Selection bias in a study on how women experienced induced abortion

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Abstract

Objective. One third of the women who had an induced abortion at the department of gynecology and obstetrics in Malmö 1989 refused to participate in an interview a year later to explore their experience and the care they had received. Using data from the mandatory preoperative visit it was then possible to compare participants with no-participants with regard to socio-demographic characteristics, reproductive history and stated reason for abortion. By continued follow-up of medical records it has furthermore been possible to ascertain how many women conceived within a year, and how many of them applied for another abortion and how many elected to continue the pregnancy to term. Setting. Department of Obstetrics and Gynecology, Lund University, University Hospital, Malmö, Sweden. This is the sole referral hospital serving the population of Malmö (approx. 230 000). Subjects. All 1285 women who underwent induced abortion at the department in 1989. +Study design. In each case information on socio-demographic characteristics, reproductive history and stated reasons for abortion was collected at the mandatory clinical visit prior to the abortion. This information was used for comparison of participants and non-participants in the planned 1-year follow-up interview. Results. Young, unmarried women of low educational status and without full-time employment or studying were overrepresented in the non-participant group. The proportion of women with children was however smaller in that group. Within 12 months after the abortion, 118 women 66 (7.7%) of the participants in the follow-up interview and 52 (12%) of the non-participants conceived again but elected to continue the pregnancy to term (P<0.05), whereas 124 of the women 80 (9.5%) and 44 (10.2%) of the respective subgroups again applied for abortion within 12 months. Conclusion. One third of the women who underwent induced abortion did not wish to be interviewed about their emotional and somatic experience of the abortion 1 year later. Non-participation at the follow-up interview was associated with socio-demographic factors which in studies about other medical problems have been shown to be associated with increased vulnerability and morbidity. Non-participation was also associated with an increased childbirth rate during the following 2 years. The large proportion of non-participants is a matter for concern as to some extent it reflects inability of the health care system to establish trustful relationships with these women. How the participants in the follow-up study experienced this relationship will soon be published in our next paper. Support from the women's surroundings and the adviser the women met at the public health care system clearly influenced the women's psychological reactions after the abortion [1]. It is therefore important to ascertain to what extent the management of abortion applicants in fact fulfils their individual needs and expectations.

Section snippets

Introduction.

All women who in 1989 underwent induced abortion at the Department of Obstetrics and Gynecology in Malmö, which is the sole referral clinic for an urban population of about 230 000, were invited approximately 1 year later to attend an interview about their experience of the care and treatment provided in conjunction with abortion.

One third of the women refused to participate despite repeated reminders. For many of the women, the reason for non-participation seemed to be a sense of guilt that

Material and methods

In 1989 1285 women underwent induced abortion at University Hospital, Malmö. The interview prior to the abortion included questions about age, civil status, relations with their partner, education, occupation, nationality, reproductive history, any type of contraception used and medical history as a part of the usual counselling process. It was possible to assess whether any of these demographic factors were associated with non-participation in the planned follow-up interview.

At this first

Statistical methods.

Relationships between demographic characteristics, reproductive history, nationality and participation in the follow-up interview were expressed as odds ratios with 95% confidence intervals. An odds ratio below 1.0 means that the evaluated factor was more common among women who did not participate in the follow-up interview.

Results.

All women who underwent induced abortion had been offered a routine check-up approximately 1 week after the abortion. This visit is free of charge in Malmö. The purpose is to detect any infections, discuss the woman's psychological reaction with a view to offering help from a social worker if required, and to follow-up the implementation of recommendations for avoiding further unwanted pregnancies.

Of the series as a whole (n=1285, 167 (13%) did not attend the routine checkup; and of the 431

Discussion:

Although women in Sweden are legally entitled to demand induced abortion until the 18th gestational week, nonetheless for many it is a procedure that causes serious emotional upset and ethical concern. Thus it is open to question whether it is appropriate to ask women who have undergone induced abortion to attend an interview about their experience of the event. One third of the present series refused to be interviewed 1 year later about their experience in this respect.

Treatment and care given

Acknowledgements

This study has been supported by grants from HSF: Rådet för hälso-och sjukvårdsforskning (Council for Medical Health Care Research in southern Sweden) and FOA: Universitetssjukhuset MAS fonder för forskning och utveckling (Malmö University Hospital funds för research and development).

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