The United States of America is one of the world’s leading countries in terms of the development of science, research, technology, and medicine. The citizens and residents of the United States have access to multiple high-quality services and procedures helping them address the existing health problems, prevent the potential ones, and minimize possible risks. However, as advanced as the US healthcare is today, it has some weaknesses and overlooked aspects compared to the foreign healthcare systems. In particular, the state’s northern neighbor, Canada, seems to have a better-organized healthcare system that is in some ways superior to that of the US. To be more precise, the Canadian post-abortion care policy (PAC) offers services and takes into consideration problems that seem to be ignored in the United States. One such issue is the provision of post-abortion counseling to women (and sometimes men) experiencing the need for emotional support and facing mental health risks.
Public Health Problem Identification
Following the definition provided by the World’s Health Organization, abortion refers to “the termination of pregnancy from whatever cause before the fetus is capable of extra uterine life” (ALARM International Program, n.d.). Moreover, there exist two kinds of pregnancy termination – the spontaneous one (caused by the anomalies and pathologies preventing the normal development of a fetus), and the induced one (initiated due to a deliberate decision) (ALARM International Program, n.d.). Abortion is widely recognized as one of the most controversial issues in health care all around the globe. In some countries, abortion is prohibited by law unless the pregnancy is a threat to a woman’s life; in the others, there are laws restricting abortion. In Canada, there is no abortion law, which means that the procedure is legally unrestricted; in fact, it has been legal for over three decades (Prasad & MacQuarrie, 2015).
When it comes to the history of the abortion policy in Canada, before the 1980s, for a woman to undergo the procedure terminating a pregnancy, the permission of a four-member committee of doctors was required determining that the pregnancy was a threat to the woman’s life (Cohen, 2013). However, at the end of the 1980s, this regulation was struck down by the Supreme Court of Canada as restricting the women’s constitutional right to liberty and security (Cohen, 2013). Various provinces of Canada may have different rules as to the period of gestation when pregnancies can be terminated; also smaller areas and islands may have no clinics performing abortions, and so the women seeking the procedure can be sent to another location; yet, there is no place in Canada where abortions are prohibited by law.
Also, in the article by deVeber and Gentles (2005) published in the Canadian Medical Association Journal (CMAJ), the authors emphasize that abortion is a traumatic procedure that can affect both physical and mental health of a woman undergoing it or even a man whose partner has had an abortion. The research collected evidence from recent years (after 2000) concerning the psychiatric admissions and problems of women after abortion and reported that the rate of psychological trauma experienced by the individuals affected by abortion is rather high; moreover, the adverse effects of the procedure may persist throughout many years (deVeber & Gentles, 2005). Among the problems reported by post-abortive women, there is depression, eating disorders, different types of anxiety, and suicidal thoughts, to name a few. The researchers concluded that the percentage of the population of post-abortive women and their partners experiencing different kinds of psychological problems is high enough for this issue to become recognized as a serious public health concern (deVeber & Gentles, 2005).
In response to the existing need for professional support among the people affected by abortion, many counseling services and organizations began to appear in Canada. The Canadian PAC policy states that the women undergoing pregnancy termination procedures must be assured by their physicians that there are post-abortion counseling programs and services available (SOGC clinical practice guidelines, 2006). This practice is not unique or specific only to the Canadian PAC. It can be found in the policy guidance provided by the Royal College of Obstetricians and Gynaecologists (2011) in England that obliges the medical practitioners to provide referrals to the post-abortion counseling to women who require emotional support.
However, the policy guides in the United States seem to overlook this aspect of PAC whatsoever, and this is an important issue knowing the rates of induced and spontaneous abortions that take place in the US annually. To be more precise, over 950 000 women underwent abortions in 2014; this number was even larger in 2013 (983 000), and in 2012 it exceeded one million (Abort73, 2017). Of them, the vast majority were women in their 20s (prevalently unmarried), and 11.4% of abortions were performed on women between 15 and 19 years old (Abort73, 2017). The need for post-abortion counseling is a problem at the national level.
Stakeholder Analysis
The Recipients
Discussing the stakeholders of the PAC policy referring to the provision of post-abortion counseling, it is needless to point out that the major stakeholders are the recipients of abortions – women. However, it is critical to emphasize that the women undergoing the procedures of pregnancy termination can be divided into several different groups. In the previous section, it was briefly specified that the vast majority of women undergoing abortions are unmarried. Also, it was mentioned that this procedure is performed on women of different ages – most of them are females in their 20s, a significant percentage of abortions are delivered to women or 15 to 19 years of age.
Also, there is a small percentage of adolescent recipients of abortions – namely, 0.03% (this number represents about 300 women per year) (Abort73, 2017). Moreover, it is also critical to note that some of the women looking for pregnancy termination are the victims of rape – a factor that is out of their control. In fact, according to the RAINN (2016) statistics, about 15% of American women become the victims of the completed rape in their lifetime; and this number represents millions of females (majorly ages 12 to 34) all around the United States of America. Many of these women have a chance of becoming pregnant after being sexually assaulted and seek the termination of pregnancy and also for PAC counseling, support services, and organizations. This is why it is crucial to provide all the women in need of such services with easy and unrestricted access to them.
Knowing that abortion is recognized as a controversial practice, it is necessary to mention that it is actively protested by pro-life organizations and individuals and can be frowned upon in some communities and groups of the population. This type of attitude expressed by the members of the general public tends to increase the pressure on the women undergoing abortions positioning them as the wrongdoers; in turn, their psychological discomfort can be aggravated.
The Researchers
Another stakeholder group in this issue is comprised of the researchers who majorly contribute to the policy-making process by revealing evidence supporting or opposing the need for certain services and practices. While the Canadian researchers gather the evidence that indicates the high rates of psychological problems experienced by post-abortive women and their partners, the major mental health agencies in the United States refuse to accept the phenomenon referred to as PASS or Post-Abortion Stress Syndrome (Babbel, 2010).
The Providers
One more important group of stakeholders includes the providers of post-abortion counseling to the women in need. They serve as a useful source of data regarding the number of women seeking this type of care, the communities these women represent, the kinds of problems they face, and due to what reasons. The Canadian Post Abortion Community Services (2016) explain that many women can experience a feeling of relief after an unwanted pregnancy has been terminated; however, there is a percentage of women who may feel the adverse psychological repercussions of abortion. The researchers link the prevalence of post-abortion grief to several different factors such as previous mental health problems of women, the length of a terminated pregnancy, the patient’s age, her religious and cultural beliefs, the community and environment in which she lives, and the conditions under which the decision to terminate the pregnancy was made (for instance, lack of support, pressure, disapproval) (Post Abortion Community Services, 2016).
The providers also name a range of symptoms associated with the phenomenon of post-abortion stress syndromes such as depression, sadness, emotional numbness, a strong desire to conceal the fact that an abortion took place, adverse emotional and physical reactions when someone mentions abortion, fear of becoming pregnant again or an obsessive desire for a new pregnancy (Post Abortion Community Services, 2016). In turn, attempting to cope with the negative psychological effects of abortion, some women turn to dangerous and harmful behaviors such as binge eating, alcohol and substance abuse, and suicide attempts.
Moreover, in some cases, the psychological consequences of pregnancy termination can occur years after the actual procedure (Post Abortion Community Services, 2016). In that way, the researchers point out the need for post-abortion counseling services. DeVeber and Gentles (2005) emphasized that the prevalence of adverse psychological outcomes of abortion is as high as 10%; and for this reason, this issue is recognized as a serious public health concern and requires measures addressing it based on policy. Having mentioned this fact, it is important to keep in mind, that the number of women undergoing abortions in Canada is much smaller than that in the United States (100 000 versus over 950 000).
The Policymakers, Supporters, and Opposition
In both the United States and Canada there is a large number of organizations and groups expressing active protests against and support for abortion as a medical procedure due to the moral and ethical problems related to it. In that way, the policymakers and governments are placed in between two clashing parts of the society. The level of pressure is high, and both parties can make very strong points supporting their perspectives and beliefs. In particular, at some point in the Canadian history, there was a governmental committee created to protect the interests of the unborn children for the purpose to balance out the views of the opposing sides in the conflict – in this case, a mother and a fetus (Cohen, 2013). However, this idea has not been successful, and as a result, there exist no restrictions on abortion in Canada that would be based on the viability of a fetus (Cohen, 2013).
To sum up, the supporters of abortion include women receiving abortions, researchers attempting to improve PAC, the practitioners providing counseling services to the post-abortive women and their partners, and the pro-choice organizations and individuals. The opposing party includes the pro-life activists and religious organizations and communities. The former see abortion as the personal matter of women who are positioned as the key decision-makers free to keep or abort their pregnancies, and the latter view pregnancy termination as an immoral and unethical solution equal to murder and selfish from the side of a woman. Since abortion is legalized in Canada and the United States, the supporters of the procedure have a stronger position; however, it looks like in America, the opposition has a significant impact on the policymakers, due to which they end up overlooking some of the important aspects of post-abortion care.
Policy Formulation
Under the regulation provided by the Canada Health Act, full public funding is to be granted to all the abortion clinics in the country (Abortion Rights Coalition of Canada, 2005). This includes services such as post-abortion care and counseling, pro-choice care, birth-control care, 24-hour services with on-call practitioners, as well as post-abortion follow-up. Due to these aspects, the care offered by the specialized abortion clinics is more effective and personalized than that delivered by large hospitals with long waiting lines, weaker privacy protection, and insufficient support that may occur due to the judgmental environments (Abortion Rights Coalition of Canada, 2005). However, large hospitals also carry a few benefits such as the provision of safety from the pro-life protests and political interference. Only a small number of clinics in Canada are violating the Health Act demanding that their patients pay for their abortions out of pocket.
In that way, in Canada, the women have unrestricted access to abortions that are majorly covered by the public funding and include pre- and post-abortion care; moreover, the latter also includes counseling since the physicians are obliged to inform every woman undergoing an abortion procedure about the available emotional support and refer a service or a practitioner performing it (SOGC clinical practice guidelines, 2006).
To compare, the Clinical Policy Guidelines presented by the National Abortion Federation (2015) of the United States contain a variety of abortion care standards that cover pre- and post-abortion procedures and mention most of the guidelines of the SOGC apart from the post-abortion counseling and support. The issue of the emotional impact of the procedure is not even mentioned in the US policy guidelines. In that way, it is possible to conclude that post-abortion counseling services may exist in the United States but the patients have to search for them on their own, and most certainly, these services are not publically funded and will require that the patients pay for them out of pocket. Logically, it is possible to conclude that many (or most) post-abortive women would not be able to access this type of care and would have to deal with their psychological problems independently.
It is possible that the fact that Post-Abortion Stress Syndrome (PASS) is not recognized or accepted by such agencies as the American Psychological Association and the American Psychiatric Association undermines the significance of this issue and creates a belief that the problem is not real (Babbel, 2010). As a result, as a suggestion helping to create a more pleasurable environment for the development of a policy adding post-abortion counseling as a necessary aspect of PAC should begin with a new body of research addressing this issue. To be more precise, a substantial scope of research and statistical evidence needs to be gathered and analyzed for the purpose to determine and define the need for change in the existing abortion care guidelines and policy.
Policy Implementation
In Canada, according to the Canada Health Act, all the abortion clinics in the country are funded by the Ministry of Health (Abortion Rights Coalition of Canada, 2005). In that way, it is possible to conclude that the policy of provision of post-abortion follow-up in the form of counseling that is one of the essential PAC practices is implemented on the federal level. Since there is no Abortion Law in Canada, the procedure is governed just like all the other medical practices. In other words, the Canadian health organizations and the Ministry of Health are in charge of the policies related to the practice of abortion.
However, the healthcare systems of Canada and the United States are very different. Therefore, it is not possible to copy the Canadian approach and regulation to improve the US abortion policy. America requires its framework fitting into the existing legislation and, possibly, correcting or improving the current policies of abortion care. To date, the coverage for abortion is severely restricted to a large number of low-income women who are insured by such programs as CHIP, Medicaid, and Medicare (Donovan, 2017). In turn, it is only logical to assume that since coverage for abortion is not provided to all the women that require it, post-abortion care procedures are also difficult to access. This is especially true for post-abortion counseling, a practice that is not even included in the PAC guidelines published by the National Abortion Federation in 2015.
In that way, if it is not possible to improve the abortion coverage for low-income patients (the complications are likely to become more significant since anti-abortion leaders are currently in power in the United States), it at least can be made available to the women who can receive abortions. However, it is important to remember that problems can arise during the implementation of the policy change. For instance, since post-abortion stress syndrome is usually exploited by the pro-life activists to support their points of view, the organizations opposing abortion could attempt to revitalize their narrative based on the fact that many women experience adverse psychological effects after having the procedure (Babbel, 2010). In this case, the potential pressure on the policy change created by the anti-abortion activists could be addressed with the help of rape statistics and the prevalence of pregnancies occurring after a sexual assault or the percentage of the American women seeking the abortion of pregnancies inflicted by rape.
Also, one of the major implementation issues in the post-abortion counseling policy would be its funding. To be more precise, the existing healthcare programs such as Medicare and Medicaid have been designed and adjusted for years specifically to address the issues of wasted costs in the US healthcare system and help the state budget save some money. As a result, the advocates of any new expenditure would find it difficult to further their policies.
Policy Evaluation, Modification, and Future Recommendations
As specified at the very beginning of this report, the United States of America is one of the world’s most advanced countries when it comes to the development of science, technologies, and medicine. Moreover, the USA provides a significant portion of international aid to the developing and poor countries through agencies such as USAID that help fund medical practices and improve healthcare systems and policies around the world. In particular, USAID directs funds for the purpose to support post-abortion care in low-income countries (Curtis, 2007). According to the data provided by USAID (2016), some of the most common causes of maternal deaths due to abortion and pregnancy complications include pre-existing health conditions, blood clots, high blood pressure, and severe bleeding. The vast majority of these issues are addressed in countries such as the United States and Canada due to high-quality prenatal and abortion care and procedures.
However, one of the PAC problems that remain overlooked in the USA is the lack of counseling and emotional support programs and referrals. To enforce change, research needs to be conducted confirming that the prevalence of psychological problems in post-abortive women is high in the United States. Also, while this action may take some time, there is another way to address this issue. To be more precise, some organizations are working to provide post-abortion counseling to women and their partners who need it. Some of them are faith-based, some are non-profit, and some are ready to work with low-income clients; in that way, if the physicians are obliged to inform the patients undergoing abortions about the existence of such services and provide referrals, then some of the women facing post-abortion issues of psychological nature could access the necessary help.
It is only logical that a procedure that has been legal in the United States for many years and that its healthcare agencies attempt to address in the developing countries should receive an appropriate amount of attention at the domestic level. It is possible to argue that psychological issues experienced by post-abortive women in the United States are not as serious as physical complications and thus, this problem does not deserve as much focus. However, as specified by deVeber and Gentles (2005), some of the women suffering from psychological issues induced by abortions tend to have suicidal thoughts and behaviors and also turn to alcohol and substance abuse to cope with the stress. These tendencies create a powerful health risk for this group of patients and amplify the significance of this issue
References
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ALARM International Program. (n.d.). Post-abortal care. Web.
Babbel, S. (2010). Post Abortion Stress Syndrome (PASS) – does it exist? Web.
Cohen, T. (2013). Abortion in Canada: breaking down the law, policies and practices. Web.
Curtis, C. (2007). Meeting health care needs of women experiences complications of miscarriage and unsafe abortion: USAID’s post abortion care program.” Journal of Midwifery & Women’s Health, 52(4), 368-375.
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