Advancing Sexual and Reproductive Health and Rights
 
Perspectives on Sexual and Reproductive Health
Volume 41, Number 3, September 2009

An Illusion of Power: Qualitative Perspectives On Abortion Decision-Making Among Teenage Women In Sweden

By Maria Ekstrand, Tanja Tydén, Elisabeth Darj and Margareta Larsson

CONTEXT: Swedish law permits abortion at the request of a pregnant woman until the 18th week of gestation. However, the extent to which the decision is truly the woman’s own is subject to debate; women are often influenced, directly or indirectly, by the attitudes of their partners, family and friends or by social norms.

METHODS: Individual in-depth interviews about the pregnancy and the abortion decision were conducted 3–4 weeks postabortion with 25 women aged 16–20 at different periods in 2003, 2005 and 2007. Interviews were audio- taped, transcribed verbatim and analyzed using latent content analysis.

RESULTS: The main reasons for unplanned pregnancy were underestimation of pregnancy risk and inconsistent contraceptive use. Pregnancy prevention was perceived as the woman’s responsibility. The abortion decision was accompanied by mixed emotions, and was seen as a natural yet difficult choice. Social norms and the negative attitudes of family and friends strongly influenced the decision. Partners and parents were regarded as the most important sources of support. After the abortion, the women felt pressured by contraceptive counselors to use highly effective contraceptives despite their previous negative experiences or worries about side eff ects.

CONCLUSIONS: Swedish teenagers’ basic right to decide whether to have an abortion may be limited by societal norms and disapproval of teenage childbearing. Given the perception that women are responsible for contraception, programs need to emphasize that pregnancy prevention is a shared responsibility; greater efforts to include males in prevention practices are needed.

Perspectives on Sexual and Reproductive Health, 2009, 41(3):173–180

DOI: 10.1363/4117309

Despite a high level of adolescent sexual experience, the large majority of female teenagers in Sweden avoid pregnancy. From an international perspective, the pregnancy rate among Swedish adolescents is low1—about 30 pregnancies per 1,000 women aged 15–19 in 2006.2 However, when pregnancy does occur, termination is the primary choice; about 75–90% of known teenage pregnancies in Sweden end in abortion, indicating an intense desire among young women to avoid pregnancy during the teenage years.2

Over the years, the abortion rate among teenagers in Sweden has fluctuated; the highest level, 29.7 abortions per 1,000 women aged 15–19, was reached in 1975, and the lowest level, 16.9 abortions per 1,000 women, in 1995. Since this lowest point, the rate has increased by almost 50%, to 24.4 per 1,000 in 2008.3 Currently, a higher proportion of teenage pregnancies in Sweden than in any other Nordic country end in abortion; in 2006, the abortion rate per 1,000 women aged 15–19 was 14.0, 16.3 and 16.7 in Finland, Norway and Denmark, respectively, compared with 24.6 in Sweden.4

The current Swedish abortion law, passed in 1975, permits abortion at the request of a pregnant woman until the 18th week of gestation.3 The extent to which the decision is truly the woman's own is subject to debate; women are often influenced, directly or indirectly, by the attitudes of their partners, family and friends or by social norms.5–7

Teenage pregnancy is often considered a public health problem because of its association with socioeconomic difficulties and health-related problems for both mother and child.8–10 The current trend in industrialized countries is to postpone childbearing, in part so that young people can finish their education, ensure economic security, obtain work experience and achieve personal goals.7,11,12 In 2008, the mean age at first birth in Sweden was 28.9 years for women;13 however, sexual debut usually takes place more than 10 years earlier, at a mean age of 16–17.14 This presents a challenge for young people to use contraceptives correctly and consistently over an extended period, and for society to encourage and facilitate that use.

During the 1970s, Swedish women became the focus in matters of sexual and reproductive health.15 With the passing of the new abortion law and greatly improved access to female-controlled contraceptive methods, women were empowered to manage their reproductive health, but also faced greater responsibility in regard to contraceptive use and pregnancy prevention. Men, on the other hand, were gradually released from family planning responsibility.15 Contraceptive counseling and pregnancy prevention efforts have since focused mainly on guiding young women toward well-planned and sexually responsible behavior. Recent studies among 17-year-old Swedish teenagers found that both sexes commonly perceive the woman as mainly responsible for contraceptive use and pregnancy prevention.16,17

The aim of this study was to deepen our understanding of issues related to teenage abortion—specifically, the circumstances behind the pregnancy, the decision-making process and the perceived support from family, friends and health care professionals in relation to the abortion.

METHODS

Procedure

We used purposive and strategic sampling,18 inviting the participation of women aged 16–20 who were applying for induced abortion at two hospital family planning clinics in one large and one medium-size city. Each potential participant was given verbal and written information about the study by a physician or midwife at the preabortion examination. All were informed that participation was voluntary and that data would be treated confidentially.

Thirty-six women signed a letter of consent, provided their contact information and agreed to be contacted for an interview with the first author approximately 2–3 weeks after the abortion. Three women later declined to participate but did not provide a reason, five could not be reached despite several attempts and three failed to attend the prearranged interview. The final sample consisted of 25 young women who were interviewed approximately 3–4 weeks after the abortion; 14 women had obtained a medical abortion, and 11 had obtained a surgical one, including one women who obtained her abortion during the second trimester. Half of the interviews took place in secluded “talking rooms” in the hospitals, and the other half were conducted by telephone. Each interview lasted 40–120 minutes. Every respondent received two movie tickets as a reward for participation.

We conducted individual in-depth interviews, using a topic guide with nine open-ended questions, developed from previous findings.11,16,17 Issues covered included the circumstances of the conception, experiences of the decision-making process and support from family and friends, the abortion itself and attitudes toward contraceptive use. The interviews were designed to be jointly shaped conversations, in which the interviewer encouraged each participant to explore her experiences thoroughly. At the end of each session, the interviewer summarized the interview and asked the participant to contribute any additional comments or mention any specific issues she wanted to highlight.

Three pilot interviews were conducted face-to-face in September–November 2003 to test the topic guide and the procedure. Because no adjustments were necessary and the women who participated met the inclusion criteria, these interviews were included in the study. The remaining in-person interviews were carried out during the summer and fall of 2005, and the telephone interviews over three months in 2007. The medical research ethics committee at Uppsala University approved the study.

Analysis

The interviews were audiotaped, transcribed verbatim and analyzed using latent content analysis.19 After the interview transcripts were reviewed, the material was condensed and meaning units were extracted; this was followed by abstraction and open coding. Similar codes were compared and merged together, and then sorted into mutually exclusive categories and subcategories. To prevent fragmentation, we checked back and forth between the emerging categories and the original text to verify accuracy. The latent content, or underlying meaning, emerged throughout the process and was finally formulated into one overarching theme. To avoid selective perception and achieve internal consistency, each author independently analyzed parts of the qualitative data and compared findings.

RESULTS

Seventeen participants were in steady relationships (of 2–12 months' duration) and had become pregnant with their current partner. None were married at the time of the interview. At the time of conception, 14 were attending high school, six were employed, four were unemployed and one was on maternity leave. Twenty-one young women had never been pregnant before, one had experienced several miscarriages, two had had previous abortions and one had a baby. The majority lived with one or both parents, but six lived with their partner.

The overarching theme emerging from the analysis was that female teenagers recognize there is an illusion of power with regard to their reproductive lives—they are responsible for contraceptive use, but have limited freedom of reproductive choice, including the right to choose whether to continue a pregnancy. This theme was reflected in six main categories: underestimation of risk and inconsistent contraceptive use, pregnancy prevention as the woman's responsibility, paradoxical feelings toward pregnancy and abortion, the influence of social norms and family and friends, postabortion reflections, and counseling and contraceptive use after abortion. Within each main category, several subcategories emerged.

Underestimation of Risk and Inconsistent Contraceptive Use

Participants' unplanned pregnancies were predominantly the result of inconsistent contraceptive use. Only three respondents had actively tried to avoid pregnancy; one had used emergency contraception, and the other two had become pregnant after a condom had ruptured or slipped. One participant had planned her pregnancy. The majority had not used contraceptives at the time of conception, thinking they could not become pregnant. Lack of motivation to procure contraceptives was commonly mentioned, and was often based on negative attitudes toward contraceptive use. Most participants felt that “hormones” should be used only “if necessary,” preferably in a steady relationship with regular sex. Condom use was rare, mainly because of general insecurity and embarrassment, particularly when a woman was having sex with a partner for the first time.

•Inattention to the menstrual cycle and fertile window. The young women either were only vaguely attentive to their menstrual cycles or had lost motivation after having tried to be careful for a while. Several practiced withdrawal, but they were seldom aware of when they were ovulating and thus did not take extra precautions during that time. This lack of awareness and interest, in combination with the use of unreliable methods, resulted in the young women's seriously underestimating the risk of becoming pregnant.

•Testing the boundaries despite awareness of risk. Even though all the young women had been aware of the possible consequences of having sex without using a contraceptive, this knowledge did not seem to influence them to be more cautious. One woman commented:

“You're perfectly aware that you're putting yourself at risk, but still…you kind of think that nothing will happen.”—17-year-old, first time pregnant

This way of assessing risks caused a continuous testing of boundaries. Risk-taking was also legitimized by friends who had sex without using a contraceptive. A participant remarked:

“Thousands of my friends have had unprotected sex thousands of times, and they've never gotten pregnant.”—18-year-old, first time pregnant

For some young women, risky behavior was caused by an urge to confirm their fertility. Another 18-year-old who had never been pregnant said, “I thought I might be sterile. Nothing had happened before, so I was actually a bit worried that I couldn't get pregnant.”

Pregnancy Prevention as the Woman's Responsibility

Contraceptive use was theoretically viewed as a mutual responsibility, but women expressed an underlying acceptance that they, and not their male partners, were “in charge” of pregnancy prevention. The respondents said their partners mostly relied on them to procure, use or provide contraceptives.

The participants also indicated that communication with partners about birth control methods was sparse or did not occur at all. One young woman explained:

“It sounds really stupid, I can see that now, but we'd never discussed those things before. You kind of think that it won't happen that easily.”—17-year-old, first time pregnant

Another recalled:

“I mean, I honestly don't think he thought much about it.... Anyway, we didn't talk about it.”—20-year-old, second time pregnant

Scarce communication and poor negotiating skills sometimes led to misunderstandings, as this comment illustrated:

“Well, I kind of thought that he wouldn't go all the way…since I had told him earlier that I wasn't on the pill or anything.”—18-year-old, first time pregnant

•Guilt over failure to use a contraceptive. Some participants expressed feelings of guilt and shame for having failed to acquire effective contraceptives. One described her experience during the preabortion gynecologic examination this way:

“You're ashamed…first because you're completely exposed, and then because you're pregnant…for not having used a condom…. There are so many things you're ashamed of.”—17-year-old, first time pregnant

No one blamed her partner for failing to use a contraceptive. One respondent had abandoned oral contraceptives after her last steady relationship, and had used no method at the time of conception. When her new casual partner had asked her about contraception afterward, she had been too embarrassed to tell the truth. She recalled:

“Afterward he said, ‘You're on the pill, right?’ As if that would be the most natural thing in the world. I just said, ‘Yes, but isn’t it a bit late for you to be asking that now?' He replied, ‘Well, you kind of take it for granted, that the girl’s on the pill.”'—18-year-old, first time pregnant

Later, her shame had almost stopped her from telling him about the pregnancy. She remarked, “At first, I didn't plan on telling him at all, since I felt so bad about having lied about being on the pill.”

Paradoxical Feelings Toward Pregnancy and Abortion

•Abortion—the natural choice and yet a difficult decision. Finding out about the pregnancy had been a shocking experience for most of the young women; this shock was frequently followed by a mixture of contradictory emotions. Some knew immediately that the pregnancy had to be terminated, believing that abortion was the natural choice in their situation. One woman explained the paradoxical feeling of being overwhelmed in a positive way by the pregnancy, yet not questioning the decision to have an abortion:

“I'd never felt as happy before in my whole life. It was wonderful. But at the same time, I felt, ‘It has to go.’ I mean, what's there to do, really?”—18-year-old, first time pregnant

However, a few women explained that they had had very strong doubts about the abortion, some even shortly before the event.

Most found it difficult to be the one with the definitive task of deciding on abortion. One young woman deliberately tried to provoke a miscarriage while participating in motocross. She said:

“I made sure to jump and do hard landings as much as possible…so it would kind of ‘fall off’ by itself…. But it didn't…. You feel awful in a way…. You don't want to be the one having to make the decision…. You rather just want to let it pour out by itself.”—19-year-old, several miscarriages

A few young women strongly desired a visual confirmation of the pregnancy, but were not allowed to see the ultrasound picture:

“I really wanted to see the baby, and I asked, ‘Please may I see it?’ But they wouldn't let me, saying they didn't want me to get a picture of it in my head. I begged and begged, but ‘No, no, no!' You don't have the strength when you're lying there, so finally I gave up. Damn, I regret that today. I don't know why—in a way it's sick—but I really wanted to see and feel…like, this is it, this is for real.”—18-year-old, first time pregnant

•Abortion for practical, social and economic reasons. Although contradictory feelings were common, and some women recalled strong ambivalence, few women had any moral concerns regarding the abortion decision. Instead, a common justification for the termination, as a 16-year-old who had been pregnant for the first time explained, was that “it would have been unfair—both for me and for the baby.” Many viewed the pregnancy as an unfortunate situation:

“I mean…because it was so extremely small, I didn't feel that it was a child or anything, but more that [the pregnancy] was a hassle since there was so much going on in school. It really wasn't a good time…. I mean, it's not right to do it, but I still don't look at it as ‘a life,’ since it can disappear just as easily as it came. It was just, I don't know…a clot of blood in a way.”—17-year-old, first time pregnant

None of the respondents found it economically realistic to raise a child on their own; they stressed that stable finances, a job and a potentially long-lasting, loving relationship were all basic necessities for raising a child. Even though a small number had partners who supported the continuation of the pregnancy, they did not view this as a real option, partly because of concerns over the risk of ending up in an unequal position in relation to the partner. One young woman said:

“I haven't even finished high school…. I mean, how would it even be possible for me to have a child? I don't want to be dependent on somebody else…. I want stability…and I don't want to live off a guy either, on his salary, in his apartment!”—17-year-old, first time pregnant

The Influence of Social Norms, Family and Friends

•The need for support. The partner involved in the pregnancy was by far the person most consulted by the young women during the decision-making process. Regardless of the women's current relationship with the partner, the vast majority chose to let him know about the unintended pregnancy. A few participants wished their partners had been more present, throughout the decision-making process and for the abortion procedure as well. One explained:

“I don't think he quite understood…how difficult I found the situation. For instance, he didn't show up at the hospital at the time for abortion. When I called him later on the same day, he was just like, ‘Oops, was it that early…?’ If he'd been there, I'm sure he'd have better understood what I was going through!”—16-year-old, first time pregnant

Parents and peers were also mentioned as important sources of support, but not all participants found it possible to reveal their situation to their parents:

“Since my parents are immigrants and Muslims, it was totally out of the question for me to tell them about the pregnancy…. They would have turned me away if they'd known. I felt I was forced to choose between my family and my unborn child.”—18-year-old, first time pregnant

The participants appreciated the neutral support given by most health care professionals, and only a few had felt the need for professional counseling. Most of the women viewed pregnancy and the abortion as a very private issue, and because of fears of negative comments from other people, were highly selective about whom to tell.

•Free to decide, as long as the pregnancy is terminated. A few interviewees had encountered openly expressed attitudes against the forthcoming abortion, such as harsh remarks or remarks about punishment from God; most of these comments were made by people of non-Swedish backgrounds. However, the reactions from partners, parents and peers were overwhelmingly negative toward a continuation of the pregnancy, and almost all declared themselves in favor of an abortion.

Respondents who were ambivalent, in particular, felt they were persuaded toward termination. One young woman said:

“My mom was very negative! Her words echoed in my head…which kind of made me feel forced to do it. I had the abortion against my own will.”—18-year old, first time pregnant

Another explained:

“In a way, I felt forced into the decision. I didn't want to do it. He [the partner] was more pushing toward an abortion than I was, if you know what I mean…. But I kind of had to put the feelings aside and try not to think about it…. I realized we did the only right thing.”—20-year-old, second abortion

Several stressed the need for more nuanced advice:

“It was weird; I became so influenced by everyone else. I never had the chance to actually sit down and think it through properly…. Everyone was really against it…. Since I was so insecure, I wanted to hear both positive and negative stuff from my family, rather than just the negative…. I was the only one being optimistic about it.”—17-year-old, first time pregnant

One of the interviewees reflected:

“Having the abortion was my own decision. However, I can imagine that…if I'd wanted to keep [the pregnancy], people would definitely have tried to convert me—especially my mom.”—16-year-old, first time pregnant

Another stated:

“If I'd decided not to terminate this pregnancy, I wouldn't have told anyone about it until it was too late for an abortion…just to spare myself all the nagging!”—20-year-old, second abortion

•The role of the partner. Without the partner's support and agreement on how to cope with eventual parenthood, women viewed abortion as the only reasonable solution; as a result, they felt torn between their partner's wishes and their own. Many participants said their partners strove to offer emotional support. Nevertheless, partners' attitudes toward the pregnancy were predominantly negative, and the majority of interviewees described how their partners made implicit but clear remarks in favor of termination:

“He said, ‘Regardless of what you choose, I'll support you—but you know what I'd prefer you to do….’ And of course I wanted to respect that.”—18-year-old, first time pregnant

Postabortion Reflections

•Abortion was worse than imagined. Immediately after the abortion, combined feelings of sadness, relief, regret and emptiness were dominant. Several interviewees also worried about not being able to become pregnant again. Generally, the abortion was regarded as worse than had been imagined, especially the bleeding and the severity of pain. One respondent stated:

“I kind of thought that I'd go there, bleed a little and then go back home, having it all done. But I learned that wasn't the case.”—17-year-old, first time pregnant

Another woman commented:

“There wasn't enough information about the bleeding and the pain, I thought. The bleeding was massive. It was very frightening.”—16-year-old, first time pregnant

•Relief or regret—abortion as a life-changing event. All the young women said that they never wanted another abortion. At the same time, most were convinced they had made the right decision. Only those who had felt ambivalent about the abortion expressed persisting regrets.

However, some described the abortion in positive terms, citing personal growth. One woman noted:

“Immediately afterward, when I woke up, I felt that I could start anew, rebuild my life again…. I certainly don't regret it, and I know for sure that this was the best for me.”—19-year-old, first time pregnant

Other respondents felt that the experience had deepened their relationship with their partner. One stated:

“The abortion has somehow brought us closer together—we're actually about to get married!”—18-year-old, first time pregnant

Counseling and Contraceptive Use After Abortion

•Variations in motivation. Although no participant wanted to have another abortion, levels of motivation toward contraceptive use after abortion varied widely. Some women demonstrated very strong determination, claiming that the abortion experience had made them more cautious. Others intended to use contraceptives but did so inconsistently or continued to have difficulty negotiating their use. A participant said:

“We've had unprotected sex, yes, but we've been extremely careful…. I have been worried, though, that I will still become pregnant…. I told him, ‘If we're going to have sex, I really want us to use a condom, and be really careful.’ But even so, it didn't happen…. I mean, if it had happened again, I don't know what I would have done! But he said, ‘I assure you nothing's gonna happen.”’—17-year-old, first time pregnant

•Difficulties with contraceptive counseling. All participants received extensive contraceptive counseling from a midwife at the time of their abortion. Some who had experienced previous difficulties in finding suitable contraceptives or who were worried about side effects found that few appealing contraceptive methods were offered. One young woman explained:

“She [the midwife] thought I should absolutely have an implant. But see, I don't want that….”—19-year-old, first time pregnant

Another stated:

“I'm on the pill now, but I don't exactly feel good about it.”—20-year-old, second abortion

Some mentioned that loved ones or health care professionals had pressured them into choosing a particular method. One young woman who had decided on an implant mentioned that her mother, who had accompanied her to the counseling session, made a crucial part of the decision:

“[The midwife] asked if I wanted it for three years or for five years. And my mom declared: ‘Five years!”’—19-year-old, several miscarriages

One participant who had become pregnant when a condom ruptured had no steady partner and seldom had sex. She had doubts about the benefits of taking hormonal contraceptives on a regular basis, but felt that her concern was not taken seriously during the postabortion contraceptive counseling. She stated:

“They practically barked at me, like, ‘Well, that's what happens when you don’t use protection!'…‘But I did use protection’…‘But then how could you have become pregnant?’ I had to explain [what had happened]. But then they said, ‘Well, we still want you to start taking the pill.’ I think they could have shown a little bit more empathy.”—19-year-old, first time pregnant

DISCUSSION

The overarching theme that emerged from the latent content analysis was that female teenagers experience an illusion of power, one that is created by the dilemma of having contraceptive responsibility but limited freedom of reproductive choice.

The abortion decision among our interviewees was strongly influenced by negative attitudes toward the pregnancy expressed by partners in particular, but also by parents, peers and societal expectations. Negative attitudes toward teenage pregnancy are widespread in Swedish society, and the norm strongly favors abortion over teenage childbearing. The societal expectations following this norm were closely intertwined with the interviewees' own attitudes; most of the young women shared the view that stable finances, employment and a long-lasting loving relationship were necessities before childbearing and that abortion was the right solution for them at that time. On the other hand, those who had strong doubts regarding the abortion expressed feelings of powerlessness during the decision-making process.

In line with our results, previous studies have shown that an abortion decision often involves conflicting and contradictory emotions.6,20,21 These are usually temporary, and most women who undergo abortion have no long-term regrets or negative effects.20,22 However, persistent ambivalence, and in some cases severe emotional distress, can occur and should not be neglected.20,23,24 A follow-up study conducted two years after induced abortion demonstrated that the strongest predictor of emotional distress in women was pressure, either for or against obtaining an abortion, from the male partner.23 In a five-year follow-up study, ambivalence prior to the abortion predicted post-abortion depression.24

Partners, parents and peers may underestimate their influence. Their direct or indirect persuasion clearly puts undecided young women in a vulnerable situation. The formal right of Swedish women to decide whether to terminate a pregnancy may therefore—in reality—not be applicable to all women, and this may undermine young women's freedom of reproductive choice. This, in turn, could increase the risk of negative emotions following the abortion.

The norm of planning, and thereby often delaying, parenthood raises several questions. Could scientific messages about the negative outcome of teenage childbearing make us believe that no young woman—or man—is capable of taking care of a child? And could negative messages about teenage childbearing spread to include older teenagers and even women in their early 20s? There may be large differences in maturity between a 16-year-old girl and a 19 or 20-year-old woman, and teenage parenting may have worse consequences for some young people than for others; these facts make lumping all teenagers together problematic. Nevertheless, regardless of their age, the women in our study all seemed to experience the same normative restraints in terms of childbearing at a young age.

As already seen in numerous studies,6,11,21,23,25,26 economic considerations were one of the main reasons for pregnancy termination. For our participants, even those with a good relationship with their partner, being dependent on someone else was highly undesirable. Several raised concerns about getting caught in a stereotypical gender role and being put in an unequal position in relation to the male, which would limit their possibilities of achieving personal fulfillment, further education and economic stability. Therefore, even when economic support was offered, reconsidering the abortion decision was not an option.

In addition, although delaying childbearing on the previously mentioned premises may be wise for many young women, there may be some unforeseen consequences. If delayed childbearing becomes the norm, the window for childbearing may narrow to only a few years, which, in the end, may reduce a woman's likelihood of becoming pregnant or her ability to have the number of children she desires.

In this study, we found that the responsibility for purchasing contraceptives and initiating their use was perceived as a woman's issue, and communication with partners about contraceptive use was scarce. Leaving the contraceptive responsibility in the hands of women has been reported as a recurring tactic among men.16,17,27–29 Perhaps because all available contraceptive methods except the male condom and vasectomy are applicable to women only, a general attitude has arisen that women are the “natural” contraceptive users.

The responsibility for purchasing contraceptives and initiating their use was perceived as a woman's issue, and communication with partners about contraceptive use was scarce.

Efforts specifically targeting young women in an attempt to enhance contraceptive compliance are extremely common; all of our participants had received contraceptive counseling in connection with the abortion. However, the attempts of health care professionals to ensure contraceptive compliance were not unproblematic; indeed, the aim of the postabortion counseling session is to prevent new unintended pregnancies. Some young women experienced the counseling as being too coercive, and felt that their previous contraceptive problems, such as compliance difficulties and fears of methods' side effects, were not addressed.

This result highlights a few important issues. First, society cannot rely solely on women as compliant contraceptive users. To prevent unwanted pregnancy, men and women need to share contraceptive responsibility, and should be empowered to better communicate about safer sexual practices, especially with casual partners in unplanned sexual encounters.

Second, young women's lack of motivation to use contraceptives and fear of methods' side effects require serious consideration. It is important that the counseling session that is available to those seeking abortion be used to create a sound dialogue with young women about the best suitable contraceptive method, with the highest chance for individual compliance.

Third, few of our respondents seemed to pay particular attention to their menstrual cycles, and awareness regarding the fertile window was low. Knowledge about fertility and the menstrual cycle is a fundamental component of women's reproductive health rights. For young women to make an informed choice in regard to pregnancy, these issues need to be given higher priority, not only during contraceptive counseling but also as a part of school-based sex education courses.

LIMITATIONS

The interviews were conducted approximately 3–4 weeks after the abortion, to reduce recall bias. That 11 women who had originally agreed to be interviewed did not participate may be explained by the sensitive nature of the subject and possible second thoughts concerning participation, especially among young women of non-Swedish backgrounds. Other studies of sexual and reproductive health matters have reported difficulties in recruiting nonnative Swedes.26,30 Young immigrant women constitute a particularly vulnerable group in matters of reproductive health.26 In our study, only a couple of young women or their families had an immigrant background. Their experiences of the decision-making process clearly differed, perhaps because they were forced to deal with different normative systems than their native Swedish counterparts. Whether cultural backgrounds affect the experiences, decision-making process and emotional well-being of women considering abortion are questions requiring further research.

Because of our qualitative approach, the data are not suitable for generalizations, and we cannot make comparisons between groups. Nevertheless, we believe that our findings will contribute to the understanding of the issues involved in the abortion decision for young women in Sweden.

Approaching young women in a vulnerable position may raise issues of concern. However, all potential respondents were informed that participation was voluntary, and after the interviews, many expressed gratitude for having had the chance to reveal their needs, thoughts and stories to an attentive outsider.

Our impression was that the participants talked openly and extensively about their abortion experiences, regardless of interview procedure. Since we did not analyze body language in any of the interviews, we cannot assess differences in the quality of responses in the face-to-face and telephone interviews.

CONCLUSION

Young women in Sweden take on the main responsibility for contraceptive use, but their power to decide against the norm when faced with an unplanned pregnancy may be limited. To freely decide whether to terminate an unplanned pregnancy, ambivalent young women may benefit from more nuanced counseling. If young women feel pressured into contraceptive use, and young men are excluded from the discussion, then the present way that young people's sexual and reproductive behavior is managed has failed; these issues need to be addressed and discussed. It is time for sexual responsibility to be considered a gender-neutral issue, and efforts are needed to include males in prevention practices to a greater extent.

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AUTHOR AFFILIATIONS

Maria Ekstrand is researcher, and Tanja Tydén is professor, both in the Department of Public Health and Caring Sciences, and Elisabeth Darj and Margareta Larsson are associate professors, Department of Women’s and Children’s Health—all at Uppsala University, Uppsala, Sweden.