- Email: [email protected]
Short-Term Grief after an Elective Abortion
J OGNN
CLINICAL,STUDIES
Short-Term Grief After an Elective Abortion Gail B. Williams, RN, PhD
=
Objective: To identify the short-term grief response after elective abortion. Design: Descriptive, comparative study. Setting: Instruments were administered in a women’s health clinic. Participants Ninety-threewomen, 45 who had a history of elective abortion within the past 1 to 14 months and 48 who had never had an abortion. Inclusion criteria included no perinatal losses within the past 5 years; no documented psychiatric history; and ability to read, write, and comprehend English. Main Outcome Measures: Nature and intensity of short-term grief. Results: Women with a history of elective abortion experienced grief in terms of loss of control, death anxiety, and dependency. Although there were no statistically significant differences in the intensity of grief in women who had a history of elective abortion and the comparison group, there was an overall trend toward higher grief intensities in the abortion group. Presence of living children, perceived pressure to have the abortion, and the number of abortions appear to affect the intensity of the short-term grief response. Conclusion: Elective abortion has the potential for eliciting a short-term grief response. Research is needed to identify which women are at greatest risk. This grief response should be acknowledged and appropriate interventions undertaken. JOGNN, 30,
174-1 83; 2001. Keywords: Abortion -Grief-
Loss
Accepted: June 2000
Nearly 50% of all pregnancies in the United States are unintended, and half of these end in elective 174 JOGNN
abortion (Henshaw, 1998). The average woman will experience at least 1.4 unintended pregnancies by age 45 (Alan Guttmacher Institute, 1998). Physical complications of abortion are rare; less than 1% of all abortion patients experience a major complication such as hemorrhage or infection (Alan Guttmacher Institute, 1998; Frye, 1993). The risk of psychologic complications is less clear, with few studies addressing a grief response after abortion. Little empirical evidence exists regarding the grief response following abortion. Estimates of negative emotional sequelae after abortion range from 2-41 ‘YO.With approximately 1.3 million legal abortions performed annually in the United States (Dagg, 1941; Koonin, Smith, Ramick, Strauss, & Hopkins, 1997), the actual number of women experiencing grief and other negative psychologic reactions may be considerable (Rosenfeld, 1992). Elective abortion can be conceptualized as a type of perinatal loss (Mahan & Calica, 1997; Williams, 1991). However, much of the literature to date has studied elective abortion sequelae from a pathologic perspective. The goal of the current study was to characterize women’s short-term grief response to elective abortion. Four research questions guided the study: (a) What is the grief response in women who experience an elective abortion? (b) Are there differences in the grief response between women who had an elective abortion and those who did not? ( c )Is there a relationship between the intensity of grief for women who had abortions and the length of time since abortion? (d) Is there a difference in the intensity of grief experienced by women who had living children at the time of abortion and those who did not?
Volume 30, Number 2
Background and Significance Lindemann’s grief theory, which served as the theoretical framework for this study, defines grief as the psychologic, social, and somatic reaction to the perception of loss (Lindemann, 1944). Grief is a universal experience and a normal reaction to loss. The essential tasks of this reaction and the resolution of grief depend on an individual’s accomplishment of grief work. Lindemann also observed that many people have trouble in the resolution of grief work because they attempt to avoid “the intense distress connected with the grief experience and to avoid the expression of emotion necessary for it” (1944, p. 143). Little empirical evidence exists about grief after elective abortion. Before the 1973 legalization of abortion in the United States, most studies focused on the medical effects of elective abortion. A review of the literature related to research after legalization of abortion reported little evidence that elective abortion was associated with negative emotional sequelae (Osofsky, Osofsky, & Rajan, 1973). A minority of women were reported to experience some feelings of sadness, guilt, and depression immediately after elective abortion. These symptoms were reported to subside within a few months. A systematic literature review of abortion studies from 1966 to 1988 reported outcome incidence rates and methodologic profiles that varied considerably across studies examining negative sequelae (Rogers, Stoms, & Phifer, 1989). A review of 225 studies of the psychologic sequelae of elective abortion reported that adverse sequelae occurred in a minority of the women studied (Dagg, 1991). When negative sequelae did appear, they were reported to subside rapidly. The most prevalent immediate psychologic sequelae reported included feelings of distress and dysphoria; data collected from months to years after abortion indicated the presence of worry, self-reproach, and guilt (Dagg, 1991). After abortion, most women demonstrate a positive reaction to elective abortion and only a few express feelings of regret (Dagg, 1991). A review about the psychologic factors related to abortion reported a relatively benign course for women after elective abortion (Adler et al., 1992). It was noted that “a woman’s responses to abortion are complex, and she may feel a mixture of positive and negative emotions” (Adler et al., 1992, p. 1198). The most frequently cited response was one of relief and happiness after elective abortion; the most frequently cited negative response was guilt. The authors concluded that for most women elective abortion was followed by a mixture of emotions, with severe negative reactions a rare occurrence. The methodologic shortcomings of the various studies reviewed include diverse samples, varying measures of postabortion responses, and different times of postabortion assessment (Adler et al., 1992).
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Zolese and Blacker (1992)reported that although psychologic or psychiatric disturbances occur in association with elective abortion, they seem to be severe or persistent in only a few women. Studies that used standardized psychiatric instruments reported negative outcome to be 10-20% (Zolese & Blacker, 1992). They indicated that certain groups may be at higher risk for psychologic sequelae: younger women, those with poor social support, multiparous women, and those with a past psychiatric history. An area of agreement is the need for prospective studies to establish the incidence of psychologic sequelae in various populations considering age, socioeconomic status, and religious background (Dagg, 1991; Rogers et al., 1989; Zolese & Blacker, 1992). Despite the number of publications about elective abortion, few studies have investigated the normal grief response after abortion. Peppers (1987-1988) was the first to document a grief response after elective abortion. The wide variation in overall grief scores reported suggests that some women experience tremendous emotional trauma. Peppers found that the longer the pregnancy continued, the more emotionally traumatic the grief resolution. When grief scores of women who had elective abortions were compared with grief scores of women who had experienced involuntary loss from miscarriage, stillbirth, or neonatal death, they were similar (Peppers, 1987-1988). The nature of the grief response to elective abortion is unclear, but abortion remains an emotionally charged issue (Armsworth, 1991). The prevailing societal attitudes regarding elective abortion affect the responses of health care providers as well as the attitudes and feelings of women undergoing elective abortion. Most studies have focused on pathologic psychologic sequelae rather than the normal grief response and have examined responses in the period immediately after abortion, ranging from hours to several months (Dagg, 1991).
Method Study Design and Sample A purposive sample was recruited from a women’s health clinic in a large southwestern city. The final sample consisted of 93 women, 45 who had a self-reported history of one or more elective abortions within the past 1 to 14 months and 48 who never had an elective abortion. Inclusion criteria included no perinatal losses of an involuntary nature, such as miscarriage, fetal demise, stillbirth, or neonatal death, within the past 5 years. Women who had therapeutic abortions for medical reasons such as fetal anomalies were not included in the current study. Additional inclusion criteria were no documented psychiatric history and the ability to read, write, and comprehend English. A power analysis estimated
JOGNN 175
that the sample was adequate for testing a two-tailed t test of the two groups of women, with the level of significance set at -05, a medium-size effect, and a power of .7 (Cohen, 1988). An alpha level of .05 was used for all statistical tests.
Procedure The study was approved by the clinic’s institutional review board, and procedures to protect human participants were maintained throughout the study. Data collectors were hired and trained by the principal investigator. All the women were recruited from the same women’s health clinic, which provided routine gynecologic care. Women were asked to participate while they waited to see their primary health care provider. If they were willing to participate and met the inclusion criteria, they were provided a research packet that explained the nature and purpose of the study and how to complete the forms. The research packet also contained the informed consent form; a demographic data form; and the grief instrument, the Grief Experience Inventory (GEI-B). Completed research packets were returned to the data collector.
Instrumelzts and Definition of Terms In this study, elective abortion is the expulsion of the products of conception by surgical intervention before 20 weeks of gestation or before the fetus has reached a state of viability. Elective abortions are performed to terminate an unwanted or mistimed pregnancy as selfreported by the study participants and are referred to as elective abortions throughout this article. Despite reports about high rates of what is termed unintended pregnancy in the United States, there is continuing need for clarification of this term. Unintended pregnancy can be described as composed of two subgroups: unwanted pregnancy and mistimed pregnancy (Moos, Peterson, Meadows, Melvin, & Spitz, 1997). Unintended pregnancy is not synonymous with unwanted pregnancy (Moos et al., 1997). In their study of pregnancy intendedness, Moos et al. (1997) reported that nearly 50% of unintended pregnancies, including both unwanted and mistimed, end in elective abortion. Forty-nine percent of unintended pregnancies result in a live birth, 14% of which are the result of pregnancies identified as unwanted (Moos et al., 1997). It is further reported that findings from many studies regarding unintended pregnancy are difficult to analyze or compare because varying definitions of unintended pregnancy are used (Peterson & Moos, 1997). In the current study, no attempt was made to distinguish between unwanted or mistimed pregnancy. Forty-five women in the study had a self-reported history of elective abortion made through a personal choice for whatever reason. These women had both unwanted and mistimed pregnancies.
176 JOG”
Intensity of grief was measured by the GEI-B, a selfreport inventory of 104 true/false statements associated with grief, which measures behaviors of individuals during the grief process (Sanders, Mauger, & Strong, 1985) and is based on the grief responses identified by Lindemann (1944).It consists of 15 scales: 3 validity scales and 12 clinical scales. Each scale of the GEI-B yields a raw score that converts to a standardized T-score. T-scores are standardized scores with a mean of 50 and standard deviation of 10. The larger the T-score, the greater the intensity of the behavior measured by the scale (Sanders et al., 1985). The three validity scales reflect the testtaking attitudes of denial, atypical response, and social desirability. T-scores greater than 70 on any of these scales indicate that the grief scores are uninterpretable and should not be included in overall data analysis (Sanders et al., 1985). The remaining 12 clinical scales measure the intensity of specific grief symptoms. The GEI-B yields a profile of grief symptoms rather than a composite grief score. Because grief appears to be a multidimensional process with multiple symptoms, this tool is useful in understanding the nature and intensity of the grief response in terms of specific symptoms. Tscores greater than 50 are indicative of grief; T-scores lower than 50 indicate no grief (Sanders et al., 1985). The GEI-B, a standardized instrument with established reliability and validity, has been used in other studies of grief (Feldstein & Gemma, 1995; Jacob & ScandrettHibdon, 1994; Murphy, 1990). Content validity was established by a panel of experts. Convergent validity was established by correlating the GEI-B with other instruments measuring similar constructs (Sanders et al., 1985). The GEI-B has been tested in the comparison of bereaved and nonbereaved individuals and also is reported to distinguish among individuals experiencing different types of losses (Sanders et al., 1985). Internal consistency of the scales was established by the values of coefficient alphas, which range from 3 2 to .84. Reported test-retest reliability coefficients range from .52 to .87 (Sanders et al., 1985). A Cronbach’s alpha of .86 was obtained for the clinical scales in the current study.
Data Analysis Raw scores were obtained from the GEI-B, and Tscores were calculated for each participant on each of the 15 scales. Before data analysis, the mean T-scores on the three validity scales for the entire sample were examined. Because of elevated T-scores (of more than 70), three women’s profiles were eliminated before data analysis as uninterpretable. T-scores above 50 were examined to answer the first research question: What is the grief response in women who experience an elective abortion? The second research question was answered by a two-tailed t test of the mean T-scores on the GEI-B for the two groups of Volume 30, Number 2
TABLE 1
Sample Demographics (N = 93) Total Sample (N = 93)
Abortion Group (n = 45)
Nonabortion Group (n = 48)
M
SD
M
23.96
4.52
23.29
n
%
n
34 12 46 1
36.6 12.9 49.5 1.1
14 6 24 1
31.1 13.3 53.3 2.2
20 6 22 0.0
41.7 12.5 45.8 0.0
18 75
19.4 80.6
5 40
11.1 88.9
13 35
29.1 72.9
23 69
25.0 75.0
10 34
22.7 77.3
13 35
29.1 72.9
40 46 2
45.5 52.3 2.3
17 24 1
40.5 57.2 2.4
23 22 1
50.0 47.8 2.2
44 33 11
50.0 37.5 12.5
21 16 7
47.7 36.4 15.9
23 21 4
52.3 47.7 9.1
SD 3.92 %
M
SD
24.6
4.97
n
%
p Value. ns p Valueb
Ethnicity White Black Hispanic Other Marital status Married Unmarried Education High school Above high school Household income
SlOK $10-$50K > $SOK c
Religious affiliation Catholic Noncatholic None
ns
ns
ns
ns
ns
Note. Because of missing data, the total number of participants does not always equal 93,45, and 48, respectively. a. By t test. b. By chi-square.
women (abortion and nonabortion). Correlation coefficients were calculated to examine the third research question. A two-tailed t test addressed the last research question. Descriptive statistics were used to describe the demographic variables.
Results Sample Characteristics The sample consisted of 93 women; 45 with a history of elective abortion and 48 with no history of abortion. Demographics were similar for both groups of women, who were drawn from the same clinic population over the same time period (see Table 1 ) . No statistically significant differences were found between the two groups of women in age, ethnicity, marital status, education level, income, or religious affiliation.
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The 45 women who had a history of one or more abortions ranged in age from 18 to 34 years (SD = 3.9), with a mean age of 23 years. Over half of these women (53.3'%0,n = 24) were Hispanic, which reflects the population of this geographic region, and 48% (n = 21) were Catholic. Approximately 89% ( n = 40) were single at the time of abortion, and 60% ( n = 27) reported no living children at time of abortion. Seventy percent ( n = 30) reported a history of only one abortion. The mean length of time since abortion was 8.36 months (SD = 3.83), with a range of 1to 14 months. The majority of the women (98%, n = 41) had a 1st trimester abortion. The mean months pregnant at abortion was 2.3 months, with a range of 1 week to 4 months. Fifty percent ( n = 22) reported "self" as major wage earner, and 41% ( n = 17) reported an annual household income of less than $10,000. Seventy-seven percent (n= 34) reported having more than a high school education. JOG"
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Most of the women (51.1%0,n = 23) responded that they were not pressured to have the abortion. Only 11% ( n = 5 ) felt very pressured to have the abortion. Eighty-nine percent ( n = 40) had received no counseling of any kind following the abortion. On the demographic data form, women were asked their primary reason for the most recent abortion (see Table 2). The primary reason varied greatly, with most of the women (40.9%, n = 18) reporting “financial” as the primary reason for the abortion. The second most frequent response was “not ready,” followed by “no desire for additional children.” The demographic data showed that of the total sample ( N = 93) only 39.1% (n = 36) had living children. Sixty percent (n = 27) in the abortion group did not have living children. Sixty percent ( n = 18) of the women in the comparison group had living children at the time of the study. These women had between one and three living children, most under 5 years of age. The children of women in the abortion group tended to be older. Data also were collected regarding deaths and other losses that occurred in the past 5 years. Both groups of women were similar in the percentage experiencing some kind of death or loss during that time. Thirtyeight percent ( n = 17) of the abortion group and 40% ( n = 19) of the comparison group did not experience any deaths in the past 5 years. To determine whether the presence of deaths affected the short-term grief response of the abortion group (n = 45),the GEI-B Tscores of women experiencing death in the past 5 years
were compared with those not experiencing any deaths. There were no statistically significant differences in intensity of grief scores. Data also were collected regarding other types of losses in the past 5 years. Women’s responses included losses such as divorce, separation, loss of a long-term relationship, relocation, and family members’ loss of health. These other types of losses were similar for women in both groups.
Nature and Intensity of Short-Term Grief Mean T-scores of the abortion group ( n = 45) were examined for the nature and intensity of the grief response as indicated by elevated T-scores on the 12 clinical scales (above 50). The women who had a history of abortion experienced grief symptoms in terms of loss of control, death anxiety, and dependency as measured by T-scores greater than 50 (see Table 3 ) .
Differences in the Nature and Intensity of Grief Response Table 3 shows the means, standard deviations, mean difference, and 95% confidence intervals for the GEI-B T-scores for women in the abortion and nonabortion groups. Mean T-scores for both groups were compared. There were no statistically significant differences between the two groups on the 12 clinical scales of the GEI-B. One statistically significant difference ( p = .04) was found between the groups on the validity scale of social desirability.
Time Since Abortion and the Grief Response TABLE 2
Primary Reason for Abortion (n = 44) Self-Reported Primary Reason Too young Inconvenient Marital problems Afraid Lack of support Financial Unwanted pregnancy Not ready Partner married No desire for additional children Best option Do not like children
Frequency
Percentage
3 1 2 1 1 18 1 8 1
6.8 2.3 4.5 2.3 2.3 40.9 2.3 18.2 2.3
4 1 1
9.1 2.3 2.3
Note. One participant did not provide this information on the demographic data form.
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There were no statistically significant relationships between the intensity of grief symptoms in women who had one or more abortions and the time since abortion as measured by the correlation coefficients. There was a weak but statistically significant ( p = .036) relationship between sleep disturbance and time since abortion (see Table 4).
Presence of Living Children and the Grief Response There was one statistically significant difference ( p = .04) in the intensity of grief of women who had one or more abortions between those who had living children at the time of abortion and those who did not in terms of loss of vigor (see Table 5). The women who had living children at the time of abortion had more loss of vigor.
Other Findings Women were requested to rate their perceived pressure to have the abortion from 0 to 7 on the demographic data form, with 0 indicating no pressure and 7 very pressured. There were several statistically significant relationships between the pressure to have an abortion and the grief scales (see Table 6). Perceived pressure to Volume 30, Number 2
TABLE 3
Differences in the GEI-B T-Scores of Women in the Abortion and Nonabortion Groups Group 1 (abortion) (n = 45) GEI-B Scale Denial Atypical response Social desirability Despair Anger, hostility Social isolation Loss of control Somatization Death anxiety Sleep disturbance Loss of appetite Loss of vigor Physical symptoms Optimism, despair Dependency
Group 2 (nonabortion) (n = 48)
95% Confidence Interval of the Difference
M
SD
M
SD
Mean Difference
Lower Bound
Upper Bound
49.76 51.35 45.48 46.95 48.17 47.93 54.51 46.45 53.55 45.03 44.27 47.64 47.98 45.84 50.93
9.53 7.5 1 9.98 11.66 11.11 8.79 10.17 8.19 9.99 9.03 8.46 12.55 8.95 8.96 11.11
49.51 49.86 50.08 42.64 44.04 47.07 52.09 45.41 50.51 47.25 42.15 45.37 46.84 44.13 49.71
9.82 8.05 10.19 10.54 9.79 11.68 10.89 9.59 9.06 14.83 8.64 11.33 7.89 7.21 1 1.45
-.024 -1.49 4.60* 4.32 4.14 -0.86 -2.43 -1.05 -3.04 2.23 -2.13 -2.27 -1.13 -1.71 -1.21
4.45 4.90 0.1 1 -9.20 -8.71 -5.24 -6.93 4.82 -7.31 -3.17 -5.67 -7.27 4.68 -5.12 -6.14
3.96 1.92 9.09 0.57 0.43 3.52 2.08 2.73 1.23 7.62 1.42 2.74 2.42 1.69 3.72
‘Critical value o f t = 2.040. p = .04.
have an abortion was statistically significantly correlated with despair ( p = .025), anger ( p = .004), loss of control ( p = .048), somatization ( p = .001), sleep disturbance ( p = .001), loss of appetite ( p = .002), loss of vigor ( p = .004), and physical symptoms ( p = .049). Women who indicated very pressured ( n = 5 ) were compared with those who indicated never pressured ( n = 37). There were two statistically significant differences (anger,p = -042, and sleep disturbance, p = .049). Those who were very pressured had higher mean g-ef intensities in terms of both anger and sleep disturbance. Women with a self-report of one abortion ( n = 30) were compared with the women ( n = 12) who had more than one abortion. A statistically significant ( p = .03) difference was found in relation to social isolation. Women who had more than one abortion had a higher grief intensity in terms of social isolation.
Discussion The goal of this study was to characterize the nature and intensity of the short-term grief response after elective abortion. Results of this study indicate that elective abortion appears to have the potential for a short-term grief response, specifically in terms of feelings of loss of control, death anxiety, and dependency. The wide range of T-scores for this population of women suggests that
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grief may be more intense for some women and leb, intense for others. Mean grief intensities were higher on all but one scale (sleep disturbance) for the abortion group of women. Most of their children were under 5 years of age,.which may account for the higher intensity of sleep disturbance in the control group. The difference obtained between the two groups of women on one of the validity scales (social isolation), although statistically significant, is not clinically meaningful. These scales are used to determine whether any responses (T-score of more than 70) should be eliminated before data analysis, which was done. Only one significant relationship (positive)was found, that between time since abortion (M = 8.3 months) and the grief symptom of sleep disturbance. For the women who had abortions, the intensity of sleep disturbance increased slightly during the 1st year following abortion. The consensus among grief theorists (Glick, Weiss, & Parkes, 1974; Lindemann, 1944; Marris, 1958; Parkes, 1965) is that although grief diminishes with the passage of time, the actual time frame may be years rather than months or weeks. The grief process is somewhat predictable in nature but also is highly individual (Roach & Nieto, 1997). The failure to detect such diminishing grief intensities in this sample may be because of the short time since abortion. Most of the women had abortions (57.8%, n = 25) within the past 9 months.
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There has been little or no investigation of grief after abortion; such a grief process may be highly individual in nature, and some symptoms may decrease over time whereas other do not. The women who had living children at the time of abortion differed significantly from those who did not in terms of loss of vigor. The presence of living children at the time of an abortion may in fact heighten the intensity of some grief symptoms for women. Perceived pressure to have an abortion appears to be associated with grief symptoms of despair, anger, loss of control, somatic complaints, sleep disturbance, loss of appetite, loss of vigor, and presence of physical symptoms in this sample of women. It should be noted that with a small sample ( n = 5), the correlation is weak. According to Dagg (1991), symptoms of distress and dysphoria are present immediately following elective abortion. It is unclear whether the symptoms reported (Dagg, 1991) existed before the abortion and perhaps were related to circumstances surrounding the abortion experience. Women with lower preabortion coping expectancies have been shown to be more depressed after an abortion than women with higher coping expectancies (Major, Cozzarelli, & Mueller, 1992). In the current study, women who had more than one abortion had greater intensity of social isolation than those who had only one abortion. Similarly, in a study of dys-
TABLE 4
T-Score Correlation Coefficients of GEZ-B Scales and Time Since Abortion
GEI-B Denial Atypical response Social desirability Despair Anger, hostility Social isolation Loss of control Somatization Death anxiety Sleep disturbance Loss of appetite Loss of vigor Physical symptoms Optimism, despair Dependency
Correlation CoefflcientS Respondents Value 0.01 -0.08 0.08 -0.01 0.05 0.05 0.01 -0.06 0.10 0.33 0.07 0.04 -0.22 -0.04 -0.10
41 40 40 41 41 44 41 44 38 40 44 44 44 44 41
ns
ns ns ns ns ns ns ns
ns .036* ns
ns ns ns ns
'p < .05.
TABLE 5 Difference in GEI-B T-Scores Classed by Presence of Living Children at Time of Abortion ~~
Group 1 (living children at abortion) (n = 18) GEZ-B Scale Denial Atypical response Social desirability Despair Anger, hostility Social isolation Loss of control Somatization Death anxiety Sleep disturbance Loss of appetite Loss of vigor Physical symptoms Optimism, despair Dependency
Group 2 (no children at abortion), .(n = 271
~
95% Confidence Intetval of the Difference
M
SD
M
SD
Mean Difference
Bound
Upper Bound
48.6 51.8 45.0 49.6 51.0 47.0 55.7 46.9 54.4 45.5 44.3 52.2 47.1 45.6 53.3
8.06 8.45 10.18 9.82 10.12 6.79 9.18 8.34 9.24 7.87 9.15 10.58 7.25 8.61 14.11
50.5 51.0 45.8 45.2 46.2 48.5 53.8 46.1 53.0 44.6 44.3 44.5 48.6 46.0 49.2
10.54 6.99 10.06 12.59 11.53 10.0 10.87 8.22 10.62 9.96 8.13 13.02 10.05 9.36 8.28
-1.89 0.77 -0.79 4.38 4.76 -1.48 1.93 0.74 1.40 0.88 0.01 7.67* -1.56 -0.48 4.14
-8.05 4.20 -7.39 -3.13 -2.22 -6.60 4.71 -4.38 -5.40 -5.04 -5.29 0.18 -7.14 -6.09 -3.74
4.26 5.74 5.81 11.90 11.74 3.63 8.57 5.85 8.20 6.80 5.30 15.15 4.02 5.13 12.03
LOWff
'Critical value oft = 2.067.p = .04.
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Volume 30, Number 2
TABLE 6
T-Score Correlation Coefficients of GEZ-B Scales and Perceived Pressure to Have Abortion
GEZ-B Scale Denial Atypical response Social desirability Despair Anger, hostility Social isolation Loss of control Somatization Death anxiety Sleep disturbance Loss of appetite Loss of vigor Physical symptoms Optimism, despair Dependency
N Correlation P CoefFcients Respondents Value -0.13 0.14 -0.26 0.35 0.43 0.13 0.31 0.48
0.09 0.52 0.46 0.42 0.30 0.19 0.22
41 40 40 41 42 44 41 44 38 40 44 44 44 44 41
ns ns ns
.025' .004*
ns .048* .001* ns
.001* .002* .004* .049*
ns ns
'p c .05.
phoric women after abortion, coercion to have the abortion was identified as a risk factor (Franco, Tamburrino, Campbell, Pentz, & Jurs, 1989). The current study had some limitations. Most grief studies have to rely on those who agree to participate. This raises the issue of volunteer error (Sanders, 1989). This issue was addressed through use of the GEI-B and its three validity scales. All women were screened for testtaking attitudes by means of the GEI-B validity scales. Another shortcoming of grief studies reported in the literature is the failure of grief researchers to use appropriate comparison groups (Dagg, 1991; Sanders, 1989). This methodologic issue was addressed by including a comparison group of women drawn from the same clinic population over the same time period. Demographic data were compared for both groups of women. The groups did not differ significantly in age, ethnicity, marital status, income, education level, or religious affiliation. Data regarding deaths in the past 5 years were collected from the entire sample. Almost 40% ( n = 36) of the sample of 93 women had experienced no deaths in the past 5 years. The number of women not experiencing any deaths in 5 years was similar for both groups of women: 37.8% ( n = 17) for the abortion group and 39.6% ( n = 19) for the nonabortion group. To control for the confounding variable of grief from losses, the study limited participation to women who had not experienced a perinatal loss of any kind other
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than elective abortion in the past 5 years. It was not possible, however, to control for all other types of losses, such as deaths, divorce, or illness, that may have occurred in the recent past. Women in the abortion group ( n = 45) were instructed to complete the GEI-B in reference to how they were currently feeling in relation to the most recent abortion experience. There were no statistically significant differences between the mean scores on the GEI-B of the women who had experienced a death in the past 5 years ( n = 28) and those who had not ( n = 17). Women in the comparison group were instructed to complete the GEI-B based on how they were feeling at present. Therefore, it is possible that the experience of other deaths or perceived losses in the past 5 years may have affected the mean grief intensities of the comparison group, which would explain the lack of statistically significant differences between the two groups of women. Statistics indicate that 52% of U.S. women having abortions are younger than 25 years of age (Henshaw, 1998; Koonin et al., 1997). Women ages 20 to 24 years obtain 32% of all abortions. White women obtain 60% of all abortions, but their abortion rates are lower than those of minority women. Hispanic women are twice as likely as are white women to have an abortion. Approximately 78% of women having abortions have no previous live births, 78% are unmarried, and 88% have a 1st trimester abortion (Henshaw, 1998; Koonin et al., 1997). From the perspective that abortion is a loss that occurs during pregnancy, a concomitant grief response appears logical. Perinatal losses and appropriate interventions have received increasing attention in the literature during the past -two decades. There appears to be agreement that most women who experience perinatal losses should be encouraged to grieve despite the length of their pregnancy (Foster, 1996; Hall, 1997) and that this grief work appears essential for the resolution of the grief process and prevention of depression and other psychologic complications (Carrera et al., 1998; Lee & Slade, 1996).Based on their recent study of miscarriage, Hutti, dePacheco, and Smith (1998) recommend that nurses attempt to understand the meaning of the perinatal loss for the woman before intervening. This recommendation supports the belief that the grief process is unique for each woman who experiences a perinatal loss. For women who choose to terminate pregnancy, their loss is somehow seen as less legitimate or less socially acceptable. The prevailing societal attitude is that these women should be pleased and relieved rather than sad (Raphael, 1983). However, these two diverse emotions may coexist (Rando, 1984). Clinicians who have worked with women who have had abortions (Gardner, 1986; Mahan & Calica, 1997; Tentoni, 1995) advocate that health care providers acknowledge and facilitate the grieving process. Shame, secrecy, and guilt may
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accompany the grief associated with the abortion experience. Support or comfort by others is frequently absent (Roach, 1997). Women may be reluctant to express feelings of grief or loss due to the controversial nature of elective abortion. According to Lindemann (1944), resolution of grief depends on how well the individual accomplishes his or her grief work. For many women, such a resolution is difficult because they attempt to avoid the distress associated with the grief experience. Similarly, Roach and Nieto (1997) point out that grief is a process and must be acknowledged and experienced. This grief process is also highly individual. Grief is painful, and the individual should be allowed to experience feelings without being pressured to move through the grief process in a specified time or manner (Roach & Nieto, 1977). All too often, after elective abortion, the woman is given the subtle message to “move on” rather than grieve. In grief following miscarriage and neonatal death, there seems to be a conspiracy of silence (Brost & Kenney, 1992) in which pregnancy loss is not fully acknowledged by society. This conspiracy of silence is heightened for women who have elected to terminate their pregnancies. Regarding grief following elective abortion, it has been emphasized that “it’s not necessarily the event, but rather the inability to grieve over the loss, which often causes physical and emotional problems later in life” (Gardner, 1986, p. 87).
Assess all women for all types of perinatal losses, voluntary as well as involuntary, on a consistent basis. Acknowledge that for some women, a grief response is a normal response to a voluntary perinatal loss such as elective abortion. Assess varying manifestations of grief after the perinatal loss of elective abortion; remember that individuals’ symptoms of grief may differ. Acknowledge that grief after elective abortion is a process and the grief work is important; however, resolution of the grief may take time. Attempt to understand the loss and the concomitant grief response following elective abortion from the woman’s perspective. Validate the loss for women who appear to be experiencing grief after elective abortion. Support the woman’s grief work whenever possible, using active listening and a supportive, nonjudgmental approach. Remember that the ability to grieve a perceived loss following elective abortion is essential for promotion of coping and prevention of possible depressive reactions.
Acknowledgment This study was supported in part by the Army Nurse Corps Scholars Fund Research Grant Award.
Conclusions Based on the findings of the current study, elective abortion appears to have the potential for a short-term grief response in some women, specifically feelings of loss of control, death anxiety, and dependency. The presence of living children, perceived pressure to have an abortion, and the women’s number of abortions should be further investigated as to their influence on the grief experience. Future investigations of a longitudinal nature are indicated to track the nature and intensity of grief symptoms over time. Additional research is warranted to identify more clearly which subset of women is more vulnerable to an intense grief reaction. From a clinical perspective, nurses should be aware of the potential for a short-term grief response following elective abortion. Nurses are in a position to facilitate the grief work that some women may require after an elective abortion. Based on the findings of this study as well as the experience of interacting with participants who have had elective abortions, the following suggestions are made to assist the nurse in planning assessment and intervention strategies for women who have had elective abortions: 182 lOGNN
REFERENCES Adler, N. E., David, H. P.;Major, B. N., Roth, S. H., RUSSO, N. F., & Wyatt, G. E. (1992). Psychologic factors in abortion: A review. American Psychologist, 47(lo), 1194-1204. Alan Guttmacher Institute. (1998). Facts in brief: lnduced abortion [Online]. Available: http://www.agi-usa. org/pubs/fb-induced-abort.htm1 Armsworth, M. (1991). Psychological response to abortion. Journal of Counseling & Development, 69, 377-379. Brost, L., & Kenney, J. (1992). Pregnancy after perinatal loss; parental reactions and nursing interventions. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 21 (6), 457-463. Carrera, L., Diez-Domingo, J., Montanana, V., Sancho, J., Minguez, J., & Monleon, J. (1998). Depression in women suffering perinatal loss. International Journal of Gynecology and Obstetrics, 62, 149-154. Cohen, J. (1988).Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum. Dagg, K. B. (1991).The psychological sequelae of therapeutic abortion-denied and completed. American Journal of Psychiatry, 248(5), 578-585. Feldstein, M. A., & Gemma, P. B. (1995). Oncology nurses and chronic compounded grief. Cancer Nursing 28(3), 228-235.
Volume 30, Number 2
Foster, A. (1996). Perinatal bereavement support for families and midwives. Midwives, 109(1303), 218-219. Franco, K. N., Tamburrino, M. B., Campbell, N. B., Pentz, J. E., & Jurs, S. G. (1989). Psychological profile of dysphoric women postabortion. Journal of the American Medical Women’s Association, 44, 113-115. Frye, B. (1993). Abortion. AWHONN’s Clinical Issues in Perinatal and Women’s Health Nursing, 4(2), 265-271. Gardner, J. (1986). A difficult decision: A compassionate book about abortion. New York: The Crossing Press. Glick, I., Weiss, R., & Parkes, C. (1974). The first year o f bereavement. New York: John Wiley. Hall, J. (1997). Miscarriage: A process of grief and healing. Midwifery Today, 41, 29. Henshaw, S. K. (1998). Unintended pregnancy in the United States. Family Planning Perspectives, 30(1), 24-27. Hutti, M. H., depacheco, M., & Smith, M. (1998). A study of miscarriage: Development and validation of the perinatal Grief Intensity Scale. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 27, 547-555. Jacob, S. R., & Scandrett-Hibdon, S. (1994). Mothers grieving the death of a child. Nurse Practitioner, 2 9(7), 60-65. Koonin, L. M., Smith, J. C., Ramick, M., Strauss, L., & Hopkins, F. (1997). Abortion surveillance-United States, 1993-1994. In CDC Surveillance Summaries, August 8, 1997; 46(No.SS-4), 37-47. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Epidemiology Program Office. Lee, C., & Slade, P. (1996). Miscarriage as a traumatic event: A review of the literature and new implications for intervention. Journal of Psychosomatic Research, 40, (3),235-244. Lindemann, E. (1944). Symptomatology and management of acute grief. AmericanJournal of Psychiatry, 101,141-148. Mahan, C. K., & Calica, J. (1997). Perinatal loss: Considerations in social work practice. Social Work in Heath Care, 24, 141-152. Major, B., Cozzarelli, M. T., & Mueller, P. (1992). Male partner’s appraisals of undesired pregnancy and abortion: Implications for women’s adjustment to abortion. Journal of Applied Social Psychology, 22(8), 599-614. Marris, P. (1958). Widows and their families. London: Routledge & Kegan Paul. Moos, M., Peterson, R., Meadows, K., Melvin, C. L., & Spitz, A. (1997). Pregnant women’s perspectives on intendedness of pregnancy. Women’s Health Issues, 7(6),385-392. Murphy, S. A. (1990). Preventive intervention following accidental death of a child. Image: Journal of Nursing Scholarship, 22(3), 174-179. Osofsky, J., Osofsky, H., & Rajan, R. (1973). Psychological effects of abortion: With emphasis upon immediate
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reactions and follow-up. In H. Osofsky & J. Osofsky (Eds.), The abortion experience (pp. 188-205). New York: Harper & Row. Parkes, C. (1965). Bereavement and mental illness: A classification of bereavement reactions, Part 2. British Journal of Medical Psychology, 38, 13-26. Peppers, L. (1987-1988). Grief and elective abortion: Breaking the emotional bond? Omega, 18, 1-10. Peterson, R., & Moos, M. (1997). Defining and measuring unintended pregnancy: Issues and concerns. Women’s Health Issues, 7(4), 234-240. Rando, T. (1984). Grief, dying and death: Clinical interventions for caregivers. Champaign, IL: Research Press. Raphael, B. (1983). The anatomy of bereavement. New York: Basic Books. Roach, S. (1997). Surviving the loss of a loved one. In L. Keegan (Ed.), Healing and the grief process (pp. 61-84). Albany, NY: Delmar. Roach, S., & Nieto, B. (1997). Understanding grief. In L. Keegan (Ed.), Healing and the grief process (pp. 1-24). Albany, NY: Delmar. Rogers, J. L., Stoms, G., & Phifer, J. L. (1989). Psychologic impact of abortion: Methodologic and outcomes summary of empirical research between 1966 and 1988. Health Care for Women International, 10, 347-376. Rosenfeld, J. (1992). Emotional responses to therapeutic abortion. American Family Physician, 45(l),137-140. Sanders, C. M. (1989). Grief: The mourning after: Dealing with adult bereavement. New York: John Wiley. Sanders, C. M., Mauger, P., & Strong, P. (1985).A manual for the grief experience inventory. Consulting Psychologists Press. Tentoni, S. C. (1995). A therapeutic approach to reduce postabortion grief in university women. Journal of American College Health, 44, 35-37. Williams, G. B. (1991): Induced elective abortion and perinatal grief. Unpublished doctoral dissertation, New York University, New York. Zolese, G., & Blacker, C. V. (1992). The psychologic complications of therapeutic abortion. British ]ournal of Psychiatry, 160, 742-749.
Gail B . Williams is an associate professov, University of Texas Health Science Center at Sun Antonio School of Nursing. Address for cowespondence: Gail B. Williams, RN, PhD, University of Texas Health Science Center at Sun Antonio, School of Nursing, 7703 Floyd Curl Drive, Sun Antonio, TX 78229-7951. E-mail: [email protected].
JOGNN 183
CLINICAL,STUDIES
Short-Term Grief After an Elective Abortion Gail B. Williams, RN, PhD
=
Objective: To identify the short-term grief response after elective abortion. Design: Descriptive, comparative study. Setting: Instruments were administered in a women’s health clinic. Participants Ninety-threewomen, 45 who had a history of elective abortion within the past 1 to 14 months and 48 who had never had an abortion. Inclusion criteria included no perinatal losses within the past 5 years; no documented psychiatric history; and ability to read, write, and comprehend English. Main Outcome Measures: Nature and intensity of short-term grief. Results: Women with a history of elective abortion experienced grief in terms of loss of control, death anxiety, and dependency. Although there were no statistically significant differences in the intensity of grief in women who had a history of elective abortion and the comparison group, there was an overall trend toward higher grief intensities in the abortion group. Presence of living children, perceived pressure to have the abortion, and the number of abortions appear to affect the intensity of the short-term grief response. Conclusion: Elective abortion has the potential for eliciting a short-term grief response. Research is needed to identify which women are at greatest risk. This grief response should be acknowledged and appropriate interventions undertaken. JOGNN, 30,
174-1 83; 2001. Keywords: Abortion -Grief-
Loss
Accepted: June 2000
Nearly 50% of all pregnancies in the United States are unintended, and half of these end in elective 174 JOGNN
abortion (Henshaw, 1998). The average woman will experience at least 1.4 unintended pregnancies by age 45 (Alan Guttmacher Institute, 1998). Physical complications of abortion are rare; less than 1% of all abortion patients experience a major complication such as hemorrhage or infection (Alan Guttmacher Institute, 1998; Frye, 1993). The risk of psychologic complications is less clear, with few studies addressing a grief response after abortion. Little empirical evidence exists regarding the grief response following abortion. Estimates of negative emotional sequelae after abortion range from 2-41 ‘YO.With approximately 1.3 million legal abortions performed annually in the United States (Dagg, 1941; Koonin, Smith, Ramick, Strauss, & Hopkins, 1997), the actual number of women experiencing grief and other negative psychologic reactions may be considerable (Rosenfeld, 1992). Elective abortion can be conceptualized as a type of perinatal loss (Mahan & Calica, 1997; Williams, 1991). However, much of the literature to date has studied elective abortion sequelae from a pathologic perspective. The goal of the current study was to characterize women’s short-term grief response to elective abortion. Four research questions guided the study: (a) What is the grief response in women who experience an elective abortion? (b) Are there differences in the grief response between women who had an elective abortion and those who did not? ( c )Is there a relationship between the intensity of grief for women who had abortions and the length of time since abortion? (d) Is there a difference in the intensity of grief experienced by women who had living children at the time of abortion and those who did not?
Volume 30, Number 2
Background and Significance Lindemann’s grief theory, which served as the theoretical framework for this study, defines grief as the psychologic, social, and somatic reaction to the perception of loss (Lindemann, 1944). Grief is a universal experience and a normal reaction to loss. The essential tasks of this reaction and the resolution of grief depend on an individual’s accomplishment of grief work. Lindemann also observed that many people have trouble in the resolution of grief work because they attempt to avoid “the intense distress connected with the grief experience and to avoid the expression of emotion necessary for it” (1944, p. 143). Little empirical evidence exists about grief after elective abortion. Before the 1973 legalization of abortion in the United States, most studies focused on the medical effects of elective abortion. A review of the literature related to research after legalization of abortion reported little evidence that elective abortion was associated with negative emotional sequelae (Osofsky, Osofsky, & Rajan, 1973). A minority of women were reported to experience some feelings of sadness, guilt, and depression immediately after elective abortion. These symptoms were reported to subside within a few months. A systematic literature review of abortion studies from 1966 to 1988 reported outcome incidence rates and methodologic profiles that varied considerably across studies examining negative sequelae (Rogers, Stoms, & Phifer, 1989). A review of 225 studies of the psychologic sequelae of elective abortion reported that adverse sequelae occurred in a minority of the women studied (Dagg, 1991). When negative sequelae did appear, they were reported to subside rapidly. The most prevalent immediate psychologic sequelae reported included feelings of distress and dysphoria; data collected from months to years after abortion indicated the presence of worry, self-reproach, and guilt (Dagg, 1991). After abortion, most women demonstrate a positive reaction to elective abortion and only a few express feelings of regret (Dagg, 1991). A review about the psychologic factors related to abortion reported a relatively benign course for women after elective abortion (Adler et al., 1992). It was noted that “a woman’s responses to abortion are complex, and she may feel a mixture of positive and negative emotions” (Adler et al., 1992, p. 1198). The most frequently cited response was one of relief and happiness after elective abortion; the most frequently cited negative response was guilt. The authors concluded that for most women elective abortion was followed by a mixture of emotions, with severe negative reactions a rare occurrence. The methodologic shortcomings of the various studies reviewed include diverse samples, varying measures of postabortion responses, and different times of postabortion assessment (Adler et al., 1992).
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Zolese and Blacker (1992)reported that although psychologic or psychiatric disturbances occur in association with elective abortion, they seem to be severe or persistent in only a few women. Studies that used standardized psychiatric instruments reported negative outcome to be 10-20% (Zolese & Blacker, 1992). They indicated that certain groups may be at higher risk for psychologic sequelae: younger women, those with poor social support, multiparous women, and those with a past psychiatric history. An area of agreement is the need for prospective studies to establish the incidence of psychologic sequelae in various populations considering age, socioeconomic status, and religious background (Dagg, 1991; Rogers et al., 1989; Zolese & Blacker, 1992). Despite the number of publications about elective abortion, few studies have investigated the normal grief response after abortion. Peppers (1987-1988) was the first to document a grief response after elective abortion. The wide variation in overall grief scores reported suggests that some women experience tremendous emotional trauma. Peppers found that the longer the pregnancy continued, the more emotionally traumatic the grief resolution. When grief scores of women who had elective abortions were compared with grief scores of women who had experienced involuntary loss from miscarriage, stillbirth, or neonatal death, they were similar (Peppers, 1987-1988). The nature of the grief response to elective abortion is unclear, but abortion remains an emotionally charged issue (Armsworth, 1991). The prevailing societal attitudes regarding elective abortion affect the responses of health care providers as well as the attitudes and feelings of women undergoing elective abortion. Most studies have focused on pathologic psychologic sequelae rather than the normal grief response and have examined responses in the period immediately after abortion, ranging from hours to several months (Dagg, 1991).
Method Study Design and Sample A purposive sample was recruited from a women’s health clinic in a large southwestern city. The final sample consisted of 93 women, 45 who had a self-reported history of one or more elective abortions within the past 1 to 14 months and 48 who never had an elective abortion. Inclusion criteria included no perinatal losses of an involuntary nature, such as miscarriage, fetal demise, stillbirth, or neonatal death, within the past 5 years. Women who had therapeutic abortions for medical reasons such as fetal anomalies were not included in the current study. Additional inclusion criteria were no documented psychiatric history and the ability to read, write, and comprehend English. A power analysis estimated
JOGNN 175
that the sample was adequate for testing a two-tailed t test of the two groups of women, with the level of significance set at -05, a medium-size effect, and a power of .7 (Cohen, 1988). An alpha level of .05 was used for all statistical tests.
Procedure The study was approved by the clinic’s institutional review board, and procedures to protect human participants were maintained throughout the study. Data collectors were hired and trained by the principal investigator. All the women were recruited from the same women’s health clinic, which provided routine gynecologic care. Women were asked to participate while they waited to see their primary health care provider. If they were willing to participate and met the inclusion criteria, they were provided a research packet that explained the nature and purpose of the study and how to complete the forms. The research packet also contained the informed consent form; a demographic data form; and the grief instrument, the Grief Experience Inventory (GEI-B). Completed research packets were returned to the data collector.
Instrumelzts and Definition of Terms In this study, elective abortion is the expulsion of the products of conception by surgical intervention before 20 weeks of gestation or before the fetus has reached a state of viability. Elective abortions are performed to terminate an unwanted or mistimed pregnancy as selfreported by the study participants and are referred to as elective abortions throughout this article. Despite reports about high rates of what is termed unintended pregnancy in the United States, there is continuing need for clarification of this term. Unintended pregnancy can be described as composed of two subgroups: unwanted pregnancy and mistimed pregnancy (Moos, Peterson, Meadows, Melvin, & Spitz, 1997). Unintended pregnancy is not synonymous with unwanted pregnancy (Moos et al., 1997). In their study of pregnancy intendedness, Moos et al. (1997) reported that nearly 50% of unintended pregnancies, including both unwanted and mistimed, end in elective abortion. Forty-nine percent of unintended pregnancies result in a live birth, 14% of which are the result of pregnancies identified as unwanted (Moos et al., 1997). It is further reported that findings from many studies regarding unintended pregnancy are difficult to analyze or compare because varying definitions of unintended pregnancy are used (Peterson & Moos, 1997). In the current study, no attempt was made to distinguish between unwanted or mistimed pregnancy. Forty-five women in the study had a self-reported history of elective abortion made through a personal choice for whatever reason. These women had both unwanted and mistimed pregnancies.
176 JOG”
Intensity of grief was measured by the GEI-B, a selfreport inventory of 104 true/false statements associated with grief, which measures behaviors of individuals during the grief process (Sanders, Mauger, & Strong, 1985) and is based on the grief responses identified by Lindemann (1944).It consists of 15 scales: 3 validity scales and 12 clinical scales. Each scale of the GEI-B yields a raw score that converts to a standardized T-score. T-scores are standardized scores with a mean of 50 and standard deviation of 10. The larger the T-score, the greater the intensity of the behavior measured by the scale (Sanders et al., 1985). The three validity scales reflect the testtaking attitudes of denial, atypical response, and social desirability. T-scores greater than 70 on any of these scales indicate that the grief scores are uninterpretable and should not be included in overall data analysis (Sanders et al., 1985). The remaining 12 clinical scales measure the intensity of specific grief symptoms. The GEI-B yields a profile of grief symptoms rather than a composite grief score. Because grief appears to be a multidimensional process with multiple symptoms, this tool is useful in understanding the nature and intensity of the grief response in terms of specific symptoms. Tscores greater than 50 are indicative of grief; T-scores lower than 50 indicate no grief (Sanders et al., 1985). The GEI-B, a standardized instrument with established reliability and validity, has been used in other studies of grief (Feldstein & Gemma, 1995; Jacob & ScandrettHibdon, 1994; Murphy, 1990). Content validity was established by a panel of experts. Convergent validity was established by correlating the GEI-B with other instruments measuring similar constructs (Sanders et al., 1985). The GEI-B has been tested in the comparison of bereaved and nonbereaved individuals and also is reported to distinguish among individuals experiencing different types of losses (Sanders et al., 1985). Internal consistency of the scales was established by the values of coefficient alphas, which range from 3 2 to .84. Reported test-retest reliability coefficients range from .52 to .87 (Sanders et al., 1985). A Cronbach’s alpha of .86 was obtained for the clinical scales in the current study.
Data Analysis Raw scores were obtained from the GEI-B, and Tscores were calculated for each participant on each of the 15 scales. Before data analysis, the mean T-scores on the three validity scales for the entire sample were examined. Because of elevated T-scores (of more than 70), three women’s profiles were eliminated before data analysis as uninterpretable. T-scores above 50 were examined to answer the first research question: What is the grief response in women who experience an elective abortion? The second research question was answered by a two-tailed t test of the mean T-scores on the GEI-B for the two groups of Volume 30, Number 2
TABLE 1
Sample Demographics (N = 93) Total Sample (N = 93)
Abortion Group (n = 45)
Nonabortion Group (n = 48)
M
SD
M
23.96
4.52
23.29
n
%
n
34 12 46 1
36.6 12.9 49.5 1.1
14 6 24 1
31.1 13.3 53.3 2.2
20 6 22 0.0
41.7 12.5 45.8 0.0
18 75
19.4 80.6
5 40
11.1 88.9
13 35
29.1 72.9
23 69
25.0 75.0
10 34
22.7 77.3
13 35
29.1 72.9
40 46 2
45.5 52.3 2.3
17 24 1
40.5 57.2 2.4
23 22 1
50.0 47.8 2.2
44 33 11
50.0 37.5 12.5
21 16 7
47.7 36.4 15.9
23 21 4
52.3 47.7 9.1
SD 3.92 %
M
SD
24.6
4.97
n
%
p Value. ns p Valueb
Ethnicity White Black Hispanic Other Marital status Married Unmarried Education High school Above high school Household income
SlOK $10-$50K > $SOK c
Religious affiliation Catholic Noncatholic None
ns
ns
ns
ns
ns
Note. Because of missing data, the total number of participants does not always equal 93,45, and 48, respectively. a. By t test. b. By chi-square.
women (abortion and nonabortion). Correlation coefficients were calculated to examine the third research question. A two-tailed t test addressed the last research question. Descriptive statistics were used to describe the demographic variables.
Results Sample Characteristics The sample consisted of 93 women; 45 with a history of elective abortion and 48 with no history of abortion. Demographics were similar for both groups of women, who were drawn from the same clinic population over the same time period (see Table 1 ) . No statistically significant differences were found between the two groups of women in age, ethnicity, marital status, education level, income, or religious affiliation.
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The 45 women who had a history of one or more abortions ranged in age from 18 to 34 years (SD = 3.9), with a mean age of 23 years. Over half of these women (53.3'%0,n = 24) were Hispanic, which reflects the population of this geographic region, and 48% (n = 21) were Catholic. Approximately 89% ( n = 40) were single at the time of abortion, and 60% ( n = 27) reported no living children at time of abortion. Seventy percent ( n = 30) reported a history of only one abortion. The mean length of time since abortion was 8.36 months (SD = 3.83), with a range of 1to 14 months. The majority of the women (98%, n = 41) had a 1st trimester abortion. The mean months pregnant at abortion was 2.3 months, with a range of 1 week to 4 months. Fifty percent ( n = 22) reported "self" as major wage earner, and 41% ( n = 17) reported an annual household income of less than $10,000. Seventy-seven percent (n= 34) reported having more than a high school education. JOG"
177
Most of the women (51.1%0,n = 23) responded that they were not pressured to have the abortion. Only 11% ( n = 5 ) felt very pressured to have the abortion. Eighty-nine percent ( n = 40) had received no counseling of any kind following the abortion. On the demographic data form, women were asked their primary reason for the most recent abortion (see Table 2). The primary reason varied greatly, with most of the women (40.9%, n = 18) reporting “financial” as the primary reason for the abortion. The second most frequent response was “not ready,” followed by “no desire for additional children.” The demographic data showed that of the total sample ( N = 93) only 39.1% (n = 36) had living children. Sixty percent (n = 27) in the abortion group did not have living children. Sixty percent ( n = 18) of the women in the comparison group had living children at the time of the study. These women had between one and three living children, most under 5 years of age. The children of women in the abortion group tended to be older. Data also were collected regarding deaths and other losses that occurred in the past 5 years. Both groups of women were similar in the percentage experiencing some kind of death or loss during that time. Thirtyeight percent ( n = 17) of the abortion group and 40% ( n = 19) of the comparison group did not experience any deaths in the past 5 years. To determine whether the presence of deaths affected the short-term grief response of the abortion group (n = 45),the GEI-B Tscores of women experiencing death in the past 5 years
were compared with those not experiencing any deaths. There were no statistically significant differences in intensity of grief scores. Data also were collected regarding other types of losses in the past 5 years. Women’s responses included losses such as divorce, separation, loss of a long-term relationship, relocation, and family members’ loss of health. These other types of losses were similar for women in both groups.
Nature and Intensity of Short-Term Grief Mean T-scores of the abortion group ( n = 45) were examined for the nature and intensity of the grief response as indicated by elevated T-scores on the 12 clinical scales (above 50). The women who had a history of abortion experienced grief symptoms in terms of loss of control, death anxiety, and dependency as measured by T-scores greater than 50 (see Table 3 ) .
Differences in the Nature and Intensity of Grief Response Table 3 shows the means, standard deviations, mean difference, and 95% confidence intervals for the GEI-B T-scores for women in the abortion and nonabortion groups. Mean T-scores for both groups were compared. There were no statistically significant differences between the two groups on the 12 clinical scales of the GEI-B. One statistically significant difference ( p = .04) was found between the groups on the validity scale of social desirability.
Time Since Abortion and the Grief Response TABLE 2
Primary Reason for Abortion (n = 44) Self-Reported Primary Reason Too young Inconvenient Marital problems Afraid Lack of support Financial Unwanted pregnancy Not ready Partner married No desire for additional children Best option Do not like children
Frequency
Percentage
3 1 2 1 1 18 1 8 1
6.8 2.3 4.5 2.3 2.3 40.9 2.3 18.2 2.3
4 1 1
9.1 2.3 2.3
Note. One participant did not provide this information on the demographic data form.
178 JOGNN
There were no statistically significant relationships between the intensity of grief symptoms in women who had one or more abortions and the time since abortion as measured by the correlation coefficients. There was a weak but statistically significant ( p = .036) relationship between sleep disturbance and time since abortion (see Table 4).
Presence of Living Children and the Grief Response There was one statistically significant difference ( p = .04) in the intensity of grief of women who had one or more abortions between those who had living children at the time of abortion and those who did not in terms of loss of vigor (see Table 5). The women who had living children at the time of abortion had more loss of vigor.
Other Findings Women were requested to rate their perceived pressure to have the abortion from 0 to 7 on the demographic data form, with 0 indicating no pressure and 7 very pressured. There were several statistically significant relationships between the pressure to have an abortion and the grief scales (see Table 6). Perceived pressure to Volume 30, Number 2
TABLE 3
Differences in the GEI-B T-Scores of Women in the Abortion and Nonabortion Groups Group 1 (abortion) (n = 45) GEI-B Scale Denial Atypical response Social desirability Despair Anger, hostility Social isolation Loss of control Somatization Death anxiety Sleep disturbance Loss of appetite Loss of vigor Physical symptoms Optimism, despair Dependency
Group 2 (nonabortion) (n = 48)
95% Confidence Interval of the Difference
M
SD
M
SD
Mean Difference
Lower Bound
Upper Bound
49.76 51.35 45.48 46.95 48.17 47.93 54.51 46.45 53.55 45.03 44.27 47.64 47.98 45.84 50.93
9.53 7.5 1 9.98 11.66 11.11 8.79 10.17 8.19 9.99 9.03 8.46 12.55 8.95 8.96 11.11
49.51 49.86 50.08 42.64 44.04 47.07 52.09 45.41 50.51 47.25 42.15 45.37 46.84 44.13 49.71
9.82 8.05 10.19 10.54 9.79 11.68 10.89 9.59 9.06 14.83 8.64 11.33 7.89 7.21 1 1.45
-.024 -1.49 4.60* 4.32 4.14 -0.86 -2.43 -1.05 -3.04 2.23 -2.13 -2.27 -1.13 -1.71 -1.21
4.45 4.90 0.1 1 -9.20 -8.71 -5.24 -6.93 4.82 -7.31 -3.17 -5.67 -7.27 4.68 -5.12 -6.14
3.96 1.92 9.09 0.57 0.43 3.52 2.08 2.73 1.23 7.62 1.42 2.74 2.42 1.69 3.72
‘Critical value o f t = 2.040. p = .04.
have an abortion was statistically significantly correlated with despair ( p = .025), anger ( p = .004), loss of control ( p = .048), somatization ( p = .001), sleep disturbance ( p = .001), loss of appetite ( p = .002), loss of vigor ( p = .004), and physical symptoms ( p = .049). Women who indicated very pressured ( n = 5 ) were compared with those who indicated never pressured ( n = 37). There were two statistically significant differences (anger,p = -042, and sleep disturbance, p = .049). Those who were very pressured had higher mean g-ef intensities in terms of both anger and sleep disturbance. Women with a self-report of one abortion ( n = 30) were compared with the women ( n = 12) who had more than one abortion. A statistically significant ( p = .03) difference was found in relation to social isolation. Women who had more than one abortion had a higher grief intensity in terms of social isolation.
Discussion The goal of this study was to characterize the nature and intensity of the short-term grief response after elective abortion. Results of this study indicate that elective abortion appears to have the potential for a short-term grief response, specifically in terms of feelings of loss of control, death anxiety, and dependency. The wide range of T-scores for this population of women suggests that
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grief may be more intense for some women and leb, intense for others. Mean grief intensities were higher on all but one scale (sleep disturbance) for the abortion group of women. Most of their children were under 5 years of age,.which may account for the higher intensity of sleep disturbance in the control group. The difference obtained between the two groups of women on one of the validity scales (social isolation), although statistically significant, is not clinically meaningful. These scales are used to determine whether any responses (T-score of more than 70) should be eliminated before data analysis, which was done. Only one significant relationship (positive)was found, that between time since abortion (M = 8.3 months) and the grief symptom of sleep disturbance. For the women who had abortions, the intensity of sleep disturbance increased slightly during the 1st year following abortion. The consensus among grief theorists (Glick, Weiss, & Parkes, 1974; Lindemann, 1944; Marris, 1958; Parkes, 1965) is that although grief diminishes with the passage of time, the actual time frame may be years rather than months or weeks. The grief process is somewhat predictable in nature but also is highly individual (Roach & Nieto, 1997). The failure to detect such diminishing grief intensities in this sample may be because of the short time since abortion. Most of the women had abortions (57.8%, n = 25) within the past 9 months.
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There has been little or no investigation of grief after abortion; such a grief process may be highly individual in nature, and some symptoms may decrease over time whereas other do not. The women who had living children at the time of abortion differed significantly from those who did not in terms of loss of vigor. The presence of living children at the time of an abortion may in fact heighten the intensity of some grief symptoms for women. Perceived pressure to have an abortion appears to be associated with grief symptoms of despair, anger, loss of control, somatic complaints, sleep disturbance, loss of appetite, loss of vigor, and presence of physical symptoms in this sample of women. It should be noted that with a small sample ( n = 5), the correlation is weak. According to Dagg (1991), symptoms of distress and dysphoria are present immediately following elective abortion. It is unclear whether the symptoms reported (Dagg, 1991) existed before the abortion and perhaps were related to circumstances surrounding the abortion experience. Women with lower preabortion coping expectancies have been shown to be more depressed after an abortion than women with higher coping expectancies (Major, Cozzarelli, & Mueller, 1992). In the current study, women who had more than one abortion had greater intensity of social isolation than those who had only one abortion. Similarly, in a study of dys-
TABLE 4
T-Score Correlation Coefficients of GEZ-B Scales and Time Since Abortion
GEI-B Denial Atypical response Social desirability Despair Anger, hostility Social isolation Loss of control Somatization Death anxiety Sleep disturbance Loss of appetite Loss of vigor Physical symptoms Optimism, despair Dependency
Correlation CoefflcientS Respondents Value 0.01 -0.08 0.08 -0.01 0.05 0.05 0.01 -0.06 0.10 0.33 0.07 0.04 -0.22 -0.04 -0.10
41 40 40 41 41 44 41 44 38 40 44 44 44 44 41
ns
ns ns ns ns ns ns ns
ns .036* ns
ns ns ns ns
'p < .05.
TABLE 5 Difference in GEI-B T-Scores Classed by Presence of Living Children at Time of Abortion ~~
Group 1 (living children at abortion) (n = 18) GEZ-B Scale Denial Atypical response Social desirability Despair Anger, hostility Social isolation Loss of control Somatization Death anxiety Sleep disturbance Loss of appetite Loss of vigor Physical symptoms Optimism, despair Dependency
Group 2 (no children at abortion), .(n = 271
~
95% Confidence Intetval of the Difference
M
SD
M
SD
Mean Difference
Bound
Upper Bound
48.6 51.8 45.0 49.6 51.0 47.0 55.7 46.9 54.4 45.5 44.3 52.2 47.1 45.6 53.3
8.06 8.45 10.18 9.82 10.12 6.79 9.18 8.34 9.24 7.87 9.15 10.58 7.25 8.61 14.11
50.5 51.0 45.8 45.2 46.2 48.5 53.8 46.1 53.0 44.6 44.3 44.5 48.6 46.0 49.2
10.54 6.99 10.06 12.59 11.53 10.0 10.87 8.22 10.62 9.96 8.13 13.02 10.05 9.36 8.28
-1.89 0.77 -0.79 4.38 4.76 -1.48 1.93 0.74 1.40 0.88 0.01 7.67* -1.56 -0.48 4.14
-8.05 4.20 -7.39 -3.13 -2.22 -6.60 4.71 -4.38 -5.40 -5.04 -5.29 0.18 -7.14 -6.09 -3.74
4.26 5.74 5.81 11.90 11.74 3.63 8.57 5.85 8.20 6.80 5.30 15.15 4.02 5.13 12.03
LOWff
'Critical value oft = 2.067.p = .04.
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TABLE 6
T-Score Correlation Coefficients of GEZ-B Scales and Perceived Pressure to Have Abortion
GEZ-B Scale Denial Atypical response Social desirability Despair Anger, hostility Social isolation Loss of control Somatization Death anxiety Sleep disturbance Loss of appetite Loss of vigor Physical symptoms Optimism, despair Dependency
N Correlation P CoefFcients Respondents Value -0.13 0.14 -0.26 0.35 0.43 0.13 0.31 0.48
0.09 0.52 0.46 0.42 0.30 0.19 0.22
41 40 40 41 42 44 41 44 38 40 44 44 44 44 41
ns ns ns
.025' .004*
ns .048* .001* ns
.001* .002* .004* .049*
ns ns
'p c .05.
phoric women after abortion, coercion to have the abortion was identified as a risk factor (Franco, Tamburrino, Campbell, Pentz, & Jurs, 1989). The current study had some limitations. Most grief studies have to rely on those who agree to participate. This raises the issue of volunteer error (Sanders, 1989). This issue was addressed through use of the GEI-B and its three validity scales. All women were screened for testtaking attitudes by means of the GEI-B validity scales. Another shortcoming of grief studies reported in the literature is the failure of grief researchers to use appropriate comparison groups (Dagg, 1991; Sanders, 1989). This methodologic issue was addressed by including a comparison group of women drawn from the same clinic population over the same time period. Demographic data were compared for both groups of women. The groups did not differ significantly in age, ethnicity, marital status, income, education level, or religious affiliation. Data regarding deaths in the past 5 years were collected from the entire sample. Almost 40% ( n = 36) of the sample of 93 women had experienced no deaths in the past 5 years. The number of women not experiencing any deaths in 5 years was similar for both groups of women: 37.8% ( n = 17) for the abortion group and 39.6% ( n = 19) for the nonabortion group. To control for the confounding variable of grief from losses, the study limited participation to women who had not experienced a perinatal loss of any kind other
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than elective abortion in the past 5 years. It was not possible, however, to control for all other types of losses, such as deaths, divorce, or illness, that may have occurred in the recent past. Women in the abortion group ( n = 45) were instructed to complete the GEI-B in reference to how they were currently feeling in relation to the most recent abortion experience. There were no statistically significant differences between the mean scores on the GEI-B of the women who had experienced a death in the past 5 years ( n = 28) and those who had not ( n = 17). Women in the comparison group were instructed to complete the GEI-B based on how they were feeling at present. Therefore, it is possible that the experience of other deaths or perceived losses in the past 5 years may have affected the mean grief intensities of the comparison group, which would explain the lack of statistically significant differences between the two groups of women. Statistics indicate that 52% of U.S. women having abortions are younger than 25 years of age (Henshaw, 1998; Koonin et al., 1997). Women ages 20 to 24 years obtain 32% of all abortions. White women obtain 60% of all abortions, but their abortion rates are lower than those of minority women. Hispanic women are twice as likely as are white women to have an abortion. Approximately 78% of women having abortions have no previous live births, 78% are unmarried, and 88% have a 1st trimester abortion (Henshaw, 1998; Koonin et al., 1997). From the perspective that abortion is a loss that occurs during pregnancy, a concomitant grief response appears logical. Perinatal losses and appropriate interventions have received increasing attention in the literature during the past -two decades. There appears to be agreement that most women who experience perinatal losses should be encouraged to grieve despite the length of their pregnancy (Foster, 1996; Hall, 1997) and that this grief work appears essential for the resolution of the grief process and prevention of depression and other psychologic complications (Carrera et al., 1998; Lee & Slade, 1996).Based on their recent study of miscarriage, Hutti, dePacheco, and Smith (1998) recommend that nurses attempt to understand the meaning of the perinatal loss for the woman before intervening. This recommendation supports the belief that the grief process is unique for each woman who experiences a perinatal loss. For women who choose to terminate pregnancy, their loss is somehow seen as less legitimate or less socially acceptable. The prevailing societal attitude is that these women should be pleased and relieved rather than sad (Raphael, 1983). However, these two diverse emotions may coexist (Rando, 1984). Clinicians who have worked with women who have had abortions (Gardner, 1986; Mahan & Calica, 1997; Tentoni, 1995) advocate that health care providers acknowledge and facilitate the grieving process. Shame, secrecy, and guilt may
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accompany the grief associated with the abortion experience. Support or comfort by others is frequently absent (Roach, 1997). Women may be reluctant to express feelings of grief or loss due to the controversial nature of elective abortion. According to Lindemann (1944), resolution of grief depends on how well the individual accomplishes his or her grief work. For many women, such a resolution is difficult because they attempt to avoid the distress associated with the grief experience. Similarly, Roach and Nieto (1997) point out that grief is a process and must be acknowledged and experienced. This grief process is also highly individual. Grief is painful, and the individual should be allowed to experience feelings without being pressured to move through the grief process in a specified time or manner (Roach & Nieto, 1977). All too often, after elective abortion, the woman is given the subtle message to “move on” rather than grieve. In grief following miscarriage and neonatal death, there seems to be a conspiracy of silence (Brost & Kenney, 1992) in which pregnancy loss is not fully acknowledged by society. This conspiracy of silence is heightened for women who have elected to terminate their pregnancies. Regarding grief following elective abortion, it has been emphasized that “it’s not necessarily the event, but rather the inability to grieve over the loss, which often causes physical and emotional problems later in life” (Gardner, 1986, p. 87).
Assess all women for all types of perinatal losses, voluntary as well as involuntary, on a consistent basis. Acknowledge that for some women, a grief response is a normal response to a voluntary perinatal loss such as elective abortion. Assess varying manifestations of grief after the perinatal loss of elective abortion; remember that individuals’ symptoms of grief may differ. Acknowledge that grief after elective abortion is a process and the grief work is important; however, resolution of the grief may take time. Attempt to understand the loss and the concomitant grief response following elective abortion from the woman’s perspective. Validate the loss for women who appear to be experiencing grief after elective abortion. Support the woman’s grief work whenever possible, using active listening and a supportive, nonjudgmental approach. Remember that the ability to grieve a perceived loss following elective abortion is essential for promotion of coping and prevention of possible depressive reactions.
Acknowledgment This study was supported in part by the Army Nurse Corps Scholars Fund Research Grant Award.
Conclusions Based on the findings of the current study, elective abortion appears to have the potential for a short-term grief response in some women, specifically feelings of loss of control, death anxiety, and dependency. The presence of living children, perceived pressure to have an abortion, and the women’s number of abortions should be further investigated as to their influence on the grief experience. Future investigations of a longitudinal nature are indicated to track the nature and intensity of grief symptoms over time. Additional research is warranted to identify more clearly which subset of women is more vulnerable to an intense grief reaction. From a clinical perspective, nurses should be aware of the potential for a short-term grief response following elective abortion. Nurses are in a position to facilitate the grief work that some women may require after an elective abortion. Based on the findings of this study as well as the experience of interacting with participants who have had elective abortions, the following suggestions are made to assist the nurse in planning assessment and intervention strategies for women who have had elective abortions: 182 lOGNN
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Foster, A. (1996). Perinatal bereavement support for families and midwives. Midwives, 109(1303), 218-219. Franco, K. N., Tamburrino, M. B., Campbell, N. B., Pentz, J. E., & Jurs, S. G. (1989). Psychological profile of dysphoric women postabortion. Journal of the American Medical Women’s Association, 44, 113-115. Frye, B. (1993). Abortion. AWHONN’s Clinical Issues in Perinatal and Women’s Health Nursing, 4(2), 265-271. Gardner, J. (1986). A difficult decision: A compassionate book about abortion. New York: The Crossing Press. Glick, I., Weiss, R., & Parkes, C. (1974). The first year o f bereavement. New York: John Wiley. Hall, J. (1997). Miscarriage: A process of grief and healing. Midwifery Today, 41, 29. Henshaw, S. K. (1998). Unintended pregnancy in the United States. Family Planning Perspectives, 30(1), 24-27. Hutti, M. H., depacheco, M., & Smith, M. (1998). A study of miscarriage: Development and validation of the perinatal Grief Intensity Scale. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 27, 547-555. Jacob, S. R., & Scandrett-Hibdon, S. (1994). Mothers grieving the death of a child. Nurse Practitioner, 2 9(7), 60-65. Koonin, L. M., Smith, J. C., Ramick, M., Strauss, L., & Hopkins, F. (1997). Abortion surveillance-United States, 1993-1994. In CDC Surveillance Summaries, August 8, 1997; 46(No.SS-4), 37-47. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Epidemiology Program Office. Lee, C., & Slade, P. (1996). Miscarriage as a traumatic event: A review of the literature and new implications for intervention. Journal of Psychosomatic Research, 40, (3),235-244. Lindemann, E. (1944). Symptomatology and management of acute grief. AmericanJournal of Psychiatry, 101,141-148. Mahan, C. K., & Calica, J. (1997). Perinatal loss: Considerations in social work practice. Social Work in Heath Care, 24, 141-152. Major, B., Cozzarelli, M. T., & Mueller, P. (1992). Male partner’s appraisals of undesired pregnancy and abortion: Implications for women’s adjustment to abortion. Journal of Applied Social Psychology, 22(8), 599-614. Marris, P. (1958). Widows and their families. London: Routledge & Kegan Paul. Moos, M., Peterson, R., Meadows, K., Melvin, C. L., & Spitz, A. (1997). Pregnant women’s perspectives on intendedness of pregnancy. Women’s Health Issues, 7(6),385-392. Murphy, S. A. (1990). Preventive intervention following accidental death of a child. Image: Journal of Nursing Scholarship, 22(3), 174-179. Osofsky, J., Osofsky, H., & Rajan, R. (1973). Psychological effects of abortion: With emphasis upon immediate
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Gail B . Williams is an associate professov, University of Texas Health Science Center at Sun Antonio School of Nursing. Address for cowespondence: Gail B. Williams, RN, PhD, University of Texas Health Science Center at Sun Antonio, School of Nursing, 7703 Floyd Curl Drive, Sun Antonio, TX 78229-7951. E-mail: [email protected].
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