The key to moving on from the pain and loss is awareness and understanding  

  Newsletter Excerpts 2009 

“Choice” and Fully Informed Consent

Abortion is supposedly all about choice, and free choice at that. However “I felt I had no choice” is a common refrain of the post abortive women who come for help.

The journey of healing for those affected by loss and trauma after abortion can open up new awareness. The perceptions and understanding of the situation - the circumstances, the relationships and the expectations through the time of the pregnancy, around the decision making time and with the termination of the pregnancy, can differ greatly then to now.

The process of revisiting the abortion experience, unpacking feelings and looking at the reality of what actually happened, enables clients to see things that they had not seen at the time. When they fully explore the context of the abortion, all the influences and contributes, many recognize how it was a decision based on fear rather than reality, a pressured pragmatic response to what felt like an intolerable situation rather than an affirmative choice, consistent with their beliefs, ideals and best aspirations.

Assisting the post-abortive woman to understand the head-heart disconnect that occurred during the crisis of pregnancy when she was considering abortion is significant. It enables her to appreciate her limited functioning at the time. The heart said “Don’t do it” but the head said “It’s the only thing I can do”.

Insights into the effects of the hormonal state of pregnancy and the crisis state on the mind and emotions are critical for the hurting post abortive woman to come to terms with her decision.The normal reaction to fear is characterized by a fight, flight or freeze response and she discovers how the fear response impacted her ability to access deeper consciousness and process consequences. The realisation often comes how she and those around her, were drawn to what appeared to be the best solution to the immediate problem, the most practical and efficacious way to escape anxiety and stress of what is perceived as an intolerable situation. The decision was about survival.

Our experiences with post abortive women show that when faced with the options and alternatives, abortion can appear to be the right thing to do at the time, even if it goes against who she is most deeply. Some maintain this position afterwards without great seeming distress. However for others the reality of the abortion surfaces soon, or even decades later, in unexpected and painful ways.

Some of the stories we hear from post-abortive women speak of how they felt let down by the systems and processes they encountered and engaged in. There is often regret and anger around having not been made fully aware of or prepared for the likely impacts of their decision.

One woman’s comments were “The system did not really support me emotionally and I certainly didn’t make an informed decision. Alternatives were mentioned but not fully explored. They talked a bit about the procedure and the possible complications of the surgery but didn’t share anything about possible effects on me or my life. They didn’t really seem to care how I felt for that matter. They saw me and my problem and were willing to fix it but they didn’t really see me and what was going on for me. I said I wasn’t sure about having an abortion and that this didn’t feel right but they supported all my reasons why it would be difficult to have my baby, until I felt it was okay to have the abortion. The way I was feeling I just needed the sickness and desperate feelings to go away.

Now afterwards I can’t believe I had the abortion. It was so not what I wanted. I wanted this child more than anything. I was so alone and everyone around me thought it strange for me to want another child. No one supported my pregnancy. I had longed for another baby for so long. I don’t understand how I felt what I was feeling. All I know is that I panicked and now I can’t forgive myself.

I have had post-abortion counselling with P.A.T.H.S. and understand and accept some of the way things happened. I still feel angry but I can see my way clear. Life is worth living and I have a family that needs me and who I love dearly.

I am pregnant again and am relieved to not be feeling so sick, nor to have the same kind of overwhelming and desperate confusing and conflicting thoughts and feelings. I am asking for and finding the support too I need this time.”

Some post abortive women believe they deserve to suffer for the “choice” they made. But was it a choice in the true sense of the word? Is a decision made in crisis a real “choice”? Consider the qualifiers for choice - free will, fully informed consent and lack of pressure or coercion. Some may believe this is available and present to all through the abortion process, but sadly this appears to not always the case. Take fully informed consent for example.

Fully informed consent around abortion, is not just the giving of details about the procedure and immediate potential post-operative problems, nor a simple cost-benefit analysis of options. This may be adequate for a tonsillectomy or an appendicectomy which are simply about the physical removal of anatomical parts needing removal. Termination of any pregnancy, at any stage for whatever reason, involves the ending of a little developing human life and it occurs in relationship. For abortion consent to be fully informed then surely it needs to include accurate information about what is being removed, and exploration of the potential psychological, spiritual and relational impacts? We are increasingly aware and accepting of the impacts on a mother and her relationships following miscarriage and stillbirth and other pregnancy losses, but fail to acknowledge and prepare people for the effects from the artificially induced pregnancy loss of abortion.

Post abortive women who avail themselves of counselling and support often bemoan the fact that they were not aware of how abortion would be so final, nor how is could cause such anguish or mental dissonance, emotional pain, grief and guilt or that it could leave them bereft and scarred. Most complain they were unaware of the risks and felt ill prepared to deal with the impacts.

Those for whom the decision for abortion actually contradicted their personal beliefs and moral code often present with major distress. For others, as they have grown and changed they look at what happened in the abortion differently and can find it hard to reconcile the past abortion with who they are now. And for a few, there is the added human tragedy that this was the only child they have ever had and they let that chance go by. This is not denying that numbers appear unaffected – if that is the case for them, that’s all very well and good. But there is a whole group of others for whom there are issues and problems afterwards. Most suffer in silence.

There some research around risk factors which indicate an increased likelihood of someone having a negative abortion reaction. There appears, however, to be no real screening for or discussion around these with those considering an abortion. It makes perfect sense later to the post-abortive women but “no-one told me” is a not uncommon refrain.

Information about foetal development is another area that seems fraught. Some women share afterwards how they were either not given information about foetal development or did not see the screen or pictures from the scans if they were performed. Although some, when asked, prefer to not look, even they can later regret that decision. Others when they asked questions around the stage of growth of their babies felt they were dismissed as if it wasn’t important to know or the reality was trivialized by the label of the foetus as a nothing – “like a 10 cent piece” “no more than a bunch of cells” “a blob of tissue” “unformed at this early stage” “nothing really there”. The acknowledgement of the life lost and willingness to use the term baby appears to be permissible for therapeutic terminations and pregnancy losses for natural reasons. How come it isn’t accorded for abortions in general? The clinical and medical approach tries to protect woman it seems from the human reality. Women who talk to us confess to having submitted unwittingly to a procedure that has altered them and their lives permanently.

At the time admittedly it may have appeared to be a relief and helpful to not have the information of the development of their little ones, or to not have to face that aspect and deal with it, thus making it easier to proceed with an abortion, but later it can create frustration and anger. Deliberate attempts by medical staff to trivialise that life and its humanity, is later seen by some as a deception and blatant insult. This can cause rage in some post abortive clients, which requires an inordinate amount of work to deal with. But there is no rage greater than that directed at self, often with dire results.

When thinking around the subject of informed consent one naturally focuses on the counselling that is offered to all considering an abortion, as is required by law. Counselling is often directed to abortion referrers and providers and tends to focus on an abortion decision rather than necessarily being about making a pregnancy decision. The subtle focus difference can be significant in the decision making process and raises question - is there a vital step missing? There is concern in some circles how so few people actually take up the offer of counselling at all. We concede that many attempting to make a decision around an unplanned pregnancy at the time do not wish to receive information or counselling.

Some women share after their abortions how once they made up their mind, determining the abortion would be the most effective way to restore stability, they often sought only that which would confirm and affirm them and support that decision. Understandably they got upset with people who attempted to offer them help, and didn’t want to have any information or to talk it through with anyone – they wanted it over and done with and wanted things back to normal as quickly as possible. However later, some see it as a disservice and realise that having had that information or being invited to confront the reality then, as painful as it might have been, would’ve been preferable to the agony that they are now experiencing, dealing with the loss and trauma of the abortion and their part in it.

There appears to be little encouragement or incentive generally to take time to really consider the options and explore alternatives and implications. The experience some describe is how they felt like once they found out they were pregnant and expressed ambivalence, it was like they were on a conveyor belt and even if they wanted to get off they didn’t know how and felt they couldn’t. This is scary stuff! And for us picking up the pieces afterwards it is very sad and perturbing to hear about that sense of disempowerment through the systems and processes that can and does occur.

To my mind fully informed consent is an ethical issue and a human right. Are we doing it well enough? How might the pregnancy decision-making processes be improved within our health services? These are good questions to ask and discuss. We need to be talking about these things more, not just in medical and counselling circles, but all areas of our community. For this is about people, ordinary people like you and me, our friends and family. It affects us all.

- By Carolina Gnad

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Mifepristone in Australasia Conference

Report by Carolina Gnad who attended this conference for P.A.T.H.S. as an interest group

This was an abortion providers’ conference held in Wellington 16-17 October. It was sponsored by Istar Ltd, a not-for-profit pharmaceutical company incorporated in February 1999. Istar was formed by five doctors to import Mifegyne (Mifepristone) from France because no established pharmaceutical firm was willing to import it. The founding directors were all operating doctors who considered that New Zealand women should have access to medical abortion as an alternative to surgery.

Mifepristone (known as RU-486 in early trials) was first available in 1980 in France and is now available in 33 countries. Early medical abortions (EMAs) have been available in New Zealand from 2001 and are being offered in six first-trimester abortion services. Currently the Family Planning Association is seeking approval to provide EMAs on site.

Claims are that EMAs being available doesn’t increase the abortion rate and that decisions for abortions or around pregnancy do not depend on the procedure employed. Early access and less expense appear to be advantages of EMAs, and they can be done even if the pregnancy is not located.

An abortion may be procured by using either Mifepristone or Misoprostol alone. However these two drugs work synergistically, so used together, studies show, they increase efficacy and decrease side effects.

Mifepristone blocks progesterone (and cortisol) receptors, and three metabolites provide 22-33% of the antiprogesterone effect. Mifepristone affects the endometrium and the gestational sac separates from the uterine wall. It also softens the cervix and makes the uterine muscle more sensitive to prostaglandins (PGs). This is why it is sometimes used in later terminations of pregnancy or inductions following foetal death. It is also used in treatment of endometriosis, fibroids, and non-reproductive use for some tumours and as an antiglucocorticoid.

Contraindications for Mifepristone use include: a diagnosed ectopic pregnancy, chronic adrenal failure, long term corticosteroid use, high allergies or bleeding disorders. Where there is an IUD in situ this needs to be removed prior to the administering the drug and the procedure continuing.

The EMA process generally occurs as follows:

  • Phase of “psychological confrontation” and coming to a decision
  • Ultrasound scan performed to determine dates and exclude an ectopic pregnancy
  • Blood tests done for a baseline HCG (Human Chorionic Gonadotrophin) level
  • Mifepristone tablets are taken (the point of no return)
  • There are different protocols but patients may go home under certain conditions between and after receiving the two types of tablets. Patients going home must have proper preparation, be a certain distance from the hospital, have good support, reliable transport, a telephone and be able to speak English.
  • Misoprostol (prostaglandin - PG) tablets are taken usually 24-48 hours later. It takes time for the Mifepristone to reach and be taken up by the progesterone receptors but the interval is kept as short as practicable to decrease side effects. Five per cent expel before Misoprostol is given, 24% expel 4-5 hours after, others more than 24 hours later.

Usually there is heavy bleeding for about half a day and bleeding may continue for 9-14 days afterwards. Fluids are encouraged and warm packs may be used to help relieve discomfort. Half of patients don’t request pain relief but if pain relief is needed Paracetamol, Ibuprofen, Diclofenac or Codeine Phosphate may be given.

Complications are considered to not be serious. There may be some diarrhoea, and vomiting which are known side effects of Misprostol. Occasionally a woman may haemorrhage, usually due to retained products of conception (RPOCs) but less than one per cent require transfusion. Where haemorrhage is more serious the abortion procedure may be repeated or the option of surgical intervention (dilation and curettage) may be taken. A small number of deaths have occurred from toxic shock associated with a Clostridium Sordelli infection - these were dismissed as reportedly it can also occur with IV drug use, skin transplants, Caesarian Section and normal delivery.

Follow-up occurs 2-6 weeks later to check expulsion has been successful, to exclude complications (by another ultrasound, HCG test and clinical assessment) and for contraceptive counselling. Figures indicate that around 1.3% of pregnancies continue at 49 days, and at 63 days gestation around 4% of pregnancies may be viable following EMA procedures. In these instances the medical procedure may be repeated or surgery required.

Staff from various clinics and hospitals gave reports on their processes and experiences to date around EMAs.

The conference also addressed aspects of later terminations and foeticide. What featured most were the medical aspects and clinical considerations. I was acutely aware of the loss and trauma we deal with counselling those after abortion and felt there was a lack of acknowledgement of this in this forum. However I was heartened when members of the Te Mahoe Unit of Wellington Hospital and Vicki Culling from Sands shared some case studies and brought something of the more human experience in and around the decision making and experiences for women, men and families.

I spoke with some midwives, nurses and counsellors and saw how views differed with individuals. They also reflected some of the difficulties working in this area, concurring that this is an area that is complex and fraught. It’s not an easy place to work no matter what one’s convictions might be.

EMA as an artificially and intentionally induced miscarriage is effectively a pregnancy-baby loss and can have repercussions for women and families which are often overlooked, minimised or discounted.

It is our hope that services will continue to grow around the country which inform people of the risks and acknowledge the often deeper and longer term impacts of a termination of pregnancy, at whatever stage or in whatever manner it is performed. We aim to provide information and equip helpers in every sector to respond to the needs of those who may experience pain and problems after their abortions.

For further information on the drugs mentioned and EMA visit the following websites: www.fiapac.org, www.misoprostol.org, www.gynmed.at, www.womenonweb.org

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A Perspective on Tolerance

What silences the post-abortive parent who may be suffering with negative emotions and pain? One thing could be tolerance. How so?

Tolerance traditionally means simply to recognise and respect others’ beliefs, practices and so on, without necessarily agreeing or sympathising. But today’s definition is vastly different.

According to Bob Hostetler, based on the assumption that all truth is relative, this new tolerance means we need to consider every individual’s beliefs, values, lifestyle and truth claims as equally valid. So not only does everyone have the equal right to his beliefs, but all beliefs are also equal, demanding praise and endorsement of that person’s beliefs, values and lifestyle.

This new tolerance gets complicated. In a belief system where the sole virtue is tolerance, then the cardinal sin is intolerance.

Since tolerance is based on the assumption that all truth is relative, it becomes not only permissible but also imperative to be intolerant of those who do not agree that truth is relative. To the relativist, then, it is not inconsistent to be intolerant, for example, of those who insist that absolute moral standards do exist (which is considered by modern society as being inherently “intolerant”). Yes it is confusing.

But, tolerance for abortion and intolerance of problems afterwards, can silence those adversely affected and be an obstacle for them seeking help to deal with resultant issues and pain associated with the experience. Permission is not granted those suffering after an abortion, to grieve or talk about their experiences - they are discounted, criticised and discredited. “We” need to push through this so called (in)tolerance and break the silence!

- By Carolina Gnad

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You can promote post-abortion healing without even talking to people about their past abortions and you don’t have to become a trained counsellor or an expert in post-abortion issues. You can sow a few words of compassion and healing into your everyday conversations which can reach those who may be affected by a recent or past abortion, or encourage others to think around the issues and break down the barriers that make it hard for those needing or seeking help to come forward.

In a simple, conversational way, where possible

  • Show understanding - announce that you have come to a whole new understanding of the abortion issue, including why people choose abortion and how it affects them.

  • Express your compassion for women and men who have had abortions, knowing how they often face the fear that others are judging or condemning them, and that they may be experiencing feelings of doubt and regret

  • Offer hope - describe how you have heard of this programme that can help women and men find peace and work through issues associated with past abortions, including dealing with secrecy and shame.

For example, you might simply say:

“I read an interesting article that gave me a whole new understanding of why women have abortions. I never really understood before how much pressure many are under to have an abortion. I also didn’t realize before how much they can feel judged and condemned by others. That fear of judgement can really make it hard for them to come forward for help or to heal. It can be quite a process for some women to deal with the loss or trauma from an abortion and sometimes they benefit from outside help. The good news is that is help for women and men who are dealing with post-abortion problems.”

That’s it. You have planted the seeds.

(Adapted from the Elliot Institute publication “Hope and Healing”)

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“Making Pregnancy Safer” Conference

18th November 2009, Auckland

This conference was organised by the Perinatal and Maternal Mortality Review Committee (PMMRC) of the Ministry of Health. The aim of the PMMRC is to identify areas in maternity and newborn care where improvements can be made in order to prevent mortality. With this aim in mind, the committee set up the PMMRC database to review all perinatal and maternal deaths in New Zealand in order to instigate a system of audit and feedback.

Cindy Farquhar, Chair of the PMMRC, presented the process and main findings of the Perinatal and Maternal Mortality in New Zealand 2007: Third Report to the Minister of Health. In 2007 there were 65,602 total births (>20 weeks gestation). In that year 677 babies died (510 foetal deaths - terminations of pregnancy and stillbirths, 134 early neonatal deaths - <7days, 33 late neonatal deaths - <28 days post partum). Most terminations of pregnancy (TOPs), it was explained, would have become foetal deaths as there were foetal abnormalities. There were in that same period 11 maternal deaths, comprising 5 direct (pre-eclamptic toxaemia, post partum and intrapartum haemorrhage), 5 indirect (other conditions) and 1 unclassifiable cause.

A range of other material was presented by various speakers - Jeremy Oats talked about the Victoria situation and statistics; Lesley McCowan spoke about small babies and improving outcomes; Karen Evison talked about improving smoking cessation approaches in pregnancy; Vicki Culling from Sands shared around support for family and clinicians; Lesley Barclay presented midwifery and keeping women safe; Jenny McDougall spoke about managing post partum haemorrhage and developing National Guidelines; Martin Sowter presented training in Emergency Obstetrics; Lucille Wilkinson on Management of hypertensive disorders of pregnancy, and Vicki Masson shared about AMOSS, a new trans Tasman project measuring maternal morbidity....

P.A.T.H.S. had the privilege of having an information table at this conference and complementary attendance. It was a good opportunity for us to network and gain insight into perinatal and maternal mortality issues.

Talking around the work of P.A.T.H.S. and connecting with practioners dealing with pregnant women and their families was invaluable. We shared our experiences and concerns, and others were forthcoming about their experiences with those with past abortions or TOPs who they work with and the impacts on health and pregnancy. Some seemed disinterested or guarded but by and large practitioners were receptive.

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