Psychological Effects of Termination of Pregnancy (TOP) By Choice on Adolescents

Introductuon: The question of whether termination of pregnancy causes psychological harm or not continues to be debated today. In South Africa, the number of terminated pregnancies is increasing at the rate at which pregnancies are occuring (Tlale 2010:29). With this finding, it is worrying to note that adolescent abortion by choice has been linked to a number of physical and psychological problems.This study focused on adolescents 18 to 21 years of age.  

Purpose: The purpose of this research was to explore and  describe how the termination of pregnancy by choice affects adolescents psychologically.

Methods: Strategy- Phenomenological research strategy was used.The lived experiences about termination of pregnacy as told by participants were described. 

Design- A qualitative design was used because it was appropriate for the exploration of the psychological experiences of adolescents regarding the termination of their pregnancies.In addition it was appropriate because the phenomenon under study was deeply rooted in the participants' personal knowledge or understanding of themselves. Qualitative research used was descriptive and explorative.

Setting-Intervies were conducted in an office at one academic hospital in Tshwane municipality, in the Gauteng Province. Potential participants were traced from the records of the hospital Termination of Pregnancy (TOP) clinic.

Population-Inclusion criteria : adolescents aged 18 to 21, who underwent termination by choice at a TOP clinic and should be able to consent by themselves.

               -Exclusion criteria : mentally disabled adolescents and adolescents who were victims of rape.

Sampling methods-Non-probability sampling, purposive sampling as well as snowball sampling methods were used.

Data gathering- In-depth, face-to-face, one-on-one interviews were used. These interviews were tape-recorded. A "grand tour" question that was asked was '' Tell me what your feelings are one year after termination of  pregnancy".  When necessary , field notes were taken.

Data collection process- Data were collected during the months of July to November 2014.  Nursing personell at the TOP clinic assisted with the selection of participants from clinic records, following the eligible criteria. The clinic manager contacted participants telephonically, requested their participation in the study and if they agreed, made appointments with them to report for interview at a designated office. Arrangements were made to reimburse participants their transport money.

Although the interviews were unstructured, the following format, as suggested by Greef(2005:295) as cited by Botma(2010:207), was followed:

.introductory pleasantries

.explaining the purpose of the research

.explaining the approximate time required

.emphasis of confidentiality of information

.tape-recording and taking notes during during the interview

.signed voluntary consent is confirmed

.remind the participant that she is free to withdraw at any time

For guidance, a list of questions as stated in the interview guide were used . Permission to tape-record the interviews was requested from participants.

Data analysis- The method followed in analysing data was the interpretive analysis of Terre Blanche, Durrheim and Kelly (2006:231) as cited by Botma, Greeff, Mulaudzi and Wright(2010:226). The following basic steps were followed: . familiarisation and immersion, where the transcripts of taped interviews were read many times in order to know the data thoroughly.

              .development of themes, where the main and the sub-themes were identified whilst reading the text

              .coding, which involved coding and linking data to identify themes

              .elaboration, where similar sections of the text were combined

              .interpretation and checking, where the analysed text was interpreted.

Trustworthiness of data

Trustworthiness of data was assessed using the criteria of credibility, transferability, dependability and confirmability (  Botma, Greeff, Mulaudzi and Wright, 2010:226)

Ethical considerations

Principles of ethical conduct adhered to were : 

.permission from the Department of Health to do research through one of the hospitals

.consent obtained from participants before the start of the interview

.principle of beneficence was adhered to 

.right to privacy confidentiality and anonimity

.the right of the participants to refusal and withdrawal from the study

Results:

Biographical data of participants

Age:

Of the six participants, two were between 18 and 19 years old and four were between 20 and 21 years old.

Ethnicity:

Five participants were Black and one was Coloured

Marital status:

Five were single and one was married

Education:

Two had secondary education and four were still studying at tertiary institutions 

Vocation:

Four were unemployed and two were in regular employment

Religious background:

All six participants were Christians. Religiosity affects disclosure of pregnancy and TOP as well as dictating a belief system and codes of behaviour. For members belonging to religious groups, religiosity may serve as a stressor if they were to abort (Hlalele,2008:23). 

Number of children:

One participant had  no children

Four had between one to two children and one had three children

Number of previous abortions:

Four participants never had an abortion and two have had one.

Duration of the pregnancy that was terminated:

.9 weeks = 1 participant

9.5 weeks = 1 participant

11 weeks = 3 participants

unsure = 1 participant

Mental health before termination of pregnancy:

Four participants stated that they did not feel satisfied with their lives, one stated that her life was not worth living and one expressed that she did not feel close to another person.

Mental health problems:

The study revealed that adolescents experienced mental health problems after termination of pregnancy. In agreement, Rausset, Brulfert, Se'journe, Goutaudier&Chabrol (2011) reiterate that women experience symptoms similar to those of Post Traumatic Stress Disorder. Mental health problems that tally with Weiten's (2013:582) are as follows:

Guilt: All participants expressed feelings of guilt for murdering their "babies". As all participants are Christians,feelings of guilt could stem from the belief that abortion is murder and therefore sinful. Hlalele (2008) contends that religion remains the social attribute that largely underpins patterns of living and  therefore dictates a belief system and codes of behaviour. Religious constructs may influence the way that adolescents react to TOP.

Confusion: All participants had conflicting emotions about TOP, as supported by the following statements that verbalised relief as well as regret about TOP: "I feel proud although it's a shame to do it"  and "I am happy that is over but I also feel sad that I had to terminate this pregnancy" (Sebola 2015:52).

Sadness: Five out of six participants stated that they were saddened particularly by seeing the "baby" and by the way the foetus was disposed after the procedure.The guilt of destroying a life was accompanied by sadness and crying.

Shame: Five participants expressed feelings of shame and this prevented them from disclosing to parents about their TOP. Shame has also been proved to be a strong precursor to low self-esteem and consequently depression (Seloilwe & Thupayagale-Tshweneagae 2009:457).

Avoidance: Five  participants said that they avoid thinking about the experience of TOP.  A study by Coleman (2006:903) affirms that high-risk depression scores were low among those groups who were most likely to report an abortion. Women who disclose abortion are less likely to experience depression than those who conceal it. 

Depression and anxiety: Four participants reported that they were either depressed or anxious after TOP.The procedure of TOP, grieving and the sense of loss,  guilt about TOP, lack of support from family may all contribute to anxiety or depression. Nolen-Hoeksema & Hilt (2009:386) in their study on gender differences in depression noted that prevalence of depression is about twice as high in women as it is in men. This means that women are by nature vulnerable to depression or anxiety even outside of pregnancy.

Anger: Four expressed anger at themselves, to boyfriends or to friends who advised them to terminate. This self-blame may lead to guilt, helplessness and sadness.

Numbness: Three participants stated that they did not feel any emotions about TOP. "I was unable to express my emotions" and "I was not feeling anything" were statements that alluded to numbness.

Flashbacks: Three participants stated that time and again they re-experience TOP in their minds.  

Sleeplessness: This was experienced by two participants and could be caused by thinking about the procedure or by guilt feelings . Nolen-Hoeksema (2001) as cited by Weiten(2013:89) writes that women have a greater

tendency than men to ruminate about setbacks and problems. This tendency may cause sleeplessness and subsequent depression.

Survivor guilt: experienced by two participants who said they felt guilty of having another child or they wanted to replace the aborted child.

Recommendations:

-Pre- and post-counselling should pay attention to emotional and spiritual impact of TOP as well as the reality of grief after the procedure

-During pre-counselling the counsellor should enquire about any pressure placed on the adolescent to abort

-Professionals working with adolescent girls need to be made aware of these symptoms sothat where a need arises they will be enlightened enough to intervene or to refer

-More qualitative research on the topic needs to be undertaken sothat findings may be published to raise awareness

Conclusion:

This study revealed that adolescents do experience mental ill-health after choosing to terminate their pregnancies. All participants felt guilty because abortion is murder. It is recommended that during pre-counselling women should be made aware of the emotional and the spiritual effects of termination of pregnancy