ARTICLE IN PRESS

Social Science & Medicine 58 (2004) 2559–2569

Wellbeing and mental growth—long-term

effects of legal abortion
.
A. Kero, U. Hogberg, A. Lalos*
( Sweden
Department of Clinical Sciences, Obstetrics and Gynecology, University Hospital, SE-901 85 Umea,

Abstract

The present study aims to increase knowledge about coping with legal abortion by studying women’s reasoning,
reactions and emotions over a period of 1 year. The study comprises interviews focusing on the experiences and effects
of abortion in 58 women, 4 and 12 months after the abortion. The women also answered a questionnaire before the
abortion concerning their living conditions, decision-making process and feelings about the pregnancy and the
abortion. Majority of the women did not experience any emotional distress post-abortion and almost all the woman
reported that they had coped well at the 1-year follow-up, although 12 had had severe emotional distress directly post-
abortion. Furthermore, almost all described the abortion as a relief or a form of taking responsibility and more than
half reported only positive experiences such as mental growth and maturity of the abortion process. Those without any
emotional distress post-abortion stated clearly before the abortion that they did not want to give birth since they
prioritised work, studies and/or existing children. The study shows that women generally are able to make the complex
decision to have an abortion without suffering any subsequent regret or negative effects, as ascertained at the 1-year
follow-up.
r 2003 Elsevier Ltd. All rights reserved.

Keywords: Legal abortion; Emotional distress; Sweden

Introduction abortion are performed in the age group of 20–24 years,

The Swedish abortion law of 1975 grants the woman
the right to have an abortion on demand until the end of
the 18th week of pregnancy (The Swedish Ministry of
Health and Social Affairs, 1983). After the 18th week,
abortion may only take place on so-called ‘‘exceptional
grounds’’. In these cases, the National Board of Health
and Welfare makes the final decision as to whether or
not the abortion will be performed. The law was
followed by an expansion in the number of family
planning clinics and the amount of wider access to
information on contraception and sexual relations. The
abortion rate has remained relatively unchanged since
1975 at 17–21 per 1000 women between 15 and 44 years
of ages (Official Statistics of Sweden, 2002). Most
*Corresponding author. Tel.: +46-90-785-2173; fax: +46-
90-77-39-05.
E-mail address: ann.lalos@obstgyn.umu.se (A. Lalos).
followed by the 25–29 years group, 30–34 years and then
teenagers. Contraceptives are easily available and all
abortions in Sweden are carried out in public hospitals.
In spite of differences in study design, there is a strong
consensus, regarding results from international studies
on abortion outcome, that relief is the dominant feeling
in the immediate and short-term aftermath and the
incidence of severe negative responses is low (Osofsky &
Osofsky, 1972; Freeman, 1978; Lazarus, 1985; Adler
et al., 1990; Dagg, 1991; Scotland, 1992; Zolese &
Blacker, 1992). Swedish studies show similar results
(Trost, 1982; Holmgren, 1988). On the other hand, few
studies have investigated the long-term emotional
response post-abortion. One study conducted almost
30 years ago showed that 94% of the women felt
satisfied with their decision to have an abortion and that
negative psychological reactions to abortion were rare
immediately afterwards and at 1–2 years follow-up
(Smith, 1973). Another study found that up to 8 years

0277-9536/$ - see front matter r 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2003.09.004
 ARTICLE IN PRESS
2560 A. Kero et al. / Social Science & Medicine 58 (2004) 2559–2569
following abortion, no negative associations occurred
with regard to self-esteem (Russo & Zierk, 1992).
Furthermore, a recent study from US have shown that
most women do not experience psychological problems
or regret their abortion 2 years post-abortion (Major
et al., 2000). In contrast, a Danish study showed that
16% of the women had psychological problems at a 4-
month follow-up, which they related to circumstances
connected with the abortion, though none regretted the
abortion itself (Schleiss, Mygind, Borre, & Petersson,
1996). Additionally, a Swedish follow-up study showed
that 16% of women experienced emotional distress 1-
.
year post-abortion (Soderberg, .
Janzon, & Sjoberg,
1998). However, in a recent study on women and men
with ambivalent feelings 1-year after abortion, we found
that ambivalent feelings did not necessarily imply that
women and men regretted the abortion or experienced
emotional distress (Kero & Lalos, 2000).
Factors found to predict post-abortion distress reflect
the complexity of the abortion issue. Women most at
risk seem to be those who experienced the pregnancy as
meaningful, who lacked support and/or experienced
ambivalence or coercion during the decision-making
process (Adler, 1975; Trost, 1982; Major, Mueller, &
Hildebrandt, 1985; Turell, Armsworth, & Gaa, 1990;
Adler et al., 1992). Other factors identified are low age,
long-term length of pregnancy, previous psychiatric
history, religiosity and adverse attitude to abortion
(Osofsy & Osofsky, 1972; Adler, 1975; Ashton, 1980;
.
Soderberg et al., 1998). However, most studies elucidat-
ing effects of abortion represent previous periods and
are short-term and retrospective. Furthermore, most
studies classify feelings, in relation to abortion as either
‘‘positive’’ or ‘‘negative’’. Thus, painful feelings, which
are usually defined as negative, are neither confirmed
nor considered as expressions of relevant or valuable
aspects of the abortion situation. This might result in
such feelings not being considered valid or run the risk
of being regarded only as something problematic and
threatening. Therefore, the purpose of the present study
is to increase knowledge about the complexity of coping
with legal abortion by means of prospectively studying
women’s reasoning, reactions and emotions before and 4
and 12 months after legal abortion.
Methods
Sample
The present study was carried out at the University
Hospital of Umea( in the north of Sweden. During a
period of 9 months in 1995, 250 women applying
consecutively for legal abortion were asked to partici-
pate in a questionnaire study. Eighty-eight percent
agreed to participate and the refusal rate of 12% was
due mainly to lack of time and delay at the hospital
.
(Kero, Hogberg, Jacobsson, & Lalos, 2001a). Among
the first 100 women, every third woman and thereafter
every second were likewise consecutively asked if they
would also be willing to participate in a prospective
interview study (a few days after the questionnaire
study, and 4 and 12 months after abortion). Thus, 98
women were asked to participate. In all, 65 women
(66%) agreed to participate in the follow-up study. It
transpired later that four women were either not
pregnant or chose to continue their pregnancies to full
term. These were excluded from the study, which thus
comprised 61 women at the 4-month follow-up and 58
women at the 12-month follow-up. To create the best
possible conditions, the responders were first contacted
in order to set up a suitable time for the interview. The
interviews lasted about 30–40 min and were conducted
over the phone by two experienced medical social
workers of whom one is the first author (A.K.). Thus,
a combination of quantitative and qualitative methods
has been chosen.
Measures
Primarily, a questionnaire was constructed based on
previous research, clinical experience and exploratory
interviews with three women who had had an abortion.
The questionnaire study covered questions about life
conditions, reasons for abortion, the decision-making
process and feelings and attitudes towards the preg-
nancy and abortion. Feelings were elicited by asking
women to select from lists of words the ones describing
their feelings. Emotions other than those listed could
also be added. In addition to recording the frequency
with which each emotion was endorsed, three categories
of respondents were noted: those who expressed only
positive feelings, only painful feelings or both positive
and painful feelings.
Based on the questionnaire, a semi-structured inter-
view was designed focusing on attitudes, feelings and
experiences 4 and 12 months after the abortion. At the
4-month follow-up, the interviews focused not only on
the current situation but also retrospectively on im-
mediate post-abortion reactions. Thus, the study design
made it possible to carry through comprehensive
analyses since each individual woman was followed
during a period of 1 year. Apart from questions with
given response alternatives and a list of words (regarding
feelings), there were a number of open-ended questions
that encouraged the respondents to express themselves
freely and allowed the interviewer to go more deeply
into the issues. The open-ended questions concerned e.g.
post-abortion psychological disturbances, experiences
and attitudes and coping behaviour concerning the
abortion. Overall, the focus in the follow-up interviews
was expressed in questions such as ‘‘What is your
 ARTICLE IN PRESS
A. Kero et al. / Social Science & Medicine 58 (2004) 2559–2569
opinion about your ability to cope with the abortion?
‘‘How do you feel about the abortion today, one year
later?’’ and ‘‘What has the abortion meant to you’’? In
addition, the women were asked if they had any positive
or negative experiences subsequent to the abortion. The
precise procedure when putting questions, which had
given response alternatives, was for the interviewer to
ask the question without mentioning the different
response alternatives and the participant to give her
free answer. To avoid misunderstandings, the inter-
viewer with the participant then chose the most suitable
response alternative.
Analyses
The answers from the open-ended questions were
written down during and in direct connection with each
interview (no tape-recording). In the analysis, the text
was discussed and classified by the research group in
order to reach dialogical intersubjectivity (Kvale, 1996).
Then three subgroups was decided based on women’s
descriptions about their immediate post-abortion reac-
tions: those who did not report any suffering (‘‘Women
without emotional distress’’), those who had had some
emotional distress (‘‘Women with mild/moderate emo-
tional distress’’) and those who reported suffering and
mourning (‘‘Women with severe emotional distress’’).
Thus, the results of the present study emanate from
three sources, the questionnaire in connection with the
abortion and the interviews 4 and 12 months after the
abortion.
Statistical analyses were performed using the statis-
tical package programmes (SPSS) version 10.0. Discrete
variables were compared with the Chi square test (Exact
test, Monte Carlo). A p-value o0.05 was considered as
statistically significant.
The study was approved by the Ethics Committee of
the Medical Faculty of Ume(a University.
Analysis of non-participants
As mentioned previously, the initial refusal rate in the
questionnaire study was 12%. Thereafter, a strategic
sample was asked to participate in a prospective
interview study. Out of these, 98 women (34%) did
not want to participate in this follow-up study.
Statistical tests of comparison were carried out between
women who did (n=58) and those who did not
participate in the follow-up study (n=33). As both
groups had participated in the questionnaire study
before abortion they could be compared concerning a
large number of variables for example age, civil status,
education, personal finances, children, partner relation-
ship, sexual life, contraceptive use and social support.
Furthermore, there were also data on attitudes and
feelings in connection with the pregnancy and the
2561
abortion, the partner’s attitude to the abortion and
experiences of previous abortion/s in all women. The
results from all these comparisons show that there were
no significant differences between these two groups of
women except for a tendency towards a lower educa-
tional level among those who did not participate in the
follow-up study (Fisher’s Exact test, po0.030).
Results
Demographic information
At the time of abortion the women had a mean and
median age of 28 years. The great majority (48/58) had a
partner relationship and more than half (34/58) was
married or cohabiting. The current pregnancy was
found to be the first one for almost half the women
(25/58). However, most of the remaining women had
children and several had three or more (11/28). All
women except two were in the first trimester and about a
fourth (15/58) had had a previous abortion. Further-
more, half the women (29/58) were employed and 18
were students. The rest (11/58) were mainly unemployed
or had parental leave. The majority (41/58) valued their
finances as adequate, while the rest reported that their
income was to low or just met their needs.
At the 1-year follow-up it was found that the majority
(40/58) still had a partner relationship with the man they
had become pregnant with. Seventeen women (17/40)
described their relationship as unchanged in quality, 18
felt it had improved, while five reported that the
abortion had influenced it in a negative way. Four
women had got pregnant again and two had already
given birth and one had had a legal abortion. Half the
women (29/58) reported changes concerning employ-
ment; either they had started to work or worked to a
greater extent than before the abortion.
Reactions and emotions post-abortion
The questionnaire study performed before abortion
showed that most women (37/58) experienced only
painful initial feelings towards the pregnancy, such as
unreal, despair, panic and grief while the rest (21/58)
also had positive feelings, such as wonder and happi-
ness. Furthermore, a third (18/58) reported that they
knew even before getting pregnant that they would
choose to have an abortion if they became pregnant. In
total, 76% of all women stated before termination the
pregnancy that nothing could make them change their
mind. However, when facing abortion almost a third
(17/58) reported only painful feelings such as anxiety,
grief, guilt, emptiness and anguish and of these five also
used the word ‘‘crisis’’ (Table 1).
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2562 A. Kero et al. / Social Science & Medicine 58 (2004) 2559–2569

Table 1
Percentage of women choosing words to express their feelings
facing abortion and feelings related with the abortion 1-year
later

Facing abortion 1-Year after

(n=57)a abortion (n=58)

Responsibility 20 86
Relief 54 72
Release 34 52
Grief 43 31
Injustice 11 24
Guilt 30 22
Emptiness 25 22
Anguishb 23 —
Impatienceb 11 —
Anger 13 14
Regret/doubt 7 14 Fig. 1. Feelings in women facing abortion (n=57; Information
Shame 15 12 missing from one woman. The question was to be omitted by
Powerlessness 5 12 undecided women) and feelings 1 year post-abortion (n=58).
Respectb 4 —
Crisis 9 2
Violationb 2 —
Self-respectb 4 — as ‘‘rather good’’ and one as bad. Fifty-seven percent of
Anxietyb 61 — the women stated that they never or almost never
Maturityc — 76 thought of the abortion, 31% thought of the abortion
Indifference 0 0 some times a month and 12% sometimes a week. More
a
Information missing from one woman. The question was to than half the women (32/58) reported only positive
be omitted by undecided women. experiences such as maturity, deeper self-knowledge,
b
These words occurred only in the questionnaire before strengthened self-esteem and identity of the abortion
abortion. process. Several had become aware of an inner strength
c
This word occurred only in the interview study after they had not realised they possessed. Furthermore,
abortion. maternal feelings, the knowledge that they were fertile
and specific female experiences were mentioned among
the positive effects. Others had become more tolerant of
The follow-up 1-year post-abortion showed that one others, and some mentioned improvement in their
woman regretted the abortion, and one talked about it partner relationship or in contraceptive practice. Those
as a mistake. However, the majority associated it with who had mixed or bad experiences related them to the
feelings of relief or release (43/58) (Table 1). Further- emotional or mental suffering, bad treatment received at
more, 50 women regarded the termination of the the hospital and/or disturbed sexual life.
pregnancy as a form of taking responsibility. However,
two women reported ‘‘some’’ mental disturbances which
they related to the abortion. Although most women Three subgroups of women
experienced the abortion as a relief, half (29/58) also
expressed parallel painful feelings such as grief, empti- Most women (56/58) were satisfied with their decision
ness and guilt (Table 1). When comparing the women’s to have an abortion in the 4-month follow-up and 48
feelings when facing abortion with their feelings related stated that they experienced the abortion as a relief and/
to the abortion at the 1-year follow-up (Fig. 1), it was or a release. Overall, the reactions of the women 4
found that the number who primarily reported only months post-abortion did not differ from the result at
positive feelings had increased from 16% to 47% the 1-year follow-up. However, one woman reported
(po0.05), while the number who reported only painful ‘‘much’’ and three ‘‘some’’ mental disturbances related
feelings had decreased from 30% to 3% (po0.05). to the abortion. At the 4-month follow-up, the women
However, those who had reported both positive and also were asked retrospectively about their immediate
painful feelings remained numerically almost the same post-abortion reactions, and three main subgroups were
(54% and 50%, respectively). found: women without emotional distress (62%),
In spite of contradictory feelings, most women (52/58) women with mild/moderate emotional distress (17%)
at 1-year follow-up considered their ability to cope with and women with severe emotional distress (21%). No
the abortion as ‘‘very good’’ or ‘‘good’’, five described it significant differences were found between these
 ARTICLE IN PRESS
A. Kero et al. / Social Science & Medicine 58 (2004) 2559–2569
subgroups concerning age, educational level, civil status,
personal finances, children and previous abortions.
Women without emotional distress
Almost two-thirds of all women (36/58) reported no
emotional distress neither directly post-abortion nor at
the 4-month or 1-year follow-up. The questionnaire
before abortion revealed that the decision to have an
abortion had been relatively free of conflict for this
subgroup of women. The majority (26/36) had not
experienced any conflict of conscience before the
abortion and only one had expressed any desire to
continue the pregnancy. None had experienced pressure
in the situation when she became pregnant or during the
decision-making process. Furthermore, asked for their
motives for having an abortion, these women stressed
that they did not want to give birth since they either had
enough children or it was not the right time to become a
parent. However, the only woman who had an abortion
due to foetal damage was at the 1-year follow-up
pregnant again.
This subgroup of women considered that the abortion
process was more or less finished when the abortion was
performed and most of them confirmed that the
abortion decision had been taken as a matter of course
and/or was the only alternative. Those who had
experienced difficulties related them to the period before
abortion. Table 2 shows some typical statements
concerning immediate experiences of the abortion given
at the 4-month follow-up. These women frequently
reflected on the fact that they had not experienced
having abortion as very distressing and that they had felt
better than they had expected. They believed, in
accordance with the social context, that they were
expected to experience having abortion as a difficult and
horrible thing. Two wondered if they appeared to be
inhuman, as they had not felt any regret, guilt or grief.
Table 2 also shows typical statements in this subgroup 1
year after the abortion. Although, these women had not
experienced any feelings of distress as a result of the
abortion, nearly a third (11/36) associated the abortion
with such feelings as grief, emptiness and guilt.
Women with mild/moderate emotional distress
In this subgroup of women (10/58), most motives for
having an abortion had to do with external circum-
stances such as the partner or the fact that the pregnancy
had occurred in a problematic relationship. The ques-
tionnaire before abortion also showed that half had had
a conflict of conscience and three stated that their
religion had made the decision more difficult. One
woman had felt pressured to have abortion against her
wish and one had got pregnant in a situation where the
man had pressured her.
2563
At the 4-month follow-up, this subgroup of women
described their feelings directly post-abortion in terms of
sadness, loneliness, shame, guilt and regret (Table 3).
However, none described their reactions as severe or as a
crisis. It was found that the distress was short-lived and
none reported mental disturbances either at the 4- or the
12-month follow-up. Furthermore, nearly all expressed
feelings of relief both 4 and 12 months after abortion (8/
10 and 7/10, respectively) and eight viewed the abortion
as a form of taking responsibility, at both the follow-
ups. None had regretted the decision although all except
two related feelings such as grief, guilt and emptiness
with the abortion 1 year later. Reflections in this
subgroup were connected with ethical considerations
and/or the disappointment of the partner. Table 3 shows
typical statements in this subgroup 1-year post-abortion.
Women with severe emotional distress
In this subgroup (12/58), the decision to have an
abortion had been made with difficulty and entailed
much conflict. For example, three clearly stated that
they wanted to give birth and another five were
ambivalent. Furthermore, nine had experienced having
an abortion as causing a conflict of conscience. Two
stated that their religion had made the decision even
more difficult. It was also found that facing abortion
these women, to a larger extent than the women in the
other subgroups, used words as grief (po0.01), doubt
(po0.01) and crisis (po0.01) and to a lesser extent the
word relief (po0.05). However, concerning the words
anxiety, self-respect, powerlessness, guilt, anger, release,
anguish, responsibility, impatience, shame, emptiness,
injustice and violation no significant differences was
found between the subgroups. In addition, this sub-
group gave explicit reasons why they could not continue
the pregnancy such as the partner’s attitude and lack of
socio-economic resources. In spite of ambivalent feelings
most were settled in their decision to have the abortion,
and all, except two, declared that in the end the decision
to have an abortion was their own.
In the 4-month follow-up, this subgroup described
their reactions directly post-abortion in terms of a
mourning process, a crisis and/or depression (Table 4).
Five had mourned the loss of a child; four related their
reactions mostly to ethical conflicts and three to lack of
support and/or unpleasant treatment at the hospital.
Five had been on sick leave. However, most women
experienced the abortion as a relief (7/12) and/or as an
act of taking responsibility (8/12) 4-month post-abor-
tion. After 1 year, most women were still reconciled to
the abortion although all of them linked painful feelings
such as injustice, grief and emptiness with the abortion.
Ten viewed their abortion as a necessity or a sacrifice. It
was also found that two women had already given birth
 ARTICLE IN PRESS
2564 A. Kero et al. / Social Science & Medicine 58 (2004) 2559–2569

Table 2
Examples of reasons for abortion and typical statements concerning experiences of the abortion process in women without any
emotional distress directly post-abortion (n=36)

Reason for abortion at the time of Statements 4 months later Statements 1 year later
abortion

‘‘yI do not want to have children
now. I am not mature enough either
mentally or practically to have
childreny’’ (Woman no 237)
‘‘yI do not want to have any more
childreny’’ (Woman no 213)
‘‘ythe relationship is too newymy
age I am 35 years oldytogether we
have five children that we must be
able to take care ofy’’ (Woman no
219)
‘‘yneither of us is ready to bring
children into the worldyboth of us
want to have planned children so the
child feels that it is loved and longed
forychildren need love and care
especially in this hard worldy’’
(Woman no 205)
‘‘I live aloneyunsure if I can keep
my job, small incomey’’ (Woman
no 131)
‘‘yknew what I wanted at
onceypleased when it was overyI
did not need to work on it,
everything has gone finey’’
(Woman no 237)
‘‘yit was a very hard 10 days
between the decision and the
procedure ysomething that
surprised meyI became aware of
new sides of myselfyit was useful to
work it throughyit was not difficult
afterwardsyno regretsy’’ (Woman
no 213)
‘‘y it was hard before the abortion,
I thought I had been carelessyI
have worked it through and I have
left the abortion behind mey’’
(Woman no 219)
‘‘yI was relieved when it was
overy I was happy that I had made
the decisiony it would have been
heavy to have an unwanted child, y
it would have been a tremendous
burdeny’’ (Woman no 205)
yit has gone fine, better than I
expectedy’’ (Woman no 131)
‘‘yright decision, I would never
have had the ability to care for the
childyI do not want to have
childreny I was not ready/
matureyit was a brave decision to
an have abortiony’’ (Women no
237)
‘‘yI have not felt any doubt or any
regretsyI know and I believe I can
have children if I should want
toybut I am not the same now as I
was thenyI have changed for the
betteryI did not know I had so
much insidey (Woman no 213)
‘‘ythe best thing I didyno guilt,
no sorrowyam I inhumany?
(Woman no 219)
‘‘y I have not told anyone about
ityabortion is something
sinfulydo not want to stir up bad
bloodyI suppose it sounds
inhuman but I have never
regretted,yvery pleased with the
decisionyI was shocked when I
learned that I was pregnantyI have
to bear it I thought, but it was not
what I felt, wanted or had thought
to do and then I felt sorry for the
childy (Woman, no 205)
‘‘ythe decision is still the right
oneyno relationship with the
manyI have been feeling much
better than I expectedyI felt
strongly that the decision was mine,
not something I did against my own
willy’’ (Woman no 131)

to a child at 1-year follow-up. Table 4 also shows typical
statements from this group 1 year after the abortion.
Discussion
Wellbeing and mental growth
The present study highlights the fact that nearly all
women experienced legal abortion as a relief or as a
form of taking responsibility, not only immediately after
the abortion but also 4 and 12 months post-abortion.
Furthermore, almost two-third had not experienced any
emotional distress post-abortion and described only
positive experiences. Overall, the reactions at the 1-year
follow-up did not differ from the results at the 4-month
follow-up. The study also shows that the majority of the
women viewed the sequels to the abortion as a process of
growth and maturation, which is in agreement with
results of some previous studies (Smith, 1973; Freeman,
1978). Furthermore, the present study establishes that
almost all the women considered their ability to cope
with the abortion as good, although a fifth had
experienced crisis reactions and almost as many reported

A. Kero et al. / Social Science & Medicine 58 (2004) 2559–2569
Table 3
Examples of reasons for abortion and typical statements concerning experiences of the abortion process in women with mild/moderate
emotional distress directly post-abortion (n=10)
Reason for abortion at the time of
abortion
‘‘yI already have three children and
I do not think I could manage one
morey’’ (Women no 39)
‘‘yI have no jobymy partner does
not want to have children nowy’’
(Woman no 197)
‘‘ythe relationship with the father
is not working outy’’ (Woman no
233)
‘‘yhave no time, no moneyyI am
too youngyI want to realise my
dreams firsty’’ (Woman no 181)
‘‘yabove all reasons connected with
my health and then our family
situationy my partner has 4
children and I have 3y sometimes
we have all the children in our
homey’’ (Woman no 161)
ARTICLE IN PRESS
Statements 4 months later
‘‘yat the beginning my thoughts
were often centred on the abortion,
it was hard, painful but not
negativey I still think of it a little, it
is not possible to stop thinking
about it but I do not have any guilt
feelingsy’’ (Women no 39)
‘‘yI have talked about the abortion
sometimes and it has worked quite
welly felt regret now and then y I
think I have been feeling good, I
think I have worked it through
nowy’’ (Woman no 197)
‘‘yit was little difficult the first two
months and I thought about what
would have become of itybut today
it is OKy’’ (Woman no 233)
‘‘ythe difficult thing was to be
alone and abandoned by my
partnery’’ (Woman no 181)
‘‘yfelt I was worthless and
cheapy’’ (Woman no 161)
2565
Statements 1 year later
‘‘ysaw the abortion as the only
possibility, I did not need a long
time to work it throughyI knew
why and everything worked wellyI
got support from my husbandybut
it is a bit of bothyI believe in God
and I was brought up to believe that
to have an abortion is to take the
foetus lifeymaybe this sounds
strangeybut it is not difficult for
me nowyI have worked through
my feelings and I know the causes of
those feelingsy’’ (Woman no 39)
‘‘yI think it was the best thing to
do, otherwise my partner and I
would not have been togetheryI
also did it because I think that a
child must have two parentsythere
was no crisis, little hard the first
monthsy had some sorrows, could
not talk to my partnery if my
partner had wanted the child I
would not have the abortiony’’
(Woman no 197)
‘‘yI think it is unpleasant that I had
to have an abortion but in that
situation and with that father there
was no alternativeystill I can feel a
sadness inside about the fact that I
had to choose abortionysometimes
I think of what it would have
becomeyreally I think abortion
should not be allowedyit is life
ythough it can be the best
alternativey’’ (Woman no 233)
‘‘yI was not certain about who the
father wasya love affair or my
previous partner who had met a new
womany my partner deceived me
and I felt very alone and
abandonedythe decision was for
the bestyI am happy about the
possibility to have abortiony’’
(Woman no 181)
‘‘yI often think that it was good
that there was no childyI do not
think the child would have been
looked after wellyfeel relief about
the decisionyI still think about
what is morally right but I do not
experience any conflicty’’ (Woman
161)

2566 A. Kero et al. / Social Science & Medicine 58 (2004) 2559–2569
Table 4
Examples of reasons for abortion and typical statements concerning experiences of the abortion process in women with severe
emotional distress directly post-abortion (n=12)
Reason for abortion at the time of
abortion
‘‘yI really wanted to give birth to
the child but our finances would not
allow ity’’ (Woman no 101)
‘‘yfinancial and emotional
insecurity, insecure futurey
enormous responsibilityyyou have
to think of the good of the childy’’
(Woman no 235)
‘‘yhave no stable partner
relationship, poor finances yit is
for the good of the childy’’
(Woman no 107)
‘‘yI have two children who are just
leaving the small child stageynow I
want to do thing for myself, educate
myselfy’’ (Woman no 27)
‘‘ya doubtful relationshipytime of
crisisy’’ (Woman no 137)
ARTICLE IN PRESS
Statements 4 months later
‘‘y considered if I did right or
wrongyafraid of sterilityyhave
been alone in all thisya friend is
pregnantyI am reminded all the
timeyI don’t think so much any
morey try to forget ity’’ (Woman
no 101)
‘‘yfelt like a murdereryabortion is
completely wrongyI have been
depressed since the abortion suffered
anguish and sleeping
problemsyisolated myselfy a
week ago I asked the child and God
to forgive me and now I have started
to talk to my partneryit has been
better and this last week I have felt
much bettery’’ (Woman no 235)
‘‘ysuffered very much mentally yI
have been against abortionyhe did
not want me to keep the childy
(Woman no 107)
‘‘ythe first week it was very
hardyI cried and thought a lot of
the childyworked it through and
talked a loty then it has diminished
yI do not think so much about it
nowy’’ (Woman no 27)
‘‘yI got into a crisisyfelt regret,
thought I had made the wrong
decision yworked through the
crisis in therapy for some
monthsynow it is alrightyI am
pregnant in 8–9 weeksy’’ (Woman
no 137)
Statements 1 year later
‘‘yit is not possible to undo it,
could not have done otherwise, have
no anxietyy but I am so afraid of
being pregnant, have no desire for
sex and I get tense because of it
ymy husband does not understand
ityI had maternal feelings when I
understood that I was pregnantyI
try to convince myself ythat I do
not want to have childrenya
defence when you have an abortion
though I did not wanted ity’’
(Woman no 101)
‘‘the abortion has been very
hardyit has been a hard and
painful yearythe decision feels
wrong and I regret itythe first four
months were terrible and I thought I
would never feel good
againythought I acted ethically
wronglyy but I can live with ityI
do not feel ashamed anymore for
having had an abortionyregarded
the abortion as a paradoxygreat
pain, release and reliefy’’ (Woman
no 235)
‘‘ybefore I thought that abortion
was something awfulyI do not
think that todayyI do not feel
ashamed of having had an
abortionyit is good to have
abortion as an alternativeyhave a
new partnerymanaged the abortion
much better than I expectedy’’
(Woman no 107)
‘‘ythe right decision in the situation
I was inymourn the child, got
pregnant againyfelt ashamed of the
new child because of the abortion
ythe pregnancy was not
plannedythought of abortion but I
could not manage to have another
oney it is right to have this
childy’’ (Woman no 27)
‘‘ywhat I did is not possible to
undoybut I will always regret
ityabortion is wrong for meyI am
so much stronger and happier now
since I got a childynow I would
manage her aloney’’ (Woman no
137)
 ARTICLE IN PRESS
A. Kero et al. / Social Science & Medicine 58 (2004) 2559–2569
mild/moderate emotional distress directly post-abortion.
The study also shows that contradictory and painful
feelings in the face of abortion do not imply that the
women per se belong to a risk group for negative
reactions post-abortion.
Several authors (Romans-Clarkson, 1989; Adler et al.,
1990; Turell et al., 1990; Dagg, 1991; Allanson &
Astbury, 1995) have identified numerous methodologi-
cal limitations in post-abortion studies. Biases that arise
from ideological viewpoints or a focusing on negative
outcome, sampling problems, short follow-up, lack of
information about subjects who choose not to partici-
pate and high percentages of dropouts. In the present
study, about one-third of the women did not want to
participate in the follow-up study. This may be
explained by the fact that the procedure put too much
pressure on several women. In an already stressful
situation and after participating in the questionnaire
study, the women were not only asked to decide whether
they would agree to participate in a prospective inter-
view study but also if they would give a questionnaire to
the man involved. However, we have not found any
other study that investigates long-term as well as short-
term outcome of legal abortion combining qualitative
and quantitative methods, which also follows each
individual woman for a period of 1 year. Furthermore,
the present study has both a well-defined population and
a thorough drop-out analysis showing almost no
differences between participants and non-participants
concerning e.g. psychosocial characterisation, current
living conditions, decision-making process and feelings
towards pregnancy and abortion. In addition, the study
has not only focused on the experiences of abortion but
also on reactions towards pregnancy.
The issue of abortion is complicated and multifaceted,
which is also confirmed in this study. Pregnancy and
legal abortion are definitely life events. Although most
women in the present study did not experience abortion
as traumatic, it is important not to trivialise the
termination of a pregnancy. The womens’ response to
abortion are complex. Though they were satisfied with
their decision and had not experienced any emotional
distress post-abortion, nearly half the women connected
the abortion with painful as well as positive feelings at
the 1-year follow-up. In a previous study, we have
shown that ambivalent feelings in relation to abortion
can be regarded as a logical response since incompatible
values and interests often clash in the decision to have an
abortion (Kero & Lalos, 2000). The complexity of the
abortion issue is also reflected in findings from
psychotherapy, which show that feelings of relief post-
abortion do not exclude other feelings such as sorrow
and grief (Lemkau, 1988). However, in the present
study, the number of women experiencing only positive
feelings in the face of abortion had increased at the 1-
year follow up, whilst the number of women experien-
2567
cing only painful feelings had decreased during the same
period. Thus, both our present study and our previously
mentioned study (Kero & Lalos, 2000) show that women
have the capacity to cope with painful and contradictory
feelings and even view the abortion as the start of a
maturing process.
To renounce motherhood
Our findings highlight that abortion can be regarded
as the obvious course of action and/or the only
alternative when the pregnancy is unplanned and/or
unwanted. Before the abortion, a great majority stated
that nothing could change their mind about having an
abortion. Statements in the 4-month follow-up such as
‘‘y I knew what I wanted at oncey ‘‘yI was so sure
about the decisiony‘‘, ‘‘y I was so definite y had no
ambivalencey‘‘ illustrate this. In addition, we have
reported in a previous paper that the whole group of 211
women in the initial questionnaire study before abortion
were deeply committed to their decision although most
also experienced painful feelings in the face of having an
abortion (Kero et al., 2001a). The present study also
indicates that 42% of the women had previously thought
of abortion as a possible solution to an unwanted
pregnancy and 54% had not experienced any conflict of
conscience when facing the abortion. The motives
behind abortion showed that the women did not reject
childbearing or children in general but except a planned
family i.e. having children with the right partner and at
the right time, and they wanted to limit the number of
children. A study in men established similar motives
.
(Kero, Lalos, Hogberg, & Jacobsson, 1999). It was
characteristic of those women who did not experience
any distress post-abortion that they stated from the start
that they did not want to give birth since they gave
priority to other factors such as their work, studies and
already existing children.
Thus, the present study indicates that in a country like
Sweden where women as well as men are expected to be
financially independent, most women assume the right
to renounce motherhood and the right to plan their
families. On the other hand, the study also indicates that
women may find it controversial to admit that they can
experience abortion as a relief. This is illustrated for
example by a statement such as ‘‘am I inhuman in I did
not experience any regret, guilt or grief post-abortion?’’
Obviously, public attitudes towards abortion have an
impact on the expectations and reactions in women who
choose to have an abortion and several studies have
discussed whether women applying for abortion give
‘‘adapted’’ answers about their reactions (Zimmermann,
.
1977; Soderberg et al., 1998). It is therefore of the
utmost importance that studies are set up so as to make
it easier for women to feel free and independent of the
interviewer. Several women in our study confirmed that
 ARTICLE IN PRESS
2568 A. Kero et al. / Social Science & Medicine 58 (2004) 2559–2569
they knew that there are expectations from others/and
‘‘society’’ which made them feel they ought to say in
their answers that they have experienced abortion as a
difficult and horrible act. However, having an abortion
is not a deviant or uncommon act—abortion is legalised
in most developed countries and a common phenomen-
on in all kinds of contexts, e.g., in Sweden (Kero et al.,
2001a).
Conversely, having children and becoming a mother
are highly valued in most societies and womanhood is
strongly associated with motherhood, care and goodness
in most cultural contexts. In addition, abortion is a
controversial issue, which deals with existential ques-
tions about life and death. From these points of view it
might be regarded as offensive and shocking if women
not only renounce motherhood but also experience relief
and wellbeing post-abortion. However, if it is taboo to
highlight and admit that legal abortion can be experi-
enced as a relief without any emotional distress post-
abortion, feelings related not only to abortion but also
to on-going pregnancy will in consequence remain
hidden and private. If this is so, there is a risk that
essential parts of women’s reproductive health and living
conditions will become invisible and impossible to
problematise or improve.
Openness concerning both unwanted pregnancies and
legal abortions is crucial, especially as these life events
are often a woman’s first experience of her reproductive
ability. In one of our previous papers, we have shown
that 43% of the whole group of 211 women in the initial
questionnaire study were pregnant for the very first time
.
(Kero, Hogberg, & Lalos, 2001b). The corresponding
number in the present study was similar. Although,
abortion was regarded as the best solution, about a third
spontaneously described discovering maternal feelings
for the first time and confirmation of fertility and
womanhood were some of the most overwhelming
reactions to the actual pregnancy. Unwanted pregnancy
and abortion are not only life events, but also important
development phases in preparing for a postponed full-
term pregnancy and motherhood. Thus, the impact of
unwanted pregnancy and legal abortion on future
experiences of pregnancy, delivery and parenthood are
important issues for future research.
Emotional distress post-abortion
The present study highlights that reactions post-
abortion cannot be separated from experiences of the
pregnancy and the decision-making process before
abortion. A previous study also showed that distur-
bances post-abortion were more often related to the
unwanted pregnancy than to the termination of that
pregnancy (Trost, 1982). According to immediate post-
abortion reactions in the present study, three main
subgroups were found, almost two-thirds had not
experienced any emotional distress, about a fifth had
had mild/moderate emotional distress and another fifth
had experienced severe emotional distress. Characteristic
of the latter group was that they had severe ambivalent
feelings and made their decision after a lot of conflict,
which are central predictors for post-abortion distress
reported in some previous studies (Major et al., 1985;
Adler et al., 1990; Turell et al., 1990). In the aftermath,
some of these women described that they had mourned
the loss of the child, some had suffered due to ethical
conflicts or because they lacked support and/or because
of unsympathetic treatment at the hospital. It is
important to note that almost all of these women, in
spite of their ambivalent feelings, had been determined
in their decision to have an abortion and had also
declared that the decision in the end was their own.
Those who considered the decision their own were able
to adapt to their reactions and had succeeded in coping
with the abortion at the 4-month follow-up. Concerning,
the two women who were found to have emotional
distress at 1-year follow-up both had been ambivalent
about the decision before abortion. These results show
that decision-making process that precedes abortion is
of decisive importance for reactions post-abortion. This
is also suggested in some earlier studies (Trost, 1982;
Turell et al., 1990; Adler et al., 1992).
Notable is that those reactions and feelings, which
involve pain usually, are interpreted as ‘‘negative’’
consequences in most abortion studies. For example,
women applying for abortion who experience their
pregnancy as meaningful are identified as a group at
risk of having ‘‘negative’’ reactions post-abortion and
are found to cope worse than those who did not have
such an attitude to their pregnancy (Major et al., 1985).
However, women in the present study who had
experienced a mourning process valued it as an
important and appropriate reaction. Obviously, it can
be misleading to indicate painful experiences as negative
one’s and not to consider them as valid within the
context. The present study points out that it is important
not to ignore that emotional distress post-abortion must
be regarded as normal and relevant when a women, for
example, chose abortion although for ethical or other
reasons she would have liked to continue the pregnancy.
Our study indicates that it is important during the
decision-making process to give women the opportunity
to respond to their feelings towards both the actual
pregnancy and the presumptive parenthood. Thus,
women should be encouraged to express grief and
suffering even if they do not regret their decision.
Conclusion
In summary, the pregnancy was found to cause
painful feelings in almost all the women, while the
 ARTICLE IN PRESS
A. Kero et al. / Social Science & Medicine 58 (2004) 2559–2569
abortion at both 4-month and 12-month follow-up was
experienced by almost all as a relief and was regarded as
the best possible solution. Almost two-thirds reported
only positive experiences as sequels of the abortion
process, such as a feeling of wellbeing and mental
growth at the 1-year follow-up. In conclusion, this study
shows that these Swedish women in general are able to
make the complex decision to have an abortion without
suffering any regret or negative effects 1 year later.
Acknowledgements
The authors would like to thank social worker
.
Katarina Bergstrom for professional assistance in
conducting the study. The project was supported by
the Swedish Council for Social Research and the
Swedish National Institute of Public Health and the
Ume(a Medical District, County of V.asterbotten.
References
Adler, N. E. (1975). Emotional responses of women following
therapeutic abortion. American Journal of Orthopsychiatry,
45(3), 446–454.
Adler, N. E., David, H. P., Major, B. N., Roth, S. H., Russo,
N. F., & Wyatt, G. E. (1990). Psychological responses after
abortion. Science, 6(248), 41–44.
Adler, N. E., David, H. P., Major, B. N., Roth, S. H., Russo,
N. F., & Wyatt, G. E. (1992). Psychological factors
in abortion. A review. American Psychologist, 47(10),
1194–1204.
Allanson, S., & Astbury, J. (1995). The abortion decision:
Reasons and ambivalence. Journal of Psychosomatic Ob-
stetrics and Gynecology, 16(3), 123–136.
Ashton, J. R. (1980). The psychosocial outcome of induce
abortion. British Journal of Obstetrics and Gynaecology,
87(12), 1115–1122.
Dagg, P. K. B. (1991). The psychological sequelae of
therapeutic abortion—denied and completed. American
Journal of Psychiatry, 148(5), 578–585.
Freeman, E. (1978). Abortion: Subjective attitudes and feelings.
Family Planning Perspectives, 10(3), 150–155.
Holmgren, K. (1988). Time of decision to undergo a legal
abortion. Gynecologic and Obstetric Investigation, 26(4),
289–295.
.
Kero, A., Hogberg, U., Jacobsson, L., & Lalos, A. (2001a).
Legal abortion: A painful necessity. Social Science &
Medicine, 53(11), 1481–1490.
.
Kero, A., Hogberg, U., & Lalos, A. (2001b). Contraceptive
risk-taking in women and men facing legal abortion. The
European Journal of Contraception and Reproductive Health
Care, 6(4), 205–218.
Kero, A., & Lalos, A. (2000). Ambivalence—a logical response
to legal abortion: A prospective study among women and
men. Journal of Psychosomatic Obstetrics and Gynaecology,
21(2), 81–91.
2569
.
Kero, A., Lalos, A., Hogberg, U., & Jacobsson, L. (1999). The
male partner involved in legal abortion. Human Reproduc-
tion, 14(10), 2669–2675.
Kvale, S. (1996). InterViews. An introduction to qualitative
research interviewing (pp. 59–80). Thousand Oaks: Sage
Publications.
Lazarus, A. (1985). Psychiatric sequelae of legalized elective
first trimester abortion. Journal of Psychosomatic Obstetrics
and Gynaecology, 4, 141–150.
Lemkau, J. P. (1988). Emotional sequelae of abortion.
Implications for clinical practice. Psychology of Women
Quarterly, 12(4), 461–472.
Major, B., Cozzarelli, C., Cooper, M. L., Zubek, J., Richards,
C., Wilhite, M., & Gramzow, R. (2000). Psychological
responses of women after first-trimester abortion. Archives
of General Psychiatry, 57(8), 777–784.
Major, B., Mueller, P., & Hildebrandt, K. (1985). Attributions,
expectations, and coping with abortion. Journal of Person-
ality and Social Psychology, 48(3), 585–599.
Official Statistics of Sweden (2002). Statistics—health and
diseases 2002:8. Abortions 2001. Centre for epidemiology:
The National Board of Health and Welfare, Stockholm.
Osofsky, J. D., & Osofsky, H. J. (1972). The psychological
reactions of patients to legalized abortion. American Journal
of Orthopsychiatry, 42(1), 48–60.
Romans-Clarkson, S. E. (1989). Psychological sequelae of
induced abortion. Australian and New Zealand Journal of
Psychiatry, 23(4), 555–565.
Russo, N. F., & Zierk, K. L. (1992). Abortion, childbearing,
and women’s well-being. Professional Psychology: Research
and Practice, 23(4), 269–280.
Schleiss, L., Mygind, K. A., Borre, R. V., & Petersson, B. H.
(1997). Psychological consequences of induced abortion.
Ugeskrift Laeger, 159(23), 3603–3606.
Scotland, N. (1992). The myth of the abortion trauma syndrom.
JAMA, 268(15), 2078–2079.
Smith, E. M. (1973). A follow-up study of women who request
abortion. American Journal of Orthopsychiatry, 43(4),
574–585.
.
Soderberg, .
H., Janzon, L., & Sjoberg, N. (1998). Emotional
distress following induced abortion. A study of its incidence
and determinants among abortees in Malmo, . Sweden.
European Journal of Obstetrics and Gynecology and Repro-
ductive Biology, 79 (2), 173–178.
The Swedish Ministry of Health and Social Affairs (Eds.)
(1983). Swedish official statistics: Family planning and
abortion. Experiences of a new law. Report from the
Committee on Abortion 1980, Vol. 31 (pp. 433–438).
.
Stockholm: Allm.anna forlaget.
Trost, A.-C. (1982) Abort och psykiska besv.ar (Abortion and
emotional disturbances). Thesis, Uppsala University, V.aster-
a( s International Library (pp. 108–109).
Turell, S. C., Armsworth, M. W., & Gaa, J. P. (1990).
Emotional response to abortion: A critical review of the
literature. Women and Therapy, 9(4), 49–68.
Zimmermann, M. (1977). Passage through abortion: The
personal and social reality of women’s experiences. New
York: Praeger.
Zolese, G., & Blacker, C. V. R. (1992). The psychological
complications of therapeutic abortion. British Journal of
Psychiatry, 160(7), 742–749.