Induced elective abortion and perinatal grief

Today health care professionals provide g rie f interventions fo r individuals experiencing such perinatal loss as miscarriage, stillbirth, and neonatal death Capitulo & M affia, 1985..

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Induced elective abortion and perinatal grief

Williams, G ail B arger, P h D

New York University, 1991

C o p y rig h t © 1 992 b y W illiam s, G ail B a r g e r A ll rig h ts re s e rv e d

U M I

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Sponsoring Committee: Professor Joanne G riffin , Chairman

Professor Ardis Swanson Professor GilbertTrachtm an

INDUCED ELECTIVE ABORTION AND PERINATAL GRIEF

Gail Barger W illiams

S u b m itte d in p a rtia l fu lfillm e n t o f th e re q u ire m e n ts f o r t h e d e g re e o f

D o c to r o f P h ilo s o p h y in t h e School o f E ducation, H e a lth , Nursing an d A rts Professions, N e w Y o r k U n iv ers ity

1991

I am the sole author and proprietor o f said dissertation; th a t the dissertation contains

no m atter which, if published, w ill be libelous or otherwise injurious, or infringe in

a n yw a y the copyright o f any other party; and th a t I w ill defend, indem nify and hold harmless New York University against all suits and proceedings w hich may be brought and against all claims which may be made against New York University by reason o f the publication o f said dissertation

Gajj^Barger W illiams

Dedicated to the late Elmer W Barger

integral to this project.

Dr Ardis Swanson, whose consistent patience and encouragement were essential to me

Dr G ilbert Trachman, whose analytical ab ility was essential to me

Dr Paul W ing, whose statistical consultation and support were invaluable

TABLE OF CONTENTS

ACKNOWLEDGMENTS LIST OF TABLES LIST OF FIGURE CHAPTER

IV REPORT OF THE FINDINGS: ANALYSIS OF THE DATA 49

iii

A uxiliary Findings 76

Discussion o f Findings Related to the Sample 79

VI SUMMARY, CONCLUSIONS, AND SUGGESTIONS

D INSTRUCTIONS FOR COMPLETION OF THE

iv

F DEMOGRAPHIC DATASHEET 107

G SCORING KEY: GRIEF EXPERIENCE INVENTORY (FORM B) 113

I INTERCORRELATIONS OF GEI SCALES WITH THE MMPI 118

J MEAN SCORES GEI FOR SURVIVORS OF DEATH OF CHILD,

V

Elevated A R > 70 and the Total Sample

3 Means and Standard Deviations GEI (Form B)

4 Means and Standard Deviations

fo r Form B (Non-Death Version)

5 T-Scores and Standard Deviations GEI (Form B)

6 T-score Correlation Coefficients o f GEI (Form B)Scales and Time Since A bortion (TSA)

7 Mean T-Scores o f GEI (Form B) by Time Since A bo rtion (TSA)

8 Means, Standard Deviations and t-tests GEI (Form B) Presence o f Living Children at Abortion

9 T-Score Correlation Coefficients o f GEI (Form B) Scales and Weeks Pregnant at A bortion (WPA)

10 Means, Standard Deviations and t-tests Comparison between Miscarriage and No Miscarriage

11 Means, Standard Deviations and t-tests GEI (Form B) Pressure Regarding A bo rtion

12 Means, Standard Deviations and t-tests GEI (Form B) Counseling Following A bortion

1 GEI (Form B) Profile 55

vii

There is a grow ing body of lite ra tu re w h ich documents the phenomenon o f perinatal grief Concentrated efforts to define perinatal grief began in the 1970s, spurred by the research of Kennell, Slyter and Klaus (1970) These studies indicated tha t death of a newborn was indeed a significant loss, accompanied by grief M ore recently Lake, Knuppel, Murphy, and Johnson (1983) depict perinatal grief as sim ilar

to th e typical grief reaction th a t ensues fo llo w in g the death o f a beloved adult

Peppers and Knapp (1980) found th a t perinatal grief occurs despite the length o f gestation Today health care professionals provide g rie f interventions fo r individuals experiencing such perinatal loss as miscarriage, stillbirth, and neonatal death (Capitulo & M affia, 1985) This is in direct contrast to previous decades when perinatal losses were no t recognized as "tru e " losses w ith a legitim ate concom itant grief reaction Prior to the last decade and a half, parents were not encouraged to grieve or were encouraged to deny th e ir feelings when stillbirths or miscarriages occurred

W hen the effects of abortion became o f interest, few if any negative sequelae were documented (Osofsky, Osofsky, & Rajan, 1973) An interesting finding o f an early study was th a t women undergoing first trim ester abortions more often used the words "th e pregnancy" or "a fetus" as compared to the women undergoing second trim ester abortions w h o used the words "this baby" or "a child" (Kaltreider, 1973)

Since the legalization o f abortion in 1973, the number o f abortions perform ed annually has steadily increased Current statistics (U.S Bureau o f the Census, 1990)

indicate th a t there were over a m illio n and a h a lf legal abortions performed in 1985

Ninety percent o f these abortions are perform ed in the first trim ester o f pregnancy

The abortion rate (number o f abortions per 1,000 women 15-44 years old) has m ore than doubled in the last decade, increasing from 13.2 in 1972 to 28.0 in 1985 (U.S

Bureau o f the Census, 1990) Despite this increase, there have been fe w empirical studies undertaken to determ ine the presence o f psychological sequelae

Is there a difference in the intensity o f perinatal grief experienced by wom en

w h o have undergone induced elective abortion w h o have living children and those

w h o do n o t have living children?

D efinitions

G rief A de finite syndrome w ith psychological and somatic symptoms fo llo w in g death

o r loss This grief is a normal reaction to a distressing situation and is accompanied by somatic distress, such as deep sighing respirations, lack of muscular strength, loss o f appetite and sense o f taste.tightness in the throa t, and a choking sensation accompanied by shortness o f breath The syndrome also includes preoccupation w ith

an image o f the deceased, gu ilt, hostile reactions, and loss o f usual patterns o f conduct (Li ndemann, 1944)

Induced Elective A bo rtio n The expulsion o f the products o f conception before

tw e n ty weeks gestation or before the fetus has reached a stage o f via b ility by medical

Intensity o f Perinatal G rief The extrem e in degree or strength to which th e symptoms

o f g rie f in relation t o a perinatal loss are felt The intensity o f perinatal g rie f in relation to the abortion experience was measured by elevated T-scores > 50 on the scales o f the Grief Experience Inventory (GEI) (Form B) (Sanders, Mauger and Strong,1985)

Perinatal The tim e before and after birth, defined as beginning w ith conception and extending through the 28th day o f newborn life (Reeder,Mastroianni, & M artin,1983)

Perinatal G rief The g rie f described by Lindemann (1944) and experienced in a specific context, fo llo w in g the death or loss th a t occurs during the perinatal period In this study perinatal g rie f was measured by scores on the several scales o f the GEI (Form B)

w hich represent th e m ultidim ensional aspects o f grief

Time Since A b o rtio n The am ount of tim e in years th a t has elapsed since th e abortion

as reported by the wom en

Theoretical Rationale

G rief is a normal response to death which is a universal experience th a t is repeatedly encountered W hen th e loss is the death o f a loved one, it threatens the individual w ith a negation o f self and a ll th a t is valued (Rando, 1984) The United States is said to be a death-denying culture where there is widespread refusal to confront death and consequently fe w e r rituals fo r recognizing it All to o often, the dying are sent to in stitu tion s to die (Rando, 1984; Kubler-Ross, 1975) There is little or

no open acknow ledgm ent o f death or com munication regarding it Very ofte n

society places unrealistic expectations on individuals about g rie f; g rie f is openly discouraged and grievers are to ld to "be brave" (Rando, 1984).

This death-denying attitud e persists despite the w ork o f Lindemann (1944) which conceptualized the human experience o f th e g rie f process Lindemann's (1944) conceptual fram ew ork o f grief and the basic tasks of the g rie f process are valid today

This conceptualization o f grief and grief work has been u tilized by many investigators (Parkes & Weiss, 1983; W ordon, 1982)inan a tte m p t to describe diffe re nt types o f losses and grief reactions Lindemann (1944) firs t described th e acute g rie f reaction

th a t occurs in response to a distressing situation and described a definitive syndrome

w ith psychological and somatic symptomatology Five distinct characteristics o f g rie f were noted to be common to all individuals

Lindemann (1944) identified three stages o f the grief process The firs t stage was considered one o f shock and disbelief, w hich is recognizable by the inab ility to accept the loss or on occasion denial tha t the loss has occurred The second stage is the period o f acute mourning, characterized by acceptance o f the loss, disinterest in daily affairs, crying, feelings o f loneliness, insomnia, and loss o f appetite There is also

an intense preoccupation w ith the image o f the deceased The third stage or resolution o f the grief process occurs as there is a gradual reentry in to the activities o f daily life and a reduction in preoccupation w ith th e image o f th e deceased

Interest in the g rie f reaction to perinatal loss was stimulated by the research o f Kennell,Slyter, and Klaus (1970) w h o modeled th e ir research after th e typical grief reaction described by Lindemann (1944) They found th a t parents experienced grief follow ing the death o f a newborn Peppers and Knapp (1980) found th a t a grief response occurs w ith stillbirths and miscarriages also Their rep ort indicated th a t the perinatal g rie f experience is sim ilar to the grief experienced fo llo w in g the death o f a

bereaved has shared a long-term relationship.

W hile it is acknowledged th a t perinatal grief is sim ilar to that w hich follow s the death of an adult, there is also some indication tha t perinatal grief m ig ht be unique

According to Furman, (1976) the g rie f follo w in g the loss o f a child involves not only dealing w ith the actual loss, but also dealing w ith th e loss o f parts o f oneself because parental love consists o f love for the child as w ell as self love

Peretz (1970) described categories o f loss Loss o f some aspect o f self was conceptualized as a loss th a t related to fantasies and expectations of w h a t a specific role m ight have been Furman (1978) postulated th a t perinatal grief encompasses

tw o distinct tasks or processes: identification and detachm ent Resolution o f parental

g rie f is facilitated when the parents have an op portunity to id en tify w ith th e ir newborn in some meaningful way The identification w ith th e child facilitates detachment or le ttin g go Viewed in this lig h t, perinatal g rie f can be arduous since there is lim ited tim e or opportunity fo r identification Furman (1978) likens perinatal loss to an am putation and advocates providing parents w ith some memory to facilitate grieving Rando (1986) suggests th a t society's reluctance to recognize perinatal loss and the concomitant grief w o rk is related to the uniqueness o f this g rie f

w ork

Kirkley-Best (1981) found th a t both intrauterine and intrapartum deaths are accompanied by a g rie f response and that many of these were follow ed by chronic grief Lakeetal (1983) reported evidence o f a pathologic g rie f reaction in some instances o f perinatal loss which they indicated was related to the lack o f emotional

support fo r the grieving parents Perinatal losses seem to be surrounded by w h a t has been term ed a "conspiracy o f silence" (Johnson-Sodenberg, 1981) Estok and Lehman (1983), in a fo llo w -u p study o f grieving parents, corroborated th a t parents found

"va lid atio n o f the loss" most helpful in th e ir g rief W hile the acute phase o f g rie f as described by Lindemann (1944) may last only weeks or months, true resolution o f perinatal loss may last months o r years (Wong, 1980) It seems typical th a t the period

o f maternal g rie f extends beyond the tim e afforded by society for support W all- Haas, (1985) reported th a t wom en w h o had first trim ester spontaneous abortions experienced grief These wom en cited lack o f support and understanding by significant others as th e ir major problem in the resolution o f grief

The lite rature (Furman, 1978; Peppers 8t Knapp, 1980; Kirkley-Best, 1981;

W ong, 1980; Johnson-Sodenberg, 1981; Estok and Lehman, 1983; La kee ta l., 1983;

Miles and Crandall, 1983; Kellner, Donnelly & Gould, 1984; Wall-Haas, 1985) documents th a t perinatal grief is experienced fo llo w in g perinatal loss Perinatal g rie f

is present regardless o f actual iength o f gestation, i.e.: spontaneous abortion, miscarriage, stillb irth , or neonatal death This phenomenon o f perinatal grief seems consistent w ith attachm ent theory A ttachm ent has been described as a

developmental process which changes over tim e (Mercer, 1981) A ccord in gto Kirkley-Best (1981) the tasks o f attachm ent may vary according to the trim ester o f pregnancy w ith attachm ent during the first trim ester representing bonding to the pregnancy W hile attachm ent begins in utero, i t may be unrelated to w a n tin g pregnancy (Tanner, 1971; K en ne ll.eta l., 1970) Cranley (1981) suggested th a ta degree o f attachm ent exists early in gestation, and th a t this attachm ent is heightened

as th e pregnancy progresses and takes on new dimensions, as w ith the actual confirm ation o f pregnancy and occurrence o f fe ta l movements The fantasies wom en

were suffering from depression as a result o f unresolved grief Viewed in this context induced elective abortion can be tho ugh t o f as having a d e fin ite po tentia l fo r perinatal grief Recently, Rando (1986) described loss in relation t o induced elective

a b ortio n in terms o f being deprived of a valued object or person

According to Lindemann's(1944) description, acute g rie f entails grieving no t only fo r the actual individual w ho is lost, bu t fo r the hopes, dreams, fantasies, and

u n fu lfille d expectations th a t the griever held fo r the lost relationship Subsequently, the griever must no t only identify w h at is being lost in the present, bu t w h a t has been lost in th e future In much the same way, the pregnant wom an, fro m th e m om ent

th a t she is aware o f the pregnancy, starts to develop feel ings regardi ng the pregnancy and the fu tu re child and to have many dreams and expectations fo r th e relationship (Rando, 1984)

Three additional studies (Katz, 1983; Rando, 1983; Redlener, 1985) explored the g rie f response related to loss o f a child using the GEI Rando (1983) found in a study o f 54 parents th a t grieving actually intensified in the th ird year o f bereavement

Katz (1983) studied 40 volunteer parents w h o had lost a child suddenly; they reported

a trend o f increased intensified grief Redlener (1985) investigated variables th a t

m ediate the long-term outcome o f bereavement Redlener reported th a t correlations between tim e since last death and GEI scale variables revealed a trend tow a rd dim inishm ent o f g rie f levels w ith the passage o f time

Rando (1986), in a review o f abortion literature, reported th a t g rie f appears as

th e individual becomes more fully aware th a t the loss has occurred and th a t tim e may vary considerably

Theobold (1985) hypothesized th a t w om en who had previously delivered a viable baby w o uld perceive the abortion experience more negatively than wom en

w h o had n o t delivered a viable baby This was n o t supported However, Rando (1986) reported tha t grief reartions have been noted at the anniversary o f the expected date o f confinement, w ith subsequent pregnancies, or w ith subsequent spontaneous abortions and in fe rtility problems Consequently, th e presence o f other living children prior to or fo llo w in g the abortion may be related to the g rie f experience

d e fin itio n o f perinatal grief has been expanded (Peppers & Knapp, 1980) to encompass various types o f losses including death o f a newborn, stillbirth, miscarriage, and spontaneous abortion To date, there has been little investigation to determ ine w hether perinatal grief reaction follow s an elective abortion

Perhaps the lack of investigation mirrors th e lack o f recognition and validation

th a t society once afforded other types o f perinatal losses Raphael (1980) cites th a t

fo llo w in g induced elective abortion, society usually gives the wom an the covert message th a t she should be relieved rather than sad Frequently the procedure is

It has been w ell documented that grieving follow ing spontaneous ab ortio n is com mon (Stack, 1984) In order fo r women to engage in th e process o f grieving

fo llo w in g such loss, the loss must be acknowledged by self and others Corney and Horton (1974) noted th a t symptoms of pathologic grief have occurred in some

w om en fo llo w in g spontaneous abortion whether or not th e pregnancy was planned

Intensity o f g rie f over tim e has been studied using th e GEI (Katz, 1983; Rando, 1980,1983; Redlener, 1985) Although these three studies representthe first th a t have begun to study loss o f a child in a more systematic fashion, u tilizin g a standardized measure o f g rie f w ith reported reliability and validity, the resultsare contradictory W hile Katz (1983) and Rando (1980,1983) found th a t g rie f intensified

in th e th ird and fo u rth year fo llo w in g loss o f a child; Relener (1985) found th a t g rie f intensity diminished w ith the passage of time

A t present nursing is actively involved in the provision o f nursing care t o individuals experiencing induced elective abortions in settings such as hospitals and

ab ortio n clinics In order to provide holistic care, nursing needs an adequate

d e fin itio n o f the needs o f this specific population Nursing research endeavors are

w arranted t o establish whether a grief reaction is experienced by this group Only i f a perinatal g rie f response is id entified can nursing begin to address appropriate interventions such as providing permission fo r these individuals to grieve thereby

fa c ilita tin g th e ir grief w o rk and preventing pathologic sequelae

It is now estimated th a t approximately 1.5 m illion abortions are conducted annually in the United States (Peppers, 1987-1988) The research, to date, indicates

th a t a small, unspecified percentage o f these wom en suffer negative em otional consequences (Lodi, McGettigan &8ucy, 1985) The exact nature and extent o f this

g rie f reaction is unknown It has been emphasized th a t some wom en may be unaware th a t emotional feelings are legitim ate fo llo w in g abortion If they are aware

o f the feelings they may be reluctant to express them since th e ir loss is a socially unacceptable one (Rando, 1986) Consequently, the num ber o f wom en experiencing negative sequelae may be underreported More data are needed regarding the factors th a t m itigate the grief response for these wom en In addition, studies th a t

u tiliz e a measure of g rie f w ith reported reliab ility and v a lid ity and study g rie f intensity over tim e are warranted

w ith a reported history of perinatal loss (miscarriage) in th e last five years completed

th e GEI (Form B) and the Demographic Data Sheet Their mean GEI (Form B) scores were compared to the mean scores of those women (n = 73) w ith o u t a reported history o f perinatal loss in the last five years No statistically significant differences

w ere found on any o f the GEI (Form B) scales so a decision was made to include them (n = 10) in the overall data analysis

3 This investigation was lim ited to wom en w h o w ere able to read, w rite and comprehend English

1986).

CHAPTER I!

REVIEW OF THE LITERATURE

G riefGrief has been defined as psychological, social, and somatic reactions to th e perception o f loss Grief is a normal reaction to loss and a universal experience w h ich

is repeatedly encountered (Rando, 1984) Lindemann (1944) developed a conceptualization o f grief and the essential tasks o f this process In his landm ark study o f the tragedy o f the Coconut Grove Fire in Boston in 1944, Lindemann described acute g rie f as a normal reaction to a distressing situation One hundred and one survivors o f relatives w ho died in the fire were interviewed These observations and clear descriptions o f acute g rie f were widely recognized as an account o f the norm al g rie f process Results o f psychiatric interviews w ith these clients revealed a clinical picture w hich was similar fo r all individuals suffering from acute grief Five

d is tin c t characteristics were noted: somatic distress, preoccupation w ith the im age o f

th e deceased, g u ilt, hostile reactions, and loss o f patterns of conduct The sensations

o f somatic distress were described as occurring in waves lasting from tw e n ty minutes

to an hour Individuals suffering from acute grief experienced a feeling o f tightness

in the th ro a t, choking w ith shortness of breath and a need fo r sighing These individuals also experienced an em pty feeling in the stomach, lack o f muscular pow er, and an intense subjective distress described as mental pain or tension There seemed

to be an awareness on the part o f individuals experiencing these symptoms th a t the y were precipitated and/or exacerbated by mention o f the deceased, or condolence calls and expressions of sympathy It was noted th a t individuals avoided these reminders in order to avoid the distressing symptomatology They also described an

altered sensorium w ith a slight sense o f unreality They were described as having an increased em otional distance from others w hile experiencing an intense

preoccupation w ith an image o f the deceased Many experienced a strong preoccupation w ith feelings o f guilt They seemed to relive th e tim e p rio r to the death o r loss in search o f a failure to do the rig ht th in g in relation to the dead individual These individuals also experienced w h a t was called a loss o f w a rm th in relationships to oth e r people They were described as having a tendency toward anger o r hostility tow ard well-intentioned members o f fam ily and friends And finally, the acutely grieved exhibited changes in th e ir pattern o f daily conduct They exhibited restlessness, an inab ility to remain still They seemed to be in a state of constant m otion, as in searching for something to do Even ordinary, routine tasks were approached w ith great difficulty

Lindemann's (1944) study was the first published systematic investigation o f bereaved individuals This study is the first attem pt to classify signs and symptoms o f typical g rie f responses based on empirical evidence Resolution o f g rie f was reported

to be dependent on how w ell th e individual accomplished his or her g rie f w ork This

g rie f w o rk is described as the achievement o f emancipation from bondage to the deceased and readjustm ent to the environment from which the deceased is absent

Finally, the individual begins to form new relationships W hat Lindemann observed is

th a t many individuals experience d ifficu lty in the resolution o f g rie f w o rk because they attem p t to avoid "the intense distress connected w ith the g rie f experience and

to avoid the expression of em otion necessary for it " (Lindemann, 1944, p 143)

Lindemann stressed tha t grief was not a medical or psychiatric disorder, but rather a normal reaction to a distressing event Failure to achieve g rie f resolution was

th o u g h t to predispose one to mental illness Finally, it was reported th a t normal g rie f

may appear im m ediately fo llo w in g the loss, o r be delayed, exaggerated o r even absent.

In 1958, Marris conducted a retrospective study o f young East London widows

w h o had lost th e ir husbands w ith in the last tw o years This study focused exclusively

on loss o f a spouse His findings indicated th a t although the m ajority o f the respondents had been w idow s fo r approximately tw o years, they fe lt th a t they had

n o t yet recovered from the loss Their lives were described as em pty and futile The study indicated th a t the widow s had w ith dra w n from social ties and had experienced frequent symptoms o f insomnia and w e igh t loss Marris concluded th a t grief resolution m ig ht require tw o or more years as opposed to the several weeks reported

by Lindemann The findings w ere based on interviews, and no inquiry was made to the duration o f these reactions

Parkes (1965), expanded upon Lindemann's concept o f grief He studied the reacti ons and feel ings o f widows fo r over 12 years He matched 22 bereaved psychiatric patients to the w idow s in Marris' (1958) study He reported typical, uncomplicated g rie f confirm ing the earlier findings o f Lindemann (1944) Following this study, he (Parkes, 1971) conducted a study in w hich he examined the longitudinal effects o f grief on 22 widows in th e London area This study revealed im p ortan t inform ation regarding the process o f g rie f and the changes th a t occur ove rtim e

w hich corroborated the belief th a t grief was a phasic process w ith no clear demarcation fro m one phase to th e next

In 1974, Glick, Weiss and Parkes studied bereaved widow s and widowers using

m ore stringent controls Structured interviews were conducted w ith 68 individuals under the age o f 45 over a tw o to fou r year period at five d iffe re n t intervals An

im p ortan t find in g was the length o f tim e involved in the grieving process which

indicated th a t the duration o f g rie f should be measured in years rather th a n weeks o r

m onths Most im portant was the fin d in g th a t some individuals never recover from

th e loss A lim itation o f th e ir findings was th a t th e ir sample centered on th e lower end o f the socioeconomic spectrum and lim its generalizability to oth er socioeconomic groups

This data was reanalyzed (Parkes, 1975) in order to determ ine w h a t variables

m ig h t correlate most highly w ith negative reactions one year a fte r the loss The principal conclusions from this study are th a t if intense grief, anger, or self-reproach expressed shortly after the loss does no t decline in intensity w ith in six weeks, a poor outcom e is predicted a year later In addition, lo w socioeconomic status, lack o f preparation fo r the loss, a sudden or unexpected loss, the num ber and intensity o f life crises experienced before the loss, were predictors o f poor outcome

The consensus among investigators o f g rie f (Lindemann, 1944; Marris, 1958;

Parkes, 1965; 1971; G licketal., 1974) is th a t there is a d e fin ite observable g rie f response fo llo w in g the death of a beloved adult The actual le ng th o f the g rie f in term s o f resolution has been redefined as years rather than weeks

Perinatal GriefInterest in the presence of a g rie f response associated w ith loss o f a child was

an extension o f the adult grief/bereavement literature In 1970, Kennell, Slyter, and Klaus studied the grief response o f 20 mothers w h o had experienced the death o f an

in fa n t ranging in age from an hour to 12 days Their study revealed no significant differences in grief indexes such as sadness, increased irrita b ility , and preoccupation

w ith the deceased related to the age o f the child Peppers and Knapp (1980) interview ed 100 bereaved mothers w h o had experienced neonatal, s tillb irth and fetal losses Using a m odified version o f The M ourning Score developed by Kennell, Slyter,

and Klaus (1970), they found no significant differences among the g rie f scores fo r the three types o f perinatal losses.

Study o f perinatal grief in the last decade and a ha lf is an extension o f the existing g rie f lite rature w ith regard to death o f a child Sanders (1977; 1979-1980) studied the differences in grief reaction among 102 newly-bereaved parents and compared them to 107 controls She developed th e G rief Experience Inventory (GEI)

to measure experiences, feelings, and behavior du ring the g rie f period The highest

g rie f intensities were found among the bereaved parents w h o revealed more somatic complaints, greater depression, anger, g u ilt and despair, than those w h o had sustained loss o f either a parent or spouse This is consistent w ith th e w o rk o f Arnold and Gemma (1983) and Hagan (1974) which id e n tifie d g rie f reactions o f parents

fo llo w in g the loss o f an in fa nt from sudden in fa n t death syndrome A conclusion o f

th e ir studies was th a t parents may never truly resolve th e ir g rie f fo llo w in g the death

o f an infant

A bortion SequelaeThe lite rature on abortion and abortion sequelae is a t best contradictory In general, induced elective abortion has no t been considered to be a cause fo r grief

Prior to the legalization of abortion in 1973, the m ajority of studies focused on the medical effects o f abortion In 1973, Osofsky, Osofsky, and Rajan reviewed the literature w ith regard to studies done fo llo w in g legalization They concluded th a t there was little evidence to conclude th a t abortion was associated w ith negative psychological sequelae They reported th a t w h ile the m in o rity o f wom en did experience some feelings o f sadness, gu ilt, and depression initially, these symptoms subsided w ith in a few months

In 1981, Doane and Quigley published a m ajor review o f the ab ortio n literature published since 1970 They concluded th a t approximately 5% o f patients reported feeling worse several months after th e ir abortion The most commonly reported symptoms, accounting for 57% o f adverse effects, were depression w ith o r w ith o u t grief, g u ilt, and crying They also indicated tha t when data was gathered a year or more fo llo w in g the abortions, almost no such symptoms were reported They concluded th a t w h ile the proportion o f clients w h o experience adverse psychological effects was small, abortion nonetheless can have the potential fo r more intense consequences depending upon the individual woman.

Raphael (1983) indicated th a t w h ile the proportion o f wom en suffering adverse effects o f abortion is small, there may be a problem w ith id e n tifica tio n o f this select population She suggested th a t some women may employ denial in order to undergo abortion and this denial may persist In the post-abortion period These women may mask th e ir em otional responses in later follow-up This a u th o r contends

th a t fo r some wom en re lie f and sadness coexist follow ing abortion

Rando (1986) suggests th a t some individuals may be more at risk fo r em otional sequelae A woman w ith a previous history of emotional illness or one w h o had been coerced or pressured into undergoing an abortion w ould be a t a higher risk fo r adverse emotional reactions

Gilver (1987) explored the psychosocial adaptation o f 16 college wom en in response to unplanned pregnancy and abortion The women w ere interview ed prior

to the abortion, 2 weeks fo llo w in g the abortion, and again at 3 to 6 m onths post abortion Half o f the w om en (8) were reported to experience continued thoughts and feelings related t o the pregnancy Four of the eight women were observed to have a marked decline in fu n ctio n follow ing the abortion

Speckhard (1985) interviewed 30 women who were perceived to vie w th e ir abortion as stressful Immediate and long-term responses included feelings o f grief, depression, anger, g u ilt, fear, surprise, preoccupation w ith image o f the aborted child, lowered self-w orth, victim ization, inability to express feelings, and discom fort

w ith small children and pregnant women They reported frequent crying, in a b ility to

ta lk regarding the experience, flashbacks, suicidal ideation, and increased alcohol use

Seventy-three percent o f the w om en demonstrated suppression o f affect as a coping mechanism fo llo w in g abortion Speckhard (1985) reported th a t fo r many wom en the stress o f abortion was relieved only after they found social systems th a t perm itted them to express feelings concerning the abortion experience The generalizability o f these findings is lim ited since the subjects were selected on the basis o f th e ir perceptions o f abortion as a stressful experience

Despite the num ber of publications regarding abortion only one has reported

g rie f response afte r abortion Peppers (1987-1988) studied 80 volunteers fo llo w in g abortion The participants were given a three-part perinatal grief questionnaire (The

M ourning Score, Kennell, Slyter, & Klaus, 1980) just prior to the procedure and then six weeks fo llo w in g the procedure The author concluded th a t the data suggest there

is a g rie f response subsequent to elective abortion The mean postprocedure grief response scores (35.45) were lo w er as compared to the preprocedure scores (60.98)

Peppers concluded th a t the g rie f is resolved rapidly There was a w ide variatio n in overall g rie f scores, w hich seems to indicate th a t some women suffer tremendous

em otional trauma The author also reported th a t the longer the pregnancy continued, the more em otionally traumatic the term ination, and the m ore d iffic u lt the g rie f resolution The grief scores of abortion clients were compared to g rie f scores o f wom en w h o had experienced involuntary fetal or in fa nt loss The data

suggested th a t the response to abortion loss was sim ilar to th a t experienced w ith miscarriage, s tillb irth , and neonatal loss Even though m ethodological lim itations prevented statistical analysis of some o f the data, the prelim inary results le nt support

t o the hypothesis o f this present study; th a t there is a d e fin ite g rie f response

fo llo w in g induced elective abortion

As Lodi e ta l (1985) point out, disagreement in the lite ra tu re still exists as to

w hether women's lives are disrupted by induced abortion The lack o f data in this area appears to be because of a reluctance to bring atten tion to any negative consequences o f abortion for fear o f being seen as providing support to the anti­

a b ortio n/pro -life groups Despite the controversy regarding abortio n, there is a need

t o determ ine w hether a perinatal g rie f response does exist

CHAPTER III METHODThis chapter describes the m ethod o f the i nvestigation The sample, the instruments, data collection procedure, and analysis o f the data are discussed.

The SampleThe sample fo r this descriptive study consisted o f 83 volunteer w om en w ith a self-reported history o f one induced elective abortion Women who m et th e study

de lim itations were contacted by th e ir prim ary health care provider and asked to participate by com pleting the materials in the research packet provided by the investigator Sites were selected in various states in order to include w om en from a variety o f settings and backgrounds In order to meet the delim itations o f th e study, wom en w e re included w ho had experienced on ly one induced elective abortion O nly wom en w ith no self-reported history o f perinatal losses w ith in the last five years and those w ith no documented psychiatric history were recruited fo r the study In addition, only wom en w ho were able to read, w rite , and comprehend English were included

A n im p ortan t determ ination o f sample size is consideration of how the resulting data w ill be analyzed In the present study descriptive statistics are utilized

It is generally recommended th a t a sample size o f at least 10, and preferably 20 to 30

be selected fo r each subdivision o f the data (P olit and Hungler, 1983) Castles(1987) recommends 30 subjects fo r each relationship analyzed The main study hypothesis was tested by exam ination o f the meanT-scores o f all the scales o f the GEI (Form B) A variety o f descriptive statistics were utilized to describe the findings The study questions as w ell as ancillary findings utilized correlational statistics and t-tests o f significance When using inferential statistics, a minim um o f 64 is appropriate fo r a

t-test (2 tail) between tw o samples w ith the level o f significance set at 05 and a medium effect size (W itte, 1980; Cohen, 1977, Tabachnick & Fidell, 1983).

A to ta l of 84 women responded utilizing the research packet The data from one wom an had t o be excluded since she reported th a t she completed th e GEI (Form B) as she remembered she had fe lt 20 years ago and no t a t the present tim e O f the 83 usable responses, 10 wom en who responded had a history o f miscarriage Therefore, the data was analyzed utilizin g the to ta l sample (n = 83), and w ith those w h o met all the delim itations (no history o f miscarriage) (n = 73), and w ith those w h o had a history of miscarriage (n = 10) The groups were similar and a decision w asm adeto include all th e sample (n = 83) in data analysis

In order to meet the delim itations o f the study, the study sample was lim ited to wom en w h o had undergone only one induced elective abortion in order to control

fo r possible effects of g rie f from oth er abortions All w om en were screened fo r their

ab ility to read, w rite, and comprehend English Women w ith a documented history o f treatm ent fo r mental illness such as schizophrenia were n o t included since it has been reported th a t psychological sequelae to abortion m ig ht be the result o f pre-existing psychiatric problems (Rado, 1986) Women were screened fo r a history o f perinatal losses w ith in the last five years Demographic data was collected regarding age,

m arital status, occupation, ethnicity, socioeconomic status, educational level, religious a ffilia tio n and participation, length o f pregnancy at tim e o f ab ortio n, time since abortion, and presence of living children Data regarding history o f oth er losses

w ith in the last five years was also collected as a check fo r g rie f in relation to other significant losses

Demoaraohic Characteristics

The sample consisted o f a to ta l o f 83 wom en w ith a self-reported history o f one induced elective abortion Demographic characteristics appear in Table 1 These wom en had a mean age of 31.9 years w ith a range o f 19-50 years of age W hile approximately 69% (n = 57) were single at the tim e o f abortion, only 15% (n = 13)

w ere single a t the time the study was conducted Approxim ately 98% o f the women (n = 81) were w h ite and 2% were black (n = 2) The m ajority o f the wom en (78.4%;

n = 65) reported some college or an undergraduate degree Only one respondent (n

= 1) had less than an eighth grade education The women reported a w ide variety o f occupations w ith slightly more than h a lf o f the sample (55.4%; n = 46) presently employed at the tim e o f the study Approxim ately fifty percent (50.6%; n = 42) o f

th e fathers o f the aborted pregnancies also had some college preparation o r held an undergraduate degree The occupations o f the fathers varied The m ajority o f the wom en (47.0%; n = 39) were Christian (non-Catholic), w hile 41.0% (n = 34) were Protestant The m ajority o f the wom en (72.3%; n = 60) reported the frequency o f attendance a t religious services to be weekly Approxim ately one fou rth (25.9%; n = 21) o f the women reported a present annual household income o f $50,000 o r greater

Over half of the wom en (58.5%; n = 48) reported th e ir husbands as the m ajor wage earner Approxim ately half o f the wom en (49.4%; n = 41) reported that the y were living w ith the ir husbands and children at present

Sixty-four percent (n = 53) o f th e sample reported having living children a t the tim e o f the study, w ith 34.9% (n = 29) having no living children The actual number

o f living children from the sample ranged from 1 to 9 w ith a mean o f

2 children The m ajority (85.5%; n = 71) o f the w om en did n o t have any liv in g children at the tim e o f abortion.

The years during which the women reported having th e ir abortions ranged from 1964 to 1990 The total sample (n = 83) remembered the year o f the abortion;

91.6% (n = 76) remembered th e month; 51.8% (n = 43) remembered the day

The women reported a mean o f 8.7 weeks pregnant at tim e o f abortion w ith a range o f 1 to 20 weeks The mean months were reported as 2.47 w ith a range o f 1 to

5 m onths gestation Only 19.3% (n = 16) reported th a t they w e re curre ntly living

w ith th e father o f th e aborted pregnancy

The primary reason fo r the abortion varied greatly w ith th e m a jo rity (16.9%;

n = 14) reporting "b e in g a fra id " astheprim ary reason The perceived pressure to have th e abortion varied for this population w ith 27.7% (n = 23) rep ortin g "never pressured" and 24.1 % (n = 20) reporting "very pressured."

The present husbands were reported by 42.2% (n = 35) o f the w om en as the individual w ho was most supportive w ith regard t o the ab ortio n experience, 26.5%

(n = 22) reported th e ir friends had been most supportive; and 19.3% (n = 16) reported "others" as being most supportive

In response to the question o f whether or n o t they received any form al counseling a fter the abortion, 60.2% (n = 50) reported th a t th e y had not had any counseling O f the 32 women w ho had counseling after the ab o rtio n , the m ajority, 34.4% (n = 11), participated in post abortion counseling

In response to whether o r not they had experienced any deaths in th e last 5years,37.0% (n = 31) reported no deaths The rem ainder o f th e wom en (n = 52) experienced a wide range o f deaths such as distant friends and relatives w ith only one woman (1.2%) reporting death o f a spouse W ith regard to oth er losses

Table 1Demographic Sample Characteristics

M arital Status (at tim e o f study)

T able 1 - C on tin ued

Race

W om an's Present Educational Level

High School Grad/GED 7Vocational School Grad 5

High School Grad/GED 24Vocational School Grad 4

Table 1 - Continued

Total Sample (N = 83)

No Miscarriage Sample (N = 73)

Miscarriage Sample (N = 10)

Frequency o f Attendance atReligious Services (Present)