The most common surgical procedure performed on women of child-bearing ages is known as induced abortion (American College of Pediatricians 2018). Induced abortions because of unintended and unwanted pregnancies occur in all societies regardless of medical, financial, educational or religious status (Torriente, Joubert & Steinberg 2016).

This study will focus on induced abortion because of an unwanted pregnancy and not on spontaneous abortion or miscarriage or abortion that takes place in order to prevent damage to the mother’s health. The term ‘abortion’ will therefore refer to legal induced abortion from here on. In South Africa, 73 072 abortions were performed in legal state health facilities in 2017 (Bhekisisa Mail & Guardian Centre for Health Journalism 2018).

Despite a notable increase in the number of studies on abortion, contradictory evidence is presented on how women experience and cope with abortion. As argued by Suffla (1997) and Thobejane (2001), there is no painless way of dealing with an unwanted pregnancy. South African research indicates several challenges, including moral conflict and negative emotions (Mojapelo-Batka & Schoeman 2003), regret, guilt, self-blame, judgement and physical pain after abortion (Mookamedi, Mogotlane & Roos 2015). However, a decision to undergo an abortion may be viewed by some as a means of resolving the stress associated with an unwanted pregnancy: it may lead to relief rather than negative psychological experiences or long-term mental health problems (Major et al. 2009). It is also possible that women may not necessarily become depressed, nor experience short- or medium-term trauma (Subramaney et al. 2015). However, evidence presented in a systematic review conducted by the National Collaborating Centre for Mental Health (NCCMH 2011) in the United Kingdom indicates significant limitations pertaining to the relationship between unwanted pregnancy, abortion and mental health.

According to the American College of Paediatricians (2018), research on abortion is often accompanied by research bias. Many researchers who are in favour of abortion seem to downplay the consequences of abortion, whilst those who oppose abortion tend to emphasise the consequences of abortion. Charles et al. (2008) indicated that whilst studies with flawed methodologies tend to find negative mental health sequelae of abortion, studies of a higher quality suggest few, if any, mental health differences between women who had abortions and their respective comparison groups. In spite of the suggestion by Robinson et al. (2009) that the most reliable predictor of post-abortion health is mental health prior to abortion, it seems that we do not have a clear and scientific understanding of the experience of abortion or of factors that influence the long-term mental health outcomes thereof.

Furthermore, no clear South African data are available on how women subjectively experience abortion and cope with it. Lazarus and Folkman’s (1984:141) classic definition states that coping includes ‘constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of a person’. More recently, coping has been referred to as the ability to mobilise, modulate, manage and coordinate one’s behaviour, emotions and attention under stress (Skinner & Zimmer-Gembek 2009). These perspectives imply that coping is a dynamic process of stress management, rather than a passive response from the individual. Taking this into account, the question this study aims to address is as follows: what broad themes can be identified from available research on the experience of and coping with abortion, and to what extent does available research reflect the dynamic nature of coping? This research could indicate a gap in research, specifically focused on the South African context. It could also provide directions for further research, whilst indirectly assisting health service providers in South Africa with the following: (1) a better understanding of women’s experience of abortion, (2) discussing and directing pregnancy options, (3) counselling and (4) referrals for post-abortion care.

The aim is therefore to systematically explore and synthesise scientific evidence on how young adult women experience and cope with induced abortion.

A rapid review of current international and national literature on the experience of abortion and ways of coping with the experience of abortion was conducted. A rapid review is an accelerated or streamlined systematic review (Ganann, Ciliska & Thomas 2010). It was specifically decided to do a rapid review as this was the first of three phases in a larger study, and as it could be a useful precursor for further research (Petticrew & Roberts 2006) based on the findings of an exploratory study like this. The guidelines of the National Institute for Health and Clinical Excellence (NICE 2012) for conducting a rapid review were used as a basic framework for this study. This rapid review aimed to answer the following two research questions: (1) how do young adult women experience induced abortion? and (2) how do young adult women cope with the experience of induced abortion?

Eleven studies published between 1973 and 2015 were identified as eligible for inclusion (see Table 1). Of these, six studies used quantitative methods (Costa, Jessor & Donovan 1987; Curley & Johnston 2013; Fergusson, Horwood & Ridder 2006; Fingerer 1973; Lundell et al. 2013; Taft & Watson 2008) and five used qualitative methods (Boulind & Edwards 2008; Gray 2015; Halldén, Christensson & Olsson 2009; Harden & Ogden 1999; Monsour & Stewart 1973). Quantitative methods almost exclusively included questionnaires and standardised scales, whilst qualitative data were primarily collected by means of in-depth interviews.

The majority of the studies focused on the mental health sequelae of unplanned pregnancy and abortion with different focuses, namely, general mental health (Fergusson et al. 2006; Harden & Ogden 1999), general stress and depression (Curley & Johnston 2013; Taft & Watson 2008), post-traumatic stress (Boulind & Edwards 2008; Lundell et al. 2013) and sexual self-image (Monsour & Stewart 1973). One of the studies was carried out in South Africa (Boulind & Edwards 2008), four in the United States of America (Costa et al. 1987; Fingerer 1973; Gray 2015; Monsour & Stewart 1973), two in Sweden (Halldén et al. 2009; Lundell et al. 2013), one each in the United Kingdom (Harden & Ogden 1999), Australia (Taft & Watson 2008) and New Zealand (Fergusson et al. 2006) and one study in both Canada and the United States of America (Curley & Johnston 2013).

The identified themes are presented according to the two aims of the research study, namely (1) young adult women’s experience of induced abortion and (2) the coping strategies of young adult women who experienced induced abortion.

It is evident from the review that the experience of abortion differs amongst women and various factors play a role in their experience of the unwanted pregnancy and abortion. The experience of induced abortion included three subthemes: the effect of premorbid factors on the abortion experience, stressors related to the abortion and negative emotions experienced in relation to the abortion. Furthermore, coping with the experience of induced abortion involved coping efforts and strategies and psychological growth gained from the experience of induced abortion These themes are not exclusive, for example, premorbid factors such as social disadvantage, partner violence and stressors related to the abortion, were found to influence the experience of abortion, whilst coping strategies were most often based on the nature of negative emotions experienced. In general, the findings of the review are not surprising as it is primarily supported by other studies within the review and by literature in general, whilst not many contradictory findings were observed.

The first noteworthy implication of the study is that certain premorbid factors may be important in understanding the experience of, and coping with, abortion. Personality was indicated by Costa et al. (1987) to influence the decision to abort or not. However, as this study was carried out three decades ago, and as attitudes about abortion have changed significantly since then, the finding should be interpreted with caution. An important question is, to what extent does a positive attitude towards abortion make the decision and coping process easier? However, even though a positive attitude towards abortion may be a protective factor, the experience of abortion is often negatively influenced by premorbid socio-economic challenges and partner violence (Taft & Watson 2008). This is especially important in the South African context because a lack of financial resources and social support (Ndwambi & Govender 2015; Sullivan et al. 2017; Torriente et al. 2016) are often indicated as the primary reasons for having an abortion. In addition, it seems that a history of partner violence is often associated with a higher rate of unintended pregnancies and abortion requests (Pallitto et al. 2012; Tinglöf et al. 2015), and is related to more stress, anxiety and depression (Tinglöf et al. 2015). The role of premorbid socio-economic factors should therefore be taken into account in abortion counselling, especially in a developing country such as South Africa.

Secondly, the abortion process is associated with a number of stressors that challenge young women on different levels. Perceived lack of support during an unwanted pregnancy and abortion is not a surprise and is confirmed by researchers such as Sa´nchez-Siancas et al. (2018). Stigma, however, is a more complex issue and may overlap with other factors, for example, perceived lack of support. A systematic review about abortion stigma (Hanschmidt et al. 2016) concluded that women who had abortions experience fear of social judgement, self-judgement and the need to keep their abortion a secret. Mookamedi et al. (2015) reported, based on a South African study, that women felt stigmatised after abortion and perceived themselves as ‘murderers’ because of their religious contexts. It is therefore no surprise that stigma often manifests as feelings of guilt, shame, anxiety, secrecy or unease about other people’s beliefs about abortion (Shellenberg & Tsui 2012; Sullivan et al. 2017). The question therefore emerges as to: whether the guilt and anxiety that women experience is because of the abortion itself, or because of contextual factors such as stigma. Experiencing ambivalence, conflict and a lack of autonomy is expected in any adverse event. The fact that the decision to abort is preceded by an unwanted (or untimely) pregnancy further complicates matters because it challenges one’s goals, identity and values. Although ambivalence and lack of autonomy may be related to perceived stigma and lack of social support, none of the studies explicitly reports it as such.

Thirdly, stressors related to abortion often result in emotions such as negative affect or emotional pain, anxiety and guilt. In some cases, these emotions develop into psychological disorders such as depression and even PTSD. It is surprising that none of the studies report on perinatal grief, although it is implied in most cases where depression or emotional pain was reported. Some contradictions or inconsistencies were also observed, for example, whereas depression was reported in several studies. Taft and Watson (2008) reported that there is no causal link between women’s abortion experiences and depression. This contradiction is also observed in the literature not included in this review (e.g. Boersma et al. 2014; Foster et al. 2015; Gomez 2018). The same is observed regarding anxiety. Even though seven studies in the review reported anxiety symptoms, this is not necessarily supported by the literature not included in the review (cf. Foster et al. 2015). The experience of pain and guilt is subjective, physically and emotionally intertwined and largely supported by the literature (cf. Mookamedi et al. 2015; Sullivan et al. 2017). However, there is not enough evidence on whether and how emotional pain and guilt are separate to either feelings of depression or anxiety. It is probably best to regard it as part of the subjective experience of both. Therefore, even though clear signs of distress are reported, the severity thereof, the extent to which it puts women at risk of developing psychological disorders and which women would be at risk still needs more clarity.

Fourthly, the review reveals two broad coping efforts, namely, avoidance and self-reflection. According to Dykes, Slade and Haywood (2011), avoidance coping is used when the memories about the abortion are suppressed by actively trying to forget and avoid thinking about it, whilst self-reflection is used when the decision to abort and thoughts and fears regarding future fertility are rationalised. Avoidance is usually perceived to be a less adaptive type of coping compared with the recognition, processing and expression of emotion (De Ridder & Kuijer 2006). The functionality of coping efforts should always be viewed in context, given the stigma associated with abortion. Avoidance may only give temporary relief. It could also be that avoidance leads women to self-reflect, which in turn may lead to avoidance if the experience of stigma and rejection is emphasised through self-reflection. However, this should be explored in future research. The lack of problem-solving coping is not adequately explained in any of the review studies, but may relate to feelings of depression and anxiety and the lack of social support. It may also be explained by the general belief that problem-solving coping fits controllable situations, whilst emotion-focused coping fits uncontrollable situations (Benyamini 2009). Therefore, future research should explore the possibility that the women in the review studies did not apply problem-solving coping, as they did not perceive their situation as controllable and did not apply more adaptive emotion-focused coping because of the stigma and secrecy of the situation.

Finally, some evidence suggests the presence of positive experiences in the form of relief and a sense of autonomy despite the challenges young women face. Quinley, Ratcliffe and Schreiber (2014) reported that abortion primarily provides relief to women who present for abortion. Not only did the participants in a study conducted by Kero, Högberg and Lalos (2004) report relief after the abortion but abortion is also described as a positive experience regarding mental growth and maturity. Although not much evidence emerged from the review, both a sense of relief and autonomy may represent a form of self-protection against resource loss from a conservation of resources perspective (Frydenberg 2014). It may even facilitate a broadening of resources from the ‘broaden and build’ theory in positive psychology (Fredrickson 2013). According to Fredrickson, even fleeting micro-moments of positive emotions are able to reshape people by setting them on trajectories of growth and building their enduring resources.

The aim of this study was to systematically explore and synthesise scientific evidence regarding how women experience and cope with abortion. A rapid review was carried out to synthesise the findings of 11 studies complying with the inclusion criteria. Because the study was exploratory in nature and because the relatively small selection of studies was heterogeneous in methodology and cultural focus, caution was taken not to make any specific conclusions but only to highlight a few general trends.

It was clear from the review that abortion is a complex emotional event that should be understood within the context of each individual. It can be concluded that an unwanted pregnancy and abortion are intertwined, and that the experience of abortion is not a one-dimensional experience in the life of a woman with an unwanted pregnancy. Each woman is uniquely acquainted with her abortion decision, experience and aftermath, mainly because the experience and coping efforts are greatly influenced by each woman’s context (including culture) and pre-abortion mental health.

The studies reviewed do not provide much information about women in a South African context. It is suggested that socio-economic disadvantages and premorbid relationships should be considered in future research. Not only does the abortion context differ but the perceived abortion stigma also stands apart for each woman’s unique narrative. One can also question whether women experience a lack of support because of stigma or because of them isolating themselves as part of the abortion process. Psychological growth after having an abortion is therefore a possibility, but not a given, and will inevitably be affected by the unique abortion context of the individual.

Further research may explore the following areas: