The Construction of Women in Abortion Services
By Maxine Lattimer

Introduction

The following paper was given as part of a day of discussion for staff and students at Kent University Women's Studies Centre held in the Autumn Term 1997. The day was about reproductive choice and was organised by Ellie Lee, a student at Kent University and Co-Ordinator of Pro-Choice Forum.

This paper is based on my PhD research which centres on an ethnographic study of two private abortion charities. I conducted participant observation fieldwork during 1995 and 1996 at the pregnancy advisory bureaux of these two organisations, an important part of which involved my sitting in on women's pre-abortion counselling sessions which they received as part of their initial consultation. I also interviewed bureau staff including counsellors, administrative staff, managers and medical staff. The research focuses on the way in which a set of cultural meanings surrounding abortion impact upon women who have abortions in contemporary Britain, particularly terms of their decision-making and their 'abortion stories' or the public accounts of their decision as presented during their counselling sessions. It also looks at how these cultural constructions impact upon those who are engaged in providing abortions i.e. the organisations and staff at my fieldwork sites. I have conceptualised these cultural ideas around abortion as a set of 'hegemonic discourses', using a Foucauldian understanding of discourse (1) and drawing on Gramsci's concept of 'hegemony' to talk about the ideological dominance of particular discourses (2).

The research explores the hegemonic ideas contained in what I have called the 'moral' discourse of abortion, which includes constructions of abortion, sexual behaviour and motherhood. These constructions contain contradictory and confusing messages, and it is clear that women faced with an unplanned or unwanted pregnancy are caught up in a clash of cultural expectations and ideals that they cannot live up to. Ideas about sexual spontaneity as well as human and contraceptive failure lead to such pregnancies, but they are perceived to be entirely preventable by responsible sexual behaviour and the use of contraception. As a result they are a source of shame and embarrassment. Abortion is the only solution if a woman wishes to end the pregnancy. Unplanned and unwanted pregnancies do not live up to ideals of 'proper' motherhood and many women feel no desire to become a mother and have no maternal feelings. If women do 'irresponsibly' continue the pregnancy in less than ideal circumstances that are not 'fair' to the child then they are open to criticism, for example single mothers who stay at home and are dependant on state welfare (3), mothers who work and leave their children with childminders (4), or teenage mothers, who were even the subject of one of 'The Health of the Nation' targets in 1992 (5).

But if women opt for an abortion they are also open to censure by a society that says motherhood is good, abortion is bad, but that babies should only be born in the 'right' circumstances. Whatever choice women make they are stigmatised. Abortion can be seen as both a proscribed and prescribed course of action in this 'moral' discourse, and this is the dilemma that women face. Abortion is proscribed act according to negative constructions of abortion, entirely avoidable and preventable according to constructions of sexual behaviour, and an act antithetical to the ideals of self-sacrificing motherhood. At the same time abortion is also a prescribed course of action according to these same constructions. Abortion is undertaken to avoid mothering in culturally inappropriate circumstances and thus is a moral act of responsibility and fairness to the unborn child and the rest of society. Women act against certain hegemonic ideas by having an abortion and in doing so they conform to other hegemonic expectations of 'proper' motherhood.

Services.

I have written elsewhere about the way in which many of the hegemonic ideas contained in this 'moral discourse' are also embedded in the law regulating abortion in Britain (6). In this paper I would like to look at the way in which women are constructed in abortion services, focusing in particular on the pre-abortion counselling provided at my fieldwork sites, and at women's own use of this counselling session to construct themselves and explain their decision. Sally Sheldon (7) has written about the way in which abortion is controlled by the medical profession and distinguishes between: 'technical control', that is the medical monopoly over the performance of legal abortions; 'decisional control', in that the doctor decides who has access to abortion; 'paternalistic control', in which even a sympathetic doctor imposes his/her own views; and 'normalising control', as the doctor has access to details of the woman's private world and from this produces an authorised account of her reality. In the organisations where I conducted my fieldwork, that is the private charitable sector of abortion provision as opposed to N.H.S. services, medical control manifested itself in rather different ways. Such organisations do play a major role in the provision of abortions through private clients and a growing number of N.H.S. contracts

Technical control of abortion was still in the hands of doctors since they actually performed the procedure, though nurses and midwives at the nursing homes played a big role in attending to the women's medical needs, particularly for late term prostaglandin abortions and early RU486 medical terminations. Technically, decisional control still rested with doctors since they had the final say and their signatures were necessary for the 'blue form' to be completed, without which the abortion could not legally be performed. However, those doctors who worked in the private charitable sector had actively chosen to be involved in abortion provision and consequently supported women's abortion requests and interpreted the law liberally to allow women to make their own choices. There was little evidence of paternalistic control from doctors, except in terms of contraceptive advice. Doctors tended to pursue the issue of future birth control vigorously as this was seen to be crucial in order to prevent further unwanted pregnancies. Normalising control continued but this function was largely fulfilled by the counselling session at the pregnancy advisory bureaux I attended. Doctors' part in the consultation tended to be brief, routine and focused on purely medical issues. They performed an internal examination or scanned the woman to determine the gestation of the pregnancy, enquired about her medical history, took a blood sample and asked about future contraception, providing a prescription if necessary. They signed the form HSA, usually only checking that the woman was sure and that the decision was her own.

Women were rarely if ever refused an abortion and no attempt was ever made to dissuade them from their choice, however the organisations were constrained by the law and the necessary paperwork that had to be completed as staff commented: 'I know it's a vague area but obviously we can't just let a woman come in and say 'I don't want to be pregnant, that's it', because of the legal side of it.' Therefore women had to be questioned about their 'private world' and their decision. It was the job of counsellors to obtain this information and write an short account on the woman's notes for the doctors who could then determine the clause under which the woman could be granted an abortion. Women were 'assessed' and 'processed' in this way. Although the counsellors at these bureaux were 'gatekeepers', they saw themselves more as advocates for the women they counselled The information they gathered and notes they made were meant to sanction the woman's request for an abortion. By presenting her decision in an acceptable way so that the two doctors would be able to sign the legal forms and allow her to have the operation they helped the client to achieve her goal. These counsellors believed themselves to be very pro-choice and pro-women. Indeed most would be dismayed at the suggestion that they were 'gatekeepers' or had such power as this was totally against their counselling persona and stated aims of sympathy and support. And also their goal of relating to clients as another woman and the feminist, 'sisterhood' side to their work which focuses on empowerment and abortion as a shared experience with other women.

Thus there was both an advocacy side to counsellors' gatekeeping in which they helped women get what they wanted, but at the same time a paternalistic side in which the counsellor 'knows best'. Counselling was not just a bureaucratic procedure undertaken to comply with the law. Counsellors had their own agenda based on sincerely held and altruistic ideas about such counselling being for the woman's 'own good', so really 'it's for them'. These counsellors believed that any woman should have the right to have an abortion if she wishes. However, they felt that they did have the right to insist that the woman talk about her decision during the counselling session, or at least had the opportunity to do so, because it was for her 'own good'. It was assumed that the reason why a woman would not want to talk was because she had been affected by the stigma attached to abortion, or because she was 'bottling up' or denying her feelings. Therefore it was for her own sake that she should explore them at this stage to prevent trauma later. The questions asked were posed in the framework of an egalitarian, 'person-centred' model of counselling. This very popular model stresses the special relationship between client and counsellor, who acts towards client with empathy and acceptance, is non-judgmental and expresses 'unconditional positive regard' for the client. Such counselling aims to be non-directive and to create an 'atmosphere of freedom' so that the client can become 'self-actualising'. The kind of control exercised by counselling is difficult to define and locate since it extends beyond a framework of medical control and operates on the level of emotions and care for the woman. The control exercised by counselling is not decisional but 'experiential'.

Counselling staff felt that they sometimes needed to be 'cruel to be kind' and make the process harder for the woman to ensure that she had thought carefully about her decision and would make the 'right' choice for her, as one counsellor explained: 'It's just prodding, maybe being a bit more challenging and saying 'it's such an important decision that you have to think about it. It may be cruel, it may be a horrible thing, you may not like me for this but I have to challenge it and you have to face it. Because in order to make the right decision, you have to think about it.' They can easily make the wrong decision if they're going to deny it, don't want to think about it, and they can be aggressive and say 'I don't want to justify this, I just want it, just do it'. I can understand them wanting to do that but sometimes the best thing is to make it a bit harder for them because it's one of the most important decisions they'll ever make in their life. They can't go back.' Counsellors also felt that it was important to challenge women who were reluctant to 'take responsibility' for their decision. One counsellor told me: 'I won't let someone get away with saying 'I have no choice'. Because they do have a choice and if they wanted the child then they would find a way to have it.'

Many staff were adamant that blanket provision of counselling as part of the consultation procedure was necessary to pick up women who 'need' counselling, even though they may not realise it themselves or may deny that they need it. They cited stories about the post-abortion problems women had as a result of not talking about their decision beforehand to justify their current practice of providing pre-abortion counselling, and pointed out the dangers of allowing women to opt out of this. As a receptionist told me: 'I think it's really dangerous the idea of getting rid of counsellors all together because often the women that say they don't need counselling are the ones that desperately do. And already it seems that there are more people coming back for post-abortion counselling because they hadn't had enough time with the counsellor in the first place, or they weren't counselled at all.'

Counsellors also acted out of a sense of professional obligation to care for their client's psychological well-being, and an important part of this was the detection of ambivalence in clients. As part of their training counsellors were taught to interpret body language, thus their special skills and experience gave them insights and allowed them to spot ambivalence this way, as one counsellor explained: 'They can be very hunched up, very closed and sort of slumped, don't have eye contact and say 'Yes, I'm very sure about my decision'. But they're not really saying that and so it's just for me to say to them gently 'Well you're saying that but I'm not really hearing that' or 'I get the feeling that (you're not), would you like (to talk about it)?' Counsellors considered looking for ambivalent feelings in clients to be as part of their professional responsibility rather than gatekeeping or policing. They felt that they had certain obligations to their client and this included a moral obligation to point out a lack of congruence between what was said verbally and body language if it seemed to imply ambivalence. They needed to be challenging to the woman and point out any ambivalence that appeared to be there, perhaps making it harder for her if necessary in order to prevent feelings being denied, to stop the 'wrong' decision being made and so protect the client from possible depression later.

As part of their professional identities, counsellors would see it as their job to provide a decent level of counselling care whether the woman wanted the service or not. This was part of doing a good job as a counsellor, providing a quality service, and whether the woman resented or appreciated their efforts was unimportant. Counsellors tended to see their role as in contrast with that of the doctors and counselling as a movement away from the medicalisation surrounding abortion. However, their introduction could be seen as an extension of this medicalisation in that they represent yet another 'professional' engaged in policing yet another aspect of women's behaviour, their mental health now, with counselling to prevent post abortion trauma. Both doctors and counsellors act as a 'professional' third party there to provide help for women in their decision making.

Self-construction.

Women were also keen to use the counselling session to explain and justify their decision for themselves, and construct themselves as 'deserving' in their request. Often women do not want to continue with a pregnancy because they themselves want to mother in different, more 'appropriate' circumstances at a later stage in life, or do not wish to become mothers at all. Women may want to pursue goals other than motherhood in their lives and continuing the pregnancy would mean giving up these things. However, women find it difficult to present their choice to abort in terms of what they want for themselves and their lives, as this seems 'selfish'. Staff spoke about women's reasons for choosing abortion and felt that most did so for themselves rather than others: 'There's a small percentage of women that feel they don't want to have an abortion but are forced into it, for financial reasons or their partner just won't support them and is definitely going to leave them if they don't have an abortion. But in the end most of the women make the decision for themselves, and if they really want to go ahead obviously they wouldn't come. If they really want to be pregnant and could cope with it, then they cope with it whatever's going on in their life really because they don't want to have an abortion.' Women continue to have their abortions every year to resolve unplanned and unwanted pregnancies but remain uneasy about their choice, as one client in counselling said: 'ethically I'm not that happy with it, but it's the right think to do'. Abortion is often described as 'the lesser of two evils', as 'wrong, but the right thing to do'. Thus women tend to appeal to aspects of the moral discourse to justify their abortion decision, both in their public abortion stories and their private justifications: 'It's to make themselves feel better and society's put them in that situation where they need an excuse for it, which you shouldn't really. The excuse is 'my partner's left me', whatever.'

The 'moral abortion' is when women choose abortion for the 'right' reasons that fit with cultural ideals. Abortion is undertaken by women to avoid 'bad' parenting, and out of a sense of 'fairness' and 'responsibility' to the unborn child and to others such as partners or parents. Thus abortion becomes a moral act of self-sacrifice. This idea of abortion as a selfless act motivated by a 'maternal ethic' fits in with societal expectations about motherhood as a self-sacrificing state of being, and femininity, with women as carers and nurturers. Women emphasise that their choice to abort is made for 'good' reasons that are not 'trivial', nor is their choice made simply out of 'convenience' or for themselves alone. They present their choice in an acceptable way, using reasons that will be understood and sympathised with. Anthropologist Heather Paxson (8) also found that the Athenian women she interviewed 'describe abortion as an unhappy but necessary and even moral recourse that enables them to avoid having children outside of marriage and to 'properly' raise the children they already have - in other words, to be 'good' mothers'. She found that 'because abortion has been used by women to limit family size, and since women do not generally consider foetuses to be 'persons' in their own right, abortion is not structurally opposed to the ideals of motherhood'.

When sitting-in on women's counselling sessions I found that ideas about 'good' motherhood were extremely influential in their accounts. These ideas were expressed in terms of 'responsibility' and 'fairness' to the unborn child and also with regard to existing children in terms of devoting enough time to them. Women talked about the 'right' way to bring up children which involved looking after the child themselves rather than paying for childcare, a prospect that was therefore impossible for single working women. Having a child that was 'planned' and 'wanted' was very important. They spoke about 'proper' motherhood and pregnancy maintaining that they wanted to 'do it properly', 'eat right', 'be sober' and generally take care of themselves and the baby. For many women this was not the 'right' time in their lives, they felt 'too young' and wanted to be 'settled down' before having children. Many were very concerned to avoid single parenthood, saying that they did not want a 'fatherless child' and wanted to be 'in a family' when they had children. Financial security was also important to give any child a 'proper start' in life, and to 'bring a child into the world' without this was 'not right'.

One counsellor spoke about how important it was to women that they had children in the 'right' circumstances. However, many women emphasised that they were unable to continue with the pregnancy because of reasons beyond their control such as their financial state, rather than admitting that they simply preferred to mother in more 'appropriate' circumstances: 'Some women will say 'If I had more money I would keep the child'. Sometimes you feel that is the case but at other times you feel they're just saying that as a reason to justify their having a termination. 'I can't have it, I'm living on my own'. 'A one bedroomed flat' they often say, 'Good relationship but we live in an one bedroomed flat'. And you can't point out that really babies are better in the parents' room for the first two years anyway so you can hear them in the night. But it is an excuse very often to make them feel better I think. Better to say that they can't. Some of them can say 'I don't want it', others have to fish around for reasons, others really do have reasons. (So) financial circumstances is often given as a reason but you do wonder really whether it is that. It's really that they hadn't planned to have a child at this stage and they want everything to be right then. They've got a set idea, a life plan, and they need to have a steady partner and get married perhaps, with a steady relationship, two years in that, and then children afterwards. If anything goes against that then they will consider a termination quite honestly.'

Some women even prefaced their abortion request with anti-abortion sentiments then proceeded to construct themselves and their circumstances as exceptional and justified, a practice that bureau staff found extremely annoying. As one of the receptionists explained: 'People say 'Well, I don't believe in abortion but because of my circumstances, blah, blah, blah'. I suppose it's denying that they're actually going through (it). When they've been inundated with 'what you're doing is wrong', it's their way of coping with it.' She described one extreme case of 'distancing' in which the woman simply could not accept that she was having an abortion and 'rang up saying the weirdest things about having a miscarriage but it wasn't a complete miscarriage. She came in and had a pregnancy test and it was still positive. She was just trying to tell herself that she was having a miscarriage and that when she went into the clinic it was just 'finishing it off' (to) justify what she's doing. It's sad that you have to go to those lengths isn't it?' Many women also appealed to aspects of the negativity surrounding abortion in order to justify their actions by emphasising how hard the decision had been and the guilt they felt, to show that they were 'paying' for their choice.

In contrast, other women spoke about their abortion choice in purely practical terms, stressing the 'inconvenience' of the pregnancy and saying 'I want to get rid of it' or 'I just don't want it'. As a receptionist commented to me: 'A lot of women talk about not having money, having too many children. But you get quite a few women who are quite honest with themselves as well and say they just don't want to be pregnant'. In her opinion 'this is what's wrong with the whole thing. You get women who say 'I couldn't possibly carry on with this pregnancy because I'm poor or I'm working and so on'. And I just think well why are you dressing it up? You don't want to be pregnant. There are genuine cases of situations where women feel forced into things but I don't think that that's the majority. I think we do have a choice at the end of the day and the choice is to continue the pregnancy or not. We're never going to get any further on issues like abortion because we help it along.'

However, these women were still constrained by the legal framework in which they must justify their request for abortion under the terms of the 1967 Act and provide specific reasons. Many women were aware of the need to 'make a case' in order to obtain their abortions and this affected their 'abortion stories' or public presentations of their choice. As staff pointed out 'It's the law that they can't come in and say, 'I just don't want to be pregnant' and that's it. You need more than that. The counsellor has to say 'Well, is it financial then?' Often women who spoke about their abortion decision in this way went on to describe themselves as 'selfish' and 'cold-hearted' for having no feelings about the pregnancy, and almost all had a strong concern for secrecy taking on-board ideas about abortion being a shameful act to be kept quiet. Thus the legal, medical and service framework, and women themselves with their need own to explain and justify their decision to abort, act to reinforce and maintain the hegemonic ideas contained in the 'moral' discourse.

(1) Foucault, M. (1972) The Archaeology of Knowledge and The Discourse on Language. New York, Pantheon
(2) Gramsci, A. (1971) Selections from the Prison Notebooks. London, Lawrence and Wishart.
(3) Dennis, N. and Erdos, G. (1992) Families without fatherhood, London: Institute of Economic Affairs Health and Welfare Unit. Davies, J., Berger, B., and Calson, A. (1993) The family: is it just another lifestyle choice?, London: Institute of Economic Affairs Health and Welfare Unit.
(4) Silva, E. B. (ed.) (1996) Good Enough Mothering? Feminist Perspectives on Lone Mothering, London: Routledge.
(5) Department of Health (1992) 'The Health of the Nation: a strategy for health in England', London: HMSO.
(6) Lattimer, M. (1998) 'Hegemonic discourses embedded in British abortion law: dominant ideas vs. women's reality' in Lee, E. (ed.) Abortion Law and Politics Today, London: Macmillan.
(7) Sheldon, S. (1997) Beyond Control: Medical Power and the Abortion Law, London: Pluto Press.
(8) Paxson, H. (1997) A 'Necessary Evil': Abortion and Maternal Morality in Urban Greece', unpublished paper presented at the Annual Meeting of the American Anthropological Association, Washington D.C.