THE ANTI-ABORTION LAW IN POLAND

THE FUNCTIONING, SOCIAL EFFECTS, ATTITUDES AND BEHAVIORS

THE REPORT - SEPTEMBER 2000

1. Index
2. Introduction - Wanda Nowicka
3. The Effects of The Anti-Abortion Act
4. Attitudes of The Medical Professionalists Towards Abortion The Report on Research of The Effects of The Family Planning, Protection of Human Fetus and Conditions for Termination of Pregnancy Act - Danuta Duch
5. Survey Conducted by The Federation Among Doctors, Nurses and Midwives on The Effects of The Anti-Abortion Act - Wanda Nowicka and Agata Zielińska
6. Attitudes of Rural Women Toward Reproduction Issues Report on The Survey Conducted by RUN - Magdalena Grabowska and Wanda Nowicka
7. Abortion and Values – The Research Report - Danuta Duch

Attitudes of the Medical Professionalists Towards Abortion The Report on Research of the Effects of the Family Planning, Protection of Human Fetus and Conditions for Termination of Pregnancy Act -Danuta Duch

By request of the Federation for Women and Family Planning, the company RUN, Research and University Network, conducted a survey on effects of the Anti-Abortion Act. The survey took place between 31 of May and 13 of July 1999, using in-depth interviews with doctors and nurses working in Warsaw, as with the professional groups connected to the practical realization of the Act.

Goals of the research

The research goal was to recognize the social and health effects of the Anti-Abortion Act of 1993, and particularly to get information about:

• To what extent regulations of the Act are known to medical professionals,
• To what extent procedures allowing for lawful abortion are known,
• How the Act is assessed by medical professional organizations: opinions about its shortcomings and merits,
• The attitude of professionals towards abortion,
• The attitude of professionals towards abortion underground,
• The attitude of professionals towards women terminating a pregnancy.

Group of respondents

10 in-depth interviews were conducted: 6 with gynecologists (2 women and 4 men) and 4 with middle level medical staff - midwives and nurses.
Respondents were:

• Of different age - the youngest have been professionally active for a few years, the oldest of doctors had 45 years of professional practice,
• Working in different health care institutions:
• - clinic for women at the district health center (D, N)
• - private clinic (N)
• - gynecological and/or obstetrics hospitals (D, N)

Doctors taking part in the survey usually worked in more than one place.
Interviews were marked with symbols. Quoted statements coming from doctors were marked with the letter D, statements made by midwives and nurses with the letter N. ³⁵ All interviews were conducted in the same way. The report does not differentiate between statements made by female gynecologists and male gynecologists. There was no significant reason for differentiation. For simplification - we use the term "nurses", meaning the group of midwives and nurses working with gynecologists.
It must be noted that groups of doctors and nurses are very different. Doctors are placed higher in the professional hierarchy - only they can conduct abortions and are exclusively responsible for legal consequences of the violation of the regulations. Nurses only follow orders from doctors and do not face legal responsibility. The differences in professional positioning of doctors and nurses result in different perspectives. Doctors relate to the law itself, hospital's management and women. Nurses relate to practicalities of the law, doctors and a woman. Extracting separate groups of doctors and nurses in the research significantly improved the picture of the Anti-Abortion Act and its social effects.

Conducting the survey

During the survey, some difficulties occurred with finding doctors and nurses to take part in the study. No person asked by phone to take part agreed to do so. In one of hospitals, all doctors working there refused one by one.
In this same hospital, two nurses did not agree to take part saying that they are against abortion. They did not agree to make a formal statement. Nevertheless, in the informal talk following the request, they gave some important information. They admitted not knowing the regulations of the Act. They also claimed that they have nothing to say about effects of the Anti-Abortion Act, because abortions are not performed in their ward, because the law forbids it. While told that the law does allow for abortion in certain circumstances they stated that they had not heard about terminating a pregnancy in their ward on the basis of fetal genetic. Spontaneously they added, that a doctor has the right to refuse performing an abortion if it contradicts his beliefs.
The third midwife working in this particular ward also refused an interview. She said that was not to be discussed. She represented a critical view of abortion - her statement suggested that if a woman doesn't want to give birth to a child, it is enough if she comes to see a doctor. She added that abortions are surely conducted in private clinics. There is number of announcements in gynecological press offering "services". She cynically commented that it is surely not only about curing erosion, but that these issues are not openly discussed because big money is involved. She also admitted that she was not familiar with regulations of the Anti-Abortion Act.
The lack of agreement to taking part in interviews concerning anti-abortion regulations - both among doctors and nurses - resulted in the prolongation of research. Three persons were involved in conducting interviews. To find anyone willing to take part in an interview, they had to gain information from third parties or say that they were coming on somebody's recommendation.
These difficulties can be explained with high level of fear and anxiety that doctors and nurses face while making statements on abortion in a public forum. All respondents and potential respondents were not convinced that interviews were absolutely anonymous.

In their work, gynecologists and assisting nurses and midwives come across women with unintentional pregnancies. In Poland, the conditions for abortion are strictly defined by legal regulations of the Anti-Abortion Act. The knowledge about situations in which a doctor can conduct an abortion is, for a gynecologist, knowledge about the possible legal actions she/he can undertake in professional practice. Being familiar with the regulations is also a condition for giving correct, reliable information to women, who find themselves with unwanted pregnancy.
Not all doctors know the full content of the Anti-Abortion Act. The situation in which "there are justified suspicions that pregnancy results from unlawful act", commonly known as a pregnancy resulting from rape, in opinion of two doctors taking part in the survey, does not constitute the basis for termination of pregnancy.

The Act does not precisely define medical indications for abortion; it only vaguely states, "constituting the threat to life or health of a pregnant woman." Nor does the act elaborate on "heavy and irreversible damage of a fetus or incurable disease threatening it's life". None of the doctors interviewed criticized this lack of precision. On the contrary - some of them pointed at advantages of such a situation.

Medical indications for termination of pregnancy appear to be very controversial for doctors.
While naming the damages of a fetus allowing for abortion, one of the doctors mentioned Down's Syndrome, which was described by him as a big, but controversial problem, because he knows mothers who have children with Down's syndrome and who love them very muchÊ(D). (See also: Abortions in hospitals)
Doctors are not fully familiar with the formal procedures of termination of pregnancy. They know that if abortion is conducted on the basis of pregnancy constituting a threat to the life or health of a mother, a woman has to have a certificate from a specialist, describing her illness and including indicators for abortion. If the indicator is heavy damage of a fetus, they know that a woman has to have results of examinations stating, what damages there are. Different doctors nevertheless point at different numbers of certificates required in such situations for a woman to submit.
In case of abortion on the ground of woman's state of health, one doctor said a referral from gynecologist and from a doctor of different specialization was needed.
In another hospital, a woman needs two independent specialists to sign: She has to have two certificates for us, coming from two independent specialists doctors and she has to submit a request to conduct an abortion. (D)
To conduct a genetic examination, a woman has to have a referral from gynecologist.
One of the doctors stated that he/she issues such referrals only for those women, who are determined to have an abortion if a defect of a child is discovered or for those, who do not know what their decision would be in such case. Nevertheless, according to one of the nurses, not all doctors inform women about the possibility of having pre-natal examinations.
According to opinion of one of doctors, not directing a woman to genetic examinations in a situation, when there are indications to do so, is misconduct. These indications are: age above 35 years, members of the family having genetic defects, or defective or abnormal fetal development shown in an ultrasound.
To have an abortion because of fetal defects, a woman has to have, according to one of doctors, certificates stating the damage and referral from gynecologist. Another doctor stated that to have an abortion because of fetal defects, a woman has to have certification of genetic tests conducted, results of ultrasound examinations with description and referral, most often from the genetics institute. And of course in such situations a patient submits a request for abortion, because this is done on her request, on her demand. (L)
Procedures in cases of pregnancy resulting from rape are less obvious for doctors. These cases are very rare, none of the doctors met with a woman wanting to have an abortion on these grounds. One of the doctors stated nevertheless, that in a hospital where he/she used to work they had a contrary situation a woman who gave birth to a child coming from rape.
Doctors are only aware, that in case of rape the opinion of the police/prosecutor's office is required.

Discrepancies in statements of doctors about procedures required for abortion result from lack of knowledge about the law and from different, not always lawful practices. Doctors, who during their practice did not come across terminations of pregnancy at work, are less confident while talking about procedures.
Nurses generally do not know the law. They admit that they didn't read it, they didn't read it all, they are not able to quote specific regulation, or that they don't know the Act that well. They conclude the regulations based on cases that they know, in which the lawful abortion has been conducted. One of them stated that pregnancy could be lawfully terminated - she knows because there was such a case. She doesn't know about genetic bases for termination because she hasn't come across it. Another nurse claimed that a certified genetic defect is the only reason for legal abortion. Woman's health is surely not a condition allowing for abortion, if women having cancer are giving birth to children. One of the nurses working in the clinic for women, based on observations of every day practice, concluded even that:

The nurses' knowledge about legal procedures in cases of lawful abortion is equally imprecise. One of nurses stated directly that she doesn't know such procedures, previously there were certificates from gynecologist required, from a specialist on a certain illnesses, psychologist, but now she doesn't know. Another nurse stated that she thinks that referral from a gynecologist is required, some examinations, or some professional board is examining the case, she doesn't know, there were no such cases. In the opinion of one of nurses, the formal procedure is unbelievably complicated and there has to be a commission. The gynecologist taking care of pregnancy:

There were such doctors, that did not say if they conduct abortions or not, other stated that they have never done it or that they do not do it at this at the moment.
None of the doctors interviewed stated that they perform abortions at the moment. Two persons admitted that it happened in the past.

The scale of a problem

All medical professionals say that the number of patients coming to them with unwanted pregnancy has decreased.

Doctors did not specify the time period of their comparisons. Do they mean in comparison to the sixties, eighties or to the period directly before introduction of restrictions in the abortion law (early nineties)? We can only suspect that they are thinking about longer perspective and earlier years. At the beginning of the nineties, the number of abortions conducted officially was not that big, comparing to previous years, as one of the doctors stressed.

Abortions in hospitals

The number of abortions in hospitals is decreasing significantly; both doctors and nurses confirmed this.

One of nurses noted with irony that the number of abortions would be even lower if abortions were illegal completely. All nurses said that the reason for dropping number of legal abortions in hospital is, among other things, the behavior of doctors themselves. Doctors did not mention this at all. Nurses nevertheless spoke of the reluctance of doctors towards issuing certificates directing a patient to have an abortion (delays, directing a patient from one doctor to another) and about smaller and smaller number of diseases, which, in doctors' opinion, constitute the reason for termination of pregnancy.
Nurses mentioned cases, where they personally witnessed or heard of seriously ill women - even if applying for an abortion - couldn't terminate the pregnancy and had to give birth to children.

One doctor and one nurse mentioned that in the past, pregnancies had been terminated because of genetic fetal defects; nowadays there are no such patients. One doctor says that they might be directed to other hospitals. According to a nurse, it is caused by the fact that earlier these services were allowed. Right now, in her opinion, such abortions cannot be performed in a hospital.

Cases of refusing abortion in hospitals are commonly known.
One of the doctors said that patients who have certificates entitling them to have an abortion, go from hospital to hospital and usually end up somewhere in the underground. Hospitals refuse conducting abortions even on the basis of genetic defects of a fetus.

One of the doctors presented it differently, the hospital waiting for patients. He works in a hospital to which after introduction of restrictions, no patients came wanting an abortion. There were abortions conducted in this hospital in time when the more liberal version of the law was binding, allowing for termination on social grounds. At the moment, according to a doctor, if there was a need - there will be doctors who would conduct an abortion. It is pointed, nevertheless, that a patient has to have "really good papers for it".
It is surely hard to explain such a situation: on the one hand women who are looking for a hospital in which they would be able to have an abortion, on the other, hospitals, where they could do it, but they don't come to them. The reason for such a situation is surely connected with inappropriate flow of information between medical professionals and the small interest shown in this problem by doctors themselves. Not all doctors know where to direct a patient.

Termination of pregnancy in private clinics, or the abortion underground

The abortion underground in Poland constitutes of doctors who conduct illegal abortions in private clinics.
The existence of the underground is widely known. There is also common conviction that having an abortion using the underground is relatively easy, the only issue being money.

Doctors and nurses stress the public knowledge about the abortion underground. They spoke of ads in press, in "życie Warszawy" and in "Gazeta Wyborcza"³⁶, in which gynecologists conducting illegal abortions offer their services. The content of such ads is ambiguous: "gynecological services…""full range of services," "services of all kinds" or "operations - cheaply". This phenomenon is common and public enough to treat every gynecologist as a one potentially conducting illegal abortions.

Information about where one can have an abortion is passed on by women themselves - patients know very well, who is doing what. A particular network is being created. Women who come to see a doctor in a situation of unwanted pregnancy are those who generally have no idea. One of nurses informed us about patients who come to hospitals informally.

Because the underground is publicly known and relatively widely accessible, women asked about abortions during medical interviews admit having them. One of the doctors stated that when asking about abortion, it is only to collect information if it was conducted professionally and if there were no complications after it. This information is relevant for the assessment of the state of health.

Different groups of women are clients of the abortion underground in Poland. The first, and probably the biggest, is those who want to terminate pregnancy on different social grounds. That is completely illegal by regulations standards.
Women who theoretically have the right to an abortion are also clients of the underground. Some of them do not want to go through the formal procedures required to conduct a legal abortion in a hospital. These women are afraid that the doctor to whom they turn, or a hospital, to which they would go, will refuse issuing a certificate and that formal procedures can take too long for a pregnancy to still being terminated. In cases of pregnancies resulting from rape, women may also not want to talk about what happened to them.
The abortion underground is also a solution for women who went through formal procedures, but were refused abortions. In this case, an abortion is "legal", although illegally conducted. This not a big group of women using underground services, nevertheless they are overt victims of binding restrictive regulations of the Anti-Abortion Act. Those women should have the guaranteed possibility of free of charge termination of pregnancy in good, safe conditions; this was stressed by one of doctors.
The abortion underground in Poland therefore plays a significant role. On the one hand, in practice, it allows for a wider realization of regulations concerning women who could terminate the pregnancy legally, but they have abortions using the underground services. On the other hand, for many women it limits restrictions imposed by the Act, allowing for terminations on social grounds.
The doctors and nurses interviewed did not express negative sentiments towards doctors who perform abortions; sometimes they even assess their activities in a positive manner. Only one doctor stated with some contempt, that adverts in press are being put by doctors who can't do anything else and are doing only this. (D)

Women's attempts at terminating pregnancies themselves

The doctors did not mention women's attempts to terminate pregnancies on their own. But all of the nurses working in hospitals spoke of these actual cases or of their suspicions that some patients could have been trying to terminate a pregnancy.
According to nurses, when women come to hospital bleeding with an incomplete abortion, the reason can be an unprofessionally conducted abortion or an attempt of self-induced abortion.
One of the nurses spoke of a patient who came to emergency room bleeding. In nurse's opinion, this woman was counting on abortion being continued. The ultrasound examination showed, however, that there was no miscarriage and the woman was given hormones to keep the pregnancy. The patient was visibly unsatisfied, and asked for release from a hospital.

According to nurses, women try to perform abortions by themselves when they were not successful with official termination, and they don't have the money to do it using the underground. There are stories around about prescriptions, home remedies for pregnancy.

It is intriguing that doctors do not mention abortion attempts by women themselves. Nurses working in a hospital, however, do. It may be that doctors do not treat "suspicions", even the justified ones, as facts, unless a woman admits what she has done, and this is why they don't talk about it. It may also be that - as it was said before - nurses are differently placed in a professional hierarchy and their perspective is different - they more often talk to patients on the informal basis and are able to get information, which is not accessible for doctors. Another explaining hypothesis would be the lack of knowledge of legal regulations among nurses - they may not know that illegal abortions should be reported to police and this is why they feel free to give such an information to a person who is conducting a research. (See also: Complications after abortion and abandonment of unwanted children).
Three nurses claimed that women are not afraid of medical staff. According to one of them, women know that we are obliged to keep that secret. (N)

General attitude towards the Act

Doctors, who were interviewed, show different attitudes towards the Act, from full acceptance to total negation.
Let four statements made by doctors to be an example of positive assessment.

Two doctors represented a totally negative attitude towards the Act. The reason for rejection of legal regulations in both cases was the recognition of the subjectivity of a person and of the right to free decision. Nor the state, or doctor, or the Church has the right to limit the right of every person to decide about one's life in a rigorous and restrictive way.

A completely different vision of a woman, a person than the one presented above, comes from a statement of a doctor who is pro Anti-Abortion Act. Summing up, in a general way the merits of the Act, he stated directly that not all women are so wise and responsible that they can make decisions in their own matters, and that those decisions have to be made by the state on their behalf. Those statements, in a very visible way, question the subjectivity of women.
The Act eliminated the possibility of abortion on request. People are different, and women are different. They are different, and not all of them, one has to say, are responsible and not all of them think about what are they doing. And because of that some decisions have to be, unfortunately, supervised by the state. (D
Nurses, as it was said before, are not familiar with exact legal regulations. Their assessment of the reality created by the Act, has a significant influence on their attitudes towards it. First of all, these are situations of women, who got pregnant when they didn't want to. From this perspective, according to all nurses, the Act is wrong. One of them said:

Other nurses said that the Act is not good in any aspect; it disregards the well being of women and deprives them of the possibilities of deciding about themselves and their lives.

Nurses, while talking about the Act, do not use political language, do not use notions such as: human rights, subjectification or objectification, but the sense of their statements is just like that. They define the Act as anti-women, because in their daily practice they see the suffering and tragedies of women, which are caused by regulations of the Act.

This is not the way; it is a matter of contraception and pro-family policy

Two doctors were wholly against the Act. They thought that limiting the right to decide about abortion would not limit the number of conducted terminations. According to one's opinion, the total ban on abortion would only influence the number of terminations conducted outside hospitals, and this means more infertile women, more looking for psychiatric assistance, more complications connected with inflammations, and more extra-uterine pregnancies.
Both doctors saw that the way to limit abortions is better sexual education and wider accessibility of contraception.

Both doctors - opponents of the Act - recognized abortion as something immoral, both said that they don't conduct abortions, both stressed that there are no women who would like to have an abortion.

One of the nurses also stated that doctors in her professional environment were very critical of the restrictive law and said, "this is not the way". For this to work, there has to be some education first, then contraception, then, finally, a restrictive law. (D) The nurses shared the same view.

The Act itself and more

Some doctors, who were not such determined opponents to the Act, also stated that the ban on abortion is not enough to limit the number of abortions. For women to give birth to children, the restrictive Act has to be accompanied by positive social policy, supporting having children. Children cannot be a burden exclusively to parents.

Some doctors said that one the condition for limiting abortion is promotion of family planning and effective contraception. This element of the policy, despite being included in the Act, is not executed at all. There is no education in schools. There are negative opinions of effective contraception; the Church is against it.

The Church's negative approach towards contraception results in reluctant attitudes in certain groups of women, and internal conflict for some doctors.

It is very hard to say that promotion of effective contraception is present in Poland, not only the Church, but also some doctors oppose it.

Irrespective of their general attitude towards the Act, doctors and nurses talked about its merits and shortcomings. Only one doctor did not see any bad sides of regulations and two doctors and one nurse stated that there was nothing good about the law.

The increase of interest in family planning, and the decrease in the number of abortions

The opinion that the Act influenced women's attitudes towards contraception and abortion is quite common:

Considering the fact that abortion is still widely accessible through the abortion underground, it is hard to recognize the restrictive law as a factor (or at least the only factor) influencing the change in women's awareness in issues of family planning. A doctor, who supported the theory on Anti-Abortion Act influencing the increase in the use of contraception, when asked by a researcher if that means that previously (before the introduction of the Act) women did not use contraception, answered:

Not all doctors connect the lower number of abortions with restrictive regulations. In one's opinion, the lower number of abortions is not a result of restrictions, but of the introduction of more contraception to the market and an increasing awareness of the society - also of a many years' discussion about the defining conditions for lawful abortions. Not the fear from compulsory maternity, but being aware that it is better to prevent than to terminate, caused the decrease in numbers of unwanted pregnancies in Poland.

A nurse also shared this view - there are fewer abortions, because of contraception promotion, and more variety (less harmful): oral contraception, vaginal contraception, and diaphragms. Women started to think about prevention.

During one of the interviews, it was concluded that the decrease in number of abortions should not be connected to the introduction of the restrictive regulations at all. This connection is only superficial.

If it is not really known, how many abortions were conducted before the introduction of the Act and after that (legal and illegal) and how many women use contraception and what contraception, this theory that the restrictions resulted in fewer abortions, sounds unbelievable, stated a doctor who does not see any good to the regulations.

There is no reliable data about the number of abortions conducted in Poland, and for as long as the law is present, there will not be. It is possible that during the nineties there has been no significant change. Nevertheless, if we take a longer perspective, correlation about increasing use of contraception and decreasing number of abortions is justified, at least in relation to those, which are officially conducted in hospitals.
Let's put together opinions and facts presented:

• There is no statistically reliable data on the number of abortions in Poland.
• The comparison of statistics concerning legal termination of pregnancies from the beginning of the nineties and today does not show a significant decrease in number of abortions; this decrease happened earlier.
• Despite the restrictions, illegal abortion is relatively widely accessible.
• In the last ten years one can observe significant improvement in quality and accessibility of contraception.

It should also be added that the public's criticism of the abortion law in effect since 1956 started as early as the 1980s.
Based on the improvement of family planning awareness during the nineties accompanied by the constantly decreasing birth rate, it would be more apt to discuss abortion regulations over a long period of time. The improvement of quality and accessibility of contraception is also very important here. Last but not least, difficulties with conducting abortions are also important: the high cost of abortion while using the underground services and difficulties in exercising the right to lawful abortion (refusals). Those difficulties existed already a few years before the introduction of the law; they also existed during the short moment during which it was more liberal.
Surely there is a number of other social factors which were and still do influence the opinions of Polish society about family planning and abortion. One can mention the policy of the state, burdening women and families with costs of supporting children, or the campaigns promoting responsible and safe sex in connection with the prevention of HIV/AIDS. It does not seem justifiable to connect growing awareness with the abortion law itself, and one should treat it as a significant simplification of thinking.

Post-abortion complications and abandonment of unwanted children

Frequent post-abortion complications are one of the negative effects of the Act, as a result of the growing number of abortions conducted outside hospitals. More cases of children from unwanted pregnancies, abandoned by their mothers in hospitals, is also a negative result.
Only one doctor met directly with a woman having post-abortion complications (after an abortion conducted abroad). She came to a hospital with a high fever claiming that she had had an operation. Doctors suspected she had conducted the abortion herself, but she consequently and with determination denied it.
Another doctor did not personally come across post-abortion complications, but he had heard of such cases - bleeding, inflammations. He admitted, that these were very rare. He thinks that in such cases women admit having an abortion, because they have no choice, they are scared, but I think they are mainly concerned about their health.

Women can be concerned not only about their health. Cases of illegal abortions should be reported to the police.

The majority of doctors did not come across post-abortion complications resulting from the use of underground services.

One of the doctors explains this fact with the high quality of operations performed by professionals. There are also anti-inflammatory antibiotics. Experiences of doctors, who took part in the survey, do not show increasing numbers of post-abortion complications in the period since restrictive regulations have been in effect.
Nurses talking about cases of post-abortion complications, nevertheless, draw a completely different picture. Even a nurse working in a clinic for women in a district health center met with such a case a few years ago. All nurses working in hospitals admit that there are cases of patients coming after having an abortion.
One nurse spoke of a patient, who was in a "bad state" when she decided to come to a hospital. She did not admit having an abortion, but it was easy to figure it out. She had a perforated uterus. Another nurse mentioned a case when a woman was admitted to the hospital after having a botched abortion abroad.
"Sometimes there are cases of post-abortion complications," says one nurse. They are admitted to hospital for observation and a uterine check-up.

There are also other reasons for such situations. According to one nurse many women come to emergency room bleeding after operations starting the abortion.

If there are patients in a ward suspected of having complications after abortion, the topic is taboo.

Similar to attempts of self-induced abortion, also is the case of post-abortion complications; the picture presented by doctors and by nurses is different. Reasons for doctors not talking about such complications are similar to those before: responsibility of doctors, obligation of reporting abortions to the police, not treating "suspicions" as facts. (See also: Attempts of women to terminate pregnancy on their own)
Only one doctor mentioned the growing number of cases of abandonment of children as a negative effect of the Act.

Another doctor spoke of infanticide, but did not connect it directly with the Anti-Abortion Act.

Other benefits and shortcomings

Two doctors stated that the right to refuse conducting an abortion based on the clause of conscience is the largest benefit of the abortion Act (mistakenly connecting the right to refusal, included in the Medical Profession Act, with the Anti-Abortion Act). When the Act of 1956 was in effect, doctors working in public hospitals were obliged to conduct abortions. For some of them it was a large problem.

For the second doctor this situation was also unacceptable, because, as he said: you do not become a doctor to perform abortions (…) it was hard to agree to do such things. (D) This decision, for many years, was made by the director of the hospital, who came and said, "today you will perform abortions." The fact that a doctor now can choose if she/he wants or doesn't want to perform abortions is seen as right. Doctors, for whom abortion constitutes a moral problem, should not be forced to terminate pregnancies.

• The Act makes the work easier - a benefit

In the opinion of one doctor, the restrictive Anti-Abortion Act makes work much easier. When abortion was legal, a doctor was obliged to talk with women. He/she at least had to present the negative effects of abortion. Moreover, if being an opponent of termination of pregnancy, the doctor was nevertheless forced to listen to what motives brought a woman to her decision. Doctors made efforts to convince women otherwise, showing good sides of having a child in her situation. Surely every decision made by a woman to terminate pregnancy, was hurtful. In a recent legal situation, the work is much easier. Doctors don't have to take part in these talks, causing large psycho-moral relief.

These persistent talks are over for me. At the moment, when a legal regulation is as it is, I don't have to justify anything. I just tell a patient that some things are not allowed by the law and I have this off my head. (D)

• The Anti-Abortion Act is too restrictive - a shortcoming

The nurses and some doctors claimed that the Act in its recent form is too restrictive and should allow for termination of pregnancy in other situations, that it should allow for abortion on social grounds.
One of the doctors stated that the Act was too restrictive not only for women, but also for doctors. A doctor should not be punished by imprisonment for conducting an abortion.

A doctor is responsible for terminating a pregnancy and can go to prison. In my opinion this is the basic shortcoming of the Act. A doctor should not be held responsible for a woman getting pregnant. (D)

• The Act is ineffective: it allows one group of doctors to profit - a shortcoming

"Women have abortions anyway, the Act is ineffective," said one doctor. Having an abortion using the services of the underground is not a problem for women, so the goals of legal regulations (limiting abortions) were not achieved. The introduction of the Act only caused an unjustified increase in incomes of one group of doctors, who conduct illegal abortions and take a lot of money for it.

I have no idea, what the abortion underground looks like; I don't know how many patients come there. But this is another thing wrong about the Act, because this is just the way of making people richer, because they take a lot of money for doing it. (D)

• The Act treats people unequally - a shortcoming

The Act affects mainly poor people. Poor women do not have the money for abortions, therefore they more often give birth to children. Supporting another child additionally lowers the home budget, which is not large anyway. Women, who are well off, can afford evading the law and have abortions underground - even if they could afford having a child.

A person is nobody without money. If one has money, one has access to everything, even to abortion. (N)
The Act concerns only the poorest women; maybe there should be some public thinking about support. The State wants more Poles, doesn't it? - If yes, it should support them. (D)
One can observe frequent cases of extreme poverty in pregnant women. (N)

• The Act endangers women's lives and health - a shortcoming

Doctors are convinced that if a woman is determined to terminate a pregnancy, she will do anything to have an abortion. These women cannot be convinced to have the baby - doctors say. They are so determined, they say: I don't want to, that's it. They are so desperate. One doctor described it:

If she really doesn't want this pregnancy, she will terminate it. She won't be able to afford going to a private clinic, to this, let's say, underground in Poland, because it's expensive, she also won't be able to afford going somewhere, somewhere where it is cheaper, to Belarus or Ukraine, or wherever else, so she will decide to do it herself, try to do it using her own methods. And now there is a question what she is going to do. She can do it so she will hurt herself for the rest of her life, or she will loose her life. These are very rare cases, but this Act provokes these things … well it may provoke, because there is a chance for it. (D)

One has to add that it is not only a chance for such cases to happen, they are happening; nurses confirm this.

• The Act is stricter in practice than it is on paper - a shortcoming

Women are refused lawful abortions in cases of serious illnesses, which endanger women's lives; statements from nurses confirm this. Complicated procedures cause women, even if they can legally have an abortion, to have it illegally. Procedures allowing women to terminate pregnancy, as mentioned before, are not well known to nurses or doctors. Even more so, they are not known to women. (See: Knowledge about conditions for termination of pregnancy and in effect procedures)

There are certain procedures in the situation of pregnancies resulting from rape. There must be an investigation and women are ashamed and embarrassed, so they usually have abortions in private clinics. (N)

There are also women who go through the necessary procedures, but have abortions using underground services, despite having the right to a safe, legal abortion in a hospital. Both doctors and nurses confirmed the fact that women are refused abortions in hospitals.

• The Act is anti-women - a shortcoming

The Act is not enough for women, nurses say. It does not take women's problems and their opinions into account. Legislators treat women as bags that carry babies, not even taking their health into consideration.

Everything we do concerns ethics. (D) - noted one doctor. Abortion is not different. The termination of pregnancy is very important. It is impossible to escape ethical and moral considerations about abortion.

All doctors agree that abortion is immoral, unethical, and that it is evil.
Negative assessment of an abortion is not an absolute; it does not result in negative opinions of every situation in which a doctor or a woman terminates a pregnancy. After a general statement of negative opinions about abortion, all doctors add "but…" which includes many very diverse concerns and doubts.

Supporting this statement, this doctor also argued that abortion is not the only unethical thing people do. Every day we commit acts which are not ethical: lies, causing unpleasantness, or, he added jokingly, killing mosquitoes.
Working in the medical profession, one meets with morally questionable events every day. Patients' lives and health are not always appropriately protected, according to recent possibilities given by medical science, especially in a situation of the Polish health care system, which for many years now has been chronically under-funded.

Values play a significant role in the resolution of moral doubts. Morally doubtful choices in medicine do not concern, as the above statement shows, only the health and life of a patient. The value of health and life, theoretically most important in medicine, are very often set-aside in practice, because financial values seem to have priority.
In social life, in the culture we live in, human life is generally a relative value.

The moral dogmatism that every termination of pregnancy is absolute evil was not accepted by any of the doctors. The doctors interviewed called for reflective morality in relation to abortion. Despite not having any doubts about abortion being immoral, they do allow situations in which abortion is justified.
For all of them, a threat to the life or health of a mother is such a justification.

The attitude of reflective morality encourages consideration of the problem from different points of view and acceptance of different opinions. It can be clearly seen in the above quoted statement. Talking about pregnancies resulting from rape, another doctor, a supporter of state control over women's actions, also accepted different points of assessment of abortion. He said that a child is not guilty of anything, but on the other hand, it is inhuman to force a woman to give birth to a child when she was raped.
One of the doctors touched on the lack of considerations of abortion from the ethical point of view, both during medical school, as well as in a public debate. Current discussions mostly present catholic, dogmatic point of view, which gives subjectivity only to a child.

The statement made by a doctor who accepts the rule of causing as little harm as possible, can serve as a conclusion on the moral assessment of abortion.

Allowing for more than one moral assessment of situations connected to abortion has something in common with the moral acceptance of the abortion underground. None of the interviewed doctors, irrespective of their own opinions about the Anti-Abortion Act and opinions about situations in which abortion is justified, assessed the abortion underground as something morally inappropriate.
Nurses were not able to consider abortion in moral categories, as doctors did. One of them agreed that yes, it is an ethical problem, because "it is a human life", but she did not go any deeper.
Another identified "moral assessment" with taking the dogmatic position: abortion is evil, always and everywhere. She contradicted it with the "medical approach", which is a reflexive opinion about abortion.

Again, two other nurses said that there are people, who consider abortion in moral categories (evil, not good, inappropriate), but there are also those, who do not connect any moral questions with abortion; they leave it outside the sphere of good and bad.

Nurses had problems considering the moral aspect of abortion in general. Their statements on this were short, and lacked depth. While interviewed, they continually referred to assessments of individual cases. Two nurses stated that it is hard to negatively appraise decisions of women, who want to terminate pregnancy or have done that, because really it cannot be known how one would act in such a situation. One of them said that when she was younger she used to think that it is better to give birth than to terminate. Now that she is older, and has a family and a child, she stays away from generalizations.

Debate on the Act - social pressure

Doctors have their own opinions about current anti-abortion regulations, they have their own thoughts; none of them, however, took part in the debate.
Why?
Because nobody asked them, nobody wanted their opinion, and besides:

Nurses also stayed out of the public debate for the same reason.
Doctors, even if asked, would prefer not to make statements in the debate. One of them does not believe in the effectiveness of taking part, another is not personally interested in this aspect of the matter.

Not everyone, nevertheless, was so inoffensive, so passive, and so ambivalent to the debate. There was one doctor who would give his opinion if asked:

Only one doctor shared a view that gynecologists, as being most often connected to the practical realization of the regulations, should have taken part in the debate on the shape of legal regulations on conditions for termination of pregnancy.
Reluctance towards stating opinions in a public forum results not only from doubt that it will be heard. Doctors being critical towards the Act are afraid of attacks by people taking the opinion of the Church as the right one.

Some doctors talk about social pressure, or even about the hunt for doctors who terminate pregnancies. This pressure, in their opinion, comes from the Church, mass media, and even some part of the medical world. It is strong enough for some doctors to be afraid of being even suspected performing abortions.

Doctors call upon actual cases, which stuck in their memory. One of them spoke of the case of a doctor from ¸ódê, who on a fervent request from a woman terminated the pregnancy in a private clinic. The pressure from journalists, and the medical environment connected to the Church caused a doctor to commit a suicide. To prove his statements about the pressure from groups connected to Church, another doctor recalled the known case of a well-known gynecologist from ¸ódê, Dr. Waclaw Dec. This doctor made public statements about a woman's right to an abortion. He said, that in his ward there are, and there will be, pregnancies terminated if a woman is in need. The doctor died in a car accident. The Church, for his "abortion actions" and public statements against the Act, denied him the right to catholic burial. This case shook and divided the public opinion and medical professional groups.

The Act divides the professional environment

One of the doctors presented a very negative description of the gynecological professional group. It shows, that gynecologists cannot really make statements about the law, because the opinions are very much divided. Working out a common position is also not possible because of the hypocrisy present in these groups. Some doctors publicly say what should be said, that they support the regulations, and are against abortion. Their practice is sometimes far from what they declare.

Considering the social, religious, and political pressure put on doctors, one cannot be surprised that only this part of doctors who have a generally positive attitude towards the Act (D) take part in public discussion.
Statements of interviewed doctors show that there are groups of gynecologists, who have negative opinions about the Act. One doctor believes that if those doctors took part in the discussion,

Another doctor, being critical of the Act, stated that the majority of doctors in his professional environment think as he does. He stressed, however, that it is a specific group, connected with science and didactic.
One nurse claims that she met with negative opinion in her professional group.

Both in public, as well as in the professional environment, this discussion has calmed down.

The professional groups are not interested, because everyone does what they want anyway.

Some form of adjustment to conditions set up by the Act appeared among gynecologists. Differences in opinions do not cause conflicts. There is a group of doctors, gynecologists, who live very well thanks to it. (D) Everyone is doing their thing and on their own account.
A significant portion of the doctors is convinced that there is no solidarity among gynecologists. They talk about the envy, which precludes professional solidarity.
If anyone can talk about solidarity among doctors, it only relates to solidarity of doctors working in this same hospital.

Nurses said that, at the moment, there are no discussions about the Act among them; there are no conflicts among personnel, caused by the functioning of the new Anti-Abortion Act. One nurse thinks that the attitude of the professional environment towards abortion is becoming more positive.

Other nurses claim that the Act did not change opinions about abortion itself.

A doctor's work in the conditions set up by the Act

The legal restrictions on lawful termination of pregnancy cause situations, which from the legal and moral perspective can cause objections. One of these situations is the refusal to conduct a lawful abortion in a hospital and conducting it for money in a private clinic. Interviewed doctors had not come across this situation.
One of the doctors talked about the practice common in small towns of refusing abortion in a hospital and sending patients to private clinics. It cannot be stated with absolute certainty what cases he had in mind: if doctors refuse abortions to women who present referrals, or to women who come to a hospital with no referral to have an abortion on social grounds, what at the moment in not legally allowed.

Some doctors said that they heard about cases of refusals of lawful abortions in hospitals and conducting them for money in private clinics. No doctor, even those who had not directly heard about it, had doubts that such cases may be happening.

Doctors' opinions on this phenomenon varied. For some, they were unmentionable. One of the doctors defined it as meanness, not different from other meanness in this world; people meet with various mean thing. (D)
Another doctor justified these unethical actions with the financial situation in which the whole professional group is finding itself at the moment.

Doctors better knew the situation of refusing legally justified abortions. Those interviewed gave two reasons for such refusals.
One of the doctors mentioned the situation in his hospital. After the right for refusal on the basis of clause of conscience came into force, the head of a hospital called a meeting of employees and asked, which doctors would conduct abortions and which refuse to take such operations because of values and beliefs. None of the employees wanted to conduct abortions. The head of the hospital ordered that a sign be placed on the door, stating that abortions were not conducted in this particular hospital. This doctor had a very negative opinion of a woman, who issued a complaint to supervisors of the hospital because of this refusal. The information on the door caused a lot of trouble, and the head of a hospital was dismissed.
The second situation, in which abortions are refused, was described in these words:

In this case, the hospital's director and his personal views decided about not conducting abortions. Doctors, irrespective of their own views, act according to the boss' orders. They do not always realize the full implications of this, that refusing abortions sometimes puts life or health of a woman in danger, acting against basic rules of medicine.

This decision is influenced not only by the views of the hospital's director, but also by the style of management. In some hospitals an atmosphere of pressure is created so that doctors do not terminate pregnancies. Doctors, who have different opinions, are afraid to state their views; they do not want to be seen as unethical, because they act against an unborn life (it is forgotten that actions can be also taken against woman's life, what is equally unethical). This situation is surely one of the reasons for the fore mentioned "double morality" among doctors. Doctors refuse in a hospital, but they don't refuse doing it in private clinics for money… some of them. (D)
There are also other places - hospitals where diversity of views on abortion is allowed. In these hospitals doctors declare being ready to perform abortions. Those who agreed to conduct abortions were able to do it with no fear of colleagues or managers assessing their actions as immoral or unethical - at least publicly.

What doctors know about each other

Not all doctors know where to direct a patient to have an abortion. One of the doctors said that it is more or less known where abortions are conducted, and where abortions are refused, and because of that one can direct a patient to the appropriate hospital. Another said that women, his patients, wander from hospital to hospital and are refused lawful abortions.
There are also different situations when it comes to abortions in private clinics. One can conclude from doctors' statements that some of them would be able to recommend a doctor who performs abortions - I tell them that there is a possibility and there is no problem. (D) The practice of sending patients to another doctors, described by one of the interviewed doctors, proves that some doctors know who is conducting abortions in private clinics.

Another doctor said:

The fact that doctors do not know where abortions are performed results not only from hypocrisy and mendacity in the environment, but also from the anxieties of doctors, who terminate pregnancies. They fear the law and other doctors: their professional reputations.

There are groups in which, to avoid uncomfortable situations, tensions, and irritations, the topic of abortion is taboo.

The research disclosed one more reason for doctors not knowing what is happening in their profession; it is the attitude of excluding oneself from a problem. Doctors opposing abortion on social grounds take this attitude. One of the doctors said that the clause of conscience allowed him to take a negative position, as he described it himself, that means staying outside of it and stating: I do not do these things and I don't even want to have an opinion on them. (D) In cases of unwanted pregnancies, he helps women by giving them addresses of organizations that help pregnant women.

We would now like to focus on the attitude of medical personnel towards women: to their rights, and in particular - to their right to an abortion.

A woman's right to decide about her pregnancy

All doctors think that in some circumstances a woman should have the right to an abortion. Irrespective of their attitude towards the current law, doctors named situations that, in their opinions, justify abortion.
Doctors agree that in a situation when pregnancy endangers the health or life of a woman, there should be the possibility of abortion. It has to be stressed, that the collected material does not specify the illnesses that are seen as life or health threatening by doctors.
Finding serious fetal defects is a principally unquestionable circumstance in which a woman should have a right to terminate her pregnancy. However, one of the doctors, as previously mentioned, was hesitant to state if Downs Syndrome constituted a significant problem because he knows mothers who have children with Down syndrome and they love them very much. (D) At the same time another doctor, giving women in any case a right to decide what will happen with pregnancy, acknowledged abortion of fetus with genetic defects as an issue which is morally problematic.
Cases of pregnancies resulting from rape did not cause significant doubts; all doctors agreed that in such a case, a woman should have the right to terminate her pregnancy. One of the doctors was skeptical, however, claiming that this reason was more controversial, although one should consider that forcing a woman to carry a child, when a pregnancy is a result of criminal act-- is inhuman… although a child is not guilty… a child is a new human being… (D)
Other situations, where, according to the doctors, women should have the right to a legal abortion:

• when a woman is mentally disturbed,
• when a woman already has a lot of children (five, six) and she gets pregnant again,
• when all contraception used by a woman fails,
• when a woman is single, has one child already, and gets pregnant again,
• when a woman really doesn't want to have a child. One doctor stated: "At the moment contraception is widely accessible, so the only exception, a really exceptional indication should be when a woman is really determined to not have a child, she will not change her mind, she doesn't want to... and that's it." (D)

While assessing the situation, morality clearly drives the opinion: is it right, morally correct, to terminate pregnancy when… Thinking of it this way encourages saying "no," because everyone acknowledges abortion as something morally evil. On the other hand, taking the perspective of a woman who found herself in a certain situation encourages saying "yes, I understand that in this situation she wants to terminate the pregnancy and that she should have such a possibility."

In doctor's opinion, this woman should have a possibility to terminate pregnancy based on her difficult financial situation; because she is a normal woman, and he understands her. Maybe considering this situation from a point of view of morality (life vs. material conditions), would lead a doctor to different conclusions.
When it comes to a woman's right to decide, one of the doctors stated that not all women are responsible enough, so that this matter could be left in their hands, and it is necessary that the state control women's actions.
Two doctors opposed the law in general, because, in their opinion, the decision about pregnancy belongs to a woman. The other one, who did not disagree with the law in principal, also mentioned women's rights and said:

Yet another doctor, a supporter of making the abortion less accessible, did not specifically mention the concept of "rights," but, at the same time, referred to the notion of "free choice." When describing situations in which women should have a right to terminate pregnancy, he said:

It seems from the doctors' statements that the relations between situations justifying abortion, a woman's right to decide, and an attitude towards the Act, are not convergent. Definite statements against the Act do not mean one is pro-abortion. It is, nevertheless, an acknowledgment of women's rights.
Nurses, who were asked to list situations in which, in their opinion, abortion is justified, frequently spoke of pregnant women being ill. They often met with cases where pregnancies which should have been terminated were not for numerous reasons. Such cases included women suffering from: cancers, epilepsy, mental illness, heart diseases, diabetes, kidney diseases.

Other situations justifying abortion mentioned by nurses, are:

• rape,
• fetal genetic defects,
• medical interviews indicating that there are children with defects in a family,
• the woman being a minor (not responsible enough),
• an elderly woman (higher probability of fetus's defects),
• when a woman, not knowing she was pregnant, worked in harmful conditions (exposed to radiation, etc.),
• when a woman, not knowing she was pregnant, took medications which could cause fetal defects,
• when a woman lives in difficult conditions and has a lot of children,
• when a woman finds herself in a difficult financial situation, or when her husband is an alcoholic,
• when a woman herself is an alcoholic or drug user.

Nurses' statements show, that while assessing if a woman should have the right to an abortion in certain situations, they pay much attention to assessing if the woman will be able to be a "good mother" for a child. If, because of financial situation, family situation, her own addictions or young age, taking care of a child would be hard or impossible for her, she should have the right to terminate a pregnancy.
Nurses working in hospital wards acknowledge the right of a woman to decide about pregnancy in every situation. They say: It is only and exclusively a woman's business. (N), there could be (a law), where women could decide for themselves (N), a woman should decide for herself (N).
Nurses, who declared themselves as Catholic, do not condemn abortion.

Women who have abortions

Women ask for abortions for the following reasons:

• the pregnancy is an extra-marital pregnancy and a woman doesn't want to become involved with a father of a child;

I think that this is not the right man, sexual intimacy is one thing, but the possibility of being with this man for a lifetime is another issue. (D)

• the pregnancy is an extra-marital pregnancy, resulting from a short-term affair;
• the family has a difficult financial situation;
• married partners already have one child, or a couple of children, and at the moment they don't want to have another one;
• the woman has different plans for life. (Two doctors stated that pregnancies are more often terminated by women who are better off and these, who want to have professional carriers);

Poor women have more children, rich women have more abortions. They justify this with not wanting a pregnancy because they want to pursue a career, because they work, because they want to further their personal development. (D)
Those who choose abortion are most often: people who have professional carriers, who are well off, between 30 and 40 years of age, already have two children, their childhood dreams came true, and when another pregnancy happens, they are paralyzed completely, they cannot imagine the future. (D)

• women don't use contraception or do it sporadically;

The majority of women who get pregnant, simply do not use protection. They either did not use any method, or sporadically used some chemical methods. (D)
Sometimes it is a young woman who only started to try and got pregnant. (D)

• cases of contraceptive failure - a woman forgot to take a pill, a condom broke during an intercourse, etc.;
• women persuaded by their husbands;

A husband tries to talk a woman into it, harasses her, "oh, you are going to have another child, and what for? Go and have an abortion" and maybe she would like to have this baby. (D)

• a woman goes through menopause;

We know of cases where a woman thinks she will not get pregnant, because she is over 40. (D)

Women usually terminate pregnancies after discussing it with the family (D), although it also happens that they come in secret.
Doctors listed numerous reasons and situations in which women terminate pregnancies. They show that pregnancies are terminated by women who are young and old; those who are pregnant with extra-marital children or are married; those who don't have children, and who already have enough children; poor, fighting financial difficulties, and rich; those who didn't use contraception or those who did, but the contraception failed. In other words, there are various situations, which make women terminate pregnancies. Sometimes they do that in secret and sometimes under family pressure.

Doctors' attitudes towards women who terminate pregnancies

Doctors are deeply convinced that a woman, who definitely doesn't want to have a child, will have an abortion, despite legal regulations. There can be a law making it easier or harder. If she really doesn't want this child, she will have abortion. Even with the current law, women, according to doctors, do not have problems terminating unwanted pregnancies.
During talks with women, doctors are able to assess if a woman is determined to have an abortion or if she still hasn't made a decision and has doubts. They know which woman can be convinced otherwise and who, for sure, cannot be convinced.
Other criteria used by doctors for describing women, is their attitudes towards pregnancy. From this point of view, some women treat pregnancy and abortion "lightly", for others, abortion is a "big ordeal." A woman's attitude towards pregnancy influences the doctor's opinion about her.

Women, who treat pregnancy and abortion "lightly," invoke irritation, antipathy and contempt. They are described as "too reckless", etc.

One of the doctors talked about single cases, where women came to have an abortion very late and one could see that they didn't treat the pregnancy seriously. In such cases, some doctors would try to postpone the abortion, so a patient crossed the time limit allowing for abortion.
Women, who not only take abortion very badly, but who also have reasons, which aren't morally doubtful, evoke the most compassion and understanding in doctors. When a woman wants to have an abortion because of genetic fetal defects or when a pregnancy results from rape, doctors not only terminate it with no problems, but also:

Nurses do not agree with the opinion that in legally permitted circumstances doctors terminate pregnancies with no problems and suffer along with their patients. In their opinion, doctors tend to send a patient from one doctor to another, they show reluctance towards issuing certificates for official abortions. They are afraid to terminate pregnancies in hospitals and postpone them for so long that even in obvious situations abortions are not being conducted. Nurses give examples of cases when women should have had an abortion (e.g. for medical reasons) and hadn't. (See: Termination of pregnancies in hospitals) Even in a case of brain cancer, doctors postponed the procedure.

According to one nurse, such a situation where obstacles were created - demanding new certificates and statements, making legal abortion less accessible for women, postponing the decision until the time limit passed - was also common during the temporary liberalization of the law (between 1996 and 1997).

One doctor and one nurse said that doctors are afraid to issue a referral for abortion and to conduct abortions in hospitals. They are not sure if they will be accused of breaking the law, because, on the one hand, it is common knowledge when abortion is permitted, but, on the other, the law can be interpreted in different ways. One of the doctors stated that in his hospital someone would surely conduct abortion if a woman had the appropriate certificates, but she would have to have really good papers.

Relations between doctors and women

Women who visit doctors because of unwanted pregnancy are treated by different doctors in different ways.
One doctor said that when the law allowed for abortions, he tried to explain all the side effects of termination, show positive aspects of having a child, and influence her decision, convince her not to terminate. When the restrictive law came into effect, he stopped having talks like these. He limited his role to explaining the law, which didn't allow for abortion on social grounds.

On the contrary, another doctor, first of all, tries to talk. He feels that in this way he is able to support a woman, help her make a decision. He calls these talks "therapeutic" and considers them to be an important part of a doctor's service.

One doctor stressed that there should be some rules as to the way these consultations should proceed. He also said that it would be good if doctors in Poland were trained for such conversations. Such training is currently unavailable.

Some doctors stressed the importance of talks with a woman wanting to terminate pregnancy. It is nevertheless hard to judge, to what extent they act according to these standards in their clinics.

Judging from the doctors' recommendations, we can infer that supportive consultations, allowing women to calmly assess the situation, and making the decision easier, are at present very rare. Doctors admit that.

According to one doctor, when it comes to advice, the situation is even worse than it used to be. It used to be that a doctor told a patient about harmful effects of abortion. At the moment, this is not the case.

Women facing unwanted pregnancies have very difficult decisions to make. It is important that they are free from stress and pressure. One doctor spoke of the psychological consequences of abortion, which he came across during his practice. He calls them " post-abortion psychological complications".

It is easy to foster restrictive attitudes based on this feeling of guilt. Demonstrations lead by older women in front of the Parliament can be treated as some kind of penance for their sins, granting forgiveness. Such behavior can be described as egoistic, which does not take into account potential harmful results to others, and as immoral.

Nurses working in hospital wards praised the doctors they worked with. They said that doctors treated patients well and that if a doctor in an emergency room was against abortion, he called his colleague, who had a talk with the woman. Doctors do not judge patients, they do not show any negative emotions, they know that women have problems, that things happen, they understand it is hard for women, etc.
Nurses are convinced, nevertheless, that there are different doctors and that they have different attitudes towards pregnant women. There are also those who will not inform a patient about the possibility of genetic testing if she is concerned about pregnancy. Some doctors will talk to a patient, try to calm her down, advise something. Another doctor might just say: it is not allowed, and that's it.
All those interviewed said that women, who come to have an abortion, need to talk. Most often they are left alone with the problem. Their situation: bad living conditions, no husband, no job, pressure from a partner or a family; all of these push women to terminate unwanted pregnancies. This is when they come to see a doctor. Only in this place, where there is the actual possibility of an abortion, do their fears come out, anxieties, pressure form others, doubts. Neither doctors nor nurses are competent and trained for such talks. Representatives of the medical profession deal with such talks as well as they can with what they have to offer: intuition, experience and one's own conscience. This situation is comfortable neither for women nor for doctors. One gynecologist mentioned the need for training. For others these are those annoying talks with patients. (D) This problem could be solved by creating centers offering psychological assistance to women who plan to have an abortion or have had one in the past. These could be organized by different organizations, associations, and foundations.

The place of nurses and midwives

Nurses and midwives are ranked lower then doctors in a professional hierarchy. They are mute witnesses of events taking place in hospitals; they observe doctors, their work, female patients. Even if they suspect something, know something, they don't go deeper, they don't say anything, don't comment. (See: Attempts to terminate pregnancies by women themselves and post-abortion complications). They don't have the possibility to undertake actions, their role remains passive.

Midwives understand women's problems. One of them stated that if she only could, she would actively help women with unwanted pregnancies.

The attitude of midwives towards women with complications after professional and unprofessional abortions is, as they say themselves, positive. They don't make judgments, they don't show any negative emotions, and they don't even let them see that they know about their problem. In the opinion of midwives, women who come to hospitals because of abortion-related complications, made difficult choices in tough situations. They had a problem, this is how it ended; they faced the consequences of their actions (complications and fear). Two midwives stressed that they don't know how they would behave in the same situation.

A nurse or a midwife can talk to a woman, calm her down, advise something. It is a very important task, when a patient comes to a doctor shaky, shocked that she got pregnant when she didn't want to, or that she is in a hospital, full of anxieties about her health and what will happen if it doesn't work out. These talks can help a woman solve her problems. They can give her advice on family planning.

A women's right to a lawful abortion and refusals in hospitals

Doctors know or have heard of cases where women were refused abortions in hospitals in situations when according to the Act they had the right to terminate pregnancy. Some doctors, nevertheless, do not see this as a problem.

Two doctors had a different opinion in this matter, they think that a refusal to conduct an abortion in a hospital is a problem. For one doctor, such behavior constitutes an ethical problem. The hospital, where a director refuses abortions, very often endangers the health or life of a woman. It acts against the rules of professional ethics, which commands to protect health and life of every person.
The second doctor considered refusals from a legal perspective. He gave a drastic example of a woman, who was wandering from hospital to hospital, with full medical documentation and a referral for termination of pregnancy, consistently meeting with refusals. She could not find a clinic to perform her abortion, even though she had the right to it. This woman didn't have a choice, she had to have an abortion underground.

When a woman has the legal right to an abortion, she should not be forced by institutions, which are established for exercising this right, to break the law and turn to the underground.
Nurses mentioned many examples of doctors prolonging formal procedures and refusing to perform abortions. In the opinion of one of them, doctors who act in this way, do not see a woman and her problems, they fail to realize what the refusal means to her.

A woman's possibilities to demand her right

Only one of the doctors surveyed thinks that a woman can exercise her right to abortion in practice.

Other doctors definitely do not see possibilities for women to exercise their rights. A doctor can refuse to conduct termination, and a woman cannot claim that she has the right to have abortion in this hospital, because patients are no longer registered in district centers.

Nurses also don't see the possibility of exercising one's right to abortion. One of them said that the National (Gynecology and Obstetrics) Consultant is theoretically obliged to refer to (a hospital) which will conduct this operation (N), but she also added that such case would certainly take so long that even if the Consultant referred to a hospital, it would be too late to terminate pregnancy.

Women's anxieties

As a matter of fact, being pregnant in itself, irrespective of it being planned or not, is connected with enormous stress. If the pregnancy is unwanted, it is a shock.
Doctors and nurses listed the following reasons for stress, anxieties and fears of women with unwanted pregnancies:

• the necessity of making a difficult decision (D, N)

When they come, they are lost, they cry, because they don't feel that they can deal with it.(D)
It strikes suddenly, and she doesn't have financial means, living conditions or whatever, it is a shock for her, she doesn't know what to do about it. (N)

• stress connected with circumstances in which she got pregnant (rape) (D)

It is inhuman to force a woman to carry a pregnancy, which resulted from a criminal act. (D)

• stress caused by a health condition of a child - defects (D)
• fears connected with the termination of pregnancy itself (D)

When a woman really decides for an abortion, it is surely very stressful for her. (…) It is a serious operation, and a woman doesn't want to, doesn't like to have such things done to her. (D)

• anxieties caused by not knowing if she will be able to find a hospital in which abortions are performed (D, N)

When a woman decides for an abortion, it usually means the beginning of a drama for her. She has to look for a gynecological ward, which will help her terminate this pregnancy. (…) Every gynecological ward, every director might refuse to conduct such an operation. Then she wanders all around Poland, looking for possibilities of termination, and usually she ends up in some abortion underground or goes to Czech Republic, Slovakia or Belarus. (D)

• being afraid of persons close to them, who can be against terminating a pregnancy (D, N)

They can be afraid of their partners, who can have different opinion about it, or their families, or their colleagues, who might find out that she was pregnant and is not pregnant anymore. (D)

• fearing post-abortion complications and being afraid of people, who can report an abortion to the police (D, N)

She had the right to be afraid, because the truth is that if we have a definite illegal abortion, we have to report it to the prosecutor's office, because it is a crime. (D)
They are afraid of being dragged to court, of being charged. (N)

• anxieties about the state of their health if complications occur

Sometimes, they experience anxiety, whether the uterus was not injured. (N)
A woman with perforated uterus was worried about her health; so was her family. (N)

According to one doctor, women are afraid to say that they had an abortion, they admit of doing so only when they are sure that this information won't be used against them, they admit it during private medical interviews.

Analysis of the collected material allows to presume that women may also be afraid of contacts with a doctor: will she be treated with sympathy; will her problems be understood; will she be sent away with nothing, because a doctor is against abortion; will he qualify her state of health as bad enough, so she should can be referred to have an abortion. Fears from lack of understanding, humiliation, difficulties of formal procedures make women conduct an informal inquiry: they come here, secretly ask nurses or midwives, that they may be this or that … and how it is here. (N)
A lot of women, who could try to have a lawful abortion, decide immediately to terminate pregnancy in a private clinic.

Women in cities and women in the country

While discussing the differences in possibilities for abortion for women in cities and women living in rural areas, doctors presented two totally different opinions.
According to the first opinion, women from rural areas use modern methods of contraception less often, and this is why they have more unwanted pregnancies. Nevertheless, it is easier for these women to terminate pregnancy, than it is for women living in cities. The community is smaller, everyone knows everything about everybody, and this allows for working out some official and unofficial procedures of dealing with these problems. This mutual offering of services in small communities began during years of economical crisis in the 80s. In the period of serious deficiencies and rationing it was easier to live in small towns. It was well known where to go to get things or arrange something, while people in large towns and cities could only count on good luck or getting services and goods by chance. According to one doctor, similar informal procedures were created to deal with unwanted pregnancies. Women living in rural areas do not have to worry about unwanted pregnancy; they know who to turn to and how much it will cost. Those who offer such services know financial possibilities of women and operations are cheaper, the price is adjusted to the possibilities of a community.

The second theory sees rural areas as highly religious communities of very strong social control, with negative attitudes towards abortion. For social, moral, and religious reasons, women in rural areas do not want to terminate their pregnancies that often, and when they do, it is more difficult.