Full thesis on Abortion and Mental Health

Here’s the full thesis, copy and pasted from word and excel –  I’m not sure how to format it properly on wordpress so it may be tricky to read in parts!
“It’s amazing what women will put themselves through”. An exploration of Irish women’s abortion experiences from the viewpoint of their reproductive health counsellors.

Thesis presented as part of the requirements for the BA in Psychology, University College Dublin.

Submitted May 2013
Table of Contents

Abstract ii
Acknowledgments iii
Overview of the Research Project iv
Literature Review v
The present Study x
Methods xi
Results xiii
Discussion xxviii
Conclusion xxxiii
References xxxiv
Appendix A xxxviii
xxxix

Appendix B xlii
Appendix C liii
Abstract
Issues surrounding women’s experiences of abortion have been widely studied internationally in the field of psychology. However, there is very little data around abortion experiences in the Irish context. This qualitative study interviewed four counsellors specialising in pre- and post-abortion counselling in Ireland (where abortion is illegal) regarding the experiences of the women and girls they counsel, and how the Irish social context of abortion impacts on their client’s experience. Data was analysed both inductively and deductively using thematically coded analysis. Results indicate that counsellors believe that restrictions on abortion do not deter women from seeking abortion, but that the barriers and obstacles in place impact negatively on women’s emotional response to their experience. Secrecy, stigmatization and denial of abortion in the public discourse also negatively impacts on Irish women. In addition, women who cannot travel abroad procure unsafe abortions in Ireland. Suggestions for future research, implications for women’s healthcare and the impact of illegality of abortion on women in Ireland were discussed.
Acknowledgments
I am very grateful to the staff of the Irish Family Planning Association and the Well Women Centres Dublin for their assistance with this project. I would like to thank Geraldine Moane and Suzanne Guerin of University College Dublin for their added support. I would particularly like to thank my supervisor, Mimi Tatlow-Golden, for her continuous patience, advice and support.
Overview of the research problem
For almost half a century, issues surrounding abortion have been widely studied internationally in the field of psychology, particularly in the United States after abortion was legalised in 1973 (Dagg, 1991). However, there is very little data in relation to abortion and the experience of abortion in the Irish context. Although many feminist scholars have documented Irish women’s experience of abortion and analyzed the socio-political struggles around reproductive rights in Ireland (Oaks, 2002) and there is also some statistical data available in relation to the number of women who avail of abortion, there is very little data regarding Irish women’s experience of abortion. In particular, there is minimal information on Irish women’s reasons for choosing abortion, their views on abortion, and their psychological reactions to the experience of having an abortion.

Ireland’s abortion policy remains the most restrictive in the European Union (http://www.ifpa.ie). With attention seen in few other European countries, activists, legal experts, politicians and Irish citizens have vigorously debated abortion and its meaning in Irish society and in Ireland’s health policy since the early 1980’s (Oaks, 2003). At a time when abortion is once again high on the political agenda and is still classed as a criminal act in Ireland under the 1861 Offences Against the Person Act (Kelly, 2003), this research aims to address the experiences of Irish women who avail of abortion.

Literature Review
Due to the illegality of abortion in Ireland, more than 4000 Irish women travel overseas each year to avail of the procedure (http://www.ifpa.ie). According to Sedgh and colleagues, constraints on accurately measuring abortion levels have become more prevalent over the years where private sector abortions, medical abortions, and the stigmatization of abortion have become more common, as all these factors tend to increase the level of underreporting (Sedgh, Singh, Shah, Åhman, Henshaw & Bankole, 2012). However, according to the UK Department of Health, between 1980 and 2011 at least 152,061 women living in Ireland have travelled to England and Wales to access safe abortion services (http://www.dh.gov.uk). According to statistics compiled by the Crisis Pregnancy Programme 1,470 women travelled from Ireland to the Netherlands from 2005-2009 to access safe abortion services (http://www.ifpa.ie). Indeed, worldwide, women who wish to terminate unwanted pregnancies will seek abortion at any cost, even when it is illegal or involves risk to their own lives (Sedgh et al., 2012).

In addition to the statistics relating to abortions obtained in a clinical setting, evidence from various countries, including some with highly restrictive abortion laws, suggests that the use of the drug misoprostol as an abortifacient has been spreading (Sedgh et al.: 2012) and there are a number of known websites which provide Irish women with this drug (http://www.ifpa.ie) Although clandestine medical abortions are likely to be of lower risk than other clandestine abortions (Sedgh et al., 2012), there is substantial variation in medical abortion regimens used illegally, and complications such as prolonged and heavy bleeding and incomplete abortions are associated with use of incorrect dosages. Therefore, these procedures are on the whole classified as unsafe (Sedgh et al., 2012). Studies from the World Health Organisation repeatedly show that restrictive abortion laws are not associated with lower abortion rates, and in fact the abortion rate is lower in regions in which women live under liberal abortion laws, but restrictive abortion laws do lead to greater numbers of unsafe abortion (Sedgh et al., 2012). This is possibly true of the Irish context, with Irish authorities seizing 1’216 abortion tablets in 2009 alone (Browne, 2013). This may suggest that the actual number of abortions Irish women are having is much higher than those indicated by the figures presented by the NHS.

There are very few psychological studies regarding Irish women’s experience of abortion. Irish women’s voices are not being heard on the subject, and the intertwining political, religious, societal and legal factors that contribute to this problem have been presented by some scholars in the last twenty years. In her 1995 article for the Feminist Review, “Silences: Irish Women and Abortion”, Ruth Fletcher interviewed 5 Irish women about their abortion experience. It considered the forces which act to prevent women in Ireland from speaking up about their experience of abortion and the various forms such silencing takes (Fletcher, 1995). It also considered the complexity of feelings and circumstances which women who have had abortions are subject to. In the Irish context, according to Fletcher, women feel frustrated about lack of space in the public forum for the voicing of the complexity of their experiences. The polarization of the public discussion of abortion has inhibited women from naming the complexity of their experiences, and some of the women interviewed expressed themselves as being caught in a vicious cycle: they felt that they would not be free to voice their experiences of abortion until the public perception changed, and yet they felt that the public perception of abortion would not change until women’s voices were heard (Fletcher, 1995).

As in the Republic of Ireland, abortion is illegal in Northern Ireland. In 2010, the UK department of Heath recorded abortions of Northern Irish residents in England and Wales as 1’110, and Republic of Ireland residents at 4’378 (http://www.dh.gov.uk). The statistics are similar in relation to the number of women travelling for abortion compared to population size, although it is to be noted that abortions occurring in Scotland are not listed. A qualitative study of seven Northern Irish women who had to travel to Britain to obtain an abortion revealed strong links between the women’s experience and the very negative public constructions of abortion in Northern Ireland (Boyle & McEvoy, 1998). These constructions are very similar to those in the Republic (Oaks, 2002). The study discusses the implications for the lack of discourse around social context issues in abortion studies.

The majority of studies show that abortion does not cause psychological distress for most women. A meta-analysis of 225 studies showing the adverse sequelae (e.g., distress, dysphoria) that occur in a minority of women seem to be the continuation of symptoms that appeared before the abortion (Dagg, 1991). More recent studies show that negative responses to abortion are mostly social. Kimport, Foster, and Weitz (2011) found that two social aspects of the abortion experience produced, exacerbated or mitigated respondents’ negative emotional experience. Negative outcomes were experienced when the woman did not feel that the abortion was primarily her decision (e.g., because her partner abdicated responsibility for the pregnancy, leaving her feeling as though she had no other choice) or did not feel that she had clear emotional support after the abortion. The study concluded that experiencing decisional autonomy or social support reduced respondents’ emotional distress (Kimport et al., 2011).

Kimport and colleagues findings are mirrored in the study by Boyle and McEvoy (1998) of women’s experience of abortion in the Northern Irish context. It discussed the role of the Northern Irish social context in influencing women’s responses, and the lack of social support available to these women (Boyle & McEvoy, 1998). The study aimed to provide an exploratory analysis of the relationship between social context and the psychological experiences of women who travel from Northern Ireland to Britain to obtain abortions (Boyle & McEvoy, 1998). The three major areas covered were deciding to have an abortion, travelling overseas for the abortion, and perceptions of future reactions to the abortion. For each area, the interviewer explored the ways in which the woman’s social context of living in a country where abortion is illegal and having to travel overseas was seen by the woman to have influenced her experience of abortion.

As discussed, social support has been deemed as a strong factor in influencing women’s psychological responses to abortion. This has been reiterated in much psychiatric and psychological research (Adler et al., 1992; Zolese and Blacker, 1992), with research finding that “the majority of studies indicate that the psychological consequences of abortion are mild and transient, but there is evidence that women who have strong religious or cultural attitudes negative to abortion do experience high levels of psychological stress following abortion” (Clare & Tyndall, 1994). Despite the legal and cultural obstacles discussed, the women interviewed in Boyle and McEvoy’s 1998 study gave reasons for abortion akin to those given by women in the United States, where abortion is legal: lack of money or resources for raising a child, commitment to education or work, and concern for other relationships (Torres & Forrest, 1988). These same factors recur as the predominant reasons for abortion in more recent studies (Finer, Frohwirth, Dauphinee, Singh & Moore, 2005). However, the Northern Irish women who travel to England for abortions are situated within the conflicting dominant public definition of abortion as murder or, at least, as wrongdoing, and their own subordinate private construction of it as necessary for them at that time (Boyle & McEvoy, 1998).

The level of secrecy which Northern Irish women felt was demanded of them may have important implications for access to medical services after the abortion. Boyle and McEvoy (1998) also discussed the data from the Belfast Family Planning Association (Furedi, 1995) which indicated that some Northern Irish women do not access appropriate aftercare because this would involve revealing that they had had an abortion. Through qualitative research with seven northern Irish women who had had abortions, the authors concluded that while their findings reflect the bulk of research regarding the psychological issues surrounding abortion, in that abortion in itself is not emotionally damaging, the difficulties faced in relation to abortion are intensified in the Northern Irish context where abortion is illegal. This is because of the dominance of the public definition of abortion with its related social practices and stigmas, and through a corresponding decrease in the women’s power to choose and impose their own definitions (Boyle & McEvoy, 1998).

More recent research suggests further problematic aspects of obtaining abortion overseas with an unknown healthcare provider (Logsdon, Handler & Godfrey, 2012). The delivery of abortion services in a specialized, unfamiliar clinic could be perceived as disadvantageous as it relates to patient care because, to the extent that women have a medical care home, it reflects a disruption in the relationship between a woman and her regular primary healthcare provider. In addition, the integration of early abortion services into primary care practice may increase continuity of care among women seeking an abortion, and perception of judgment from the regular health care provider may also prevent women from disclosing a previous abortion, causing a disruption in continuity of care (Logsdon et al., 2012).

In Mexico City, abortion was legalized in 2007. However, as in Ireland, abortion remains illegal in the rest of the country. Studies have been conducted in relation to the obstacles facing women outside of the city when having to travel long distances for abortion, with findings suggesting that place of residence was reported as an obstacle by participants, with travel costs being part of the issue (Becker, Diaz-Olavarrieta, Juarez, Garcia, Sanhueza Smith & Harper, 2011). Difficulty arranging transportation was more commonly reported by less-educated and unmarried women (Becker et al., 2011). This may be a very pertinent study in relation to abortion in the Irish context, with costs centring around €1000 for a woman to obtain an abortion in the UK, including flights and accommodation as well as the procedure itself (http://www.ifpa.ie).
The present study
The present study aims to reproduce some of the work done by Boyle and McEvoy (1998) in the context of the Republic of Ireland by focusing on the themes which arose in their research. This research was chosen as it is a qualitative study regarding the Irish context, as is the present study. It will also raise the questions that arise in the above mentioned studies by Becker et al (2011) and Logsdon et al (2012) in relation to the Irish situation of the necessity for overseas travel to access abortion. It will be a qualitative study in which interviews are held regarding Irish women’s abortion experiences. However, for ethical reasons, the interviewees will be counsellors specialising in women’s reproductive health, as opposed to women who have had abortions. The present study will explore counsellor’s views of the reasons Irish women choose abortion, along with what obstacles, if any, women describe in obtaining their abortion; their feelings about the abortion they obtained; and their views on accessing medical and/or psychological after-care in Ireland. The study will also explore counsellors’ experience of women’s reasons for choosing to take illegal abortion pills at home in Ireland rather than travelling abroad to obtain the abortion via a clinical procedure. The study also aims to explore the ways in which the Irish social context affects Irish women’s abortion experience.

Methods
Research Design: In the present study, a qualitative design using a questionnaire was used. Open-ended questions were thematically coded and theme frequencies were coded across the data set. The analysis was both inductive and deductive, and was approached from the realist method, which reports the experiences, meanings and the reality of participants (Braun & Clarke, 2006). Interview questions were composed deductively through the literature presented in the above review. Particular attention was paid to issues arising from the social context of abortion in Ireland, in line with the data presented in the research by McEvoy and Boyle (1998). In addition, potential obstacles relating to travelling for abortion were discussed, in light of the research presented by Logsdon, Handler and Godfrey (2012) and Becker and colleagues (2011). Counsellors were also tentatively asked about women talking abortion pills, as per the study by Sedgh and colleagues (2012) that use of the abortion pills has been spreading.
Participants: Participants comprised of four female qualified psychotherapists working as reproductive health counsellors. Ages ranged from ranging 42 to 56 years of age. Two counsellors are employed with a national family planning clinic while the two other counsellors are employed with a national women’s healthcare centre. Both organisations offer pre and post abortion counselling. Two participants identified as having no religious affiliation, one identified as a non-practicing Catholic and the other as Church of Ireland. Years of counselling experience ranged from five to twenty, with period of time spent working specifically in women’s reproductive health counselling ranging from seven months to sixteen years.
Materials or Apparatus: A question sheet and a Dictaphone were used. Data was then stored on the researchers password protected hard-drive and deleted from the Dictaphone.

Procedure: Participants were contacted via email, through the Directors of counselling at each organisation. Once the directors approved of the study they allowed their employed counsellors to be contacted directly. Interviews were then arranged over the phone, and took place either in their place of work or a coffee shop nearby. The interview was then recorded on a Dictaphone. Interviews lasted approximately 45 minutes. Recordings were then transferred to a laptop for manual transcription. Once the data was transcribed, the recordings were transferred to a password protected hard-drive.
Ethics: The participants were briefed on the interview process and were then required to sign a consent and confidentiality form (Appendix C) before the interview began. Due to the illegality of the taking of abortifacients in Ireland, counsellor’s comments relating to clients taking these drugs had to be quite vague.
Results:
The first part of the analysis involved numbering data extracts from the interviews which answered the questions posed, along with inductively gained data which presented other information which occurred spontaneously. These data extracts were then grouped into codes, including descriptions of women’s experiences such as; reasons for abortion, emotional responses, attitudes, reasons for seeking counselling and obstacles created by travel. A second researcher analysed an interview independently to generate codes as well as higher-level themes where codes clustered meaningfully. After discussion with this researcher, codes were brought down from 84 codes to 76 (see Appendix A) by amalgamating recurring or similar codes. Themes arising from the analysis (e.g. societal attitudes; the counsellor’s experiences of their clients) were then applied. Finally, the themes were re-examined by both researchers and were brought down from 22 themes to 16 (see Appendix B). Themes are highlighted below in italics, while each of the four counsellors interviewed are indicated in brackets beside their quotes as C1, C2, C3 and C4.

The counsellors
The counsellors experience of their clients:
The analysis found that it was the counsellor’s experience that women do not go into the decision of abortion lightly:
“In my experience, nobody goes into abortion lightly, I really don’t think that”. (C1)
They also believed that if a woman seeks an abortion, nothing will stand in their way;
“They will always find the money”. (C4)
“It’s amazing what women will put themselves through”. (C1)
While counsellors believed that stigma plays a very large role in the Irish abortion experience, the act of talking about abortion can reduce stigma for the women:
“More and more women are telling their partners by virtue of coming in and I think that’s helping, it’s decreasing the stigma”. (C3)
It is also the experience of the counsellors interviewed that the negatives surrounding public discourse are not what counsellors hear from their clients:
“The negative feelings aren’t around the abortion. Those adjectives that are thrown around about abortion are not what we hear; it’s around other issues that arise in their lives that are maybe connected in some way in a deeper unconscious level around the abortion, around the pregnancy, around their own being”. (C1)
Counsellors also find that the client gets lost on the Irish political debate:
“I think it’s the black and white of it. When you have those extremes, there’s no allowance in those extremes for the client. Those two sides always make me say ‘does anybody know about the client here? Does anybody hear the client’s stress? Does anybody see the crisis of this person?’” (C1)
“They don’t have choices and they’re told they shouldn’t have choices and it seemed to go against the support for a human being” (C1)
The abortion counsellor’s work is extremely compacted:
“The client is in crisis when they come in. It’s extremely compacted work and it’s impactual. You’re getting the beginning, middle and end in maybe one or two sessions. You don’t have the pleasure or the ease to work with someone over twenty sessions”. (C3)
While counsellors cannot discuss clients who have used abortion pills in Ireland due to its illegality, they do say in their experience, Irish women are indeed seeking and using illegal abortion pills:
“If the client brings that into a session we have to be very mindful, because we want them to get a safe procedure” (C4)
“The medical council and customs seized over a thousand a few years ago. So that’s only the tip of the iceberg. I’d say the people who have taken it and have for want of a better word, successfully had an abortion I don’t think we’ll even see them, they won’t be on the radar.” (C1)

The counsellor’s emotions
Among the challenges counsellors face in their role, the most challenging that arose for them is that of women whose foetuses have fatal foetal abnormalities:
“The most challenging clients are the ones that find out they have a foetal abnormality because they’re often very much a planned wanted pregnancy. That challenges me and they’re often very late decisions within the pregnancy.”(C3)
There is great satisfaction in the job in that the counsellors feel that they are helping women by seeing them through the process:
“It’s very satisfying if you have a number of sessions with women, that you can follow them on that journey, that you can support them”. (C1)
However, the counsellors voiced anger and frustration with the current legal and social barriers that their clients face and find it challenging to manage these emotions during their sessions with the client:
“In the counselling context that can be frustrating because I’m also trying to manage my own emotions as well as the woman’s emotions. The social context surrounding everything, my anger and frustration is there and that’s part of the job that can be challenging.” (C1)
“The biggest thing is the emotional reasoning around this that it’s just not going to go away, nothing is going to make it ok. Even if all the laws supported it totally, the govt drives me mad with dragging their heels, these laws might change yet somebody who has been raped or there’s been incest, none o this is being dealt with either.” (C3)

The counsellors
The counsellor’s role and the goals of counselling
Counsellors see their role as one of facilitation – helping the client to understand their own feelings around their experience:
“You’re teasing out any ambivalence in a non judgemental way.” (C1)
“Helping someone to unravel what’s best for them outside of what others may have said” (C3)
In pre-abortion counselling, many clients have already made up their minds regarding what choice they will make regarding their crisis pregnancy:
“In some cases women may just have one session, they’ve made their decision” (C1)
Supporting the client’s autonomy and choices is very important in the counselling process:
“It became terribly important to feel that I was supporting them in their own choice and autonomy” (C3)
The counselling process allows the client to come to understand themselves and their feelings:
“Seeing them come to hear themselves, acknowledge themselves within the crisis” (C3)
The role of the counsellor is a supportive one, and the goal of the counselling sessions is to make the client feel supported, whatever decision she makes:
“There’s more knowledge, less ignorance, less panic. I’ve seen people come in and they’re really, really panicked and I think they’re very panicked about what I’ll be like, can I support them, or am I going to turn into some demon is telling them what they should and shouldn’t do. Those negative feelings can become very overwhelming, and become misplaced.” (C3)

Counsellor’s attitudes and views regarding abortion
All counsellors interviewed believe that women would have a more positive emotional response to abortion if it was available in Ireland. They believe it should be legal to appease this problem and are frustrated that it is unavailable in Ireland:
“It would lessen the impact if they didn’t have to travel”. (C3)
“I think if it was legal here it would give the women more time to think about what they wanted to do.” (C4)
“They would accept it quicker”. (C4)
“There would be less trauma.” (C4)
“It absolutely impacts on them that they have to travel.” (C1)
Counsellors believe that women do not have choices in Ireland due to the legal restrictions:
“They don’t have choices” (C3)
“They’re told they shouldn’t have choices and it seemed to go against the support for a human being, women in crisis and what you could do.” (C3)
While counsellors feel that the Irish medical profession is in a grey area that needs clarifying, the still hold that the proposed legislation for abortion under certain circumstances does not deal with the reality around abortion and women’s needs:
“Our medical profession is in a grey area that needs to be sorted” (C2)
“There’s still this blanket way of dealing with things in Ireland” (C3)

The clients
Backgrounds of the clients
There is a complete variety in the women that present for abortion counselling, across age, education level, relationship status and socio-economic status.
“From low incomes to high incomes; Women would have only done primary school education to women who are seriously working in high professions. It doesn’t discriminate” (C4)
“Youngest I’ve seen is 13 and oldest is 49 and the reasons for the crisis pregnancy are so, so mixed” (C3)
Counsellors also find that whether women identify as “pro-life” or “pro-choice”, their attitudes can change when they are faced with their own crisis pregnancy. They become more understanding of the complexity of abortion choices and may make decisions they did not expect to:
“Some of them who would have been very anti abortion, or wouldn’t have really thought about it, just were against it, kind of suddenly think well Jesus, I’m in this situation now, there’s obviously other women in this situation”. (C1)
“This is people who might have said they didn’t agree with abortion, and until you have a crisis pregnancy that belongs to you you’ve no idea how it might actually feel about it.” (C3)
“People, who are pro-choice, often feel when they have an unplanned pregnancy that they can’t actually terminate”. (C3)
“You’ve got to feel it to live it really.” (C3)

Client’s reasons for choosing abortion
According to counsellors, the reasons women chose abortions are varied and multi-layered. Many reasons that are cited frequently include lack of finances, lack of support, failed contraception, ill health, cases of rape, and letting the family down. What seems to present very frequently is the timing in life, and that women are just not ready to have a baby, or in many cases, another baby:
“The financial restrictions” (C1)
“Even people who might already have children, be married, but they just cannot afford to have another child” (C3)
“We have some women whose relationship has broken down and they don’t think they can go through it alone.” (C1)
“The timing in their life or in the circumstances in which it happened.” (C1)
“It’s hard to pin down because sometimes the women may not say the reason, they may not explore that enough, but I would say it’s just multilayered.” (C1)
“Failed contraception” (C3)
“Occasionally people have raised the possibility of rape” (C3)
“Letting the family down” (C3)
“Their doctor would have told them to never get pregnant again because their heart would suffer. So they travel.” (C4)
“Small percentage with mental health, but they’ll travel anyway” (C4)
What clients are looking for in counselling
Counsellors said that women are seeking non-judgemental support and accurate information regarding their options:
“Looking for non judgement”. (C1)
“For someone who can give this accurate information, and when they get that they’re very content and quite relieved and that’s very satisfying”. (C1)

Women’s reasons for, and needs, in counselling
Counsellors views were that for many women, counselling is about coming to terms with and accepting their decision to terminate a pregnancy:
“Then you can talk about the reality of it, and the reality suddenly becomes more bearable. And the illusion lessens a little bit. They cope better with the idea of what they went through. I hope so.” (C3)
“I think they hit blips where they may feel that they’ve made the best decision but then something triggers the response of not being as sure of their decision as they felt. So they get a bit ungrounded.” (C3)
Their reasons are complex and varied. Counsellors say that the distress of the client is often not about the abortion however, but instead it is around external issues around the abortion, such as relationship problems and other life events:
“Their own set of circumstances, and their own uniqueness, what they bring to the session. There’s layers of complexity there that are colouring the session that we have to manage.” C1
“There’s also all sorts of other issues around it, it’s not just around the abortion it’s all around decision making, the ambivalence” (C1)
“In general the women that we would see or hear from, if they’re coming back with their story on abortion, it is usually around other life events that have brought some symptomatic feelings to the fore. That’s not necessarily regret.” (C3)
“The circumstances around the abortion and the relationships relating to the abortion can be a trigger; it might be a relationship issue rather than an abortion issue”. (C3)
“The abortion can be kind of like a catch all for everything that goes wrong, and that’s not necessarily true.” (C3)
Issues surrounding side effects
Some women have medical side effects and need physical aftercare. However, due to the illegality of abortion in Ireland and the secrecy surrounding it, counsellors believe that women may lie to hospitals or their GP about having had an abortion.
“When they do come back in a number of weeks they might have a medical issue, a side effect issue”. (C1)
“They could present at a hospital and pretend that they’re miscarrying, and the symptoms would appear very similar, there might not be any knowledge that they had taken anything, so it could be treated as a spontaneous abortion. They are still then in the records system as having had a pregnancy and a miscarriage, and some people don’t want that on file”. (C3)
The client’s attitudes
According to counsellors, the majority of women who terminated their pregnancy felt that it was the correct decision for them, and that their experience was positive. While some women do have difficulty, most are able to move forward with their lives:
“They made the best decision they could”. (C3)
“It was the right decision at that time of their life.” (C4)
“The majority of women come to that conclusion. There’s acceptance at the end really” (C4)
“The majority would say their experience was positive in as much as it can be” (C1)
“Some would put a lot of thought into that, and some would go get it done and be able to get on with their lives” (C1)
Some people are still unaware that it is legal for them to travel abroad to obtain abortion:
“There’s still a lot of people who don’t realise it’s not illegal to travel for the abortion, because under the 1861 Act it’s illegal to have an abortion here. It’s all linked” (C3)
Despite the anti-abortion propaganda and protesting in the country, it is not a deterrent for women who seek to terminate their pregnancy:
“Protesting doesn’t deter women; it makes it a little more vicious” (C1)
No woman wants to have to go through an abortion:
“I’ve never had anybody in the room who wanted to be here. Ever. Nobody comes in and says I’ve always been waiting to have an abortion”. (C3)

The client’s emotions
Counsellors hold that having to travel to obtain abortion creates added emotional difficulties for women seeking abortions:
“Sometimes the travel is more traumatic than the ending of a pregnancy”. (C4)
“It’s quite a long, arduous; it’s not just about getting on the plane and back. I think the women would say this is part of it, I’ve got to do it, taking time off work, having to make excuses, maybe not being able to tell anyone, the distrust, going under the cover of darkness. It contributes hugely to the anger and frustration around it, hugely.” (C1)
“There’s a whole cycle that’s very much perpetuated by all of those barriers and stigmatization. The more barriers that are there the harder it is.” (C1)
Religious beliefs can create an emotional struggle around a woman’s abortion:
“If they have a deep religious belief, especially with Catholicism, it’s shame and guilt. Guilt because you shouldn’t do it” (C4)
Relief is the most common feeling for women who have ended their pregnancy:
“Relief is a common feeling” (C2)
“Even though we see a lot of emotions, the overriding one is relief. That’s what we’re hearing.” (C1)
Women are presenting with anger and frustration due to the obstacles they are faced with when trying to obtain an abortion:
“They can’t believe that they can’t discuss it over the phone in this day and age.” (C1)
“The actual travelling absolutely, why do I have to do this, people get very frustrated and angry and some in disbelief in this day in age they can’t get it in their own country.” (C1)
Shame and regret are not emotions that often present in counselling:
“I don’t think shame presents often, I think it’s a word that’s bandied about but that’s not necessarily our experience. Or regret.” (C1)
Counsellors believe that termination of pregnancy can be a profound experience, and as with any issue in life, emotions around an abortion are complex and multilayered:
“Women don’t take the decision lightly; it’s something much more profound”. (C1)
“It’s very hard to pinpoint one particular negative feeling. We’re human, we’re complex beings, and it becomes enmeshed in something else” (C1)
Counsellors also hold that most women have the resilience and resources to cope emotionally after an abortion:
“Most have the resilience and the resources to be able to work through that and understand that, or have a partner that can support them.” (C1)
Irrespective of all the emotions that can occur around an abortion, according to counsellors, the actual termination of a pregnancy does not in itself appear to be emotionally damaging to the clients:
Overall, abortion in itself isn’t damaging.” (C3)
“Even though women are presenting with emotional issues, there’s always going to be one or two people, people who have chaotic lives before an unplanned pregnancy are still going to have chaotic lives after an unplanned pregnancy, it just becomes another part of the chaos.” “You’re going to always get somebody who has emotional issues, and then they have an abortion and it becomes part of those issues, but then the abortion could be used as the issue. But you could say the say about pregnancy; they could say the same about anything.” (C3)
Counsellors state that the idea of guilt is being pushed onto women by society:
They can feel guilt that they don’t feel guilty.” (C2)
“Should I not feel bad because I’ve done something wrong?” (C2)
“It’s like they’re feeling guilty for not feeling guilty. Because even though we see a lot of emotions, the overriding one is relief. That’s what we’re hearing.” (C1)
“Some people are very relieved. But that’s a difficult one to put out. There’s not a great tolerance towards relief “how can you be relieved you had an abortion”. It doesn’t fit. You’re meant to feel bad, just like every baby is wanted, every pregnancy is wanted, and so it doesn’t fit with society’s declarations.” (C3)
Secrecy is a very burdensome problem for Irish women who seek, or have had, abortions:
“It’s not just about getting on the plane and back. I think the women would say this is part of it, I’ve got to do it, taking time off work, having to make excuses, maybe not being able to tell anyone, the distrust, going under the cover of darkness. It contributes hugely to the anger and frustration around it, hugely”. (C3)
Fear presents as a frequently occurring emotion for clients. Women are afraid of divulging to their GPs that they want to terminate, or have terminated a pregnancy. They are also afraid that they are not getting the correct information in spaces outside of the IFPA and the Well Woman Centre. Because of the Irish legal restrictions on abortion, they may not seek aftercare and/or necessary medical care for fear of their abortion being discovered:
“That’s she’s not being given all the information that she requires. There can be fear that they may not, and that’s about perceptions as what they see the service as presented as.” (C1)
“They may be afraid to go and seek medical care afterwards because of the illegalities”. (C3)
“There’s a fear of divulging to their GP, there’s different rural areas, different attitudes. In some cases women come to us because they can’t go to their GP. I had a woman come up from Kerry. She didn’t even want to go in the county”. (C1)
Abortions required due to fatal foetal abnormalities are very distressing for the client in pre-abortion counselling:
“They’ve made a connection and then their world is literally turned upside down.” (C3)
Negative emotions present when women are coerced into the decision to have an abortion by other people in their lives:
“A lot of women that have a problem afterwards haven’t gone in to it really being their decision. Coerced by parents or boyfriends, when that happens it makes it much more difficult. Who haven’t gone into it really as their decision.” (C2)

The support that clients receive from family, friends and partners
Although women will often tell someone that they have had an abortion, it will usually just be one person. They will limit the people they tell about their experience for fear of judgment from others. There also seems to be an increase in partner and family support in counselling accompaniment:
“Most people seem to look for some support outside the room” (C3)
“Either the partner knows or one very close family member, or friend”. It’s all to do with fear of being judged, the stigma.” (C4)
“There certainly seems to be an increase in support, coming in with a partner or friend or mother or father.” (C1)

Issues facing migrant and trafficked women in Ireland

Migrant women face far more difficulties in obtaining abortion due to travel restrictions:
“The travel restrictions for migrant women. There’s a whole gamut of different restrictions that are put in place” (C1)
“New communities have visa issues, and access to visas, and the UK has clamped down an awful lot. Especially Nigerian people, they’re better off going to the Netherlands embassy. The procedure can take two to three weeks, but they also need a re-entry visa from Ireland, and that takes 4 days.” It can take 2 to 3 weeks for the couple to get all that information. That’s a long time in a crisis pregnancy.” (C4)
Because of the greater restrictions in place for migrant women, they are more likely to Migrant take risks and attempt unsafe abortion procedures:
“The new communities as well. Possibly bring over their own stuff” (C4)
“There’s a huge amount that goes on that we know nothing about in truth. I’ve counselled people who have had herbs sent over and it hasn’t worked” (C3)
“So they’ve ended up maybe having to travel eventually and then there’s issues with visas. It doesn’t allow them to go to England. Somebody who has refugee or asylum status might have no papers, it can take months. This creates more possibility of unsafe abortion, absolutely; I’ve no doubts about that, that stuff goes on. Back street abortions are still alive; I have come across one or two”. (C3)

The Irish Social Context
The emotional barriers faced by women
Travelling alone to another country to avail of a medical procedure is emotionally distressing for many women:
“The whole experience of having to travel, feeling very alone in it”. (C2)
“It’s a big trauma for them. Sometimes it takes them a while to open up, because it’s so traumatising for them. Sometimes the travel is more traumatic than the ending of a pregnancy”. (C4)
“Very impersonal, the fact that they’ve got to go to another country, there’s a difference, that’s it really, it’s a different country, you’re very alone” (C2)
Having to lie and keep secrets about travelling is also emotionally distressing:
“Not being able to tell people” (C2)
“Having to hide it, to tell lies about it -that would be all the kind of negative things.” (C2)
Whilst organising the logistics for an abortion overseas can be very stressful:
“It’s not just her travelling on its own; it’s the whole logistics, everything around that. There’s so much organising you have to do beforehand, not just getting the money for it”. (C1)
However, all the barriers do not deter women; they just create more distress for them:
“Even with all the barriers if they want to do it, they won’t be deterred, the barriers just exacerbate it and makes it more distressing” (C1)

The physical barriers faced by women in Ireland
The logistics of going overseas create a lot of difficulty for women. From the extra costs and getting time of work to arranging childcare, extra difficulties are in place due to having to travel. In addition, many women are making medical decisions based on the time restrictions created by being in another country, and are getting surgical abortions instead of medical abortions as it means they can get home to Ireland more quickly:
“Trying to get time off work” (C1)
“Trying to get childcare” (C1)
“There’s many, many things that she has to put in place before she can actually go and access this service. She can’t get a bus 20 minutes down the road and access that, so that can be very frustrating” (C1)
“Money is usually the big thing” (C2)
“Money is an issue, things are tighter. Some women will come in and may have heard about the Abortion Support Network.” (C1)
“Added expense for the early medical is you have to stay a minimum of one night over in the UK.” (C4)
“Many opt for D and C so they can get in and out more quickly. Or if their partner goes with them, or say for example is minding other children at home. Or they haven’t told anyone else” (C4)
Terminations are happening in later stages of gestation because many more factors need to be in place before the abortion can go ahead, such as getting enough money to travel:
“There’s then how long it might take to get the money together, or they may not be sure of their dates”. (C1)

Societal attitudes & the effect of anti-abortion propaganda
Women who have abortions may feel ostracized, as they are told that abortion does not happen in their country. This makes the experience more difficult:
“The fact that we’re told that we don’t have abortion in Ireland, that it sets you apart” (C2)
The current heat of the political debate and public anti-abortion campaigning is upsetting women who have had abortions. They may have been fine, but now due to an increase in political debate and anti-abortion advertising they are presenting for counselling with negative emotions:
“What we’re seeing with all this media stuff, with all this propaganda, women that had abortions maybe 6 months ago or a few years ago are saying, oh, maybe I do need to go too counselling, so what is that about?” (C1)
“Why are these women coming out of this now? It’s trying to tell them that they have emotions that they may not have, trying to shame them.” (C1)

Discussion
The aim of this study was to highlight the experience of Irish women who have had abortions from the viewpoint of their counsellors. Themes were split between three areas – the counsellors, their clients, and the Irish social context. Counsellors report that the reasons women give for choosing abortion include lack of money or resources for raising a child, timing in life, lack of support and concern for other relationships. These findings are in accordance with those presented by Finer and colleagues (2005) and Torres & Forrest (1988). In relation to clients emotions, the research found that negative emotional outcomes were experienced when woman do not feel that the abortion was primarily her decision. This is in line with the research by Kimport, Foster and Weitz (2011). The evidence presented by Clare and Tyndall (1994), that some women who have strong religious attitudes negative to abortion experience emotional struggles in relation to these beliefs, is also an issue for some Irish women, particularly catholic women, according to counsellors.

Counsellors hold that any negative feelings women present with are not usually around the actual abortion, but other issues in their life that may relate to their abortion, such as relationship problems, lack of support, and feelings of being ostracised. Counsellors hold that the client is lost in the political debate, and their needs and the reality of abortion in Ireland is not being addressed. Counsellors believe that secrecy, stigma and lack of support in Irish society all contribute to extra difficulties for Irish women. These findings are reflective of the research by Boyle and McEvoy (1998), who concluded that while their findings reflect the bulk of research regarding the psychological issues surrounding abortion, in that abortion in itself is not emotionally damaging, the difficulties faced in relation to abortion are intensified in the Northern Irish context where abortion is illegal.

This study also found that in due to the illegality of abortion and the stigma surrounding abortion in Ireland, counsellors believe that women may not disclose having had an abortion to their GPs and other healthcare providers, with anecdotal evidence of women travelling out of their county altogether just to obtain advice and information on abortion. Counsellors report that abortion secrecy is a very burdensome problem for Irish women, and fear of revealing a previous abortion to their medical provider is common. These findings are similar to the research by Logsdon and colleagues (2012), who found that a perception of judgment from the regular health care provider may also prevent women from disclosing a previous abortion, causing a disruption in continuity of care. Boyle and McEvoy (1998) also found this to be the case in their study of Northern Irish women, stating that the level of secrecy which Northern Irish women felt was demanded of them may have important implications for access to medical services after the abortion.

Regarding the difficulties surrounding travelling for abortion, counsellors report that travel costs are also a very big issue, along with other logistics facing women who must travel, such as finding childcare and time of work. This is reflective of the study by Becker and colleagues (2011). It would be reasonable to suggest that this is more difficult for women with less means, both financial and in relation to support. Counsellors report that some women are self administering the abortion pill, and that this is a particular problem for migrant women who do not have access to travel visas, with counsellors reporting knowledge of unsafe abortion practices among migrant women. According to Sedgh (2012), self-administering abortion pills is classified as unsafe abortion.

One of the aims of this research was to understand women’s experience of abortion in the Irish social context. As with Fletcher’s (1995) research, counsellors reported that the polarization of political and social discourse on abortion in Ireland has an adverse effect on women. Frustration and anger with the obstacles and barriers faced, along with the stigmatization felt by women who do have abortions, are common emotions that women present with in pre and post abortion counselling. Counsellors hold that while women are generally accepting of their decision to terminate a pregnancy and usually feel a sense of relief, issues surrounding guilt and shame are created via the social context and public debate. Counsellors also believe that propaganda is confusing women about their emotions, making them question whether they should in fact feel guilt and shame instead of moving forward with their lives. Counsellors report that a recent resurgence in media coverage, anti-abortion propaganda and political debate has brought women into counselling who had not previously sought post-abortion counselling. Counsellors believe that this propaganda and discourse is negatively impacting on women who have had abortions. Counsellors do not, however, believe that protesting and propaganda deter women from seeking abortion, but simply make it more difficult and upsetting. This is reflective of the research by Boyle and McEvoy (1998), where they found strong links between women having to travel to Britain and negative public constructions of abortion. It discussed the role of the Northern Irish social context in influencing women’s responses, and the lack of social support available to these women (Boyle & McEvoy, 1998).

The obstacles faced by Irish women are also extremely frustrating for the counsellor, particularly when it comes to very much wanted pregnancies that are unviable due to fatal foetal abnormalities. Counsellors cite these frustrations as challenging. Counsellors believe the lack of choices and autonomy that women face in relation to their reproductive rights in Ireland goes against the counselling ethos of support for a human being.

While counselling is about helping women come to terms with having chosen to have an abortion, counsellors also believe that abortion would be less traumatic with acceptance reached sooner if women did not have the extra obstacle of having to travel to obtain abortion. Some counsellors believe that women would actually take more time with deciding the best course of action for them in relation to their options around a crisis pregnancy. Counsellors also believe that the extra barriers Irish women face in obtaining abortions perpetuates stigmatization which creates emotional difficulties for their clients. While the barriers do not deter women from obtaining abortion, they exacerbate the difficulty of the situation and make it a more distressing experience, according to counsellors.

Counsellors state that the physical implications of lack of availability of abortion in Ireland create a situation where terminations are happening in later stages of gestation because more logistical and financial factors need to be in place before the abortion can occur. Counsellors also report that many women are undergoing surgical abortion instead of medical abortion so that they can get back to Ireland more quickly, often because they cannot afford to stay away from home longer than one day.

A very problematic issue that arose in this study is the extra restrictions placed on migrant women in Ireland, and the ways in which they may attempt to terminate pregnancies. Counsellors report that asylum seekers with refugee status and migrant women with visas that do not allow EU travel have fewer options, delaying the abortion process and/or leading to situations where women are using pills, herbs and backstreet abortions deemed as unsafe (Sedgh et al, 2012).

Methodological Strengths and weaknesses of the study
One of the weaknesses of this study was that analysis of counsellor’s assessment of some women’s needs following an abortion was inherently limited without information on the clients themselves. The study was carried out by an undergraduate, therefore, it was not ethically feasible for women who have had abortions to be contacted directly. Another weakness was that the pool of participants was still quite small. However strengths of the study included that the counsellors interviewed were split between employees of two different reproductive health organisations. In addition, the four different counsellors who participated in the interview had forty nine years collective experience as counsellors, with twenty two years and nine months of this work specifically specialising in reproductive counselling with their current employers.
A strength of the research was that a second researcher analysed a section of the data independently to generate codes as well as higher-level themes where codes clustered meaningfully. After this, the first researcher finalised codes and themes. Approaching the data deductively allowed for specific themes and ideas to be concentrated on as the analysis was driven by the research question.
Future studies would benefit from a larger pool of participants, along with direct access to women who have had abortions. In addition, it would be of great interest to gain access to migrant women regarding their abortion experiences, as well as Irish women who have undergone abortion in Ireland through obtaining the medical abortion pill. Interviews with online abortion pill providers may provide interesting data in relation to Irish women. Studies involving direct contact with service providers in the UK and Netherlands would be of great interest, as they are dealing directly with Irish women while they go through their abortion. Future research would also benefit from interviewing volunteers at abortion support groups who assist Irish women with low means.

Conclusion
Despite all the social perceptions and political debate in Ireland regarding abortion, significant silence exists in discussions about women’s emotions and experiences. Irish abortion counsellors believe that they and their clients lack a voice in the public discourse. The decision to have an abortion is typically motivated by multiple and diverse reasons, and Irish women are not deterred by the legal restrictions currently in place. The secrecy and denial regarding the existence of Irish abortion in Ireland and subsequent lack of social support is deemed by counsellors as negatively impacting on Irish women who seek and/or have had abortions, and the lack of access to abortion creates extra distress for women. These findings suggest that legalizing abortion in Ireland may be beneficial to women’s emotional responses to their abortion experience, and may also allow access for women who have no option but to choose unsafe methods of pregnancy termination due to travel restrictions.
References
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http://www.ifpa.ie

http://www.dh.gov.uk

APPENDIX A – Codes
1. Reasons for abortion 1a. Lack of Money: 97, 210, 276, 340

1b. Lack of Support: 7, 39, 147, 41, 147, 257, 277, 282

1c. Timing in life: 144, 146, 209, 272, 274, 275, 342, 437, 446
1d. Multilayered: 145, 271, 273,
1e. Failed contraception: 260, 280, 420, 423
1f. Rape:261,439, 448
1g. Letting the family down: 341
1h. Health: 441, 442, 443, 444
2. Complete variety in women who have abortions – across age, education level, relationship status and socio-economic status 3,4,34, 36, 37, 38, 418, 419, 447, 135, 136, 259
3. Women do seek and use abortion pills 174, 176, 262, 263, 267, 268, 306, 314, 429, 436, 469, 468, 466
4. Fatal foetal abnormalities very challenging 9, 179, 211, 251, 252, 253, 254, 269, 358, 379, 401, 402, 434
5. Obstacles created by travel 5a. Time off work: 11, 103,
5b. Being alone during travel: 13, 43, 55, 56
5c. Getting childcare: 105, 292, 457
5d. Secrecy & having to lie: 15, 57, 291, 301, 456, 473, 474, 520
5e. Difficulty travelling from country: 104, 106, 150, 291, 304
5f. Finance: 10, 106, 105, 156, 164, 177, 178, 290, 184, 281
5g. Being away from home: 43
5h. May not tell GP, can only get info in clinic: 151, 152, 387, 388, 17,46, 317, 318, 320, 363, 364
6. Emotional difficulties created by need to travel 5, 14, 15, 14, 55, 56, 95, 94, 162, 163, 164, 43, 44, 104, 300, 302, 304, 303, 456, 460, 462, 463, 461

7. Women don’t go into decision lightly 33, 50, 21, 52, 113, 201, 496, 512, 513
8. May be conflict in decision with partners and/or family 4,35, 250, 249, 490
9. Reasons for counselling 9a.accepting decision and coming to terms : 1,2, 18, 323, 353, 121, 322, 352
9b. complex and varied: 108, 109,110, 121, 122, 123, 124, 199, 324, 325,
9c. Support: 406, 479, 346, 350, 351, 389

10. Preference for surgical abortion 6, 471, 472
11. Women will find a way no matter what 8,40, 148, 229, 459
12. Negative emotional impact of Irish restrictions 15, 21, 59, 93, 94, 95, 96, 187. 188, 189, 372
13. Women will talk to a friend, limited though for fear of judgment 16, 71, 368, 476, 477, 509, 510
14. Irish context negatively impacting via stigma and denial 45, 67, 68, 100, 101, 167, 165, 168, 187, 188, 189, 191, 194, 217, 218, 219, 221, 330, 331, 332, 337, 354, 355, 372, 373, 381, 382, 464, 500, 510, 511, 514
15. Protesting and propaganda is not an obstacle 12, 155
16. Current propaganda and politics upsetting women who have previously been ok after abortion 19, 20, 47, 48, 53, 22, 67, 68, 72, 73, 74, 30, 31, 187, 188, 189, 194, 220, 221, 505, 504, 506
17. Society pushing idea of guilt onto women 48, 47, 19, 20, 49, 22, 53, 54, 74, 31, 187, 188, 354, 355, 484, 485, 486, 487, 494, 501, 502, 503
18. Women don’t use abortion as contraception 51
19. Relief a common feeling 23, 188, 216, 336,409, 479, 489
20. Most felt it was correct decision 23, 335, 497, 498, 499
21. Belief of counsellors that women would have a more positive emotional response to abortion if available in own country. Believe it should therefore be legal. Frustration that it’s not. 59, 60, 15, 32, 107, 162, 163, 231, 232,236, 354, 373, 374, 377, 378, 516, 517, 518, 524, 528, 529, 530, 531
22. False presentation that we don’t have abortion in Ireland, makes women who do feel ostracised, makes experience more difficult 60, 15, 61, 93, 100
23. Secrecy a very burdensome problem 63, 15, 25, 165, 372, 393, 412, 474, 480
24. Whether women identify as pro-life or pro-choice – when it’s their own crisis pregnancy they become more understanding of the complexity of abortion choices and may make decisions they did not expect to 26, 65, 66, 295, 296, 299
25. Religion can create emotional struggle 21, 65, 26, 213, 214, 215, 255, 256, 493
26. Organising logistics for overseas abortion stressful 164, 165
37. Counselling often not about the abortion, it’s about external issues around the abortion, such as relationship problems etc. 64, 79, 109, 110, 108, 121, 122, 123, 124, 199, 206, 207, 326, 327, 328, 329, 331, 352, 353, 415, 481, 482, 483
28. Coercion negatively impacts and can be a big problem 28, 157, 159, 411
29. Irish medical profession are in a grey area that needs to be sorted 75
30. Women are looking for non judgmental help 80
31. Women are seeking accurate information 81
32. Satisfaction in job by helping women, seeing them through the process from before to after 83, 76, 86, 392
33. Counselling is facilitation for working out of own feelings and owning the experience, non directive, teasing out 87, 88, 89, 91, 205, 245, 246, 247, 248, 348, 349, 353, 414, 416, 417
34. Fear that not getting correct info in other spaces 90
35. Some have medical side effect issues and need aftercare 115, 466, 467, 507
36. Find out about counselling through clinics in UK, word of mouth or internet 115, 116
37. Migrant women face more difficulty due to increased travel restrictions 98, 99, 132, 160, 173, 307, 308, 425, 427, 428
38. Anger and frustration with the social and/or legal barriers for women is challenge for counsellor 107, 381
39. Go through surgical procedure when not necessary instead of medical due to travel restrictions 127, 128, 129, 130, 471, 472
40. Ignoring Irish abortion happens means we don’t have correct figures 137
41. Women are coming in earlier in gestation and are more informed 138, 142, 347
42. Abortions can happen later because of the extra arrangements and funds needed for travel 139, 140, 142
43. Some women have to go back again as got dates wrong 141
44. Barriers don’t deter, just make it more distressing and difficult 148, 165, 167
45. Women are angry and frustrated by the obstacles they are confronted with 152, 162, 165, 169, 170, 293, 294, 410, 490
46. Majority of women say there experience was positive in as much as it can be 161
47. Seems to be increase in partner or family support in counselling accompaniment 180, 230
48. There is a change in attitudes towards abortion – more positive 181, 237
49. Talking or telling someone can reduce stigma 182, 230
50. Counselling beforehand is important 185
51. Many have their mind made up 186
52. We don’t know how many women tell a private counsellor and don’t present here 196, 197
53. Shame and regret do not really present 198
54. It can be a profound experience 202
55. The negatives surrounding abortion in public discourse are not what counsellors hear from their clients 199
56. Some have difficulty, many just get on with it and are ok 203, 357
57. Emotions are complex and multilayered around abortion like any life issue, as we are complex beings 204
58. Most women have resilience and resources to deal with the negativity 222
59. There’s fear of divulging to GP 225, 226, 227
60. Counsellors believe it highly important to support clients in choices and autonomy 239, 242
61. Women don’t have choices in Ireland 241, 242
62. Extremely compacted work 244
63. It’s a human rights issue 243
64. Helping them come to hear/understand themselves, their feelings 246, 245
65. Women may not seek aftercare and necessary medical care for fear of being “found out” because of the legal situation in Ireland 265, 466, 467
66. Still some people unaware that it’s not illegal to travel for abortion 320, 321
67. Counselling reduces fear, people can come in very panicked and overwhelmed
68. May lie to hospital/GP about bleeding or side effects 365, 366
69. Nobody wants to have to have an abortion 356
70. The client gets lost in the political debate 354, 355, 359, 360
71. Proposed legislation does not deal with the reality around abortion and women’s needs 381, 382,
72. Abortion in itself isn’t emotionally damaging 383, 384, 385, 386
73. Lack of sex education is a problem in Ireland
74. Some counsellors believe women may not rush into abortion in some cases if there wasn’t the panic of getting to the UK 403, 404, 405, 524
75. Abortion counsellors do not get to give their voice 532
76. Migrant women taking risks with unsafe abortion as they face greater restrictions 309, 310, 311, 312, 313, 315, 468, 475
APPENDIX B – Themes
Themes Codes Data extract examples
The counsellor (data-extracts in brackets)
1. The Counsellor’s experience of their clients 7. Women don’t go into decision lightly (33, 50, 21, 52, 113, 201, 496, 512, 513)

11. Women will find a way no matter what (8,40, 148, 229, 459)
49. Talking or telling someone can reduce stigma (182, 230)
55. The negatives surrounding abortion in public discourse are not what counsellors hear from their clients (199)
70. The client gets lost in the political debate (354, 355, 359, 360)
62. Extremely compacted work (244)

3.Women do seek and use abortion pills (174, 176, 262, 263, 267, 268, 306, 314, 429, 436, 465, 469, 468, 466) 50: “In my experience nobody goes into abortion lightly, I really don’t think that.”
459: “They will always find the money.” 229. “It’s amazing what women will put themselves through”
230: “More and more women are telling their partners by virtue of coming in and I think that’s helping, it’s decreasing the stigma”

199: “The negative feelings again aren’t around the abortion. Those adjectives that are thrown around about abortion are not what we would hear; it’s around other issues that arise in their lives that are maybe connected in some way in a deeper unconscious level around the abortion, around the pregnancy, around their own being”
354: “Yes. I think it’s the black and white of it. When you have those extremes, there’s no allowance in those extremes for the client.” 355: “Those 2 sides always make me say does anybody know about the client here. Does anybody hear the clients stress. Does anybody see the crisis of this person?”

244: “the client is in crisis when they come in. It’s extremely compacted work and it’s impactual – you’re getting the beginning middle and end in maybe one or 2 sessions, you don’t have the pleasure or the ease to work with someone over 20 sessions.”

465: “If the client brings that into a session we have to be very mindful, because we want them to get a safe procedure” 174: “ The medical council and customs seized over a thousand a few years ago. So that’s only the tip of the iceberg”. 267: “I’d say the people who have taken it and have for want of a better word, successfully had an abortion I don’t think we’ll even see them, they won’t be on the radar.”

2. The counsellors emotions 4. Fatal foetal abnormalities very challenging (9, 179, 211, 251, 252, 253, 254, 269, 358, 379, 401, 402, 434)

32. Satisfaction in job by helping women and seeing them through the process (83, 76, 86, 392)

38. Anger and frustration with the social and/or legal barriers for women is challenge for counsellor (107, 381) 251: “The most challenging clients are the ones that find out they have a foetal abnormality because they’re often very much a planned wanted pregnancy”. 253: “That challenges me and they’re often very late decisions within the pregnancy.”

“86: “It’s very satisfying if you have a number of sessions with women, that you can follow them on that journey, that you can support them”.

107: “In the counselling context that can be frustrating because I’m also trying to manage my own emotions as well as the woman’s emotions. The social context surrounding everything, my anger and frustration is there and that’s part of the job that can be challenging.” 381: “The biggest thing is the emotional reasoning around this that it’s just not going to go away, nothing is going to make it ok. Even if all the laws supported it totally, the govt drives me mad with dragging their heels, these laws might change yet somebody who has been raped or there’s been incest, none of this is being dealt with either.”
3. The counsellors role and the goals of counselling 33. Counselling is facilitation for understanding one’s own feelings about the experience (87, 88, 89, 91, 205, 245, 246, 247, 248, 348, 349, 353, 414, 416, 417)

51. Many have their mind made up (186)

60. Counsellors believe it highly important to support clients in choices and autonomy (239, 242)
64. Helping them come to hear/understand themselves, their feelings (245, 246)

9d. Support (346, 350, 351, 389) 88: “You’re teasing out any ambivalence in a non judgemental way.” 245: “Helping someone to unravel what’s best for them outside of what others may have said”.

186: “In some cases women may just have one session, they’ve made their decision”.

239: “It became terribly important to feel that I was supporting them in their own choice and autonomy”.

246: “Seeing them come to hear themselves, acknowledge themselves within the crisis”.
389: “Because it’s a crisis, you’re given information and it can be info overload sometimes.” 351: “350. There’s more knowledge, less ignorance, less panic. I’ve seen people come in and they’re really, really panicked and I think they’re very panicked about what I’ll be like, can I support them, or am I going to turn into some demon is telling them what they should and shouldn’t do”. 351: “Those negative feelings can become very overwhelming, and become misplaced.”
4. Counsellors attitudes and views regarding abortion in Ireland 21. Belief of counsellors that women would have a more positive emotional response to abortion if available in own country. Believe it should therefore be legal. Frustration that it’s not. (44, 59, 60, 15, 32, 107, 162, 163, 231, 232,236, 354, 373, 374, 377, 378, 516, 517, 518, 524, 528, 529, 530, 531)

61. Women don’t have choices in Ireland (241, 242)

71. Proposed legislation does not deal with the reality around abortion and women’s needs (382)
29. Irish medical profession are in a grey area that needs to be sorted (75) 60: “The fact that we’re told that we don’t have abortion in Ireland – that it sets you apart”. 374: “It would lessen the impact if they didn’t have to travel”. 524: “I think if it was legal here it would give the women more time to think about what they wanted to do.” 516: “they would accept it quicker”. 517; “there would be less trauma.” 44: “It absolutely impacts on them that they have to travel.”

241: “They don’t have choices”. 242: “They’re told they shouldn’t have choices and it seemed to go against the support for a human being, women in crisis and what you could do.”

382: “There’s still this blanket way of dealing with things in Ireland.”
75: “Our medical profession are in a grey area that needs to sorted”

The client
5. Clients backgrounds 2. Complete variety in women who have abortions – across age, education level and socio-economic status (3,4,34, 36, 37, 38, 418, 419, 447, 135, 136, 259)
24. Whether women identify as pro-life or pro-choice – when it’s their own crisis pregnancy they become more understanding of the complexity of abortion choices and may make decisions they did not expect to (26, 65, 66, 295, 296, 299)

450: “From low incomes to high incomes. Women would have only done primary school education to women who are seriously working in high professions. It doesn’t discriminate”. 259. “Youngest I’ve seen is 13 and oldest is 49 and the reasons for the crisis pregnancy are so, so mixed”
65: “Some of them who would have been very anti abortion, or wouldn’t have really thought about it, just were against it, kind of suddenly think well Jesus I’m in this situation now there’s obviously other women in this situation”. 295: “This is people who might have said they didn’t agree with abortion, and until you have a crisis pregnancy that belongs to you you’ve no idea how it might actually feel about it.” 296: “People, who are pro-choice, often feel when they have an unplanned pregnancy that they can’t actually terminate”. 299: “You’ve got to feel it to live it really.”

6. Clients reasons for choosing abortion 1a.Lack of finances (97, 210, 276,282, 340)
1b. Lack of support (7, 39, 147, 41, 147, 257, 277)
1c.Timing in life (144, 146, 209, 272, 274, 275, 342, 437, 446)

1d.Multilayered (145, 271, 273)
1e.Failed contraception (260, 280, 420, 423)

1f. Rape (261,439, 448)

1g.Letting the family down (341)

1h. Health (441, 442, 443, 444)
97: “The financial restrictions”. 282: “Even people who might already have children, be married, but they just cannot afford to have another child
147: “We have some women whose relationship has broken down and they don’t think they can go through it alone.”

144: “the timing in their life or in the circumstances in which it happened.”
145: “It’s hard to pin down because sometimes the women may not say the reason, they may not explore that enough, but I would say it’s just multilayered.”
280: “Failed contraception.”

261: “Occasionally people have raised the possibility of rape”

341: “Letting the family down”
443: “Their doctor would have told them to never get pregnant again because their heart would suffer. So they travel.” 444: “Small percentage with mental health, but they’ll travel anyway”
7. What clients are looking for in abortion counselling 30. Women are looking for non judgmental help (80)

31. Women are seeking accurate information (81) 80: “Looking for non judgement”.
81: “For someone who can give this accurate information, and when they get that they’re very content and quite relieved and that’s very satisfying”
8. Women’s needs in/reasons for counselling 10a. Coming to terms with and accepting their decision (1,2, 18, 323, 353, 121, 322, 352, 353)
10b. complex and varied: (108, 109,110, 121, 122, 123, 124, 199, 324, 325)

27. Counselling often not about the abortion, it’s about external issues around the abortion, such as relationship problems etc. (64, 79, 109, 110, 108, 121, 122, 123, 124, 199, 206, 207, 326, 327, 328, 329, 331, 352, 353, 415, 481, 482, 483)

353: “Then you can talk about the reality of it, and the reality suddenly becomes more bearable. And the illusion lessens a little bit. They cope better with the idea of what they went through. I hope so.” 322: “I think they hit blips where they may feel that they’ve made the best decision but then something triggers the response of not being as sure of their decision as they felt. So they get a bit ungrounded.”
108: “Dealing with the complex issues that women deal with”. 110: “Their own set of circumstances, and their own uniqueness, what they bring to the session. There’s layers of complexity there that are colouring the session that we have to manage.”
109: “There’s also all sorts of other issues around it, it’s not just around the abortion it’s all around decision making, the ambivalence” 207: “In general the women that we would see or hear from, if they’re coming back with their story on abortion, it is usually around other life events that have brought some symptomatic feelings to the fore. That’s not necessarily regret.” 328: “The circumstances around the abortion and the relationships relating to the abortion can be a trigger, it might be a relationship issue rather than an abortion issue”. 329: “The abortion can be kind of like a catch all for everything that goes wrong, and that’s not necessarily true.”
9. Issues surrounding physical side effects of abortion in Ireland 35. Some women have medical side effect issues and need aftercare (115)

68. May lie to hospital/GP about bleeding or side effects (365, 366) 115: “When they do come back in a number of weeks they might have a medical issue, a side effect issue”.

365: “They could present at a hospital and pretend that they’re miscarrying, and the symptoms would appear very similar, there might not be any knowledge that they had taken anything, so it could be treated as a spontaneous abortion.” 366: “There’s still then in the records system as having had a pregnancy and a miscarriage, and some people don’t want that on file”

10. The client’s attitudes 20. Most felt it was correct decision (23, 335, 497, 498, 499)

46. Majority of women say there experience was positive in as much as it can be (161)

56. Some have difficulty, many just get on with it and are ok (203, 357)
66. Still some people unaware that it’s not illegal to travel for abortion (321)

15. Protesting and propaganda is not an obstacle (12, 155)

69. Nobody wants to have to have an abortion (356) 335: “They made the best decision they could”. 497: “but it was the right decision at that time of their life.” 499: “The majority of women come to that conclusion. There’s acceptance at the end really.”
161: “the majority would say their experience was positive in as much as it can be”.
203: “Some would put a lot of thought into that, and some would go get it done and be able to get on with their lives”
321: “There’s still a lot of people who don’t realise it’s not illegal to travel for the abortion, because under the 1861 Act it’s illegal to have an abortion here. It’s all linked”
155: “Protesting doesn’t deter women, it makes it a little more vicious”
356: “I’ve never had anybody in the room who wanted to be here. Ever. Nobody comes in and says I’ve always been waiting to have an abortion”
11. The client’s emotions 6. Emotional difficulties are created by need to travel (5, 14, 15, 14, 55, 56, 95, 94, 162, 163, 164, 43, 44, 104, 300, 302, 304, 303, 456, 460, 462, 463, 461)

25. Religion can create emotional struggle (21, 65, 26, 213, 214, 215, 255, 256, 493)

19. Relief is a common feeling (23, 188, 216, 336, 337, 409, 479, 489)

50. Women are angry and frustrated by the obstacles they are confronted with (152, 162, 165, 169, 170, 293, 294, 410, 490)
45. Shame and regret do not really present (198)
54. It can be a profound experience (201, 202)
57. Emotions are complex and multilayered around abortion like any life issue, as we are complex beings (204)

58. Most women have resilience and resources to cope after an abortion (222)

72. Abortion in itself isn’t emotionally damaging (383, 384, 385, 386)
17. Society pushing idea of guilt onto women (48, 47, 19, 20, 49, 22, 53, 54, 74, 31, 187, 188, 354, 355, 484, 485, 486, 487, 494, 501, 502, 503)
23. Secrecy a very burdensome problem (63, 15, 25, 165, 372, 393, 412, 474, 480)
34. Fear that not getting correct info in other spaces (90)

65. Women may not seek aftercare and necessary medical care for fear of being “found out” because of the legal situation in Ireland (265, 466, 467)

59. There’s fear of divulging to GP (225, 226, 227, 228, 365, 366)
4. Fatal foetal abnormalities very challenging (9, 179, 211, 251, 252, 253, 254, 269, 358, 379, 401, 402, 434)

28. Coercion negatively impacts and can be a big problem (28, 157, 159, 411)
462: “Sometimes the travel is more traumatic than the ending of a pregnancy”. 44: “It absolutely impacts on them that they have to travel.” 165: “it’s quite a long, arduous, it’s not just about getting on the plane and back. I think the women would say this is part of it, I’ve got to do it, taking time off work, having to make excuses, maybe not being able to tell anyone, the distrust, going under the cover of darkness. It contributes hugely to the anger and frustration around it, hugely.” 166: “There’s a whole cycle that’s very much perpetuated by all of those barriers and stigmatization. The more barriers that are there the harder it is.”
493: “If they have a deep religious belief, especially with Catholicism, it’s shame and guilt. Guilt because you shouldn’t do it”.
23: “Relief is a common feeling”. 188: “even though we see a lot of emotions, the overriding one is relief. That’s what we’re hearing.”
152: “They can’t believe that they can’t discuss it over the phone in this day and age.” 162: “The actual travelling absolutely, why do I have to do this, people get very frustrated and angry and some in disbelief in this day in age they can’t get it in their own country.”

198: “I don’t think shame presents often, I think it’s a word that’s bandied about but that’s not necessarily our experience. Or regret.”
201: “Women don’t take the decision lightly”. 202: “it’s something much more profound”
204: “It’s very hard to pinpoint one particular negative feeling. We’re human, we’re complex beings, and it becomes enmeshed in something else”
222: “Most have the resilience and the resources to be able to work through that and understand that, or have a partner that can support them.”
383: “Overall, abortion in itself isn’t damaging.” 384: “Even though women are presenting with emotional issues, there’s always going to be one or two people” 385: “people who have chaotic lives before an unplanned pregnancy are still going to have chaotic lives after an unplanned pregnancy, it just becomes another part of the chaos.” 386: “You’re going to always get somebody who has emotional issues, and then they have an abortion and it becomes part of those issues, but then the abortion could be used as the issue. But you could say the say about pregnancy; they could say the same about anything.”
48: “They can feel guilt that they don’t feel guilty.” 49: “Should I not feel bad because I’ve done something wrong?” 188: “it’s like they’re feeling guilty for not feeling guilty. Because even though we see a lot of emotions, the overriding one is relief. That’s what we’re hearing.” 189: “Why are these women coming out of this now? It’s trying to tell them that they have emotions that they may not have, trying to shame them”. 336: “Some people are very relieved. But that’s a difficult one to put out. There’s not a great tolerance towards relief “how can you be relieved you had an abortion”. It doesn’t fit.” 337: “You’re meant to feel bad, just like every baby is wanted, every pregnancy is wanted, and so it doesn’t fit with society’s declarations.”
165: “It’s quite a long, arduous, it’s not just about getting on the plane and back. I think the women would say this is part of it, I’ve got to do it, taking time off work, having to make excuses, maybe not being able to tell anyone, the distrust, going under the cover of darkness. It contributes hugely to the anger and frustration around it, hugely”
90: “Or that’s she’s not being given all the information that she requires. There can be fear that they may not, and that’s about perceptions as what they see the service as presented as.”
265: “They may be afraid to go and seek medical care afterwards because of the illegalities”.
225: “There’s a fear of divulging to their GP, there’s different rural areas, different attitudes” 226: “In some cases women come to us because they can’t go to their GP.” 227: “I had a woman come up from Kerry” 228: “She didn’t even want to go in the county”. 365: “They could present at a hospital and pretend that they’re miscarrying, and the symptoms would appear very similar, there might not be any knowledge that they had taken anything, so it could be treated as a spontaneous abortion.” 366: “There’s still then in the records system as having had a pregnancy and a miscarriage, and some people don’t want that on file.”

254: “They’ve made a connection and then their world is literally turned upside down.”

28: “A lot of women that have a problem afterwards haven’t gone in to it really being their decision. Coerced by parents or boyfriends, when that happens it makes it much more difficult. Who haven’t gone into it really as their decision”.
12. Support from family, friends and partners 13.Women will talk to a friend, limited though for fear of judgment (16, 71, 368, 476, 477, 509, 510)
47. Seems to be increase in partner or family support in counselling accompaniment (180, 230)

49. Talking or telling someone can reduce stigma (182, 230) 368: “Most people seem to look for some support outside the room”. 509: “Either the partner knows or one very close family member, or friend”. 510: “It’s all to do with fear of being judged, the stigma.”

180: “There certainly seems to be an increase in support, coming in with a partner or friend or mother or father.”

230: “More and more women are telling their partners by virtue of coming in and I think that’s helping, it’s decreasing the stigma.”
13. Issues facing migrant and trafficked women in Ireland 37. Migrant women face more difficulty due to increased travel restrictions((98, 99, 132, 160, 173, 307, 308, 425, 427, 428)
76. Migrant women taking risks with unsafe abortion as they face greater restrictions(309, 310, 311, 312, 313, 315, 468, 475) 98: “The travel restrictions for migrant women”. 99: “There’s a whole gamut of different restrictions that are put in place”. 425: “new communities have visa issues, and access to visas, and the UK has clamped down an awful lot.” 426: “especially Nigerian people, they’re better off going to the Netherlands embassy”. 427: “The procedure can take two to three weeks, but they also need a re-entry visa from Ireland, and that takes 4 days.” 428: It can take 2 to 3 weeks for the couple to get all that information. That’s a long time in a crisis pregnancy.”

468: “The new communities as well. Possibly bring over their own stuff”. 309: “There’s a huge amount that goes on that we know nothing about in truth. I’ve counselled people who have had herbs sent over and it hasn’t worked”
310: “So they’ve ended up maybe having to travel eventually and then there’s issues with visas” 311: “It doesn’t allow them to go to England”. 312: “Somebody who has refugee or asylum status might have no papers, it can take months”. 313: “This creates more possibility of unsafe abortion, absolutely; I’ve no doubts about that, that stuff goes on. Back street abortions still alive, have come across one or two”

The Social Context

14. The emotional barriers and obstacles faced by Irish women 5b. Being alone during travel (13, 43, 55, 56)
5d. Secrecy & having to lie (57, 58, 291, 301, 456, 458, 473, 474, 520)
5g. Being away from home (43)

5h. May not tell GP, can only get info in clinic: 151, 152, 387, 388, 17,46, 317, 318, 320, 363, 364
44. Barriers don’t deter, just make it more distressing and difficult (148, 165, 167)

26. Organising logistics for overseas abortion stressful (164, 165)
55: “The whole experience of having to travel” 56: “feeling very alone in it”. 460: “It’s a big trauma for them.” 461: “Sometimes it takes them a while to open up, because it’s so traumatising for them.”462: “Sometimes the travel is more traumatic than the ending of a pregnancy”.

57: “Not being able to tell people” 58: “having to hide it, to tell lies about it -that would be all the kind of negative things.”
43: “Very impersonal, the fact that they’ve got to go to another country, there’s a difference, that’s it really, it’s a different country, you’re very alone”

363: “They could definitely be afraid of telling their own GP. They often withhold”. 151: “Even accessing counselling services, a woman can’t get information over the phone, she has to come in for a session.” 152: “They can’t believe that they can’t discuss it over the phone in this day and age”
148: “Even with all the barriers if they want to do it, they won’t be deterred, the barriers just exacerbate it and makes it more distressing”

164: “it’s not just her travelling on its own; it’s the whole logistics, everything around that. There’s so much organising you have to do beforehand, not just getting the money for it”

15. The practical barriers and obstacles faced by women in Ireland 5a. Time off work (11, 103)
5c. Getting childcare (105, 292, 457)
5e. Difficulty travelling from country (104, 106, 150, 291, 304)
5f. Finance (10, 106, 105, 156, 164, 177, 178, 183, 281, 290)
39. Go through surgical procedure when not necessary instead of medical due to travel restrictions (127, 128, 129, 130, 471, 472)
42. Abortions can happen later because of the extra arrangements and funds needed for travel (139, 140, 142) 103 “trying to get time off work”
105: “Trying to get childcare”

106. “There’s many, many things that she has to put in place before she can actually go and access this service. She can’t get a bus 20 minutes down the road and access that, so that can be very frustrating”
10: “Money is usually the big thing”. 183: “Money is an issue, things are tighter. Some women will come in and may have heard about the ASN.”
471: “added expense for the early medical is you have to stay a minimum of one night over in the UK.” 472: “Many opt for D and C so they can get in and out more quickly. Or if their partner go with them, or say for example is minding other children at home. Or they haven’t told anyone else”.

139: “there’s then how long it might take to get the money together, or they may not be sure of their dates”

16. Societal Attitudes & the effect of propaganda and protests 22. False presentation that we don’t have abortion in Ireland, makes women who do feel ostracised, makes experience more difficult (60, 15, 61, 93, 100)

16. Current propaganda and politics upsetting women who have previously been ok after abortion (19, 20, 47, 48, 53, 22, 67, 68, 72, 73, 74, 30, 31, 187, 188, 189, 194, 220, 221, 505, 504, 506) 60: “the fact that we’re told that we don’t have abortion in Ireland, that it sets you apart”.
187: “What we’re seeing with all this media stuff, with all this propaganda, women that had abortions maybe 6 months ago or a few years ago are saying, oh, maybe I do need to go too counselling, so what is that about?” 189: “Why are these women coming out of this now? It’s trying to tell them that they have emotions that they may not have, trying to shame them.”

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