No one needs to know! Medical abortion: Secrecy, shame, and emotional distancing

Abstract

In 2021, 10,841 abortions were carried out in Norway, of which 95.3% were medical abortions. In this phenomenological study, we explore women’s experiences connected to performing a medical abortion at home. We conducted 22 interviews and analyzed the data using Giorgi’s descriptive phenomenological method. Our analysis revealed four crucial constituents: The logical and sensible choice—doubt beneath the surface; Secrecy and the dubious comfort of hidden shame; Emotional distancing as a coping strategy; and Moving on—and revisiting the meaning of the abortion. We discuss and reflect on these findings drawing on insights from existential phenomenology and contemporary research.

Alongside birth control pills, safe and accessible abortion has given women the means to exercise greater control over their reproductive destiny. The World Health Organization (World Health Organization, 2021) states that lack of access to high quality and respectful abortion care, as well as the stigma associated with abortion, represents a threat to women’s physical and mental health throughout their life. Globally, abortion has been and remains highly controversial as it involves issues such as gender equality, human rights, and existential and ethical dilemmas. Women live with and are forced to navigate these controversies and dilemmas in their specific social and cultural context.

Medical management of abortion was introduced in Norway in 1998. The method is easily available, waiting lists are short, and it is considered a safe and effective method. In 2021, it was used in 95.3% of all pregnancy terminations in Norway (Norwegian Institute of Public Health (NIPH), 2022). However, women undergoing a medical abortion describe side effects such as severe abdominal pain and cramping, nausea, vomiting, fever, in addition to a lack of pain relief and information about the procedure (Georgsson & Carlsson, 2019; Henderson et al., 2005; Ngo et al., 2011).

In this phenomenological study we explore the feelings and thoughts of Norwegian women that have performed a medical abortion at home. Via a Facebook page, we invited women to share their experiences with us. They were more than willing to share their stories, from which we teased out generic meanings. The authors intend to contribute to practice literature that might be valid for women in other countries and relevant for an international interdisciplinary audience involved in women’s health issues.

Background

Numerous unplanned pregnancies, followed by childbirth, breastfeeding and caring for infants, have historically been a woman’s destiny, affecting her opportunity to pursue other projects in life. With the introduction of birth control pills and access to safe abortion, women were able to control their reproductive destiny. The issue of abortion involves existential questions concerning the value of human life, personal autonomy, freedom, gender roles, and sexual morality (Jelen & Wilcox, 2003). For more than half a decade, abortion has been a highly divisive and controversial subject, with the so-called pro-choice liberal and feminist side arguing for women’s right to control their own bodies and the so-called pro-life conservative and religious side arguing for the human rights of the embryo/fetus as a potential person. Conditions and limits to qualify for abortion vary significantly across countries and have changed over time due to shifts in the political climate. Some countries, such as Poland, Malta, El Salvador, Nicaragua, and the Dominican Republic, still have strict regulations or complete abortion bans.

In countries allowing women access to abortion, the legal time limit varies from 10 to 24 weeks of gestation. Since 1974, Norwegian women can demand an abortion within the first 12 weeks and request one via application to an abortion board within 18 weeks of gestation; between 18 and 22 weeks, abortion is permitted only on the grounds of grave risk to the mother’s health or if the fetus is not viable (Norwegian Directorate of Health, 2021; Schrumpf, 1984). Within these time limits and regulations, Norwegian women today can choose whether and when to have children.

Since the introduction of medical abortion in Norway in 1998, women have also been able to self-manage abortion in a private setting. In 2021, 10 841 terminations were carried out, equivalent to 9 per 1000 women (15–49 years old). The majority of elective abortions (84.5%) were done within the first nine weeks of gestation and 95.3% were medical (NIPH, 2022). Medical abortion is considered a safe and effective method of termination in early pregnancy (Kulier et al., 2011). The procedure starts with the administration of mifepristone at a clinic followed by the administration of misoprostol at home. Few side effects have been reported, but one study found that women performing a medical abortion at home felt unprepared and lacked information about the effects and side effects of the procedure (Aamlid et al., 2021). Many felt that the information they received about bleeding and pain related to the abortion was insufficient, and some women said that in hindsight they would have chosen to terminate the pregnancy in hospital if they had known what would happen. While some women have reported insufficient pain management during their abortion (Georgsson & Carlsson, 2019), many women who chose to terminate pregnancy at home were satisfied and would recommend the method to a friend (Ngo et al., 2011). Few studies have investigated women’s experiences when performing medical abortion.

The literature on abortion indicates that there still is a strong social stigma, including in Western countries where the procedure is legally accessible (Hanschmidt et al., 2016). Women who undergo abortions challenge social norms. Women’s experiences of abortion have involved fear of social judgment, self-judgment, and a need for secrecy (Cockrill & Nack, 2013; Hanschmidt et al., 2016). In this phenomenological study, we explore women’s experiences of coping with emotions connected to home medical abortion.

Methods

This research and its methodology are based on the phenomenological philosophy of Husserl (1983/1913) and Merleau-Ponty (2012/1945). In phenomenology, intersubjectivity and empathy enable us to empathize with others and gain direct knowledge of their intentions and emotions. From the dyadic relationship between two persons to the larger shared cultural world, we are intimately connected with each other and co-constitute a common lifeworld. Yet we are also formed by the world we live in, which is sedimented in our embodied consciousness. Our knowledge of the world is thus perspectival and (in)formed by our embodied consciousness and personal, social, and cultural history.

Through our intentional consciousness we have the capacity to take a step back and reflect on the impact of our personal and socio-cultural history and describe how this may shape our perception of and being in the world. We can engage in what Husserl (1983/1913) called the epoché and phenomenological reduction. Through the epoché, we suspend or bracket our taken-for-granted natural beliefs and theories about a phenomenon. We “reduce” (the phenomenological reduction) our experience of the world to phenomena as they appear to the consciousness rather than worldly facts.

Participant selection and data collection

The study is part of a research project exploring Norwegian women’s experiences of medical abortion at home and was performed by a team of five researchers with varied backgrounds in health care and teaching, including public health nursing, psychology and midwifery. Information about the project was published on a university website and on Facebook. To be included in the study, women had to have carried out a home medical abortion before 11 + 6 weeks gestational age. Women with terminations due to missed abortion were excluded from the study. We included 22 women who satisfied the inclusion criterion and confirmed their participation by email. All abortions were conducted in Norway. One participant lived in the UK and the remaining participants resided in various parts of Norway, both urban and rural. They were all Caucasian and between 24 and 45 years of age, and all but one were of Norwegian origin. Their education level and civil status varied, and altogether they had had 26 medical abortions, mainly between 2010 and 2019. Fifteen women had one or more children born before or after the abortion, and eight women were childless.

Research team members conducted individual interviews with the women from October 2019 to January 2020. The women chose the location; some felt most comfortable being interviewed in their homes while others preferred a neutral setting. Two women were interviewed via telephone or video call, and the othersface-to-face. We used an interview guide consisting of three open-ended questions concerning the women’s overall experiences of carrying out medical abortion at home, their experiences of being informed and supported by health care providers, and the follow-up care they received after the abortion. They were encouraged to talk freely and were only interrupted when there was a need for clarification or elaboration. After the interview, the participants were given the opportunity to raise emotional issues triggered by the communication. The interviews lasted between 10 and 71 minutes (mean 47 min) and were digitally recorded and transcribed verbatim.

Data analysis

To analyze the data, we used Giorgi’s (2009) descriptive phenomenological psychological method. Adopting the attitude of phenomenological reduction, we first read through the transcript of each interview several times to gain a sense of the whole. Second, we separated the text into meaning units when we detected a shift in meaning relevant to the phenomenon under study. Third, we transformed the meaning units into a more psychologically sensitive language. This step is the most challenging one, where we empathically intuit and verbalize the often implicit and complex meanings that are inherent but not directly articulated by the participants. To derive more general meanings, we used the methodological step of “imaginative variation.” By imaginatively varying the different lived aspects of the phenomenon and trying out different levels of abstraction, we worked to find eidetic descriptions that could encompass the experiences of other women in similar contexts. The last step involved synthesizing the transformed meaning units from the different interviews into a general meaning structure at a higher level of abstraction.

We analyzed ten interviews which contained rich and diverse descriptions of the phenomenon, strictly following the procedures in Giorgi’s method. The remaining interviews were read carefully and analyzed critically for new meanings, and the general meaning structure was adjusted when appropriate.

Reflexivity

The research team’s background and general preunderstanding of abortion and women’s rights related to abortion can serve as a strength as well as a limitation when conducting a study about women’s experiences of home medical abortion. In this study, all authors are health professionals. One is a clinical psychologist, while the others are midwives or public health nurses. All have clinical practice from caring for women and their families during pregnancy and birth as well as the postnatal period. They also teach master’s degree students in midwifery and public health nursing, and their research interests concern women’s health, including sexual and reproductive health and women’s rights related to these issues. Thus, we found that our theoretical and professional backgrounds enabled us to explore the phenomenon from different perspectives. We acknowledge that our view on women’s rights to accessible abortion unwittingly may have impacted our research and presentation of findings. To keep preconceptions at bay, we engaged in the phenomenological attitude involving the epoché and the phenomenological reduction as described above. Our systematic, transparent and descriptive analysis further ensured the validity of our findings.

Ethics

We conducted the study in accordance with the World Medical Association Declaration of Helsinki Principles for Medical Research Involving Human Subjects (World Medical Association, 2013). Further, it was approved by the Norwegian Center for Research Data (22708) and assessed by the Regional Committee for Medical and Health Research Ethics, which considered it to be outside the remit of the Act on Medical and Health Research (36616). The participants received oral and written information about the study before the interviews started. They were informed that they could withdraw from the study at any time without consequences and that any data they had contributed would be deleted.

Results

General meaning structure

Through our analysis we revealed that the women in this study terminated their unintentional pregnancy because this was perceived as a logical and sensible choice in their current life predicament. However, ambivalent feelings and thoughts of “what if” were clearly present beneath the surface, for some more than others. The women experienced the abortion as immensely difficult, both emotionally and personally, with invasive feelings of guilt and shame for being irresponsible and not in control. Having the abortion at home shielded the women from the perceived condemning eyes of others, and it could also feel like a form of punishment. They felt that they were not in a position to complain or request needed care because they had put themselves in this situation. The act of emotionally distancing themselves from the pregnancy was described as a pervasive coping strategy for the women. This way of coping minimized the meaning of the pregnancy and made it “less real,” in order to reduce painful feelings of grief, guilt, or shame. Once the women had made the decision to terminate the pregnancy, they wanted to “get it over and done with.” However, they repeatedly revisited the memory of the abortion and its meanings and implications. Most of the women did not regret their decision, yet an emotional reaction to the abortion occurred, often after months or years.

For the sake of analysis, we separated the general meaning structure into four interrelated constituents: The logical and sensible choice—doubt beneath the surface; Secrecy and the dubious comfort of hiding in shame; Emotional distancing as a coping strategy; and Moving on—and revisiting the meaning of the abortion.

The logical and sensible choice—doubt beneath the surface

The women in this study described how they suddenly became unintentionally pregnant when in an unstable relationship or an unsuitable life situation. They presented logical and sensible arguments for choosing abortion. Some women described a strong feeling of not wanting to be pregnant: “But I did feel very clearly that I knew really soon that I didn’t want to be pregnant” (i12). For others, the nature of the relationship with their partner was an important factor in their decision. They experienced their relationship as unhealthy or the timing of the pregnancy as a major challenge.

We had only just met … because it was so early on, and I was terrified that I would be left alone with the fourth child as well, you know. I quite simply didn’t know how I would cope with it in practical terms… It was just chaos. (i9)

Some revealed that their perceived limited capacity to care for a new child and concern for their older children were important: “He has three children, and I have three children. It absolutely didn’t suit us to have another child. It was kind of a consensus decision that we cannot cope with this” (i1).

Ambivalent feelings and thoughts of “what if” were clearly present under the surface of the experience for the women in this study, although some women struggled more with uncertainty and ambivalence than others did. Those who experienced strong ambivalence and uncertainty relied more on others’ opinions when deciding to terminate the pregnancy. “We had gone through it a lot at home, back and forth, should we do it or not. I was really like … I’d love to have it, but then I left most of the decision up to him [partner]” (i11). Some of the women in our study expressed ambivalence because they feared not being able to conceive and give birth to a child at a later stage in life:

My greatest concern about it, which perhaps made me consider not doing it … what will this do to my body? What if it stops me from having more children? Then I’m sure I’ll feel I’ve made a very stupid choice. (i3)

Abortion was experienced by some as surprisingly easy to arrange, “just make a phone call,” yet the decision was experienced as immensely difficult emotionally and personally. They described troubling thoughts of “playing God,” having the power to end “a life,” and somehow removing a child that was “meant to be born.”

The dubious comfort of hiding in shame

Abortion conducted in the privacy of their own home had a double meaning for the women. Most of them initially found it positive to be able to have the abortion at home, as it made it less public and allowed them to keep it a secret. Many reported a sense of relief because the alternative of hospitalization meant a lack of confidentiality, more questions requiring answers and explanations, and, for some, having to arrange a babysitter or request sick leave. “I think this is about perhaps wanting to hide. Because I think it’s still seen as a little shameful” (i16). At the same time, the women experienced strong social stigma because they had unintentionally become pregnant and chose to terminate the pregnancy. Some women experienced being sent home by health care workers to perform the abortion as a form of punishment for being irresponsible and becoming pregnant: “It can almost be felt like a punishment” (i19).

The women described feelings of guilt and shame because they felt that they should be in control of bodily reproductive functions, and practically able to care for a child despite choosing abortion, and because they felt identified with the “type of woman” who chooses an abortion. “I couldn’t complain. It served me right. I already had problems with being an adult and still choosing to have an abortion. So, for a period I imagined that they deliberately failed to give me something [stronger painkillers]” (i7).

Most of the women told very few other people about the pregnancy and the subsequent abortion, and a few told no one, not even their partner. When few people knew about, or were witness to, the abortion, they felt that this made it “less real.” They hoped to go swiftly back to the life they had had before the pregnancy, almost as if it had never happened. “I hadn’t needed to tell anyone, I just did it and then it was over” (i19). One woman deliberately chose to be open about her elective abortion with a wider circle of friends and at work with the aim of normalizing abortion and decreasing the social stigma. She experienced mixed responses to her openness: some in her circle signaled that they were uncomfortable and did not want to hear about it, others silenced her to prevent conflict with people with a negative view on abortion, while her teenage students were positive to her openness and expressed a willingness to explore different perspectives and ethical views on abortion.

Although many of the women initially thought that they would feel secure when conducting the abortion in their own home, they experienced it as a lonely, painful, and often frightening experience. Several women did not have anyone with them during the procedure because they were reluctant to ask somebody for support and thereby allow them to witness this private and vulnerable episode. “I believe I was told … that I shouldn’t be alone … But who could you bring with you for something like this, then (i9)?” Because they felt responsible for their own predicament, they did not feel in a position to complain or request needed care. They suffered in shameful silence. “It’s the punishment for being careless … You shouldn’t tell people about it, it’s taboo. There’s a kind of ‘white trash’ stigma attached to it. They’re the unskilled, uneducated girls” (i16).

For most of the women, the abortion process was a very difficult, painful, frightening, and lonely experience. The women we interviewed that identified themselves as liberal and modern feminists nevertheless silenced themselves because of the general social stigma connected to abortion. They described having openly defended women’s right to control their own bodies and access to free abortion. However, finding themselves in “the group of women” who opt for abortion was a qualitatively different experience and their perspective changed. They felt vulnerable, were afraid of judgment, and kept the abortion secret from most of their friends and family.

Many of the women in our study also felt insecure and worried whether something was physically wrong during the procedure. They worried about whether they had put in the pill correctly, how long the abortion would take, or how much bleeding or pain was normal. The information they had received was not sufficient to ease their worry, and because they were reluctant to call the hospital for information or help, they suffered in silence. “So it’s easy to get scared. And I think so too, because I bled for two to three weeks [first abortion], and then it stopped. Now I’ve gone three full months. So it’s no fun” (i13).

Emotional distancing as a coping strategy

Emotional distancing emerged as a pervasive coping strategy. By distancing themselves emotionally from their pregnancy, the women aimed to reduce emotional pain related to choosing to terminate. “I’ve said that it [the abortion] is like scraping the skin off an arm. Dead cells, sort of, or perhaps a little more than that” (i16). For a few women, this strategy enabled them to go through with the abortion. The act of emotional distancing was lived through in different ways. It was evident in the way they consciously and subconsciously avoided emotionally investing themselves in or connecting with the fetus.

I deliberately tried not to touch my belly, because I thought that this would build the smallest possible relationship, or try to engage with that feeling of motherhood, because the more I recognize this and feel that – oh, that’s my baby and all that, the more it will hurt … It was just a matter of getting it over and done with. (i15)

Most of the women were reluctant to look at the fetus during the routine ultrasound or the aborted fetus in the toilet bowl, as they anticipated that this would induce emotional pain, guilt, and shame. The women who had looked at the ultrasound image of the embryo/fetus described this as a painful experience, and many regretted doing so. “I felt it was a painful experience, absolutely. After all, you can see a tiny fetus with a beating heart. And that really generates many ethical, moral, difficult human dilemmas inside me” (i1). The few women who had seen the fetal tissue in the toilet bowl, described it as a terrible experience they were not prepared for: “It’s the worst thing I’ve seen in my entire life. That picture is etched onto my retina, it’s not a pretty sight” (i18).

The women were reluctant to discuss their thoughts and feelings about their pregnancy and choice of abortion with health care professionals. One woman said: “I put on the kind of rational, sort of adult side of myself, and shut out the emotions right there and then … so from looking at me, I don’t think you would have guessed that this was a difficult choice” (i1). Similarly, another woman described how not talking about her abortion was a strategy to protect herself from realizing the implications of her pregnancy and the resulting emotional pain.

And I felt that I couldn’t or didn’t want to talk to anybody about it [the abortion] … because that would make it more real. It would be more … it would make me realize that … that I had been pregnant. (i15)

The women felt vulnerable and exposed in relation to health care workers and often perceived questions about their decision to terminate the pregnancy as demands for explanation or justification. This increased their already existing feelings of shame, leading them to avoid deeper conversations and to expedite the appointment at the hospital and the abortion procedure. Many of the women did not want to explore their options, or what these different options might mean for them. “I knew that I had to go through with the abortion afterwards. Which after all is really difficult, because you just feel that you want it to be over and done with” (i15). They had already made the decision to have an abortion when they arrived at their hospital appointment, and just wanted to get it done as quickly as possible. The stretch of time from their decision to the abortion appointment was difficult as it often involved ambivalent and difficult feelings and thoughts.

The fact that embryo was still alive, growing and developing, only to be removed, was hard to think about, yet impelling and creating more time for ambivalence and uncertainty. One woman described this waiting period as absurd, horrific, and painful. “[W]ell, it’s not enough that I’m pregnant and I’m going to remove it … but I need to wait until the kid has a heartbeat, so I can see and hear it first, and then we can remove it” (i3).

A subgroup of the women who were more uncertain and ambivalent about their abortion expressed disappointment that the health professionals they encountered did not create an open space for a non-directive dialogue around different possibilities and the complicated feelings involved.

Even if you decide to end it, you’re a little attached to it anyway, so it feels kind of peculiar when it’s just: “So, here are these pills, this one goes up there, and in a couple of days you will need to take these. And good luck.” (i11)

They expressed that they might have changed their decision if health professionals had explored the complexity of their feelings, their current situation, and future possibilities.

Moving on—and revisiting the meaning of the abortion

In the hours and days after completing the abortion, the women experienced a wide range of emotions. Some of them were relieved that the difficult and painful abortion process was over, and wanted to go back to their normal life. Others struggled with distressing thoughts and emotions and found it difficult to concentrate on their studies or work.

And I struggled with that for many, many days afterwards. It was so creepy, it was so scary, it was so shameful … Doing it using medication was by no means an easy way out. (i4)

Most of the women expressed a desire to move on with their life; they did not want work through the experience with a health care worker or anyone else. To them, moving on meant actively avoiding thinking or talking about the meaning of either the pregnancy or the subsequent abortion.

(T)he more I have to relate to it, the more I need to make a deliberate choice, the more I need to realize that I’ve removed and rejected a child. I’ve killed a fetus … I didn’t really want to accept what I’d done. The simpler this process was, the less fuss there was around it, the less I needed to relate to it and internalize it. (i12)

They described the abortion as an event that was somewhat disconnected and isolated from their life. “It has almost become a separate chapter in that phase of my life that I think in a way I may have pushed it to the back of my mind” (i9). Yet they struggled to emotionally distance themselves from the abortion. The women in our study described revisiting and reflecting on the abortion and its meaning and impact on their life after some time, often years later. They described confronting feelings of grief, guilt, and shame or thoughts about the child that could have been.

I’ve continued to dwell on it. For example, I calculated … when the due date would have been … and that’s when it became a bit painful, because …that made it kind of more real, that this … actually could have been a child. So, I made it more painful for myself … tried not to engage with it, but it’s difficult not to … I have nothing to be ashamed of, try to sort of … both justify this to myself, and assure myself that this was the right choice, … and … and … try to tell myself this. (i15)

One woman who later found it difficult to have children felt that this was a punishment for her earlier decision to remove a healthy fetus. Some of the women said that they had not struggled emotionally with the decision to terminate their pregnancy. Nevertheless, they still reported feeling the social stigma and keeping the abortion secret from most of their friends and family.

It’s very shameful … Both that they [friends] should think of me as a person who has had an abortion … I’m also afraid that maybe they have one attitude on the outside and another attitude privately … That they will look at me differently, as a child murderer, or something. And I’m also afraid that they won’t be able to keep it secret. (i15)

Most of the women directly or indirectly expressed that being confident that they made the right choice did not prevent them from reflecting on the moral and ethical dimensions of abortion with the accompanying painful and difficult feelings.

It’s a quite natural part … of, like, all human actions … that we choose something, and we sort of need to explore it and recognize the consequences of it, emotionally too. But, you feel sad, and it’s hard, and quite simply it’s difficult to think of that action, that you put an end to a life that could have been. (i21)

Discussion

Through our phenomenological study on women’s experiences of carrying out medical abortion, we found that the women presented abortion as a logical and sensible choice, but at the same time expressed doubts beneath the surface. They performed the abortion in secret, yet with the dubious comfort of hidden shame. Using emotional distancing as a coping strategy, they aimed to protect themselves from shame, guilt, and grief. After the abortion the women wanted to move on with their life, but they found themselves revisiting the meaning of the abortion.

Biological imperatives, subjective will, and morality

The women felt that their life was suddenly halted by the unplanned and unwanted pregnancy. They felt conflicted, experienced a lack of control over their body, and were distressed by the thought of the independently developing embryo in their womb. As conveyed by Beauvoir (1974/1949), the female body, through its reproductive functions, the onset of menstruation, pregnancy, birthing, and breastfeeding, is a recurrent reminder of our biology and intimate connection with nature. Most of the time, our biological bodies are invisible to us and our focus is on projects out in the world. We “live” our bodies as mediums or openings onto the world (Merleau-Ponty, 2012/1945). However, whenever our corporality becomes an obstacle, we are suddenly taken aback, focusing on our bodies more as resisting objects that restrict our access to the world (Koukal, 2019; Leder, 1990).

In pregnancy, women are subject to the forces and pull of biology as the seed of life grows inside them, which disrupts or changes their corporality and can make them feel in conflict with themselves (Koukal, 2019). Pregnancy takes place in women’s bodies, but it can still be felt as “not theirs” in the sense that it has a “strong hold” on them (p. 7). In terms of their embodied selves, the unwanted pregnancy and independently developing embryo/fetus represented something other or alien, from which the women in our study wanted to emotionally distance themselves.

Phenomenologically understood, both pregnancy and abortion involve a sense of de-subjectification, alienation, and objectification of self, where a woman feels identified with and reduced to her biological body as one of many belonging to the female human species. Sartre (1993/1943) points out that as human beings we have a dual nature as we are both subject and object for ourselves. We are grounded in and dependent on our factual bodies. We can, however, never be reduced to our biological nature, as we can also consciously reflect on ourselves as beings; consciousness is “being-for-itself” reflecting on “being-in-itself” (Sartre, 1993/1943). In Sartre’s words, a significant hard facticity (the pregnancy) has entered the women’s life, which they must choose whether to accept or reject, which will have consequences far beyond the pregnancy. Most of the women in our study felt that the abortion process disturbed their sense of self as a woman and was a lonely, frightening, and painful experience that raised ethical and existential questions. According to phenomenology, our intentional subjectivity frees us to make our own choices and enables us to separate ourselves from the destiny of biological chance and the laws of nature (Beauvoir, 1972/1947). The women in our study used this freedom and took action to regain their embodied selves and former lifeworlds by terminating the pregnancy. However, this freedom from nature comes with a moral responsibility. Moral consciousness exists only to the extent that there is disagreement between nature and morality. It would disappear if the ethical law became the natural law (Beauvoir, 1972/1947, p. 10). This moral responsibility weighed heavily on the women, and they described conflicting feelings and thoughts about terminating the pregnancy. They felt troubled by the act of ending “a life” and disturbing the natural process of procreation, questioned themselves, and felt pressured to defend their choice of abortion. They worried about the consequences of their choice and whether they would have regrets in the future.

Social constitution and subjective transcendence

The women in our study described a self-protective resistance to integrating the cultural meanings of pregnancy and the ensuing act of abortion into their life history and identity. They protected themselves by distancing themselves psychologically and emotionally. This meant minimizing the meaning of the situation by keeping the abortion a secret and avoiding thinking about and feeling it through their current predicament. As people, we do not live in a vacuum; rather, we are subject to strong influences by social and cultural norms and regulations. The fact that there is a time limit for legal abortion means that the pregnant body is, in an important sense, also owned and controlled by society. These regulations and social norms become further entrenched when they are aligned with the powerful forces of factual biological imperatives that pregnancy represents (Koukal, 2019). Our lived world is not entirely self-constituted: it is a common world that is in essence intersubjectively co-constituted (Husserl, 1973/1931). We are born or “thrown” into a world already filled with sedimented social meanings (Heidegger, 1996). We can experience these sedimented meanings as cultural ideals that help shape the way we regard ourselves and our identity (Koukal, 2019): In the guise of prenatal care and broader cultural conceptions of maternity, social power literally—not metaphorically—moves through pregnant body subjectivities. (p. 12)

Through our intentional consciousness, we can achieve a reflective distance from these cultural meanings and opt to accept or reject them. However, even when we reject them, these social norms still have a strong hold on us and the formation of our embodied self-identity. Indeed, the women in the study experienced the sociocultural, intersubjectively divisive meanings of abortion as painful, as they felt shame and the impulse to hide and protect themselves. Maintaining secrecy around their pregnancy and abortion was felt to be important to protect them from judgment. Talking with health professionals about their situation unfortunately tended to augment feelings of shame. The desire to protect oneself from anticipated stigma by maintaining secrecy and personal distance when seeking abortion services has been described by researchers in several previous studies, including from North America, the United Kingdom, Mexico, and South Africa (Cockrill & Nack, 2013; Gresh & Maharaj, 2011; Sorhaindo et al., 2014).

Abortions, social norms, and identity

The women in this study described fear of being negatively defined as “the type of woman” who has abortions, which involved both a sense of de-subjectification and an identity crisis. Thus, phenomenologically speaking, our sense of identity is tightly interwoven with our past. “The past is precisely and only that ontological structure which obliques me to be what I am from behind” (Sartre, 1993/143, p. 172). We are born, develop, and live within a culture with higher order intersubjective narratives concerning women’s sexuality, social roles, pregnancy, and abortion. Our study indicates that internalized and anticipated stigma around abortion is still a powerful force shaping the experience and identity of modern Norwegian women. For the women in our study, this implied that it was the health professionals who yielded the power during the appointments at the hospital, in which they felt vulnerable, exposed, objectified, and judged. They wanted to escape anticipated judgment and negative objectification by others.

Minimizing the meaning of the pregnancy

The women in this study all described struggling to distance themselves emotionally from their abortion and to diminish its meaning, as well as that of the pregnancy. This distancing had two functions for the women. Firstly, it guarded against feelings of shame and guilt connected to perceived negative socio-cultural meanings. Secondly, it counteracted their inclination to invest the pregnancy and their potential motherhood with meaning. Thus, they avoided thinking about the pregnancy and giving it meaning to protect themselves from shame, guilt, and grief. From an existential-phenomenological perspective, we actively choose our attitude toward the world and how to emotionally react (Sartre, 1962/1939, 1993/1943). According to Sartre, emotion is a mode of existence, or a way of being in and apprehending the world. The women tried to change their painfully divisive predicament by conferring a lesser presence upon the pregnancy, seeing it as “less real.” Through what Sartre calls “magical behavior,” they sought to diminish the meaning of the pregnancy, making the choice for abortion less painful. “Consciousness does not limit itself to the projection of affective meanings upon the world around it; it lives the new world it has thereby constituted – lives it directly, commits itself to it, and suffers from the qualities that the concomitant behavior has assigned to it” (p. 78). The women wished to flee from the factuality of their pregnancy and abortion, but doing so somehow risks giving it more power, or “magical” reality. Because the cultural meanings of pregnancy and the choice to terminate were constituted by the women, fleeing from these meanings only meant being more captivated by them. According to Sartre, we normally do not reflect on this self-captivation; rather, we attribute these meanings to “objects” in the world, in this case to the pregnancy and the abortion.

Resolution through authenticity

Some women were able to partially resolve their conflicting feelings by terminating the pregnancy and thereby eliminating the problem (unwanted pregnancy and motherhood) and emotional situation. For others, the absence of the aborted child was present in their thoughts years after the abortion alongside feelings of guilt, shame, and grief. Cockrill and Nack (2013) found in their study that shame-induced secrecy when performing an abortion may result in a lack of emotional support and increased psychological distress and social isolation. For most of the women in our study, resolution was achieved by reflecting on and establishing a new relationship to their pregnancy and subsequent abortion, often years later. This involved acknowledging the facticity and working through the meaning of the pregnancy and the abortion while taking responsibility for their choices or, in Sartre’s (1993/1943) terms, being authentic. It was important to reflect on their situated choice and the sociocultural meanings of abortion, without conferring upon themselves enduring personal qualities as “a certain type of woman.” Most of the women felt that they had made the right choice and did not regret the abortion, but at the same time emphasized the importance of acknowledging complex, paradoxical, and ambiguous feelings. Looking back, they realized that they could have used someone to talk to who did not objectify them and who could have helped them navigate and reflect on the complex emotional and social situation they unwillingly found themselves in, and reduce their feelings of shame and guilt. This finding concurs with a previous study by Kjelsvik et al. (2019) on women’s experiences of decisional ambivalence pre-abortion, where they found that women, despite considering themselves autonomous and responsible for their choice, still expressed a need to involve health care personnel in their decision.

Participants in the politicized debate over abortion have regrettably simplified and overinterpreted women’s reactions to abortion as either relief or regret, leaving little room for complex, paradoxical, and ambiguous emotions. As Reardon (2018) has pointed out, this extends into academia, where researchers have tended to either minimize or emphasize mental health risks, depending on their personal convictions on abortion. In our findings we found support for a more comprehensive perspective that honors women’s often complex emotional reactions connected to performing an abortion. Most importantly, the women in our study expressed the need for personalized and empathic care from health personnel, which could reduce feelings of shame and guilt. An open and non-judgmental attitude that invites women to share their thoughts and feelings and reflect on the complexity and ambiguity of their predicament is recommended. Pregnancy and abortion have important existential dimensions, and health professionals could use the insights from existential phenomenology in their practice. We acknowledge that our research was conducted on a small sample in Norway, which may limit the transferability of our findings. Further research on women’s experiences of home medical abortion is needed, especially in other geographical and cultural contexts.

Conclusion

Abortion is a complex and ambiguous phenomenon with important personal, social, ethical, and existential dimensions that are deeply felt by women. As a coping strategy, the women in our study distanced themselves psychologically and emotionally from the pregnancy and the abortion. To reflect authentically on the meanings and implications of abortion involves a courageous and emotionally painful effort on the part of the affected women. Encountering a distant professional and instrumental attitude from health care workers may make it more difficult for women to recognize and address these meanings, deepening their sense of de-subjectification and emotional distancing. The tendency of participants in the political debate to overinterpret or oversimplify women’s reactions to abortion as either relief or regret, may hinder honoring their experiences and need for personalized and empathic care.

Declaration of conflicting interests

The authors declare that there is no conflict of interest.

Funding

The author(s) reported there is no funding associated with the work featured in this article.