/absence and results of prenatal testing were not examined. If these data had been included, more insight about postabortion anxiety might have been obtained. Because this investigation was limited to Japanese women, the findings cannot be generalized to populations outside of Japan. Nor can the results be generalized to thegeneral public in Japan because this was a convenience sample. The participants were self-selected. They also may have responded with socially acceptable answers to the questionnaire. Furthermore, the use of the same questionnaire in a short interval may have distorted the findings on the second occasion (Knowles, Coker, Scott, Cook, & Neville, 1996). Because of the lack of appropriate measures, ad hoc items were used to measure interpersonal relationships 494 JOGNN
and attitude toward abortion. The use of researcherdeveloped measures with unknown reliability and validity significantly limits the current study. Future investigators should use measures with established reliability and validity. This study was limited to an investigation of women’s state anxiety as determined by a questionnaire immediately after having an abortion. Future researchers could examine the long-term outcomes of these women’s anxiety, as well as of their other psychologic symptoms. In addition, clinical levels of anxiety should be identified via interview. To further understand the mechanism of postabortion anxiety, information about the partner will be needed. Replication of the current study may shed more light on the psychologic issues related to elective abortion.
Nursing Implications In many countries, it is the midwives and nurses who offer emotional support to women undergoing elective abortion. Nurses should be encouraged to learn more about the psychologic and physical adjustment of such women. Because postabortion anxiety is significantly linked to a woman’s attitude toward abortion, midwives and nurses should be sensitive to the stigmatization of elective abortion (Prettyman & Cordle, 1992). Medical staff members need sufficient time to interview women seeking elective abortion-particularly women with conservative attitudes toward abortion. These women may need extra attention from nurses before and after abortion. It may be desirable to assign the same nurse/midwife as the attending staff. Care should be exercised to prevent further abortions. Counseling and education in contraceptive techniques should be offered to these women and, possibly, to their partners. A liaison with psychiatrists and psychologists may be recommended in some cases. Volume 30, Number 5
Not only should midwives and nurses be impartial toward the woman’s choice to have an abortion, but they also should be considerate about the woman’s life goals and value judgments. This is an issue not only for nursing but also for health care in general, public education, and policy making.
M i d w i v e s and nurses should be impartial toward women’s choice to have an abortion.
Graduate and postgraduate nursing and midwifery education should include the psychologic adjustment of women undergoing abortion in addition to the clinical, ethical, and legal aspects. In summary, the current study underscores the importance of studies of anxiety and interventions available to women seeking elective abortion. Women’s attitudes toward abortion may be a neglected factor related to postabortion anxiety. These issues could be considered in the wider context of Japanese women’s general health.
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Embree, R. A. (1998). Attitudes toward elective abortion: Preliminary evidence of validity for the Personal Beliefs Scale. Psychological Report, 82, 1267-1281. Erikson, R. C. (1993). Abortion trauma: Application of a conflict model. Pre- and Perinatal Psychology Journal, 8, 33-44. Gold, M. A., & Coupey, S. M. (1998).Attitudes of inner-city female adolescents toward medical and surgical abortion. Journal of Pediatric and Adolescent Gynecology, 11, 127-131. Greer, H. S., Lal, S., Lewis, S. C., Belsey, E. M., & Beard, R. W. (1976). Psychosocial consequences of therapeutic abortion King’s termination study 111. Social Science and Medicine, 128, 74-79. Hamill, E., & Ingram, I. M. (1974).Psychiatric and social factors in the abortion decision. British Medical Journal, 1, 229-232. Knowles, E. S., Coker, M. C., Scott, R. A., Cook, D. A., & Neville, J. W. (1996). Measurement-induced improvement in anxiety: Mean shifts with repeated assessment. Journal of Personality and Social Psychoiogy, 71,352363. Norup, M. (1997). Attitudes towards abortion in the Danish population. Bioethics, 11, 439-449. Ogino, M. (1995), Marriage and sex. In T. Inoue & Y. Ehara (Eds.), Women’s data book (pp. 74-75). Tokyo: Yuhikaku. Prettyman, R. J., & Cordle, C. (1992). Psychological aspects of miscarriage: Attitudes of the primary health care team. British Journal of Gynecology Practice, 42(356),97-99. Smith, L. B., Adler, N. E., & Tschann, J. M. (1999). Underreporting sensitive behaviours: The case of young women’s willingness to report abortion. Health Psychology, 18, 37-43. Speckhard, A., & Rue, V. (1992). Postabortion syndrome: An emerging public health concern. Journal of Social Issues, 48, 95-119. Speckhard, A., & Rue, V. (1993). Complicated mourning: Dynamics of impacted postabortion grief. Pre- and Perinatal Psychology Association of North America, 8,5-32. Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). Manual for the State-Trait Anxiety Inventory (self-evaluation questionnaire). Palo Alto, CA: Consulting Psychologists Press. SPSS, Inc. (1988). SPSS-X user’s guide (3rd ed.). Chicago: Author. Suzui, E. (1997). Abortion in Japanese society: Coping and need for a support system. Kawasaki Iryo-hukushigakkai-shi, 7, 237-248 (in Japanese).
Yasuko Kishida is a lecturer, School of Nursing, Shimane Medical University, Shimane, Japan. Address for cowespondence: Yasuko Kishida, RN, MPH, MA, 89-1 Enya-cho, Izumo, Shimane, 693-8501 Japan. E-mail: [email protected].
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