The influence of social class on parity and psychological reactions in women coming for induced abortion.

OBJECTIVE: To test the hypothesis that the correlation between legal abortion and socio-economic conditions, known from the time when abortion was restricted, has current validity. To evaluate the effect of social class on network support and psychological reactions. DESIGN: Consecutive sampling and semistructured personal interviewing. SUBJECTS: 444 women living in the city of Gothenburg and applying for legal termination of pregnancy in the first trimester. SETTING: The department of gynaecology at a university hospital with primary care responsibility for legal abortions. RESULTS: The 667 health administration districts of Gothenburg were ranked into four groups according to the mean income. Women living in lower socio-economic districts were younger. Irrespective of age, previous experience of induced abortion was more common among them (p < 0.001). Unsatisfactory network response or support was common (37%), but equally shared between the social classes. Discontinuation of oral contraception during the previous six months was twice as common among teenagers (40.0%) as among other women (p < 0.001) but without social differences. Pitman's permutation test was used for statistical analyses. CONCLUSION: Socio-economic conditions have a strong and inverse correlation to previous experience of induced abortion. Psychological reactions and needs did not vary with class.

PIP: Given attempts on the part of the Swedish parliament to restrict access to abortion, investigations of the social class composition of current abortion seekers are essential. In this study, socioeconomic data were collected on 444 consecutive first-trimester abortions performed at Sweden's University of Gothenburg Hospital in 1986-87. Gothenburg's 667 districts were classified into four strata on the basis of mean income for males 25-49 years of age and percentages of home ownership and families receiving social welfare. 45 abortion patients were in group A (high income), 74 in group B, 98 in group C, and 227 in group D (poverty level). Mean gestational age was similar (9.4 weeks) in all groups, but low-income abortion patients were significantly younger and had twice the rate of prior abortions than the most affluent women (48.9% versus 24.4%). Moreover, 15.4% of the poorest women compared to only 2.2% of the wealthiest women had undergone another abortion within two years of the index pregnancy termination. There were no significant differences along social class lines in terms of emotional responses to the need for abortion or perceptions of support from significant others. Overall, these findings confirm that any attempts to curtail abortion rights would have the greatest impact on low-income women. They further suggest a need for increased family planning program resources in low-income districts, including distribution of free contraception, to reduce the high incidence of repeat abortion.

Abortion ethics--women's post abortion assessments.

BACKGROUND: Induced abortion is often discussed in terms of ethics. The aim of the present report is to describe the abortion ethics as it was expressed by women undergoing a legal abortion. OBJECTIVE: Moral considerations expressed during semistructured interviews by 128 women two weeks after a first trimester abortion in Stockholm 1987-90 are reported. RESULT: The women had faced a choice between abortion and parenthood. At the time of the abortion many of them were living under conditions that meant they were unable to offer a child the security they regarded as a child's right. The conflict the women spontaneously described as their main moral dilemma was not a conflict between the woman and the fetus, but a conflict between several close relationships, also concerning the prospective father. The ethics that the women applied to the problems of abortion was founded on a long-term responsibility to care for persons in their relationships. CONCLUSION: The women interviewed had three levels of moral reasoning simultaneously present. 1. A theoretical level--most of all concerning other women--a liberal view of rights: abortion should be a freely obtainable option. 2. A theoretical level--above all, concerning themselves--a restrictive deontological view: the extinction of life is morally wrong and should be avoided. 3. A practical level--when the problem was a reality: a consequentialist ethics of care. According to this ethics of care it was important that the abortion could be performed as early as possible during pregnancy.

Ambivalence during early pregnancy among expectant mothers.

Ambivalence during the early stages of pregnancy is a known phenomenon, among expectant mothers as well as among applicants for abortion. The conflict of wanting or not wanting to have a child must be solved in the decision-making process that precedes the choice of whether to interrupt a pregnancy or carry it to full term. The time limit for this decision making process is reduced by the medical abortion methods now available. Hasty early abortions as well as delayed abortions create problems and should be avoided. The present Swedish study, based on 123 semistructured interviews conducted among expectant mothers, focuses on this ambivalence during early pregnancy. Fifty-five percent of the interviewees reported that the current pregnancy was planned, 14% had become pregnant in spite of using contraceptives. Fifteen percent had considered an abortion during the current pregnancy. Ten in-depth interviews revealed how women contemplating abortion dealt with their ambivalence and finally decided to continue the pregnancy. The study shows that no one but the pregnant woman herself can arrive at the informed analysis necessary for a well-considered decision about the future of her pregnancy. However, all pregnant women should be offered the opportunity to talk about their situation, their thoughts and feelings to a neutral listener, in order to make that decision.

Prenatal diagnosis for psychological reasons: comparison with other indications, advanced maternal age and known genetic risk.

In Sweden, about 20 per cent of women undergoing prenatal diagnosis (PND) have the test for 'psychological reasons', which means that they strongly fear giving birth to a disabled child, but have not reached the age limit. Women undergoing amniocentesis or chorionic villus biopsy for these reasons (n = 38) were studied by questionnaires with regard to distress during test procedures. They were compared to women examined because of a known or strongly suspected high risk of giving birth to a congenitally disabled child (n = 27) and to women examined because of an age more than 37 years (n = 144). The most distressed were women who had a high genetic risk. The women who had the test because of their age reported less distress. Women examined for psychological reasons, were moderately distressed, but reported the highest frequency of influence by the distress on their daily living. Women in all groups, however, felt a similar support by the normal test result and reported the whole procedure as rather easy. Different psychological determinants of anxiety of giving birth to a disabled child are discussed. The 'psychological indication' for PND means that the women's private interpretation of her risk, and not only the statistical limit, motivates PND.

Prenatal diagnosis and psychological distress: amniocentesis or chorionic villus biopsy?

The psychological reactions of 211 women undergoing prenatal diagnosis (PND) with amniocentesis (group A, n = 122) or chorionic villus biopsy (group V, n = 90) were examined by questionnaires and interviews. The distress experienced while waiting for the test, during the test procedure, and while waiting for the result was reported by the women, both in questionnaires and in interviews. In the questionnaires, no difference between the two diagnostic methods was observed. In the interviews, however, the women undergoing amniocentesis appeared significantly more distressed by the procedure. In group A 97 per cent and in group V 100 per cent wished a method which, like chorionic villus biopsy, could be used in the first weeks of pregnancy. The risk of miscarriage was, as described in other studies, regarded as a serious threat by the pregnant women.

Decision making during the prenatal diagnostic procedure. A questionnaire and interview study of 211 women participating in prenatal diagnosis.

Counselling in connection with prenatal diagnosis (PND) is a common task for the obstetrician and the midwife. However, the decision making processes of pregnant women are not completely known, for instance, the questions of women's autonomy, the decision on how to act in the case of an abnormal test, and the partner's participation in the decision. A questionnaire and interview study was carried out among 211 women undergoing PND by amniocentesis or chorionic villus biopsy. Most women in the sample indicated that PND was completely voluntary. However, at the same time almost every woman reported that it was difficult to decline from PND when offered. Even before the visit to register at the antenatal clinic, most of the women (83 per cent) had made up their minds to have PND. At the time of the test, many of the participants (62 per cent) had decided in favour of a legal abortion if the test indicated an abnormality in the fetus. At the same time, however, the data indicate a need for reflection and ambivalence, which the medical staff have to accept. In the questionnaire most of the women stated that they and their partners had similar attitudes towards PND, but when interviewed 38 per cent of the women admitted some differences between their own attitudes and their partners'. Although some women reported considerable deliberation and ambivalence, most of them said that they would undergo PND in another pregnancy.

Prognostic factors vs. outcome in male-to-female transsexualism. A follow-up study of 13 cases.

Thirteen male-to-female transsexuals were investigated 6 to 25 years after surgery. Thirty-five prognostic items were compared with each of three outcome variables. Traumatic loss of both parents in infancy was connected with repentance at follow-up. A childhood family of an overprotective mother and a distant father, on the other hand, was prognostically favourable. Contrary to most previous reports, high sexual activity and bisexual experience was associated with fair sexual adjustment and with non-repentance after sex change. The repenting individuals, on the other hand, had been a-sexual or hyposexual before surgery. Completed military service, a history of typically masculine, hard jobs, and a comparatively late (more than 30 years of age) first request for surgery, were found to be negative prognostic factors in sex-reassignment evaluations. The phenomenon of ambivalence or hesitance during the trial period is discussed. Both too much and too little ambivalence may suggest a poor prognosis.

Long-term follow-up of "sex change" in 13 male-to-female transsexuals.

Thirteen male-to-female transsexuals were investigated in an intensive interview study. The follow-up period varied between 6 and 25 years, with an average of 12 years. Surgical outcome was disappointing, and only one-third of the patients where a vaginal construction was carried out had a functioning vagina. The importance of patient cooperation postoperatively is pointed out and reasons for noncooperation are discussed. The generally held view of transsexuals as hypo- or asexual is questioned. In this study, one-third of the patients were very active sexually both before and after radical genital surgery. More than half of these castrated and estrogen-treated former males experienced orgasm, but only one-third were judged as having a fair or good sexual adjustment after sex reassignment. The possibility of unsuccessful surgical results must continue to be an important part of presurgery reality orientation both in doctors and patients. One striking finding is that overall sexual adjustment is often unchanged by genital surgery. Psychosocial adjustment showed a slight improvement after surgery. However, the majority of patients (eight) were judged to be unchanged. Repentance was chosen as the most crucial single outcome variable. One patient had officially requested reversal of sex change and another three were judged as repenting surgery in more indirect ways. Thus for a total of four individuals (30%), sex reassignment was considered retrospectively to be a mistake. Despite their returning to a male social role after surgery, however, two of the repenting patients were judged as fairly well adjusted from a psychosocial point of view.

Marital disharmony four and a half years post partum. Effects on parent-child relationships and child development.

This longitudinal study of primiparous women concerns factors related to the quality of the marital relationship 4 1/2 years after the birth of the first child. Information was independently collected from the women, their husbands and children. A poor relationship to the partner and impaired mental health in the women post partum were associated with marital disharmony at follow-up. In disharmonious marriages more often than in others parents were estimated to have a rejecting attitude towards their child and the child to have a rejecting attitude towards its parents. Further, in these marriages poor parental relationships of boys were more common than those of girls and socially immature boys as compared to socially immature girls overrepresented.

Postnatal emotional balance in women with and without antenatal fear of childbirth.

Women in the later stages of pregnancy were identified as 'suffering' or 'not suffering' from fear of childbirth by means of a special questionnaire. The two samples were interviewed two months after delivery. Women with antenatal fear of childbirth were found to run an increased risk of sustaining severe emotional imbalance postnatally with possible implications on their relationship to the child.

Experience of delivery in women with and without antenatal fear of childbirth.

Late pregnant women with and without fear of childbirth were identified by means of a questionnaire. Their delivery experiences were estimated by means of interviews 3-4 days after parturition. Women with antenatal fear of delivery were found to run an increased risk of having a negative delivery experience and of possibly also finding difficulties in the attachment to their children in the immediate postnatal period.

Identification of women with significant fear of childbirth during late pregnancy.

An unselected, consecutive series of 139 third-trimester pregnant women was investigated concerning 'fear of delivery'. Two methods to identify women with this sentiment were used independently and on the same occasion; i.e. a personal interview and a questionnaire including statements concerning 'fear of childbirth' to be affirmed or denied. The results obtained by the two methods were found to correspond well, i.e. much the same women who had verbally expressed significant fear of delivery during a personal interview were also identified by means of the inventory technique. A questionnaire may therefore replace a personal interview as an instrument to conveniently accumulate a sample of pregnant, 'anxious' women to be further studied with regard to the possible etiology and various expressions of their 'fear of giving birth'.

Sex-role patterns, paternal rearing attitudes and child development in different social classes.

Sex-role patterns, the father's rearing attitude and the child's intellectual and emotional development in different social classes were studied in a randomly selected sample of 58 Swedish unbroken families of a small child. Working class men and women married younger and the women were more often house-wives. Working class men had more often been reared in an "authoritarian" way and more often reared their children in the same way. Upper middle class men had taken a more active part in the care of the child. Working class children scored lower on the intelligence tests, especially the verbal ones and were more often estimated as socially immature.

Mental health of 58 Swedish men living together with their wives and preschool children.

The mental health of the man was studied in a random sample ogf 58 Swedish unbroken families. Men with mental symptoms above an approximate median were compared to men with mental symptoms below the median. Thirteen of the men with mental symptoms were regarded as suffering from clinical psychopathology. Men reporting many mental symptoms more often than the others, had poor contact with their parents and poor mental health during childhood and adolescence, and also their parents' marriage had been disharmonious. Men with mental symptoms above the median more often tended to have a less satisfying relationship to their wives and children. This same group of men usually had low incomes and tended to be dissatisfied with their job and present dwelling. There was no relationship between the man's current mental health and the child's report of its emotional contact with its father in a projective play session. Nor was the number of mental symptoms related to the emotional and intellectual development of the child.

Fear of childbirth in late pregnancy.

A consecutive unselected series of 139 pregnant women were personally interviewed during their 31st--33rd week of gestation concerning their feelings at the prospect of the anticipated delivery. A severe fear of childbirth was admitted by 9 women (6%), and another 23 (17%) expressed a more moderate, but still distinct fear of delivery. Fear of physical pain was not found to be a dominant contributing factor, and an augmented service for obstetrical analgesia will, therefore, not suffice to curtail the problem of fear of childbirth. Instead, fear of childbirth, if present, must be promptly identified and correctly evaluated to be adequately treated.

Father/child relationship: background factors in the father.

This investigation studied by direct interviews in a randomly selected sample of 58 Swedish unbroken families, factors of importance for the father's experience of his preschool child. The father's experience of his child was shown to correlate with the child's experience of him. Fathers experiencing their child in a positive way had been more active in the care of the child, less "authoritarian" and more physically intimate. They described good marital relations. Fathers with a low income or unsatisfied with their job were more negative towards their child than others. There was no association between the father's mental health and his experience of his child. Fathers reporting poor early parental contact were less positive towards their child than others. The man's relation to his own father was more connected with his experience of his child than his relation to his own mother, especially when the child was a boy.