Forty-five women who passed the criteria for study inclusion were approached for participation and 31 agreed to be interviewed. Among the 14 women who rejected participation, reasons were reluctance to discuss the study topic, unavailability for the planned interview as well as time constraints, disapproval from husband/partner to participate and concerns with confidentiality.
The socio-demographic profile of the 31 women who participated is shown in Table
. These women had their last induced abortion between July 2010 and May 2011 and all of their last abortions were medical in nature. Ten to Nine women reported that it was their first time having an induced abortion. The remaining had experienced more than one induced abortion with some having gone through both surgical and medical abortions.
Background characteristics of the women
Themes that were generated from the data analysis comprised of: personal abortion experiences, experiences towards accessing abortion services and information, fear about abortion and its side effects, feelings and emotions post-abortion, abortion decision making and support, and needs of women to cope with abortion.
Personal abortion experiences
Most of the women claimed that medical abortion was similar to having normal menstruation with stomach cramps but few pointed out that they experienced intense pain and longer bleeding duration than the usual menses.
“Not very pain.(The bleeding) at first bit darker in colour, and after that it was normal – like the usual period, red in colour. When I was bathing, there were some solid little pieces, but there wasn’t a lot, some were like 5 cents [in size], some were like 20cents [in size]” (29yrs_Chinese_secondary education level_single_admin clerk)
“Very painful.I cannot bear even after few minutes. Then you can feel it [foetus] you know when suddenly it falls down. You can feel that it is no longer alive you know” (23yrs_Malay_tertiary education _married_clerk)
Most of them preferred medical abortion compared to surgical methods (D&C/MVA) as it took up less time, was cheaper, was more convenient and could easily be done at home, with little or no pain like normal menstruation. Women with impressions that surgical abortion would be painful, weaken the body and impose the need to stay in the clinic for post-abortion monitoring influenced some women to choose medical abortion.
“Can say that [that she opted medical abortion] because I scared to have surgical abortion and it is more expensive, so take medicine is much cheaper” (26yrs_Chinese_secondary education _married_salesperson)
In contrast, women who preferred surgical abortion (MVA) reasoned that they did not have to see or go through bleeding and pain. In addition, complete abortion can be achieved at the end unlike medical abortion which was perceived to be time consuming and completeness could not be assured.
“Surgical abortion is OK because after he washed all the blood inside, only some left. So, we won’t feel the stomach pain. Is easier because we will not be scared as we don’t see the clotted blood comes out because the doctor cleaned everything inside. Is just some spotting. That is usual after the procedure”(26yrs_Malay_tertiary education_married_clerk)
“Because I eat the pills, the menstruation is very heavy. ,I came to check that time they say cannot [incomplete abortion], need to do abortion [MVA] again., Did it twice, very inconvenient .If you do [surgical] abortion at the first time, you are ok when you go back” [43yrs_Chinese_secondary education_married_housewife]
Experiences towards accessing abortion services and information
The main barriers to abortion were the lack of abortion services and information. Most of them could only obtain abortion information and service by asking friends or colleagues. They further noted that the information was often superficial and inadequate. Information obtained through the media was rare. Difficulties in obtaining information caused anxiety in women seeking abortion services and also to search for detailed information to make an informed decision. They were not sure which doctor would offer the service as not all doctors provided this service. One woman narrated that she had gone to few clinics before finally finding a clinic that provided such a service. Women in this study had the perception that government hospitals do not provide abortion services as it was illegal and thus did not make an effort to ask for this service in government hospitals. Some revealed that since they could not find the service, they had to resort to using traditional abortifacients. They did claim that they were not effective. Medical abortion was also noted to be uncommon.
“For me is very difficult. If you got pregnant, if you want to do abortion, you cannot go to government clinic or hospital. You can only come here [private clinic]” (38yrs_Indian_secondary education_married_housewife)
“No I didn’t go anywhere. Because if go to government [hospital], need to give birth to the baby. Cannot have abortion in government hospital, because they are very strict, conservative, very traditional mind, say abortion is illegal” (29yrs_Chinese_secondary education_single_admin clerk)
Since abortion was a controversial issue and considered a taboo, women who sought abortion information as well as the services had difficulties in requesting for them directly. With regard to abortion services, one woman claimed that she was asked for a pregnancy scan first and then found out about abortion. In addition, the women also felt that it was embarrassing to ask information about abortion service as they ‘knew’ it is a sin and feared other people would talk, behind their back. A single woman claimed that she did not go back to the previous clinic where she had her first abortion as she felt embarrassed to let people know that she was going for her second abortion.
“Is embarrassing to tell them because we know all these things are sinful. We tell them we want to abort. Later, there will be people who will talk behind our back” (22yrs_Malay_secondary education_married_housewife)
“(laughing) I already had [abortion] before, I don’t want to go back. They will say this girl come again. Because they got my profile. So, I don’t want [to go back to the same clinic again]” (25yrs_Chinese_secondary education_single_hairstylist)
Cost did not seem to affect women’s access to abortion. Since all the women interviewed had obtained abortions in the clinic where they were recruited, the majority felt that the abortion fee charged was reasonable and commensurate with the services they received. However, there were some who found the fee to be high especially surgical abortion (RM400-RM700) which was more expensive compared to medical abortion (RM150-RM260). The cost influenced some women to opt for medical abortion as it was cheaper. One woman felt that no matter what the cost was for abortion, women were compelled to pay due to desperation to terminate the unwanted pregnancy.
“Yeah, money is a problem because my husband is the only one working. I’m housewife with three children and also I have to support my father-in-law. I take pills because first time I did washing [surgical abortion] it cost almost RM500”(38yrs_Indian_secondary education_married_housewife)
“But if someone wants to abort. No matter how expensive it is, they are willing [to pay]”(35yrs_Malay_secondary education_married_nasilemak seller)
Pertaining to abortion services in the clinic, the women were satisfied with the service given particularly towards the detailed and clear information received on the types of abortion offered, systematic information on the processes for medical abortion and the emphasis on post-abortion follow-up care. The follow-up care involved ultrasound scanning to ensure completeness following medical abortion. The patients were appreciative that they were not charged but instead were refunded for the remaining medications that they did not need, if the abortion was complete.
With regard to health providers in the clinic, many were satisfied and felt they were able to discuss with the doctors on the options and had time to decide on abortion and contraception. Unmarried women were appreciative of the non-judgmental treatment received from the clinic. Several women had negative experiences in other clinics; one unmarried women claimed that she faced resistance in trying to enquire for abortion service while another women compared the kind and positive attitudes of health providers in the clinic with those from other clinics whom they noted were ‘clinical’. With regard to government hospitals/clinics when seeking abortion services, the women felt unhappy as the doctors were judge mental with their personal beliefs that abortion is wrong and sinful. They were told off, that abortion was against religion and were asked to carry their pregnancy to term and later put up the baby for adoption.
“I am already pregnant so the doctor wants to set up antenatal care appointment. I said ‘Wait doctor’. I went with my husband. ‘My children are still young, wait’. Doctor scolded ‘Cannot abort. Is wrong” (28yrs_Indian_secondary education_married_part time driver)
“’Why you want to throw [abort]? You know that is a sin right’, the doctor said” (22yrs_Malay_secondary education_married_housewife)
The women were also pleased with the pre- and post- abortion counseling that they received as part of its comprehensive abortion services. They felt the pre-abortion counseling was not prejudiced and judgmental but served to provide information and clarified fears/doubts and misinformation. However, some felt that there was a lack of details about abortion. Some women appreciated that the pre- and post-abortion counseling involved their partners.
Fears about abortion and its side effects
The major fears experienced by women were primarily incompleteness of the procedure and future infertility. Other fears were safety issues and uncontrolled bleeding. There were doubts about the effectiveness of medical abortion and worries about the potential harmful ingredients in the medication. With regard to surgical methods/MVA, there were fears that the procedure would weaken the body.
“After the procedure, I have thought about whether the baby is completely washed out. When I was checking, I felt a little bit nervous and I was afraid that the baby couldn’t be completely washed out” (29yrs_Chinese_secondary education_single_admin clerk)
“I have heard people said if have abortion, then is hard to get pregnant again (in the future)” (22yrs_Malay_secondary education_married_housewife)
“Doctor said by taking this medicine, 99% can come out. At first, I don’t believe. I know that my body is strong. It won’t come out. Can it be aborted by taking medicine? I am surprised” (28yrs_Indian_secondary education_married_part time driver)
The women reported that they had not experienced any side effects but only normal post-abortion effects. Nevertheless, some were still concerned about infections and future consequences such as possible infertility, damaged uterus or reproductive cancer resulting from surgical methods. There was also a fear of giving birth to a handicapped child or a child will be born with some abnormality in the future.
“Like maybe virus or bacteria .Sometimes, the instruments that they use may cause infection in our womb. Scared if it affects my future pregnancy” (31yrs_Malay_tertiary education_married_clerk)
“After abortion, doctor won’t encourage us to get pregnant in 2years. They are afraid if the child will be different [abnormal]” (22yrs_Malay_secondaryeducation_married_housewife)
“[after surgical abortion] As for the future. is quite worrying. scared if the uterus is damaged, or if there is cancer or what. But if through medicine [medical abortion], for me it is safe because it doesn’t involve anything” (22yrs_Malay_secondaryeducation_married_housewife)
Only one woman showed confidence with modern abortion methods and believed that it should be safe.
“Because now, I think the technology has improved already. So, I am not scared of any side effects” (25yrs_Chinese_secondaryeducation_single_hairstylist)
Post-abortion feelings and emotions
Abortions brought a myriad feelings to women who had experienced it, from seemingly “no feelings”, not wanting to think about the abortion, relief, feeling of sadness and loss.
“I think I don’t have any feelings. No, I didn’t feel (the) loss or anything. Not at all. I didn’t think about this. I didn’t think that thoroughly” (38yrs_Chinese_primary education_married_factory QA)
“For me, abortion.I feel satisfied, a relief” (35yrs_Malay_secondary education_married_nasi lemak seller)
“Oh.you see it comes out [foetus], feels very sad, really sad” (23 yrs_Malay_tertiary education_married_clerk)
The women also reported feelings of post-abortion regret and this feeling came from the guilt of aborting the baby. This feeling was related to the cultural and spiritual ties of the women as they felt they had sinned against God. There were also few women who felt guilty towards the unborn baby. Some of them coped with these feelings through prayers, asking forgiveness from God and the unborn fetus.
“One month after the wash [abortion], we already sinned. After that, I went to ask for forgiveness. Me and my husband and children bring. [to temple] let him [the unborn foetus] know, asked for forgiveness. The child [unborn foetus] also has no life right. I asked for forgiveness from him [the aborted foetus]. Whether he knows or not I don’t know. But I aborted, the baby I abort right. Please forgive” (28yrs_Indian_secondaryeducation_married_part time driver)
“Feels guilty. Is between us and the One above. We know we already made a huge sin but we hope He (God) will understand our situation. Not like we simply just want to do this [abortion] right? People said it’s really such a waste. Usually we prayed. Increase our prayers, asked for forgiveness from the Above. Forgive our sin. We didn’t do it on purpose” (22yrs_Malay_secondaryeducation_married_housewife)
“I am a Buddhist. Everything, every single thing also has a soul although it hasn’t taken shape yet. It is also a life because it’s a life so I blamed myself. Before the abortion, even a dot is also a life. I told the baby it’s not I don’t want you but life forces people to do things. I have no choice but to abort you”[29yrs_Chinese_secondaryeducation_single_admin clerk]
Abortion decision making and support
Majority of the women declared that the decision to abort was theirs but some had to persuade their partners about the decision. Although some initially reported that it was a joint decision, they later revealed that it was them (the women) who first decided and got their husbands to agree later. One woman stated that the decision to abort should be between husband and wife and should not involve other people (e.g. family member) as that would only add confusion to the decision making.
“Don’t know. Some they gave positive [opinion], some negative. Those I don’t want to listen, I discussed with my husband. Husband said ok, direct [straight for abortion]” (28yrs_Indian_secondaryeducation_married_part time driver)
As for those who were not married, the decision to abort was not because of her unmarried status but in not wanting to marry her boyfriend whom she thought was not the one for her. Another single woman claimed that she was forced to abort as her boyfriend claimed that he was not ready for marriage nor was he financially capable to support a family.
“First time I aborted because so young and then that guy, I don’t think he is my man. So the second time [when I was pregnant] my friend told me, “Now with your age, you also can get married. Why don’t want you want to marry”. I was thinking the man is the one [I would want to marry]. So told him but he scared he cannot afford, because want to take care of two of us. Because he actually cannot say the words [ask the girl to abort]. I think, you know, guys, so, I decide myself [to abort]” (25yrs_Chinese_secondaryeducation_single_hairstylist)
The spouse/partners also played a role in terms of supporting the women in obtaining abortion services. The support came in the form of moral and physical support such as accompanying the women to the clinic, seeking information on abortion, locating abortion services and paying or sharing the cost of abortion.
“Is really a tensión, sad right. I said in Islam it is a sin. I feel scared. I just kept my patience. Let him know [husband], shared with him. He said is not like want to do what, not that [we] purposely wanted this [pregnancy] right.it happened” (22 yrs_Malay_secondary education_married_housewife)
“My husband also searched in the Internet and he finds how many weeks is that? Is it a sin or not? He was looking at the Google and the Internet and all the stuff. He followed me to the clinic as well” (29yrs_Indian_tertiary education_married_support specialist)
“Umm…about the money, I have thought about it. I’ve discussed with my boyfriend and he helped me out with the money” (29yrs_Chinese_secondary education_single_admin clerk)
Some women also received support from their mothers and good friends when the mothers took care of them, post-abortion, while they could confide their feelings and emotions with regard to the abortion with good friends.
“Er…my mum said because she old already. She also hope I can marry have baby. So she said if you can marry, no need to have abortion so I can be a grandmother. Yeah, it’s her wish but I said I don’t want she didn’t scold me. Also she took good care of me and cooked sesame oil chicken and ginger. Also good friend gave me support. Ya, I kept talking and telling them my feelings then she just say abortion is. She said abortion in the world, outside of the city and overseas, America, England there abortion is a very normal thing. Then she said no worry. She said never (become) too sad and upset your emotions. So, now I feel much better” (29yrs_Chinese_secondary education_single_admin clerk)
Needs of women in coping with abortion
The women highlighted two main abortion needs; abortion information and abortion services.
Many asserted that there is a need for abortion information to be disseminated to the public to increase public awareness and knowledge on this issue. Among the types of abortion information desired were the consequences or side effects, availability of the service, methods of abortion, abortion procedures and post abortion care. Most women had concerns about long term consequences of post-abortion but were not sure of the validity of the information and would like to receive detailed information about side effects.
“If let’s say we are pregnant, will there be effects on the child or what?” [29yrs_Malay_secondary education_married_operator]"
"“There are. like people said difficult to get pregnant again, is it true? I want to know more details about that” (22yrs_Malay_secondary education_married_housewife)
Need for information on abortion availability and accessibility were also highlighted by some women as some of them faced difficulties in locating or gaining access to the service. The women viewed that abortion information should be disseminated to the public to curb baby dumping as they reasoned that baby dumping is a greater sin and far worse compared to abortion.
“But in another way is better [abortion] then to throw the baby away right [baby dumping]. Abortion is already a sin that is being committed. If abort is a sin, throwing away baby is more sinful. Then the child has to suffer embarrassment. Is better like that [to abort]. If can, is okay to be disseminated [information on abortion availability]” (29 yrs_Malay_secondary education_married_operator)
“Because they all do all this [abortion], is wrong, but at least there are no baby dumping. There are no far worse and severe consequences” (25 yrs_Malay_secondary education_married_clerk)
Since the introduction of medical abortion was fairly recent, women expressed the desire to seek information about the side effects, safety, process, availability, effectiveness, ease of consumption of pills, cost, post abortion care and the advantages compared to other methods.
“The safety is the same [both surgical and medical abortion]. But don’t know. That’s why I feel because, when they do that [medical abortion] they didn’t use instrument. So may be is safer [compared to surgical abortion]. But we don’t know because there might be side effects inside [in the womb]. We don’t know about that. Because they never told us all these right? Like if we do this [abortion], what are the effects to our womb or if our uterus is ok or not ok” (29yrs_Malay_secondary education_married_operator)
Women felt that current abortion services are not easily found thus making it so difficult to obtain the service. Some viewed that abortion should be legalised by the Malaysian government in view of the occurrences of baby dumping and unsafe abortions which they had heard about.
“Em… I think government should give a way to provide legal abortion for Malaysian women. To make it less harmful for women who want to have abortion. But they can’t get the service legally, so they do it out there illegally. That can cause harm to their body. Can get the effect like won’t be able to get pregnant again, all the other effects” (25yrs_Chinese_tertiary education_married_housewife)
Pre- and post- abortion counseling were raised as an effective means to help women cope with abortion. Counseling could be used as a channel of delivery of detailed information about abortion and serve as psychological support to unearth their feelings and emotions so that women could relieve their anxiety about abortion. In addition, it was also mentioned that pre- abortion counseling could assist women in making informed decisions, i.e. whether or not to have an abortion.
“If me, there is a need [for counseling]. Like us, is it true when the doctor said there is nothing - like I always think, eh is it true? Is it really safe? Are there effects or not. Sometimes, after we wash [abort], why do we feel different? Feels like.always after we gave birth right. why is it that she looks different? Feel that she is bloated, why? Not from the effects of this [abortion] right? By right, he/she [doctor] should explain” [22yrs_Malay_secondary education_married_housewife]
“Like.what people said, counseling is okay because we talk to the person, chat with her to calm her down. Don’t give her tension. Counseling can help” [22 yrs_Malay_secondary education_married_housewife]
Future follow up following abortion were asked for by some women to safeguard the possibility of any long term side effects. One woman wished for more follow ups in case of long term effects of abortion.
“And then the follow up. Make sure our body is… is in good condition.” (25yrs_Chinese_tertiary education_married_housewife]
“The follow up, I’m quite dissatisfied with it because they only see ‘oh ok, now is clean nothing’. If can, let’s say we try after 3months or 4months we come back again [to the clinic]. We do the check up again. Like after [abortion] of course we would like to know the effects [of abortion] after 3months or 4months how. Scared if the effects will come right. With follow up, we can ask the doctor, the doctor will explain to us maybe because of imbalance or what”(22yrs_Malay_secondaryeducation_married_housewife]