A discussion of the necessity to reduce abortion rates
- A case study on Greenland
Speciale af Turi Hermannsdottir
Kort beskrivelse af specialet
Jeg spørger i mit speciale, om det er nødvendigt at lave indsatsområder for at nedsætte den provokerede abortrate i Grønland. Dette gør jeg fordi jeg mener at denne debat mangler i felten omhandlende abort. Der er lavet meget epidemiologisk arbejde og mange indsatser for ar nedsætte raten, men der er mangel på debat om hvorvidt det er nødvendigt. Mit speciale kan ses som et præ-studie af et større kvalitativt studie om Grønlandske kvinders holdning til provokeret abort.
27. januar - 2015
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There is a vast amount of epidemiological work and statistical data in Greenland. The State Institute of Public Health, Department of Greenland has developed a range of epidemiological work, where some of it is specifically on abortion. Insights in attitudes, expectations and feelings following abortion are however lacking. Induced abortion rates continually exceed the birth rates. That is, abortion seems to play a great role in women’s (possibly also men’s) lives, thus the aim of this paper is to search for scientific evidence of whether or not it is necessary to reduce the abortion rates. Literature shows that there are various factors that play part in a bad abortion experience and that counselling can perhaps be an effective method of preventing possible negative emotions. The paper therefore argues in accordance with literature that pre- and post-abortion counselling by a psychologist should be offered all women undergoing abortion. The paper argues in accordance with the literature, that public health interventions with the aim to reduce the abortion rates are not necessarily needed but instead an optimisation of pre- and post abortion counselling is needed. Furthermore, the paper stresses the importance of other reproductive health promotion interventions (many of whom already are in process, as for instance, Nûno Tutillugu, Iggu, the ‘Early Action’ project, etc.). For further research, it is advised to conduct more qualitative work on how women feel prior and after an abortion in Greenland.
I would like to give a special thanks to Sara Johnsdotter, my supervisor, for valuable insights, constructive feedback and inspirational talks. You have been very helpful and have gone beyond what has been required of you as a supervisor. I would also like to thank the rest of the second floor at Hälsa och Samhälla, you have encouraged me and made the last months of my writing pleasant. I will miss sitting in the office with you.
Above that, my thanks go to my family and friends, especially my father who has taken the time to be my second supervisor, and my boyfriend who has supported me and encouraged me. Thank you.
In the beginning of 2000 the induced abortion rates in Greenland exceeded the live birth rates (see table 6). This incidence is unseen in other Nordic countries (see figure 3). It is not a specific group of women who undergo abortion (Arnfjord et al. 2001, Bjerregaard and Senderovitz 1995) nor is it a specific age group (see figure 2 and table 7), which makes it difficult for public health professionals to customise a successful public health intervention.
In the Arctic Research Journal (ed. Bjerregaard 2001: 7 – 11) it is reported that abortion procedures are not simple procedures. The report continues to state, that the procedure can cause increased risks of physical and psychological complications, and that an abortion should not be used as an anti-conception method. Furthermore it emphasises that it is not a recommended way of starting a woman’s reproductive career.
Other reports claim that the procedure of an induced abortion is “rather” simple but due to the frequency of induced abortions, especially in Greenland, it should be considered to be of public health importance (Zhou et al. 2002: 331 – 332). In addition, the report emphasises that there is not enough knowledge on the possible complications and therefore the gravity of the situation is not certain.
Abortions are prevalent in many countries. Greenland has one of the highest abortion rates but even if the rates were to be reduced substantially, it would still be a common phenomenon and thus a part of life experience (Kero et al. 2001, b) and a necessary part of family planning (Kero et al. 2001, a).
“Although pregnancy is a biological process, it is also firmly a socially constructed reality and, in practice, discursively operates as a continuum rather than a binary status” (Kimport 2012: 106).
Each induced abortion is an individual experience, and dependent on several factors. The feeling of grief or relief is not constant and therefore can change and vary. Negative emotions following abortions may not always be caused by the actual abortion but “some circumstances can make abortion emotionally difficult” (Kimport 2012: 119) and thereby socially constructed instead of biologically determined.
The focus of this paper is to determine if efforts are needed to reduce the rates of abortion in Greenland. In this context, it is necessary to stress that it may be more complicated to investigate possible psychological consequences following legally induced abortion than investigating the possible physiological consequences. Studies on psychological consequences are inconsistent and unclear. There are some studies that claim a higher risk in negative emotions but none show evidence of psychological diagnosis, like for instance depression, or long-term negative emotions. Studies that do find significant evidence to claim a relationship between negative emotions and legally induced abortions do not report any causal relationship but identify possible confounders, which may alter the initial result.
Various pregnancy prevention interventions have been funded in Greenland since 1997 but rates do not seem to be affected by the many interventions and programmes. In this dissertation, a review of the literature on possible complications following legally induced abortion is presented. The general literature will hence be discussed in concern to evidence from Greenland. Finally, it will be discussed how a country with one of the highest abortion rates in the world goes about the prevalence.
The aim of the paper is to determine if efforts are needed to reduce the abortion rates in Greenland. The aim is reached by a better understanding of the sociocultural factors that may influence abortion experiences in Greenland, through epidemiological and anthropological studies. To answer the main question I have developed multiple research questions.
- What has been the focus of previous reproductive health interventions in Greenland?
- What have been the effects of previous reproductive health interventions in Greenland?
- What are the attitudes to abortions in Greenland?
The first and second research questions are posed in order to better understand the general perceptions of abortion among health professionals and policy makers. Are there initiatives and deliberations to decrease the rates? Is abortion argued to be a public health problem? Is it discussed as an isolated issue or interconnected with other reproductive health issues, such as sexually transmitted diseases?
I assume that if there are public health interventions aimed directly at decreasing the induced abortion rates, it may imply that it is viewed as a public health problem. Furthermore, I want to investigate if previous reproductive health interventions have reduced the abortion rates.
The third research question will create a better understanding of the general perceptions of abortion in the population. Are abortions stigmatised or subject to taboo? Are abortions viewed as a contraception method?
Good-quality literature review with a systematic approach
My study will take form of a ‘good quality literature review’ (Aveyard 2014) with a systematic approach.
In the following sections I will give a description of:
- the literature search-strategy;
- how the quality of the literature was evaluated, method of appraisal;
- and how I will analyse the literature.
Even though I will not fulfil the requirements of a systematic literature review, advocated by Cochrane or Campbell Collaboration-style (Aveyard 2014: 12), which would require more time and perhaps even colleagues, I will maintain a “systematic approach” to my literature review.
A literature review will assist me in providing an overview and summary of the available literature on the topic, especially in Greenland. I find that a literature review is important due to the scarce literature on the topic in Greenland and the inconsistency in the literature both in Greenland and from other countries. To better be able to understand the local sociocultural climate on abortion in Greenland, I find that a literature review can assist in what can become a qualitative study on the topic.
The two most frequently used databases were Malmö University’s database and PubMed. Due to many providers’ access cost, I have mostly used Malmö University’s database, which gives me free access to other databases like JSTOR, Springer, EBSCO, SAGE journals, Science Direct, and many more. My quality criteria for providers and journals have been that they are well known and much used by other researchers and universities. Other used sources – especially facts on Greenland and abortion – have been The Greenlandic National Board of Health and Prevention (PAARISA); The Danish State’s Institute of Public Health; PAARISA’s webpage for promoting safe sex for teenagers; and TV- and radio-programme Nûno Tutillugu. In addition to scientific databases, my supervisor has also provided me with some literature.
Key search words have been, induced abortion; safe abortion; consequences; outcome; physiological; psychological; Greenland; Inuit; etc.
Method of appraisal
I got a vast result list from the literature search, and found that it was necessary to sort out which were relevant and which were less relevant.
Going through the literature I went through some general questions, in accordance to Aveyard (2002: Chapter 3 and 5):
- What kind of paper is it (e.g. research, theoretical, practice, or policy)? And how relevant is it?
- What are the main findings/conclusions in the paper?
- Which papers are at the most relevant?
- What are the strengths and weaknesses of the paper?
- Where did I find the paper?
- What is it and what are the key points?
- How has the author come to their conclusions?
- Who has written it?
- When was it written?
- Why has it been written?
When I had ‘identified’ the papers, I arranged them in groups, in order to maintain a more systematic methodological approach. After having read and often re-read the papers, I wrote a short ‘summary’ and, if appropriate, which other paper it was relevant to. This was done so I could easily go back in the literature and find the relevant ones. Since my research questions ideally should be supported by qualitative research papers and theoretical papers on abortion in Greenland I arranged the papers in relation to what was most relevant and could best help me answer the question. The last of Aveyard’s (2002) questions: “What are the strengths and weaknesses of the paper?” can be seen as the ‘critical appraisal’ and combining the three first questions.
I argue that papers on illegal abortions and their outcomes are irrelevant to my study because of the different settings an illegal and legal induced abortion necessarily will have. Furthermore statistics on illegal abortions are often unreliable. An illegal abortion may be performed under unsafe settings, e.g. performed by an unauthorised doctor or that the tools might not fulfil standard criteria, which can result in worse consequences than a legal induced abortion performed under safe settings. A vast amount of literature on abortion discusses negative health outcome after an unsafe or illegal abortion and as these were not regarded relevant to my study, I disregarded them.
Literature on psychological outcome after legal induced abortions was selected in terms of relevance and methodological quality. Relevant literature was on legal, safe, induced abortion, concerning Western or Nordic countries, if not specifically Greenland or Inuit in Canada. The criteria for methodological quality was met if the stated aim, a large sample size in quantitative studies, and evidence of thorough statistical analysis, were clearly stated in the argument. On the other hand, it is challenging to successfully differentiate between highly normative papers and scientifically ‘valid’ papers. I have therefore also taken the standpoint that if a given article has been published in an acknowledged scientific journal I have to assume that the article meets standard scientific criteria.
Since I chose to disregard papers on illegal induced abortions, it ruled out all countries that do not have legal induced abortions. One could argue the relevance of literature from small or isolated communities and peoples closely connected to their indigenous culture. I do find it relevant to compare studies from Nunavut, Inuit in Canada, to studies from Greenland. However I argue that other societies may not easily fulfil criteria for comparisons. It would for instance not be relevant to compare studies from small and isolated communities in larger societies, since Greenland is an autonomous country, geographically unattached to any other country and the whole population shares the same culture. I find that Inuit in Nunavut, Canada, are the most similar society to Greenland, and have therefore also referenced to some studies from Nunavut.
The high prevalence of abortions in Greenland, strains the Health Ministry on a financial level (Bjerregaard ed., 2001: 5). The total cost of a surgical abortion in Greenland is 15.000 DKK and with an average of about 900 surgical abortions each year it is a cost of 13,5 million DKK (Nûno Tutillugu 2009-2010, episode 6). In other words the yearly expenses for induced surgical abortions account for 1,25% of the total expenditure of the governmental health sector. The budgetary constraints are however not something that is discussed further in the current research.
To maintain the study’s scope within the limits of the paper, I chose to discuss the high prevalence of abortion in Greenland based on the available literature. For further research, I advise a qualitative study in the form of interviews and participant observation. As I have explained in the introduction, I find it important that the abortion procedure is as optimal as possible, because of their high prevalence.
The critical appraisal can be seen as the first stage of the analysis process. The next stage is the development of themes of my findings or results.
Analysing the literature and the theoretical framework
As I have stated, my study will take form of a literature review, however, in addition to this I will also make use of a social constructionist discourse analysis approach when discussing and analysing the literature (Jørgensen and Phillips 2002).
There is no one definition of social constructionism, however there are some key assumptions that social constructionists share (Burr 2003: 2 – 5):
- A critical stance toward taken-for-granted knowledge
- Historical and cultural specificity (depending on where and when one lives)
- Knowledge is sustained by social process (interactions between people, i.e. in constant change)
- Knowledge and social action go together (how we understand a phenomenon will change our social action toward it. E.g. alcoholism is today seen more of a sickness than an informed choice of way-of-life, and therefore should we rather see alcoholism as something that should be treated, medically/psychologically, and not something punishable).
“[The] social world, including ourselves as people, is the product of social processes, [therefore] it follows that there cannot be any given, determined nature to the world or people” (Burr 2003: 5). Of course, social constructionists do not counter argue the realness of material objects in the world, such as a rock. A rock is not a social construction. The word is but the fact that it is an object will not depend on any historical or local context. In accordance to the French philosopher Michel Foucault, “deconstructionism emphasizes the constructive power of language as a system of signs rather than the constructive work of the individual person” (ibid. p. 17).
As I am taking a social constructionist theoretical position to my research approach, I adopt what is similar to a Foucauldian discourse analysis. With this approach, some methodological paradoxes arise, for instance “the ‘objective-talk’ of scientist becomes just part of the discourse of science through which a particular version, and vision, of human life is constructed” (Burr 2003: 151). That is, according to social constructionism objectivity is something that is impossible to reach because no matter how un-biased the method we use is, we will always be affected by subjectivity to some degree, e.g. through our motivation to the study, our pre-understanding of the world, our theories and hypotheses, etc. In other words we always view the world from some position. “The researcher must view the research as necessarily a co-production between themselves and the people they are researching”, so that “the task of the researcher […] becomes to acknowledge and even work with their own intrinsic involvement in the research process and the part that this plays in the results that are produced” (Burr 2003: 152). According to Burr (2003), another problematic issue with this approach is the power-relation that is created between the researcher and the ‘subject’. The researcher is often regarded to behold the knowledge and thereby in power. It is not only within the field of research that this power-relationship is constructed; also in the social world we find it. This is what Foucualt argues in his texts. A researcher’s ‘voice’ is often seen as more powerful than the ‘lay-person’s’ ‘voice’. Even just the word ‘subject’ and ‘lay-person’ highlights the power-relation. It is important from the social constructivist’s point of view that these relations change. In some disciplines ‘subjects’ are referred to as ‘informants’ or ‘respondents’, which rhetorically seeks to stabilise the power-relation.
“Gergen (1999, 2001a) advocates ‘collaborative inquiry’, where the research process is informed by the needs and aims of the participants; Orford (1992) recommends ‘community psychology’, which aims to empower service-users by involving them in identifying problems and finding solutions. These approaches can include ‘action research’, where the aim of the research is not just to study some existing state of affairs but to change them for the better, and where the values and political agenda motivating the research is therefore explicitly acknowledged. Such research is potentially empowering, since ‘it is about finding participant-led ways of improving specific problematic social situations.” (Burr 2003: 155).
Despite of changing the view we understand research within social constructionism it is still subject to methodological critique. For instance, the theory seeks to take a critical stance towards relations, hypotheses, etc. but sometimes lacks a critical stance to itself as a social construction. Furthermore, how we normally understand the concept of reliability and validity within research is not applicable within social constructionsim. “Reliability is the requirement that the research findings are repeatable, and therefore not simply a product of fleeting, localised events and validity is the requirement that the scientist’s description of the world matches what is really there, independent of our ideas and talk about it.” (Burr 2003: 158). This understanding is not appropriate in the discourse analysis because according to a social constructionist’s point of view “all knowledge is provisional and contestable, and accounts are local and historically/culturally specific” (ibid.). And also due to this understanding of the social world, social constructionists struggle to justify their analyses. There are several criteria or guidelines one can follow as a researcher. The criteria are dependent on which approach to research is used however these are not something I will explain further, since I regard it as broader than the scope of this paper. Within the Foucauldian concept of discourse, they “are ways of speaking about or otherwise representing the world which actually constitute us as persons. We are the subjects of various discourses and our subjectivity, our selfhood, is understood in terms of the positions that are available to us” (Burr 2003: 169, see also Jørgensen and Phillips 2002).
Literature on legally induced abortions in Greenland is scarce, which results in various limitations. Much of the literature on induced abortion is oriented towards a normative question or is biased due to normative standpoints. Charles et al. (2008) highlight that research on induced abortions has improved in the last two decades however it still tends to be “biased by political motivations” (Charles et al. p. 436).
Another outcome of the scarce literature is that data on the subject is inconsistent and induces different understandings of the abortion incidences and possible consequences.
A third outcome is that I am forced to compare across cultures and cases of singular and multiple induced abortions, which may affect the validity.
Norden (2014) reported 56.370 inhabitants in Greenland in 2013, where among 16.818 live in the Capital, Nuuk. It is a self-governed country within the Kingdom of Denmark. The population growth rate was -0,16% in 2014. The fertility rate is 1,98 per woman aged 15 – 49 years. There are 89% Greenlandic Inuit and 11% Europeans (where among many are Danish).
In this section I will present the discursive field of abortion by using international literature and evidence. Later in the paper, I will use this discourse together with Greenland as a case study.
There are two strands of literature: papers on illegally induced abortions; and legally induced abortions. Since Greenland has had legal abortions since 1975 and they are performed under safe conditions, in a hospital, the papers on illegally induced abortions are hardly relevant to my research and therefore not included.
Papers on legally induced abortions are again divided into sub groups: reported psychological complications and reported physiological complications.
In a register-based study from Denmark, (Zhou, W. et al. 2002) of 56117 induced abortions, there were short-term complications within two weeks-time after the abortion (such as bleeding, infections and re-evacuation) in 5% of the cases. The researchers conclude that even though the short-term complication may be few, it is still considered a public health issue due to the frequency of the procedure. This would imply that the abortion rates in Greenland are a public health issue due to the high rates.
A second study from Denmark looked at the relationship between induced abortion and breast cancer risk. No significant association was found between increased risks of breast cancer following induced abortion (Braüner et al. 2013).
One study from Australia (Watson et al. 2012) looked at the potential relation between prior intracervical procedures and very preterm birth. Results showed a significant association between very preterm birth and curettage during abortions requiring cervical instruments. There were no relationships between very preterm birth and suction aspiration or any other abortion procedures that do not require cervical instrumentation. The researchers advice, that the midwife/doctor should be aware of medical history with intracervical procedures and abortions, with potential following pregnancy (Watson et al. 2012). The results may not qualify for a situation with merely induced abortions, since the study included both spontaneous and induced abortions.
A number of studies looking at the relationship between induced abortion and clostridial infections found a very rare relationship. Due to the gravity of clostridial infection, the researchers advice midwives/doctors to have high suspicion for diagnosis in women with nonspecific symptoms 2 to 6 days after the abortion procedure (Fischer et al. 2005, Meites et al. 2010, Dempsey 2012).
I found no evidence, other than the previous mentioned Australian study (Watson et al. 2012) of induced abortions decreasing women’s fertility, preterm birth, ectopic pregnancy, spontaneous abortion, or low birth weight (Frank et al. 1993, Virk et al. 2007, The Danish Public Health Portal 2014). I have not been able to find any studies on this subject in Greenland.
To sum up, evidence shows that there is a small statistical significant increased risk of short-term physiological complications following induced surgical abortion. In countries with high abortion rates a 5% increased risk of complication can be seen as a public health issue. I have found no statistical significant evidence of long-term complications following surgical or medical induced abortion. Of severe complications, but also very rare, a relationship between the fatal clostridial infection after a medical induced abortion was found. Due to the rarity of the infection I don’t regard it as a public health issue, but agree with the researchers (Fischer et al. 2005, Meites et al. 2010, Dempsey 2012) that doctors/midwives should be aware of nonspecific symptoms 2 to 6 days after the abortion procedure. In general, literature supports that medical and surgical induced abortions are relatively safe procedures.
Systematic reviews show no significant relationship between abortion and long-term mental health consequences (Charles et al. 2008), but that there are some signs of emotional distress in the first few months, however no affect in the long-term (Bradshaw and Slade 2003).
A stratified population-based longitudinal study, with 768 female students between the age of 15 and 27, from Norway (Pedersen 2008), finds that young women in their 20’s have a significantly increased risk of depression after an induced abortion, even after controlling for a vast amount of potential confounders. Although it seems that there is an increased risk of depression among women in their 20’s, teenagers do not seem to have an increased risk of depression after induced abortion. Again it is noted that studies on abortion and health outcome are “inconsistent” (Pedersen 2008) and that the literature on the area is of poor value, as Charles et al. (2008) and Bradshaw and Slade (2003) also conclude. Charles et al. (2008) find that the studies with the most robust methodology did not show any relationship in terms of abortion and negative mental health outcome. Pedersen (2008) finds that the most robust studies, conducted in New Zealand, showed a positive relationship between induced abortion and negative mental health outcome. Due to the complication of comparing across cultures, Pedersen (2008) notes that “New Zealand’s abortion laws are much more strict than Norway’s, and this in itself could possibly increase the risk of social stigmatization and negative sentiment regarding abortion”. He concludes that the results suggest that there is an increased risk of depression after an induced abortion “among young Norwegian women, but not among teenagers”, and in the light of “local sociocultural climate” he suggests, that despite the lean abortion law in Norway, social stigma might also affect the young Norwegian women to feel guilt, low self-esteem and depression (p. 427, see also Hosseini-Chavoshi et al. 2012, Major and Gramzow 1999).
In a 30-year longitudinal study a weak association between abortion and mental health disorders was found (Fergussen et al. 2008). Again in 2009 (Fergusson et al. 2009), in a more in depth study, strong and negative emotions were still associated with induced abortion but that despite of the negative emotions almost 90% reported that the abortion procedure was the right decision. The researchers note, “These findings are not consistent with strong pro-life positions that depict unwanted pregnancy terminated by abortion as having devastating consequences for women’s mental health. Equally, however, the findings do not support strong pro-choice positions that claim unwanted pregnancy terminated by abortion is without mental health risks” (Fergusson et al. 2009: 425).
A study from New York (Major et al. 2000) included 442 randomly selected women at 1 out of 3 abortion provider’s sites. Women with a history of previous mental health disorders, younger women, and women who have already had children, seem to have an increased risk of feelings of regret (even two years post-abortion) or psychological problems.
In a study of qualitative interviews (Christiansen et al. 2003: 91), with 14 Danish women who had an abortion at least a year before the interview, it is proposed that an abortion is a momentous event and needs some kind of processing. Some women are more prone to being more heavily negatively affected than others (see also Söderberg et al. 1998, Pedersen 2008, Birkler 2014).
There are many studies that find no significant relationship between poorer mental health following a legally induced abortion (Kero et al. 2004, Charles et al. 2008, Schmiege and Russo 2005, Gilchrist et al. 1995, Russo and Zierk 1992, Steinberg and Russo 2008 and Steinberg 2011) but there are also studies that find a relationship between induced abortion experiences and negative health outcome. In studies where they control for possible confounders, they find possible risk factors for worsened mental health after an abortion. The confounding factors can be: 1. feelings of ambivalence about the decision; 2. low level of social support; 3. if the pregnancy was initially planned/wanted; 4. “presence of unresolved ethical issues or religious concerns”; and 5. late abortions (Cameron 2010, Söderberg et al. 1998: 177). This means that a statistical significant relationship between induced abortion and negative health outcome may be found but is non-significant when including for potential confounders, which may imply that there is not a causal relationship between induced abortion and negative mental health outcome, e.g. depression or negative emotions (Stotland 2011, I will discuss this further in section ‘A socially constructed reality’). The results indicate that induced abortions do not seem to have universal or constant consequences. An abortion is an individual experience and the emotional outcome will be dependent on a variety of factors.
Again, I have not been able to find any studies on this subject in Greenland, which is why I have turned to studies from various other countries that met my methodological criteria.
Misinformation and myths about induced abortion should show a clear distinction from scientific evidence. Antiabortion and pro-abortion activists generate misinformation by relying on and using “anecdotal ‘evidence’”, singular cases and misinterpretation of scientific findings.
Clearly, once a young woman is pregnant, it is no longer a choice between having a baby or not having a baby. It is a choice of having a baby or having an abortion; it is a choice between having a baby or having a traumatic experience. (Rubin and Russo 2004: 76 quote by Reardon, D. C. 2002)
It is not only the antiabortion activists that create misinformation and myths. A misunderstanding from both extreme poles, antiabortion and proabortion supporters, is that they both assume something to be universal or constant which is not, according to “research findings from medicine, reproductive health, anthropology and sociology” (Kimport 2012: 105). According to Kimport (2012), antiabortion supporters claim that every woman is inherently determined to feel attached to any pregnancy, and will therefore feel grief and regret in case of abortion. Prochoice supporters, on the other hand, claim that women who have chosen to abort do not get attached and will feel relief following an abortion (p. 106). Kimport (2012: 107) emphasises that “the simplistic assumptions about women’s attachment to pregnancy forwarded by abortion right opponents and proponents alike are inaccurate”.
One of the consequences of the misinformation and myths that the poles generate is to affect expectations and beliefs about emotional experiences following abortions, whether it be positive or negative. The antiabortion discourse generates stigma, which leaves women having an abortion in a worse situation and in more risk of negative mental health outcome. The extreme pro-choice activists claim that women will not attach themselves emotionally to a pregnancy, when they have decided to have an abortion, and will feel relief instead of any negative emotion (Kimport 2012: 106). This also generates a negative reaction in those women who do feel initial attachment to the pregnancy, but choose to abort despite of this. These women might grieve the loss of the pregnancy at the same time as feeling that it was the right and best choice for them and the foetus (Christiansen et al. 2003).
Both poles evoke strong feelings and “[intensify] the gauntlet of obstacles that women seeking abortion already face” (Keys 2010), furthermore, I argue, they are a threat to scientific abortion research. Many researchers have studied the psychological responses to abortions (Birkler 2014, Söderberg et al. 1998, Pedersen 2008, Charles et al. 2008, etc.) and how women cope with the event (Keys 2010, Kero et al. 2000, Goodwin and Ogden 2007, Littman et al. 2014 and Foster et al. 2012). Keys (2010) refers to interactionist theory, which emphasises the importance of women’s “social world”, which, according to the theory, will be a factor in shaping her abortion experience. The social world can include factors as, support networks, structural conditions, political climate (Keys 2010: 43) and public discourse (Pedersen 2008).
Extreme prolife claims and extreme prochoice claims can be argued to have negative influences on women. Noting that “self-punishment is not what we would typically regard as a healthy coping mechanism” – implying that extreme prolife claims can have this effect on women – while “suppressing feelings can also have destructive consequences” (Keys 2010: 65).
Activists’ debates and rhetoric does not affect women at the point of choosing an abortion. At the point of finding out about a pregnancy the woman will act more ‘instantly’ and will not take time to read or listen to different arguments in antiabortion and prochoice claims. However, even if the woman acts instantly at the point of pregnancy, the social world can influence every woman prior and/or post abortion (Keys 2010: 64). Keys’ findings propose what role “ideology plays in shaping emotional experience” and explains, “abortion does not automatically elicit one set of emotions; prior socialization is a critical factor” (Keys 2010: 64).
In an American study (Foster et al. 2013) with 956 interviewed women in 30 different abortion clinics it is described that the environment for abortion seeking women has changed over the past decade. Earlier abortions were performed in the hospital in contrast to now, where there are many “stand-alone clinical facilities” and even if this was done to protect women from “products of conception” and meeting other visible pregnant women (Keys 2010: 65 – 66, Navne 2003), it has also “[enabled] abortion rights opponents to concentrate their protests at these facilities”, which may have a negative affect on women’s emotions when seeking an abortion (Foster et al. 2013: 81). One can therefore say that the environmental change has had both negative and positive results. The negative consequence is that women who seek an abortion are easy to find and can be confronted by protesters. Some women will ultimately not be affected by the protesters while others will feel negative emotions. This could for instance be a woman who has had difficulties deciding for the abortion who will feel worse if confronted by protesters (Foster et al. 2013: 86). It does not seem, however, that the presence or intensity of protesters has long-term consequences (Foster et al. 2013). As previously stated, evidence does not show that the activists’ debate and rhetoric affects women at the time of finding out about a pregnancy and choosing an abortion or choosing to continue the pregnancy, however the affect is prior and post abortion. The debate and rhetoric affects women on an emotional level, for instance on what they should choose (an abortion or continue the pregnancy) and/or how they feel post abortion (guilt/regret or relief). Abortion procedures are performed in hospitals or emergency clinics, in Greenland, and therefore it is not possible to know the woman’s business. I have not found any evidence of pro-life or pro-choice protests, in Greenland, and therefore I argue that women are not exposed to harassment from these groups. As previously mentioned and will further explain, harassments and negative rhetoric may increase women’s risk of experiencing emotional distress and/or regret (Keys 2010, Kimport 2012, Pedersen 2008, Hosseini-Chavoshi et al. 2012). One can imagine that the lack of harassment and negative rhetoric equally means that abortion-seeking women have lower risks of negative sentiments. This does not mean that there is no harassment of women who seek an abortion. It is just not manifested as a physical and active protest.
In accordance with the presented literature, I argue that we cannot predict any particular emotion after an abortion. Abortion experiences and coping mechanisms are dependent on prior socialization (Keys 2010), the public discourse (Pedersen 2008), the reason for abortion (Christiansen et al. 2003, Birkler 2014), the social- and socioeconomic situation and availability of support network (Söderberg et al. 1998).
The rhetoric of abortion may raise a lot of semantic confusion, since there are several words to describe one and the same thing (Birkler 2014). However, not only is it a choice of word that might be value-laden: pro, neutral, or anti, but there are also different perceptions of the actual action (induced abortion), which most often are visible in the choice of word. Furthermore are there technical terms to the procedure, which are not value-laden. The clinical terms are not per se better or less coloured. For instance, it sounds easier to get rid of a zygote than an embryo, which is a choice of word the clinician can use. Generally an embryo is referred to from 0 – 8 weeks, foetus 8 – 22 weeks and infant week 22 – birth (Birkler 2014: 33). The intervention in itself stems from the Latin word “abortus provocatus” which means artificial induced abortion or a provoked abortion. Spontaneous and induced abortions are distinguished. Within provoked abortion, induced and selective abortions are also distinguished, since the latter is performed due to unwanted characteristics of the foetus (which is not legal in many of the countries with legal abortion). In terms of value-laden words within the abortion debate, the chosen concept (word) expresses the intension (meaning) and sometimes also refers to the extension (for instance, is the debate referred to a woman who uses induced abortion as a contraception method or a 10-year old, who after a rape seeks an abortion?).
Figure 4. The relationship between intension, conception and extension
Conception (word) Extension (reference)
(source: copy of Figure 1.6 in Birkler 2014:34)
This shows that the debate has a complex language since there are three different factors that are affected by each other. The complexity can affect the contextualisation in a society. The word manifests the meaning and sometimes also the reference, which also can reflect the meaning. A simpler language, by for instance using the same word for the same thing, would eliminate underlying meanings and references. Because of the meaning and references are manifested through the words, the chosen word (if negative) will stigmatise individuals who choose abortion. I can only imagine, that in Greenland, this stigmatisation is not as strong as it might be in other countries, due to abortion’s commonness. Almost everyone will know someone who has had an abortion, and therefore also understand the complexity of the situation.
In this section I will discuss further how the woman’s own life experiences and the public discourse on the subject influence her emotions following a legally induced abortion. The reason behind the abortion may influence the woman’s emotional experience (Christiansen et al. 2003, Birkler 2014). One could speculate that a woman who becomes pregnant without planning so but has made an informed choice for abortion, feels confident and perhaps receives emotional support, will most likely cope differently than a woman who seeks an abortion due to a felt necessity, for instance due to religious beliefs or due to a separation or divorce (Birkler 2014). The woman’s motivations behind the abortion decision are important to account for when looking into psychological consequences following an abortion, because they can have significant impact on how the woman will cope afterwards. Some studies (many of which are cited in this paper) find a non-causal relationship between negative mental health and induced abortion. As Stotland (2011) notes “There is sufficient evidence to conclude that induced abortion may be a symptom, but is not a significant cause, of mental health problems in adolescents” (p. 343). Thus, for instance, romantic relationship loss is the direct cause for the negative emotions, and the abortion a necessity or ‘symptom’.
From a philosophical point of view, I will here refer to a social constructionist understanding, that of which “within a particular worldview, some forms of actions become natural, others unthinkable. Different social understandings of the world lead to different social actions, and therefore the social construction of knowledge and truth has social consequences” (Burr 1995: 5, Gergen 1985: 268 – 269 in Jørgensen and Phillips 2002: 6).
Social stigma, the reason for abortion, and late abortions, are all identified factors that can have a negative influence on the woman’s abortion experience (Christiansen et al. 2003, Kimport 2012: 106, Broen et al. 2005 and Bielecki 2005: 35, Goodwin and Ogden 2007).
In some societies abortion is described as a taboo and where the health professionals make an effort to ‘protect’ the abortion-seeking woman from ‘products of conception’ (Keys 2010 and see footnote 2). In other societies it is not described as a taboo and not something the health professionals regard as a sensitive matter (Navne 2008). It is reported that some abortion providers seek to “[distract] women from the discomfort of the procedure and [conceal] the products of conception” (Keys 2010: 65 – 66), and women who have had a previous abortion often avoid being near babies/children and/or pregnant women (ibid. pp. 53 – 54). Navne (2008), being Danish, describes her experiences in Greenland as surprising and describes how she felt that she had some ethical considerations, which perhaps were not necessary in the context of Greenland. She describes in her field notes, “My prejudice was that it was unethical to sit and point with a big pregnant belly during talks [interviews] with women who had decided to get an abortion” (translated, Navne 2008: 52) and therefore she stopped her interviews during her pregnancy, but describes later that this might have been a misunderstanding and predicts that women in Greenland would not be negatively affected by the ‘big pregnant belly’, ‘products of conception’ or the presence of newborns. Based on literature, I argue that there might be specific cultural understandings, expectations and ethics in terms of induced abortion, however it does not counter argue that each woman will have her own personal understanding, expectation and feelings toward the abortion that she seeks or has had.
Despite the attachment to Denmark, the vital statistics in Greenland differ from the neighbouring Nordic countries.
Figure 1. Suicides per 100 000 per sex
(source: Norden 2013: 56)
The male suicide rate in 2011 was 100 per 100.000 men in Greenland while in the other Nordic countries the rates were between 10 and 25 per 100.000 men, as seen in the figure above.
Table 1. Life expectancy at birth
(source: Norden 2013: 37)
Life expectancy at birth for men in 2011 was 68,3 in Greenland while in the neighbouring Nordic countries it was ranging between 77,2 and 79,9. For women the life expectancy rate was 73,0 in Greenland and ranging between 81,6 and 84,9 in other Nordic countries (see Table 1 above).
Figure 3. Total abortions per 1000 women (15 – 49 years of age) from 2000 – 2009
(source: Nomesco 2011: 61)
As figure 3. shows, the total abortion rate is likewise disproportionately higher in Greenland than in any of the other Nordic countries.
The Faroe Islands, Iceland, Åland and Finland do not have free abortions to the extent that women can freely choose to terminate a pregnancy. Women in the respective countries have to fulfil a number of “social and/or medical criteria” (Nomesco 2011: 52) in order to be granted an induced abortion.
The reported consumption of hormonal contraceptives is surprisingly higher in Greenland than in other Nordic countries (see table 2), considering the high abortion rates.
For further analysis, one could speculate that there is a relationship between induced abortions and other social incidences and conditions. Of a random sample (N=1393) of the Inuit population in Greenland, from 1993-94 (Curtis et al. 2002: 110), 47% of women and 48% of men had ever been a victim of violence. Of sexual abuse it was 25% of women and 6% of men. 8% of the women were sexually abused as children, where as for men it was 3%.
Statistical calculations found that having been physically or sexually abused was significantly associated with a number of health problems: chronic disease, recent illness, poor self-rated health, and mental health problems (ibid. p. 117). Unfortunately the researchers did not investigate the relationship between current sexual health and violence, or current sexual health and sexual abuse. In current sexual health I included: current sexual life; use of contraception; number of pregnancies; number of spontaneous miscarriages; number of induced abortions (and if any of them where due to sexual abuse); and history of sexual transmitted diseases. The significant associations between health and violence/sexual abuse can be seen as an indicator that violence and sexual abuse may also be associated to induced abortions or risky sexual behaviour. The search for this suggested association could be important for further research because it highlights the complexity of the issue and emphasises how it should be regarded as interconnected to other social problems, on a micro level and macro level.
According to Curtis et al. (2002: 118) the prevalence of violence is somewhat higher in Greenland than in Denmark. Among men the difference is not striking but among women, Greenlandic women are notably more often victims of abuse than women in Denmark. Among other Nordic countries the prevalence was somewhat mixed. Finland had equally high rates as Greenland but Iceland had lower, as Denmark. Furthermore, even though there are very few studies investigating violence and sexual abuse among Inuit and other Indigenous people, Curtis et al. (2002: 119) refer to the Canadian Panel on Violence Against Women from 1993, that estimated that the prevalence of sexual abuse in Northwest Territories, i.e. where the Inuit live, are 4 – 5 times higher than in the rest of Canada. Above that Curtis et al. (2002: 120) found that alcohol abuse was significantly associated with violence. And family members more often assaulted women while people outside men’s household more often assaulted men. This could be interesting to further investigate, to see the prevalence of women who choose to terminate a pregnancy due to violence from the partner or someone else in the household (see also Bielecki 2005). Another study on sexual assaults in Greenland (Mejlvang and Boujida 2007) also found that sexual assaults were often inflicted by someone closely related to the victim (in 92% of the cases) and that half of the times both victim and offender were severely affected by alcohol. These findings support Curtis et al.’s findings (see also Baviskar and Christensen 2011).
There are emergency clinics in all the larger towns, inhabiting 550 to 5500 persons, i.e. 15 emergency clinics in total, and the National Hospital is situated in the Capital Nuuk. Most ordinary medical procedures are performed in Greenland but a number of specialised procedures, that require more advanced technical equipment and specially qualified staff not present in Greenland, are referred to Denmark. The smaller hospitals or emergency clinics have 1 to 4 physicians. There are several geographical barriers to maintain a modern health care system (Niclasen and Mulvad 2010). For instance the lack of roads between the towns creates a barrier for quick transport between emergency clinics. Bjerregaard et al. (2003) write that there is a non-balanced economic expenditure on care in respect to prevention and advice that more should be spent on preventing diseases and promoting health, however effective health promotion is a “life-long process” and in order for it to succeed, new research is needed as well as a political will (Bjerregaard et al.: 9 – 10). The health care system has remained unchanged since the 1920’s but in 2008 the government agreed upon a reorganisation of the health care system in two regions by 2010 and that in 2011 it was to be implemented in other regions. The reorganisation focused on tying the regions together through better communications with the help of telemedicine and electronic patient file systems (Niclasen and Mulvad 2010: 443).
“The health transition among the Inuit reflects the interaction of genetic and environmental factors” (Bjerregaard et al. 2003: 32). Changes in the ecosystem and the society are determinants of health (Marmot and Wilkinson 2010: 45 – 83); these can for instance be dietary intake, physical activity; and higher level of polychlorinated biphenyls (PCB’s), dioxins, toxaphenes, etc. in traditional foods; and income, education, housing, employment, etc. (see also Graph 2).
The rapid changes that Greenland and other Indigenous Arctic societies have undergone have “influenced all aspects of their way of life” (Niclasen and Mulvad 2010: 439, see also Curtis et al. 2005 and Bjerregaard et al. 2003.). Interaction with Europeans and Americans in the 1900’s is thought to have resulted in the onset of infectious diseases, such as small pox, influenza, whooping cough, intestinal infections, tuberculosis, hepatitis, pneumonia, meningitis, etc. Even if many of these infectious diseases have decreased with time the rates are still high in comparison to other Western countries (Niclasen and Mulvad 2010). Later on with what one can call the westernisation in Greenland, “Western diseases” have increased. These are diseases common in the Western countries, such as cancer, ischemic heart disease, stroke, diabetes, obesity, hypertension and mental health problems (Bjerregaard et al. 2003, Bjerregaard and Curtis 2002). In addition to the increase in infectious and chronic (“Western”) diseases, injuries and societal pathologies have also increased. Of course Inuit hunters have been in risk of injuries due to hunting and the harsh natural environment but with the availability of alcohol, incidents have increased. Injuries and societal pathologies, e.g. house fires, motor vehicle accidents and suicide, are shown to have strong correlation with the intake of alcohol. Adolescent suicides, homicides, assaults, and sexual and non-sexual abuse are all of “major public health concern” (Bjerregaard et al. 2003: 32). The cultural transition that Greenland has been going through is still going on and they are becoming more and more ‘Western’ or modern (Bjerregaard and Curtis 2002).
Inuuneritta is Greenland’s largest public health programme. The first public health programme, Inuuneritta 1 (2007 – 2013) had a large focus on reproductive health issues, as for instance unintended pregnancies, teenage pregnancies, sexually transmitted diseases and induced abortion. The second public health programme, Inuuneritta 2 (2013 – 2019), has a larger focus on alcohol, marihuana, smoking, physical activity and diet. Other programmes still focus on reproductive health. PAARISA, the National Board of Health and Prevention, has throughout many years developed several types of reproductive health interventions (see section ‘previous abortion interventions’).
Despite a large number of interventions and reorganisation in the health care system in Greenland, the vital statistics do not seem to have been affected much (see figure 1, 3, 5 and table 2, 5, 6, 7). The vital statistics form a complex and interdependent system. The results of public health strategies and interventions may therefore not be visible at first hand. Cultural and historical aspects of the public’s health might help us understand the complexity of the situation. Perhaps in time we will see a positive effect of interventions, structural reorganization and the spread of telemedicine, in Greenland.
All induced abortions are performed in hospitals or emergency clinics in Greenland. All induced abortions within the 12th week of gestation are performed as surgical abortions. Induced abortions after the 12th week of gestation, with special grants, are performed as medical abortions. In Denmark women can choose between a medical or surgical abortion, where 60% choose surgical while 40% choose medical (Sundhedsstyrelsen 2009).
PAARISA has made a flyer for women who are considering abortion. The flyer has information on the abortion procedure and descriptions of various situations the woman who is considering an abortion can be in. The flyer advises women to talk to someone before making a decision. The woman will be offered a “support-conversation” (støttesamtale) when she contacts her doctor. The support-conversation’s purpose is to help the woman make her own choice on an informed basis. The support-conversation is not supposed to pressure the woman into a specific choice. After an induced abortion, the woman is again offered a support-conversation. It is important to notice that the doctor is supposed to inform the woman about her right to the support-conversations and give her the needed contact information, but the abortion-seeking woman has to seek the support-conversation herself. I have not been able to find any documentation of how many women make use of these conversations. The persons, who can perform the support-conversation, are general practitioners, social workers and priests.
Parental or guardian permission is required for women under the age of 18 to have induced abortion. The abortion procedure is performed at the hospital or emergency clinic and is free of charge. With a surgical abortion, a preliminary check-up is performed, to determine the length of the pregnancy and to check for any sexually transmitted diseases. In case of any sexually transmitted diseases they are treated before the abortion. The surgical abortion is performed under full anaesthesia. The procedure lasts for about 10 – 15 minutes and it is often possible for the patient to go home after a couple of hours.
In a study on induced abortion (Bjerregaard et al. 1996), the focus was to gather more knowledge on the reasons for the high abortion rates in Greenland. All women in the Northwest region in Greenland, who had a positive hCG test (i.e. pregnant) in one of four emergency clinics, were asked to participate in the study. 257 agreed to participate (81%). Of Danish speaking women, there were three abortions and 19 continued pregnancies. Following analyses only apply for the remaining 235 Greenlandic speaking women. The Greenlandic speaking women were allocated into following groups 79 abortions and 156 continued pregnancies. It was not possible to collect any general characteristics of women who were at risk of becoming unintended pregnant and seek abortion. For instance, the mean age of the group who continued the pregnancy and the group who got an abortion were equal (25,9 and 24,9 years of age, p = 0,23). There was a small difference but not statistically significant, in the length of education of the two groups. 74% of abortion seeking women and 88% of women who continued the pregnancies were married or living with their long-term partner. Overall, the living conditions of the two groups showed very little difference. There was the same proportion of adults in the households, same amount of rooms in the houses, same proportion of persons owning a cell phone or telephone and same amount of years in one household. Statistical analyses also showed some significant factors. For instance, the study found that, more abortion-seeking women were unemployed (p = 0,01). The abortion-seeking women mastered Danish worse than the women who continued the pregnancy (23% of abortion-seeking women notified that they spoke Danish without difficulties, where among the women who continued the pregnancy it was 37%, p = 0,05). Of statistical differences in living conditions more children were living in the same residence of the abortions seeking women (a mean of 1,65 children in abortion seeking women’s households and a mean of 1,36 children in women proceeding the pregnancy, p = 0,05). The abortion-seeking women also lived under slightly tighter conditions. This means that abortion-seeking women have given birth to more children on average. It showed that the abortion-seeking women had in total given birth to more children, experienced more previous abortions and were previously treated for more sexually transmitted diseases. At last, the abortion-seeking women were asked why they had chosen an abortion. “The vast majority (87%) answered the question and almost all the responses showed a clearly understandable reason” (p. 17). That is, according to these statistical analyses, the sexual behaviour among Greenlandic people might be more risky than in the other Nordic countries, however when considering an abortion the reasons are similar between Nordic countries and Greenland.
(Bjerregaard et al. 1996)
In another study (Arnfjord, M. et al. 2001: 21 – 45) the aim was to identify the characteristics of the women who turn to the health clinic in Nuuk and Aasiaat for a pregnancy test (hCG test). The researchers hope that the results will assist future public health initiatives to reduce the number of unintended pregnancies. They hypothesise that unwanted pregnancies end in induced abortion. The study included 363 women (of whom 192 were not pregnant, 81 pregnant choosing childbirth, 80 pregnant choosing induced abortion, and 10 ‘other’ [four with pregnancy outside of uterus; one who got an evacuatio; one with spontaneous abortion; two who had not made a choice at time of survey; one diagnosed with abortus imminens; and one who moved]). No clear characteristics were found for, who becomes pregnant, who seeks an abortion if pregnant, or who continues the pregnancy if pregnant (Arnfjord, M. et al. 2001: 42 – 43). I find that the lack of clear determinants is something that makes this incidence interesting. The few strong associations that were found in the respective study were for instance, spoken language. According to these results it seems that there is an association between spoken language and induced abortion. Twice as many women who reported to master Danish without difficulties and use Danish in their daily life reported that the pregnancy was planned, where as there were twice as many women who spoke Greenlandic in their daily life who were unintended pregnant and wanted an abortion. Bjerregaard et al. (1996) propose that the poor Danish language skills can reflect their lower level of education. However, I would argue that there might be several reasons to the poor Danish language skills, for instance, one could imagine that those who use Greenlandic more than Danish perhaps have closer ties to the Inuit culture or adaptation of lifestyle (see also Bjerregaard et al. 2002).
(Arnfjord, M. et al. 2001: 21 – 45)
The reported use of contraception does not show an obvious tendency of risky sexual behaviour. 49% women reported that they had used the p-pill (hormonal contraception) within the last year, 20% reported they had used condom and 20% had used a spiral. It was only 34% of the women who were aware of emergency contraception (Morning-after-pill) and very few had made use of it (p. 38). Despite the non-traditional tendency to promote emergency contraception, like the Morning-after-pill, Arnfjord et al. (1997: 133) advice, among other initiatives, to improve the knowledge of the Morning-after-pill as an implementation method to reduce the number of unintended pregnancies. However, an increase in use of emergency contraception would not promote healthier or safer sexual behaviour.
Table 2. Consumption of hormonal contraceptives, DDD per 1000 women aged between 15 – 49 years/day
(source: Nomesco 2013: 41)
Table 2. presents the consumption of hormonal contraceptives (aged 15 – 49 years), in contrast to figure 5. that shows sales of emergency prevention.
One can assume that the reported consumption of hormonal contraceptives and the actual or correct consumption do not coincide, since a correct use of these contraceptives should reduce the amount of pregnancies. It may imply that people buy the prescribed contraceptives, but do not use them, or they use them incorrectly. Incorrect use, can for instance be to forget to take a pill, and depending on which day you forget to take it, can have great impact on the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The FSH and LH stimulate the ovaries to make an egg ready and stimulate the mucosa to receive the egg, when fertilized. In case of a high level of oestrogen, the pituitary gland will not produce FSH and LH. If one forgets to take the p-pill during the first and/or the third week of the p-pill-cycle, then you are at a higher risk of ovulating, and thereby fertile (reference: personal conversation with friend who is a gynaecologist).
As reported, Greenlandic people do not use the same amount of emergency prevention as the other Nordic countries. However, figure 5 is showing a slow increase in the sales of emergency prevention from 2001 – 2012.
Figure 5. Sales of emergency prevention per 1000 women aged 15 – 49 years, 2000 – 2012
(source: Nomesco 2013: 41)
In this section I will use anthropological literature and evidence from Greenland, to discuss the local sociocultural climate – here among public discourse, expectations and cultural settings.
I include this cultural view of the discussion not because I argue that it can or will explain the entire truth but rather contribute to a partial explanation or at least an association to what impact abortion has on women in Greenland. I argue that I cannot explain what impact abortion has on women in Greenland looking merely at abortions and merely asking question on abortions. Rather, I argue that the abortion issue functions together with a complex web of other cultural and behavioural aspects. If policy makers seek to decrease the abortion rates in Greenland by merely looking at the narrow issue, on abortion as an isolated subject, I do not believe it would be successful. I argue, that in terms of public health interventions, one needs to discuss the anthropological understanding of the local sociocultural climate because sociocultural factors may have an impact on the experience.
”The social management of the family begins prenatally, with the manipulation of marriage and birth control practices such as contraception and abortion, and continues long into the postnatal period, through infanticide, fosterage, adoption, and a myriad of other means” (Bledsoe 1990, quoted in Navne 2008: 11). And as Navne (2008: 11) describes: “Reproductive decisions include decisions about pregnancy, abortion or childbirth, maternity or adoption services. […] Reproductive decisions thereby inscribe themselves in anthropological discussions about cultural perceptions of life course and kinship” (translated).
Many researchers have claimed a ‘pan Inuit social structure’, already starting in 1932 with Weyer (Tróndheim 2010: 41). Not up until the 1970’s is this concept being challenged by other researchers.
In the 1970’s researchers of Inuit matters discussed whether or not Inuit kinship was biologically or culturally determined (Tróndheim 2010). To relate this to the current study one could ask, is the risky sexual behaviour a part of the Inuit culture, that lies deep within the individual, and has not been demolished with the modernisation studies by the Danish Monarchy or has the risky sexual behaviour arrived with the modernisation studies?
Eskimo kinship studies were confusing and non-consistent among researchers. On one hand they argued that Inuit had the same kinship structure as the Victorian family, namely the nuclear family, but on the other these two social structures were not compatible, constructing the idea that ‘the Inuit were not from an evolutionary point of view the ‘primitive others’ but rather the ‘primitive’ version of Western Europeans because Inuit lived in small family groups like Europeans’ (translated, Tróndheim 2010: 44), but that sometimes there were exceptions, like for instance with additional kin members, e.g. through adoption or wife-swopping. Some researchers explained this tendency to be a result of the harsh conditions the Inuit lived under.
Many researchers share the identification of the flexible kinship system (Tróndheim 2010, Navne 2008, Petersen 2003 and Nuttall 2000 cited in Navne 2008). Navne (2008: Chapter 5) reflects the flexible kinship onto what she identifies as “flexible motherhood”, which I will explain further in the following section.
Many features in the kinship system in Greenland along with economical and social change can be expected to have changed since the 1970’s.
Navne (2008 p. 78 and p. 90 – 91) describes the cultural ideal to be a fertile woman, capable of bearing a child, and being a man capable of fertilising a woman, and the pride of giving one’s own mother a grandchild. She explains that being able to reproduce is related to recognition and increased social status. Further she describes these ideals as coming from the ‘family community’ (ibid.: Chapter 4). The other community is described as the ‘political community’, which represents ideals of finishing one’s education before having children and that education is related to maturity, recognition and social status. During her fieldwork she met a narrow group of women who combined these two types of ideals, to become a mother at an early age (ideals from family community) and still try to finish the education they started (ideals from political community). This group of women must have been extremely narrow because in 2011 there was only 0,36% of tertiary level graduates (aged 20 – 64) in Greenland. While in Denmark there were 1,13% tertiary level graduates (aged 20 – 64) (own calculations from data in Norden 2014). That is, it would be difficult to conclude anything general about this group of women, since they are so few.
In the light of Navne’s (2008: Chapter 5) presentation of motherhood as being determined by actions and not biology, this non-definitive, non-biological determined view on motherhood could be thought to have a respective influence on the view, attitudes and feelings to abortion. If a woman would not become instantly connected with the feelings of motherhood merely due to the pregnancy perhaps she would not be greatly affected by an abortion. If motherhood is determined by actions, the action to get an abortion shows that the woman has chosen not to be a mother. The question is, if the feelings of motherhood follow the cultural aspect of motherhood through actions. That is, if a woman steps out of her motherhood for a while, for instance to study for a longer period in another place, does it also mean that she emotionally retreats from her child? I argue here, that the term ‘mother’ does not necessarily have to have the same values as it has for the same word in another culture. To give an example, my own understanding of the term mother, which is a product of the society, surrounding and family I was raised in, carries the values of caring; protection; showing the ‘right’ path in life; and unconditional love. The term mother does not necessarily have to entail the same values for women in Greenland. Perhaps the term mother is associated with primarily carer, but does not imply ones feelings towards the individual. Which equally means, that if a mother chooses to step out of the actions of motherhood, it does not necessarily mean that she has emotionally stepped out of motherhood (Keesing and Strathern 1998: Chapter 9).
In Nuuk abortions are performed every Wednesday at Dronning Ingrids Hospital (DIH). Wednesdays are referred to as ‘abortion-day’ (Navne 2008: 24). The way people in a society talk about abortion, either merely the procedure or ones own experiences, vary greatly from society to society. In Greenland, it seems that the debate about abortion is not subject to taboo or moral condemnation, neither is sex before marriage or unplanned pregnancies (ibid. p. 36 and p. 44).
Navne (2008) expresses that women in Greenland show sign of joy when finding out about a pregnancy, even if the woman chooses not to continue the pregnancy and seeks an abortion. It seems that it is not only in Greenland that women show signs of joy and excitement due to pregnancy, even when not wished for. A reported joy of confirmation of ‘womanhood’ and ‘fertility’ is also present among Danish women (Birkler 2014: 56 – 57) and Swedish women (Kero et al. 2001a). The positive feelings are however not always isolated. In all three studies, women also report negative emotions, such as “unreal, despair, panic, grief and guilt” (Kero et al. 2001a: 1488). Kero et al. (2001a) emphasise that these “contradictory feelings in relation to both pregnancy and abortion are common among abortion-seeking women but are very seldom associated with doubts about the decision to having an abortion” (p. 1489). Meaning, that even though the process of resorting for an abortion and the actual procedure have resulted in many contradictory feelings, also if it has been only negative feelings, they do not regret the decision (Kero et al. 2001a, Navne 2008 and Birkler 2014).
As mentioned, factors like the public discourse, expectations and cultural settings may have an influence on the women’s feelings and emotional outcome following an abortion (Pedersen 2008, Keys 2010). Women, who have had an abortion and are exposed to stigma and taboo, can be more likely to experience negative feelings like depression, regret, guilt, etc. (Pedersen 2008). Navne (2008) describes increased social status among Greenlandic young women through showing proof about one’s sexual activity and fertility. She writes that almost every morning someone announced out loud, to the whole class and teacher to hear, that she/he had to go to Venerea (the sexual health clinic) (Navne 2008: 90 – 91). Not something to be ashamed of, in fact almost just the opposite. Navne (2008) proposes that the recognition of fertility is being challenged with the high abortion rates. She explains,
“The young women experienced that the positive attention concerning their pregnancy presented itself regardless of whether they choose to give birth or have an abortion, regardless of whether they chose to care for the child themselves or let someone else care for it, regardless of whether it was born outside or within marriage. Notwithstanding that an unplanned pregnancy always deposits difficult considerations and feelings, many women also experienced that the pregnancy was tied to status, recognition and respect, regardless of outcome.” (translated, Navne 2008: 91)
With this description and the example of the sexual health clinic above, one could imagine that the same non-shame and non-taboo is present when women go to the clinic to get an abortion. One could also expect that many young women leave the classroom on Wednesdays to get an abortion at DIH (Navne 2008: 24), since this is the only day in the week that abortions are performed.
Another qualitative study on 8 Greenlandic women just three years earlier did not have the same results (Bielecki 2005). In comparison to the narratives in the school, that Navne (2008: 45) presents, there was an older informant (37 years old) in Bielecki’s (2005) study, who reported that it was uncomfortable for her, as a single woman, to go to the clinic SANA to collect condoms. She reported that people sitting there would be able to see that she collected condoms and know that she was single and talk ill about her.
It seems that it is common for women to have repeated induced abortions in Greenland (Bjerregaard et al. 2001, Bielecki 2005) and in a survey (Arnfjord et al. 2001: 38) of 193 women who took a hCG test in Nuuk and Aasiaat between the age of 15 – 49, more than half of the women had had one or more previous abortions and 30% of those had had more than two abortions. A qualitative study (Bielecki 2005) on possible causal explanations for repeated abortions among 8 Greenlandic women suggests that the main reasons for abortion are that Greenlandic women, like Danish women, prefer having children within the frames of the “perfect family” and it showed that if anything deteriorated from this, in the presence of a pregnancy, most of the women found an abortion to be the best option. Another reason for choosing abortion was due to the reason for the presence of the unintended pregnancy, namely due to violence and/or strongly affected by alcohol during conception. The third main identified reason for abortion among the interviewed women was pressure from the male partner. In general, findings show that women who have had unplanned pregnancies are in difficult social situations and find that abortion is their best option. Several reasons for the lack of contraception during intercourse and choice of abortion were identified. The women showed lack of knowledge about contraceptive use, reproduction and physiology. In some cases, especially among the women in steady relationships, it was found, that the women often wanted a child but when the male partner was reluctant, the woman chose to abort (a choice between the baby and their partner). Social factors were identified, which made the maintenance of contraceptives difficult. For instance, to remember to take the p-pill (hormonal contraceptive) each day when one’s life is turbulent and affected by violence and alcohol were identified as social factors that made a correct use of p-pill more difficult. The women also reported that when the male sexual partner did not want to use a condom they did not feel comfortable demanding it (Bielecki 2005).
Abortion health interventions
”The Home Rule Government in Greenland and PAARISA, the Department of Health (Ministry of Health) have the goal to reduce the abortion rate in Greenland with 50% within the next five years.” (Meldgaard 2003: 267)
In 2002 the abortion rate was 821, in contrast to the birth rate at 940. Five years later, at the time of the Home Rule and PAARISA’s deadline, i.e. in 2007, the registered birth rate was 850 (Office of the Chief Medical Officer 2007: 11) and the abortion rate was 887 (ibid. p. 21). 9 years later, i.e. in 2011, the birth rate was 810 (ibid. p. 5) and the abortion rate was 737 (ibid. p. 3). That is, the abortion rate was not reduced with 50%. In fact it increased with 66 abortions and was thereby higher than the birth rate. 12 years have gone since the five-year strategy and the abortion rates have not reduced.
Despite the unchanged abortion rates, PAARISA and the Home Rule Government in Greenland have made several initiatives (mainly health education interventions) to reduce the incidences.
The Home Rule Government writes in the Public Health Programme, Inuuneritta, “unwanted pregnancies are a major health problem in Greenland, and almost every second pregnancy ends in abortion. It is both older and younger women who seek induced abortions and the women are from all layers in society however with a small tendency in lower socioeconomic status”. They continue, “PAARISA has since 1998 worked on prevention of sexually transmitted diseases and have since 2003 had particular focus on unwanted pregnancies due to the high abortion rate. The aim is to reduce the abortion rate with 50% within a five-year period” (translated, Inuunerritta 2007: 23). PAARISA has so far conducted disease prevention and health promotion work on following initiatives:
- Campaigns in radio and TV and publication of leaflets with information on abortion and prevention
- Distribution of condoms to the older students in the education system, dorms, hotels and restaurants
- Consultancy for hospitals and health centres
- Broadcasting of the short stories “Paaraluta”, which was prepared on the background of a short story contest in 2001. The short stories are written by people between 15 and 18 years of age and are own narratives
- Broadcasting of the contraception bag “Paaraluta” for prevention consultants and health care with materials for sex education in elementary school
- Establishment of helpline “AIDS-helpline”
- Training courses in regards to HIV/AIDS for voluntary consultants in the AIDS-helpline and other interested prevention consultants
- Marketing of International AIDS day
- Publishing the book “Livet er også dit – historier om HIV og AIDS” (transl.: “Life is also yours – stories on HIV and AIDS”)
- Training young volunteers in Nuuk to be in charge of education and information work among young – also called “Inuusuit-Oqaloqatigiitta” (transl.: “Young dialogue”)
- Publishing information material on prevention and sexually transmitted diseases
- Generating debate on TV and radio broadcasts about sex life
PAARISA’s campaign, within the hospitals, in 8 communities (Ittoqqortomiit, Upernavik, Ilulissatm, Aasiaat, Maniitsoq, Paamiut, Narsq and Qaqortoq) aimed to “recognise the problem and wishes for the future effort from the perspective of professionals (health professionals, teachers, preventive workers)” and in a study they found that there is low collaboration between and among lay people, health professionals and key persons in the society; inadequate quality of sexual health education in school; too limited access and too few options of different methods of contraception; and moral standards in the communities and society in general. The report concludes that in order to reduce unwanted pregnancies, the factors mentioned above should be put in focus (Meldgaard 2003). Also in Nunavut, Canada, researchers have focused on a more holistic approach to abortion (Cole 2003), with the aim to “address the need for culturally specific data on beliefs and behaviours in order to design and implement appropriate public health interventions”, in the form of a promotion booklet, to “give youth a tool that will promote healthy choices and give non-judgemental information about sexuality” (Cole 2003: 270). Cultural belief differences were found between Inuit and non-Inuit. In Nunavut a higher quality in sex-education has been proposed as being a factor in reducing the number of unintended pregnancies that end in induced abortions.
The most recent sexual health interventions carried out have been developed through the Public Health Programme Inuuneritta, which has the following strategy within the area of sexual health:
- Each sexual act shall be based on lust, mutuality and absence of sexually transmitted diseases;
- Each pregnancy shall be wanted;
- To promote the public’s capacity in relation to healthy sexual behaviour.
Three Public Health projects, with the focus on sexual health, have been coordinated and financed in partnership with PAARISA and the Ministry of Social. All three projects (‘Dukkeprojektet’ [translated: The Doll Project], ‘Klar til Barn’ [transl.: ready for baby] and ‘Tidlig indsats overfor gravide familier’ [transl.: early action for pregnant families]) were set to run until 2013. “Klar til Barn” and “Dukkeprojektet” focus primarily on prevention, while “Tidlig indsats overfor gravide familier” is secondary prevention, where the aim is to reduce the risks of neglect of care for the coming baby.
The Doll Project’s main aim is not to reduce the abortion rates but rather to promote wanted pregnancies. In spite of that, the outcome-evaluation is measured through the abortion rates. If the project has been successful, the abortion rate of the age group participating in the project should be reduced significantly (Wistoft and Stovgaard 2013).
A reduction in teenage childbirths was seen in Nuuk from 2008 to 2010 and the conclusion was:
“The abortion incidence among teenagers between 16 – 17 years has increased and decreased among young teenagers (14 – 15 years), which can be a sign of that the Doll Project has influenced the younger teenagers to develop a more realistic understanding of the demands in relation to becoming a parent and that they thereby exhibit more responsibility than they did prior to the Doll Project. Abortions among older teenagers (18 – 19 years) has decreased, which primarily can be explained by fewer pregnancies – i.e. a positive development” (Wistoft and Stovgaard 2013: 61)
I could not find any statistical analyses of their results, and argue that the report is missing validity due to this. The number of abortions and pregnancies can vary from year to year but it does not mean that there is a statistical significant difference. That is, the decrease that the researchers have noticed does not necessarily have to be statistical significant or a result of the Doll Project.
The Doll Project had no influence on the risky sexual behaviour and did not promote healthy and safe sex. The rates on sexually transmitted diseases are of public health concern in the whole country however incidences are even higher in the villages on the coast than in Nuuk (Wistoft and Stovgaard 2013: 62). The risky sexual behaviour, that results in the many unintended pregnancies, sexually transmitted diseases, induced abortions or sometimes child neglect, is a complex matter and possible initiatives should perhaps focus on a holistic method because the incidences are related to each other.
The focus of this paper is to determine if efforts are needed to reduce the abortion rates in Greenland. Using literature on abortion and the research questions posed in the methodology carries out the assessment. In this section, the literature on abortion will be discussed in relation to the literature from Greenland, and this way a conclusion will be constructed.
Literature indicates that there is a small increased risk of short-term physiological and psychological complications following induced abortion. In addition to the risks, I have presented literature discussing what possible importance the local sociocultural climate can have on the emotional experience. Based on this, the two following questions will be discussed: If abortions are not subject to taboo and stigma in Greenland, might this decrease the incidence of negative feelings, as for instance shame and guilt? And, what significance does the abortion prevalence have on the public acceptance and expectations towards abortions?
A more strict abortion law “could possibly increase the risk of social stigmatization and negative sentiment regarding abortion”, i.e. “reactions to abortion are, as one may assume, strongly coloured by the local sociocultural climate” (Pedersen 2008: 427).
Factors that can have a negative influence on women’s abortion experience have been identified as, social stigma; the reason for abortion; and late abortions (Christiansen et al. 2003, Kimport 2012: 106, Broen et al. 2005, Broen et al. 2006 and Bielecki 2005: 35). Thus, we cannot conclude that any particular emotion follows after an abortion in all women. Literature has proposed that the emotional experience is socially constructed (Pedersen 2008). How one will cope after an abortion can depend on prior socialization (Keys 2010), the woman’s “lived experience” (Kimport 2012: 106), the public discourse (Pedersen 2008), the reason for abortion (Christiansen et al. 2003, Birkler 2014), the social- and socioeconomic situation and availability of support network (Söderberg et al. 1998, see also Scott and Carrington 2011 on social networks).
It seems that there are many unfortunate stories connected to the reasons for induced abortions. Bielecki (2005) writes that many women report that they choose to abort an unintended pregnancy due to their partner’s attitude, alcohol, violence and other social situations. It is possible that the reported reasons for abortions cause worsened mental health and not the abortion procedure on its own, as the literature supports (Christiansen et al. 2003, Kimport 2012: 106, Broen et al. 2005 and Bielecki 2005: 35, Birkler 2014, Stotland 2011, Keys 2010, Pedersen 2008). At the same time, it does not seem that abortions in Greenland are stigmatised or subject to taboo according to Navne (2008). This discussion is especially important in terms of determining best possible aims for reproductive health interventions.
Of evidence within the literature, there was a small significant increase in physiological short-term complications (Zhou, W. et al. 2002). Some studies found a relationship between distress and/or negative emotions following an induced abortion (Söderberg et al. 1998, Pedersen 2008, Birkler 2014, Stotland 2011, Cameron 2010, Christiansen et al. 2003, Major et al. 2000, Fergusson et al. 2008, Fergusson et al. 2009, Hosseini-Chavoshi et al. 2012, Major and Gramzow 1999), while others did not (Kero et al. 2004, Charles et al. 2008, Schmiege and Russo 2005, Gilchrist et al. 1995, Russo and Zierk 1992, Steinberg and Russo 2008 and Steinberg 2011). Overall, the studies that found a relationship between negative emotions following induced abortion showed that there were no long-term consequences (Bradshaw and Slade 2003) and no evidence of causation (Cameron 2010, Söderberg et al. 1998: 177).
Thus, it can be argued that negative emotions, after an abortion, might not be solely caused by the actual procedure, but could perhaps in some cases be linked to the reason for the abortion. That is, it seems that the literature generally agrees that possible confounders might alter the relationship between negative emotions and induced abortion. As previously mentioned, despite of the possible affect that “lived experience” (Kimport 2012: 106) and ideology/public discourse (Keys 2010: 64 and Pedersen 2008: 427) can have on the woman’s emotional response, an abortion is an individual experience, and therefore it is not possible to predict a certain emotional response.
When having said this, I have also argued, that despite of the low risks, there will nevertheless be women who are at risk of negative emotions following an abortion, even in Greenland, which can be caused by several identified factors. The women who do experience negative emotions following an abortion should be offered emotional support. The emotional support, I propose can be pre- and post-counselling by a professional. The health professionals should arrange the counselling, so that it is not the woman’s responsibility. As previously mentioned, I was not able to find any documentation of how many women make use of the support-conversation that is available so far. Furthermore, the counselling should be performed by a non-biased party, for instance a professional counsellor/psychologist, and not by the doctor, mother, friend, partner, or anyone else who can have a personal opinion about the particular decision. Some women find it comforting to speak to a relative or friend, which is positive. Others feel the need to speak to someone more professional and nonbiased.
The abortion debate in Greenland has been proposed by several people to be more of a public health problem in the eyes of health professionals and foreigners in Greenland than it is for the Greenlandic population. Bjerregaard et al. (2001) disagree and state that it “tastes, according to Greenlandic and Danish tradition, too much of political correctness” and continue: “it cannot from any point of view be acceptable that the majority of young women start their reproductive career with one or more unwanted conceptions [pregnancies] and induced abortions” (translated, p. 18). A critique of Bjerregaard et al.’s (2001) statement can be, that the study’s stated aim is not to discuss whether there are negative consequences to continue an unintended pregnancy or if there are any negative consequences to induced abortion. As mentioned earlier no studies on psychological or physiological consequences following induced abortion have been conducted in Greenland. Bjerregaard et al.’s (2001) study aims to identify the characteristics of women who seek an abortion, i.e. an epidemiological study – and as previously mentioned, their findings do not show a strong indication of characteristics in general, but some variables show weak statistical significance. The statement above shows signs of being normative. They do not refer to any other findings that show or explain why it is not ‘acceptable’ to start ones ‘reproductive career’ with an induced abortion. Neither do they explain what Greenlandic and Danish ‘tradition’ is and how they are similar.
When one sees the high abortion rates in Greenland, it might be easy to conclude that there are too many induced abortion in Greenland compared to other countries, and it can make one think that abortions are used as a contraceptive method. Instead, perhaps there are not too many abortions in Greenland but rather too many unintended pregnancies. One could argue that there are too few abortions in relation to the unintended pregnancy rates. “The focus on the many abortions in Greenland was questioned. An unwanted child can bring a much larger load on the woman than an abortion and in this light the question was raised if there perhaps were too few induced abortions in Greenland. However at the end of the day an induced abortion is an inappropriate method of contraception” (translated, ed. Bjerregaard 2001: 7, see also Hansen and Skafte 2009). In this concern, findings from epidemiological research do not show a tendency of using induced abortions as contraceptives. Through a qualitative study on 8 Greenlandic women, Bielecki (2005) finds three main reasons for repeated induced abortions: 1. A wish to have children under wished circumstances, i.e. that both partners want the child; 2. If the conception occurred due to violence/rape or during strong influence of alcohol; 3. If the male partner is reluctant and threatens to leave the woman due to the pregnancy. In addition, Bielecki (2005) found three main reasons for not using contraceptives: 1. Women who wanted a child and therefore choose not to use contraceptives; 2. Women whose lives are turbulent and affected by violence and alcohol can forget to take the p-pill correctly; and 3. If the male partner does not want to use a condom. Another study finds that women in Greenland report the same reasons for induced abortion as they do in other Western countries (Bjerregaard et al. 1996). That is, in accordance to the referred literature, women in Greenland do not use induced abortions as a contraceptive method and they report the same reasons for choosing an abortion as in other Western countries. This could indicate that the risky sexual behaviour in Greenland is caused by a more complex factor, perhaps interdependent on other social factors in Greenland, which I have not accounted for in my paper.
None of the literature I have come across has mentioned anything about antiabortion or proabortion protesters in Greenland. Based on this and the narratives from Navne (2001), I take it as an indication that abortion is not subject to taboo in Greenland. This, however, is not a constant state. Stigma and taboo can suddenly arrive despite its previous situation. One could argue that the modernisation that has been occurring in Greenland for the last half century has not shown all of its results or consequences (Curtis et al. 2005, Bjerregaard and Curtis 2002). The outcome of a rapid change might present itself years later after the change’s occurrence. People in Greenland might change their attitudes and expectations about abortion and if this happens, I argue that the abortion rates might not be reduced because of this, but that perhaps women who turn to abortions, will experience stigma and taboo, like in many other countries. And then, one could expect, it would become a public health problem.
According to statistics and literature, it is prevalent for a Greenlandic woman to have had one or multiple induced abortions in a lifetime. And there are no clear characteristics of the abortion-seeking women and women who have had no abortions. For what we know, the reported reasons for induced abortion are similar to the reported reasons in other Nordic countries, where however, the rates are notably lower.
Based on reported reasons, we can conclude that women in Greenland do not understand or seek induced abortion as a contraceptive method. The high rates might instead reflect women’s sexual risk-taking behaviour. I would say that there are two options, following unprotected sex – if a pregnancy is not wanted – one can take an emergency contraceptive pill within the following 72 hours, or one can wait and take a pregnancy test, and hope that a conception did not take place, but if conception has taken place, take an abortion. It seems that the majority of women in Greenland choose the second option. There can be several reasons for this, and therefore I recommend a qualitative study, to investigate the reasons for not choosing an emergency contraceptive pill following unprotected sex.
For further research, I argue that more in-depth knowledge about the risky sexual behaviour among people in Greenland and the expectations and feelings following induced abortion is needed. There is not enough research on the understanding of these two factors, while a lot of money is used to affect the current situation. I argue, if we do not understand the behaviour and the feelings we cannot affect the current situation. Long-term research and interventions are needed and instead of working towards a specific goal it is more efficient to work in a method where the people living in the community identify the goal. This, I argue, is necessary, mainly because risky sexual behaviour and the abortion rate are not isolated factors. They are affected by other social factors, which make them complicated to affect.
As for public health interventions, I recommend an optimisation of abortion procedures, especially in regards to pre- and post-abortion counselling, and more focus on risky sexual behaviour (i.e. health promotion). I furthermore advice that focus should be placed on reducing the incidence of sexually transmitted diseases (promoting a safe and healthy sexual behaviour) instead of induced abortions, because of two main reasons; the abortion rates highlight another problem, namely that women become pregnant when they do not wish to, where counselling could be a beneficial help, and secondly, an increase in protected sex, will reduce the prevalence of unintended pregnancies.
Through the chosen literature and my discussion, I have aimed to determine if efforts to reduce the abortion rates in Greenland are needed and accomplishing this I explain the complexity of the topic as well describe it in the context of how it is understood and seen upon in Greenland.
In conclusion, I have found some literature that has identified some risks in short-term physiological complications and a relationship between negative emotions and induced abortions. As I have showed in my discussion, I have also found literature that does not find any relationship between negative emotions and abortion. However, women’s emotional experience following an induced abortion is not universally or biologically determined. It is an individual experience where different factors/themes can play a role in shaping the emotional experience. In accordance to the literature, I have gathered that factors, that can play a role in shaping the emotional experience are, prior socialisation; public discourse; reason for the abortion; social and socioeconomic situation; and availability of support network.
Since abortion experiences have been proposed by the literature to be somewhat dependent on the local sociocultural climate, it is important, as public health professionals, that we ‘treat’ situations as they are understood in the given context. I have argued that in Greenland, abortion does not seem to carry the same stigma and taboo as they do in many other countries, and that due to this women are not as disposed to carrying the negative sentiments as in other cultures where it is subject to taboo, shameful and stigmatised (Pedersen 2008).
In accordance with a broad array of literature (Cougle et al. 2005, Ney et al. 1994, Raatikainen et al. 2006, Foster et al. 2012, Kero et al. 2001, Nobili et al. 2007, Pedersen 2008, Hosseini-Chavoshi et al. 2012, Fergusson et al. 2009, Cameron 2010, Kimport 2012, Charles et al. 2008, Söderberg et al. 1998, Broen et al. 2006, Bradshaw and Slade 2003, Rubin and Russo 2004), I argue that there should be pre- and post-abortion counselling available to all women undergoing an abortion. The optimisation of the abortion procedure can be seen an important public health effort due to the transition that Greenland is in (Bjerregaard and Curtis 2002, Curtis et al. 2005). Current attitudes, expectations and public discourse on abortion may very well change over time. In case abortion becomes shameful and subject to taboo it is of great interest to have a well-functioning pre- and post-counselling procedure.
Due to the relatively safe procedure and low evidence of psychological and physiological consequences, it seems that there is no reason to develop interventions specified to reduce the prevalence of legally induced abortions. Perhaps it is more important to ensure that the procedure is as comfortable as possible and made on the most informed basis. This way, we can ensure that the women who choose to have an abortion will have the best possible experience and will be comfortable with their decision, even though it is a difficult decision for most women. As a last indicator for why it might not be necessary to develop abortion reduction interventions, it is proposed that there perhaps are too few abortions in Greenland (ed. Bjerregaard 2001: 7, see also Hansen and Skafte 2009, Bielecki 2005). In other words, there are perhaps too many unintended pregnancies, where many choose to abort and others choose to continue the unwanted pregnancy.
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Graph 1. Sociocultural factors influencing health
Figure 2. Abortions relative to live births, by age, average 1993 – 2010
(source: own calculations) (NB! The x-axis shows the respective age of the girls)
Figure 6. The proportion of induced abortion of the number of induced abortions and deliveries in the Nordic countries 1975 – 2008, %
(source: Gissler 2010: 175)
Table 3. Diagnosed cases of Chlamydia per 100 000 inhabitants 2000 – 2009
(source: Nomesco 2011: 71)
Table 4. Notified cases of gonorrhoea and syphilis per 100 000 inhabitants aged 15 years and over, 2009
(source: Nomesco 2011: 70)
Table 5. Education in Greenland
(Source: Greenland Statistics 2013: 25)
Table 6. Number of live births and reported abortions from 2000 – 2014
Table 7. Legal abortions
(Greenland Statistics 2013: 28)
 Products of conception can be products such as a doll that shows the woman’s uterus with an embryo, or images of conception and perhaps birth, and in leaflets of pregnancies, birth and breastfeeding, etc.
 The most common test of pregnancy involves the detection of a hormone known as human chorionic gonadotropin (hCG) in a sample of blood or urine (http://medical-dictionary.thefreedictionary.com/Human+Chorionic+Gonadotropin+Pregnancy+Test)
 This result section needs further explanation. Meldgaard (2003) explains the awareness of the professionals on the positive effects of role models; that use of alcohol, rape and other cultural aspects were related to unwanted pregnancies. Furthermore the professionals added cultural aspects “a culture were young girls become mothers because their own mothers find it positive to become a grandmother” (p. 269). Similar to Navne’s (2008) findings.
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