The Lived Experience of Teen Girls’ Abortion in Taiwan

In-depth interviews about the experience after having an abortion were conducted with 20 teenage girls in Taiwan. Six themes emerged by using Colaizzi’s phenomenological methodology: (a) returning to “normal” life as soon as possible, (b) seeking abortion resources, (c) neglecting post-abortion care, (d) disturbed by the fetus ghost, (e) concern about virginity loss and choices for future, and (f) re-examining relationships with partners. Teenage girls received tremendous social and moral pressure due to their traditional cultural and social environment when they went through the abortion experience. The study helps health professionals understand the experience of those girls.


Introduction
Unwanted pregnancy during adolescence remains a crisis in many countries around the world (Aruda, 2011) and is as serious in Taiwan as anywhere else. The abortion rate for unmarried teens in Taiwan is about 4.8% (Ministry of the Inferior, Department of Household Registration Affairs, 2011). A deluge of unwanted pregnancies arising each September following summer vacation contributes to Taiwan's having the worst adolescent abortion rate in Asia (Singh & Darroch, 2000;Wu, 2004). Abortion is a preferred option among pregnant young women internationally, and approximately half of teenage pregnancies end in abortion (Hoggart & Phillips, 2011, Kjelsvik & Gjengedal, 2011Kuo et al., 2010). It is estimated that 90,000 to 130,000 aborted fetuses were due to teen pregnancy in Taiwan each year (Collison, 2011). Few studies have examined the experience of Taiwanese women who undergo abortions. In a society influenced by traditional Taiwanese culture, discussion of the experiences of adolescents with abortion is limited. Doctors and nurses tend to consider abortion as minor surgery and neglect the unique impact and stress of abortion on the adolescent (Gesteira, Diniz, & de Oliveira, 2008; B. U. Lee & Yang, 2000, 2002.

Background
Teenage girls are placed in a more complicated situation compared with adults when deciding to abort their child. Reasons for terminating an unwanted pregnancy are as follows: (a) fear of parents' reaction and shame, (b) inability to provide child care due to financial constraints, (c) attending school or too young, (d) not ready for motherhood, and (e) rejection from boyfriends while pregnant (Al-Sahab, Heifetz, Tamim, Bohr, & Connolly, 2012;Fergusson, Oden, & Horwood, 2007;Sedgh et al., 2006). Two Swedish studies revealed that teenagers accepted abortion as an appropriate option for them to end an unintended pregnancy. However, those teenagers experienced mixed feelings toward the abortion (Ekstrand, Larsson, Von Essen, & Tyden, 2005;Halldén, Christensson, & Olsson, 2005). Allanson (2007) mentioned that although most women experienced a feeling of relief and improved emotional well-being, some women experienced emotional difficulties following an abortion. Ambivalence and complexity in the abortion decision are common, which may result in a sense of guilt, loss, grief, anger, regret, and depression after abortion (Cappiello, Beal, & Simmonds, 2011;Kjelsvik & Gjengedal, 2011;Weitz, Moore, Gordon, & Adler, 2008). Furthermore, adolescent girls were afraid of being blamed by others for their pregnancy and did not want to discuss their decision but preferred information and immediate referral (Kumar, Baraitser, Morton, & Massil, 2004). They had received formal education on sexual health, but very few of them had used the knowledge when having sex (Acharya, Bhattarai, Poobalan, Teijlingen, & Chapman, 2010;Centers for Disease Control and Prevention, 2011;Kalyanwala, Zavier, Jejeebhov, & Kumar, 2010). Their knowledge on abortion and related laws was inadequate for them to make informed decisions, and most felt alone, confused, ashamed, and guilty about their situation (Pedrosa & Garcia, 2000). However, other studies have revealed no relationship between abortion and adverse outcomes, such as depression, anxiety, and low self-esteem (Schmiege & Russo, 2005;Steinberg & Russo, 2008).
One study showed that most adolescent girls were physically, to some degree, malnourished and did not rest after abortion, which may result in anemia and urinary tract infections (Molatlhegi, 2007). There is no doubt that a young woman with an unintended pregnancy sacrifices the protective effect of a term delivery should she decide to abort and delay childbearing (Thorp, Hartmann, & Shadigian, 2003).
Abortion law (the Eugenics and Health Care Act) was legalized in Taiwan in 1984, and a woman can request an induced abortion if she believes that the pregnancy will adversely affect the psychological or physical health of her or her family life (Collison, 2011). However, those younger than 18 years old need their parents' or guardian's consent. The debate between pro-life and pro-choice has never been an issue in Taiwan. The law has been accepted by the general public and religious parties, mainly because of the stigma associated with unwed motherhood and lack of an adequate adoption system (Collison, 2011). A survey (Chong, 2000) reported that nearly half of teenagers in Taiwan said they would consider abortion when unintended pregnancy occurs although they perceived abortion as a crime or a sin. A pregnant teenager generally has four options in Taiwan: getting married, adoption, abortion, or being a single mother. However, if a teen chooses to be a single mother, little support and help from society are provided for her.
Many countries expect women to maintain their virginity until marriage (Essizoğlu, Yasan, Yildirim, Gurgen, & Ozkan, 2011;Wang & Ho, 2011). Having sex before marriage is considered shameful; those who engage in premarital sex often suffer mental anguish. Taiwanese people believe that the chastity of women is an important determinant of family honor. Such "honor" under certain circumstances may represent self-esteem, a guarantee that preserves one's personal morals. Some women do request virginity restoration before marriage (Essén, Blomkvist, Helström, & Johnsdotter, 2010). In traditional Taiwanese culture and social values, pregnancy out of wedlock is an unacceptable, dishonorable, unspeakable issue for the family (The Garden of Hope Foundation, 2001;Hung, 2010;Tau, 1995). For this reason, pregnant teenagers do not seek support from family members or inform parents of the truth, but rather follow advice from friends and obtain information from the media. Moreover, they have the abortion completed in illegal clinics, resulting in potential physical and psychological trauma (Hung, 2010;Yu, 2012). To relieve the guilt after abortion, some teenagers visited temples to appease the so-called "foetus ghost" (Buchan, 2008, p. 17). A fetus ghost means a miscarried or aborted fetus that has not been named by its parents (Moskowitz, 2001). Instead of being named and buried by its own parents, the miscarried or aborted fetus will be handled by the abortion clinic as medical waste in Taiwan. Because the fetus is not carefully buried and blessed, it cannot go to heaven or the next life. So, it is thought that they have hatred for their parents and siblings and will take revenge on them (Hibino, 2005;Kuan, 2006;Wilson, 2009).

Purpose
Our study purpose was to explore the lived experience of unmarried teenage girls in Taiwan after having an abortion. Lived experience refers to experiences of the world of everyday life (Streubert & Carpenter, 2011). Schutz (1970) explained that the world of everyday life is the "total sphere of experiences of an individual which is circumscribed by the objects, persons, and events encountered in the pursuit of the pragmatic objectives of living" (p. 320). Colaizzi's (1978) phenomenological method was used to examine the experiences of unmarried adolescents who underwent abortion. This methodology matches our study purpose. Phenomenological methods area is used to explore certain life experiences and describe the structure and essence of these phenomena (Streubert & Carpenter, 2011). Colaizzi (1978) stated that life experiences are shaped by the individual's interaction with other persons and/or the environment. To understand any phenomenon, life experiences must be analyzed. The method is appropriate for this study because little is known about this experience and it made possible an exploration of adolescent women's experience of abortion, with regard to themselves, their family, and society.

Method
The research team has strong background in conducting qualitative research. T.Y.L. has expertise in teen pregnancy and research methodology, and she has been principal investigator on many qualitative research studies, two of which were recently published in well-known journals (T. Y. Lee, Kurtz Landy, et al., 2014;T. Y. Lee, Li, & Liaw, 2014). She also teaches qualitative research courses at the graduate level at a university in Canada. T.Y.L. provided mentorship to the rest of the research team in interview techniques and data analysis procedures. Co-investigators C.C.C., C.M.C., and Y.C.L. obtained their PhD in nursing and are knowledgeable about phenomenological research. M.H.W. brought expertise in teen pregnancy and is familiar with the steps in conducting qualitative research. In phenomenological research, the researchers often bring their perspectives, experiences, values, beliefs, and identity to the data collection and analysis process. To reduce potential biases, the researchers maintained a non-judgmental attitude and were open to new ideas.

Participants
Purposive sampling was used. Eligible participants were firsttime pregnant women under 20 years of age. Twenty women who had undergone abortion at hospitals or gynecological clinics in Taipei, Taiwan agreed to participate in the study. The ages of the participants ranged from 14 to 19 years (M = 17.8). Seven had a junior high school diploma, and 13 were still in high school. Only one participant was employed. Four participants were Buddhists, and one was Christian. The rest did not claim a specific religious affiliation. The gestational ages of their pregnancy ranged between 4 and 12 weeks at the time of the abortion. Fourteen underwent dilation and curettage (D & C), and six took Mifepristone (RU-486).

Ethical Considerations
The study was approved by the institutional review board of a medical center, two local hospitals, and three gynecological clinics. Confidentiality was assured to each participant by use of a code number on interview transcripts. Participants were informed of their right to withdraw from the study at any time. Written consent was obtained after explaining the study protocol to the participants and their guardian if the participants were younger than 18 years old.

Data Collection
C.C.C. contacted participants and described the study purpose and procedure to them face-to-face. Contact with participants began on completion of hospital or clinic registration. A basic data questionnaire was filled out by the consenting participants. Interpersonal trust was established by accompanying a participant through the entire surgical and therapeutic process. One week after abortion, an in-depth, one-on-one interview using open-ended questions was conducted by the second author and digitally recorded. Each interview started with the following question: "What is your experience after having an abortion?" Explorative questions such as "How?" "What are your feelings about that?" or "Could you please give me an example?" were used to encourage participants to provide thorough and comprehensive descriptions. The interview was terminated when no new data were surfaced. The interview took approximately 60 to 90 min. Participants chose a convenient and comfortable location for the interview. The study was completed in 2009.

Data Analysis
The interviewed data were transcribed verbatim from audiotape into written Chinese (the language in which the data were collected), and the transcripts were analyzed using Colaizzi's (1978) six-step phenomenological method. The six steps are as follows: (a) Read participants' descriptions of the experiences to acquire a sense of the whole, (b) reconstruct the content into significant statements, (c) extract significant statements, (d) form themes from the significant statements, (e) integrate results so as to make a portrait of the facts, and (f) construct the essence of the phenomena (Colaizzi, 1978).
The five authors individually read all of the interview data. Then, they worked together to analyze and verify the accuracy of the formulated meanings and emerging themes.
If disagreement occurred, data were reanalyzed until consensus was reached. NVIVO 10 software was used to organize and analyze the data.

Rigor
The trustworthiness of the research was established according to its credibility, transferability, confirmability, and dependability (Streubert & Carpenter, 2011). Credibility of the data was ensured by using thick description of adolescent girls' experience of having an abortion and all participants reviewed the results to validate that they truly captured the essence of their experience. Dependability is confirmed in conjunction with credibility (Streubert & Carpenter, 2011). Transferability was promoted by knowledge transfer including publishing the findings of the study and presenting the findings at a variety of occasions, so the potential users can read and utilize them (Lincoln & Guba, 1985). To facilitate confirmability, an audit trail should be left, which documents the activities over time so that others can follow the research (Streubert & Carpenter, 2011). In this study, research notes and memos were kept to ensure the confirmability.

Results
The essential structure of the teenage girls' experience after having an abortion was synthesized as follows: When the participants realized that they were pregnant they sought abortion resources by asking friends and classmates, as well as searching for information from the Internet. They were afraid and under stress, and the first notion that came to mind was to have an abortion for a variety of reasons. In particular, they wanted to return to their regular lifestyle as soon as possible. After abortion, they felt guilt and were disturbed by the fetus ghost. They went to a temple to pray for the dead fetus and obtained comfort by doing this. They resumed their routine activities quickly without concern for after-abortion care. However, they worried about the loss of virginity and future options of marriage. They re-examined their relationship with their partner and decided to protect themselves from possible pregnancies by having control over their contraceptive use.
Six themes were extracted that capture the essential structure of the teenage girls' lived experience: (a) returning to "normal" life as soon as possible, (b) seeking abortion resources, (c) neglecting post-abortion care, (d) disturbed by the fetus ghost, (e) concern about virginity loss and choices for future, and (f) re-examining relationships with partners. These themes are elaborated below.

Returning to "Normal" Life as Soon as Possible
Participants were surprised and afraid when the pregnancy was confirmed. Most of them desired to solve the problem as quickly as possible. They thought abortion would be the right choice for them because they were still in school, too young to be married, and not ready for being a mother. Many believed that if they had a child, their plans for the future would be interrupted. They would have to drop out of school to take care of their own child. Most importantly, they were afraid of their parents' reaction because they expected their parents would be very angry and may exile them out of the family. They were also afraid of other people's point of view on their pregnancy. Having an abortion became a necessity in their current situation. They believed that abortion could reduce the impact of pregnancy on them and their life could return to the pre-pregnant state. They discussed possible options with their significant others: sisters, friends, or partner, but not parents. Their hope was focused on returning to "normal" as soon as possible. One of the teenagers stated, "I was terrified. How could this happen? I was frightened and stupefied at first, but my next reaction was to get an abortion." Another teenager mentioned, "I could not go to school like this. It made me look ugly and made all activities inconvenient. What would people think of me seeing me in this condition?" A third teenager described her feeling toward imagining having her baby as follows: I felt sick and wondered about the consequences of having a child. Gradually, the idea became strong and made me feel even physically uncomfortable. Things bothered me, like I would have to take care of my baby all by myself and I could no longer act in the way I used to.
As indicated above, participants experienced a range of emotions after the pregnancy was confirmed. They felt panic when they pictured future life with a pregnancy or a child. They made their own decision about the abortion after considering the possible hardship of continuing the pregnancy.

Seeking Abortion Resources
Participants had received sex education from their schoolteachers and had knowledge of contraceptives; however, most of them asked friends for advice instead of consulting teachers, medical professionals, or parents. They worried about the accessibility of reliable abortion services. Some of them checked the Internet to find a "good" clinic because they were afraid of the potential risks and complications. Although medical or surgical abortion is a simple and safe procedure nowadays, they had read many tragic stories regarding illegal or unsafe abortions from the media reports. Examples mentioned were pelvic inflammatory disease and uterine perforation after undergoing illegal abortion, undiscovered ectopic pregnancy, or the long-term effects of infertility. They felt nervous about the upcoming operation, especially the severe pain accompanying medical abortion. They described having sleep difficulties and said they cried often at night.
They were also worried about the possible medical expense involved in the abortion. For a pregnancy under 12 weeks, the cost is about NT$5,000 to NT$12,000 (US$167-US$400). If the pregnancy is over 12 weeks, the price is much higher. Three participants informed their family of the pregnancy and obtained financial support from grandmothers or sisters. Ten shared their concerns with their partner and asked for emotional and financial support. The rest had to use their own savings or borrow money from their friends due to refusal by their boyfriends. One participant said, When I found out that I was pregnant, I called my boyfriend directly and told him to prepare money for the abortion. I worried about how to find a good hospital. I did not want to hurt myself. I cried hard and told myself not to be hurt.
Abortion is a complicated and difficult decision for most participants, not to mention the possible negative outcomes afterward. Participants carefully chose a creditable abortion clinic to have the abortion done. However, due to inexperience and limited resources, they underwent great physical and psychological stress before the abortion. Lack of financial support meant that participants had to delay their abortion to obtain enough money needed and hence increased the risks to physical health.

Neglecting Post-Abortion Care
An information sheet that described what to expect and do after an abortion was given to the participants. Although participants were anxious about the potential complications before abortion, they did not take good care of their body after abortion. Most participants experienced vaginal spotting, abdominal cramping, or slightly elevated temperature. They took some vitamins, antibiotics, and drank lots of fluid by their physician's order, but they did not have a motivation to receive the Taiwanese traditional post-abortion care. They had heard older people or their mother say that post-abortion care is very important for recovery from abortion and should be similar to postpartum care. For example, women need to constrain their activities, not wash their hair or body, and eat nutritious food. All these Taiwanese traditional rituals were viewed as tedious or impossible by the participants. Because most parents were not informed of their child's pregnancy and abortion, it was impossible for participants staying home to have any specific care. They usually went back to school the next day after abortion to avoid revealing their secret to others. A characteristic description of this feeling was as follows: "I went back to school the next day. I didn't want my classmates or teachers to be suspicious about my absence. I didn't want people to talk about something behind me." Some of the participants did rest a few days after abortion, but they were intolerant of the bed rest. For example, one participant said that "Lying in bed for 3 days I felt that my bones had fallen apart."

Disturbed by the Fetus Ghost (Yingling)
Some participants were afraid that the spirit of the fetus (fetus ghost) would harm them. The Taiwanese believe that at the moment when a life is created (fertilization of an egg), a spirit will approach the fertilized egg. When a pregnancy is ended by abortion, the physical part of the fetus is removed from the mother's body, but the spirit of the fetus still lives in the mother's body. Because the fetus is removed by force, it will take revenge and haunt the woman or her family. After participants saw the fetus through ultrasound images, this reinforced their belief that a fetus is a human being and an abortion is a murder. These feelings translated into guilt when abortion was performed. They felt relief at having chosen abortion; at the same time, they were frightened by the supernatural threat. They were plagued by chilling dreams and hoped to break the debilitating paranormal curse. One teenager reflected that a keeper at the temple told me that he once met a girl who had an abortion at 3 months' gestation. The Yingling did not leave her alone, and the girl's family was repeatedly involved in car accidents. I was afraid that the Yingling would also wrong me like that and come back to harm me.
Another participant said, "I went to a temple and did a service there. I hope my child will go to heaven or be reborn to a family who needs a child." To appease the fetus ghost, this participant consulted a Feng Shui specialist and a fetus ghost pacification service was provided in the temple. She prayed for the fetus ghost and hoped it could impregnate another woman and leave her body.

Concern About Virginity Loss and Choices for Future
Participants were worried about people's opinion of them no longer being a virgin. Taiwanese cultural traditions place special value and significance on virginity, especially in the case of unmarried females. Maintaining chastity before marriage is a very important notion of honor and worth. As a result, participants were afraid of possible gossip after their abortion. Because having sex only after marriage is what they have learned from school and family, and having abortion is evidence of losing one's virginity and beginning a sexual relationship. Participants expressed that they did not plan to marry their present boyfriend and worried about the impact of the abortion on their choices for future marriage because men would like to marry a virgin. A characteristic statement was as follows: "When boys say they don't care, it's just superficial. Actually, they do care." Also, "What would happen in the future if I meet someone I love? How could I explain to him what happened in the past?" Prior to the abortion, participants said they had not thought carefully about what it meant to lose their virginity and having a sexual relationship before marriage. However, after abortion, they had more concerns about the consequences of this in terms of social status, the moral issue, and with regard to interpersonal relationships.

Re-Examining Relationships With Partners
After having an abortion, participants said they understood that there is a price to pay for unprotected intercourse. They felt they should not concede to their own and their partner's sexual desire. They indicated they were knowledgeable about the precautions to take, but it was too embarrassing for them to access contraceptive services because of their unmarried status. They were also afraid of side effects of some contraceptives, and so, using condoms was their only option. However, they did not use condoms consistently because of their partner's refusal. One description of this view was as follows: "I am afraid he will trick me again and not use a condom! I think that if I decide to have sex again, at least I must know how to protect myself, it's better to use contraception." Participants did not want to have an unintended pregnancy in the future and realized that having safe sex is very important, but they still worried about their partner's attitude toward using contraceptives. The abortion experience made participants realize the lack of responsibility of their partner because half of the participants had the abortion without being accompanied by their partner. Thirteen had already separated with their partner before the interview. They also expressed that their partner, if present, lacked concern about their plights and lacked comprehension about how to deal with the situation. Furthermore, it made them aware of the fact that love is not as perfect as it seems but needs to withstand tests and trials. Some participants mentioned that they were left alone to make the decision and went through the whole process with little support from their partner. They had decided not to depend on men and thought they should focus on themselves instead. A description of this common feeling follows: My boyfriend was not willing to make a decision with me; I had to decide by myself. He was there (during the abortion procedure), but he didn't know how to help. He couldn't understand what my feelings were. Those few days I was really miserable, so it's obvious that I do not need a boyfriend to get on with my life. By the way, I think I was too kind to my boyfriend. Now, I don't think I can be like that anymore. I see it all very clearly now. I will focus on my studies.

Discussion
The results of this study enrich knowledge and understanding of unmarried teenage girls' abortion experiences in Taiwan. Six themes were extracted: (a) returning to "normal" life as soon as possible, (b) seeking abortion resources, (c) neglecting post-abortion care, (d) disturbed by the fetus ghost, (e) concern about virginity loss and choices for future, and (f) re-examining relationships with partners. These findings support the teenagers' abortion experiences described in earlier Western studies (Ekstrand et al., 2005;Halldén et al., 2005;Kumar et al., 2004). Social and moral pressure found in this study is similar to findings in South Asia (Acharya et al., 2010) and India (Kalyanwala et al., 2010). However, teenagers in this study described two unique experiences as indicated within the themes concerning the fetus ghost and loss of virginity. Few studies of teenage abortion have mentioned these phenomena, which are likely inked to cultural differences.
The guilt feeling experienced by the participants in this study after having abortion was described by many other studies (Allanson, 2007;Weitz et al., 2008). However, the participants in this study experienced additional stress. The traditional myth of the fetus ghost deeply affected their feelings toward the unborn baby. According to Taiwanese tradition, the aborted fetus experiences great pain and is adherent to the mother's physical body and causes harm to her. A study done in Hong Kong also mentioned this self-blame post-abortion feeling and fetus ghost revenge (Hung, 2010). A ceremony done by a Taoist priest to appease the fetus ghost can alleviate the stress and guilt women often feel after having abortion. It also provides comfort to young women who may be too frightened to tell their parents or too shy to seek assistance from professional counselors. The physical and mental problems caused by fetus ghosts are relieved after the ceremony (Buchan, 2008). In Japan, the Buddhists also perform a similar ceremony named "mizuko kuyo" to memorialize lost fetuses (Hibino, 2005;Wilson, 2009). A Japanese study conducted by Hibino (2005) explored the spirituality of women who had undergone induced abortion. Women who participated in the Mizuko Kuyo ritual reported that abortion created crisis in their relationships with their partners. Therefore, their partners' support and participation in the mizuko kuyo ritual were both important to them. The women were empowered by their faith in the fetuses' spirits.
The issue of a haunting fetus has rarely been reported by Western studies. This difference in experiences can be attributed to the cultural differences and the use of counseling services in Western countries. To Taiwanese people, going to a temple is a kind of counseling because most Taiwanese do not usually use professional counseling services (Collison, 2011). A recent study done by Wilson (2009) reported that mizuko kuyo has gradually come to America, where it has been appropriated by non-Buddhists as well as Buddhist practitioners. However, the meaning and purpose of the ritual have changed greatly in the American context. In Japan, mizuko kuyo is performed to placate the potentially dangerous spirit of the angry fetus. In America, it has come to be seen as a way for the mother to mourn and receive solace for her loss. Further studies need to be done to explore the different meanings of the ritual of mizuko kuyo in different countries.
Concern about virginity loss is another unique theme experienced by the participants in this study. Although Taiwan is modernized and influenced by Western cultures, sexual double standards still prevail in Taiwanese social structure. Men emphasize female virginity as an important criterion when considering marriage; however, they are eager for premarital sex with their virgin girlfriends (Wang & Ho, 2011). A study done in Turkey (Essizoğlu et al., 2011) echoed the double standard in the value of virginity, showing that more male students (76.7%) than females (11.1%) viewed female virginity as a significantly important issue in a marriage. No statistical data were provided, but "hymen repair surgery" was frequently reported by media in Taiwan. No wonder the participants in this study were worried about the effect of their losing virginity on possible future marriage. Surgery to restore virginity might be a solution for those women (Essén et al., 2010), but it involves social, legal, and ethical issues. Further research is needed before making any suggestion to Taiwanese adolescents who are concerned about virginity loss.
Apart from the two unique themes described above, the present study also revealed similarities with findings from previous studies. This study indicates that getting life back to normal is imperative for Taiwanese adolescents who undergo abortion. All the participants in this study had completed their abortion within the first trimester, which was consistent with the finding of an Indian study (Kalyanwala et al., 2010) that most (75%) of the unmarried young women received an abortion in the first trimester. This experience differs from that of adult women who wrestled with abortion decisions for 3 to 10 days after learning they were pregnant (B. U. Lee & Yang, 2000). One possible explanation might be that teenagers have more pressure from peer, school, family, and social norms than mature women regarding having a baby before marriage, so they will make the decisions for abortion promptly to return to their usual lifestyle (Fergusson et al., 2007). Accordingly, some participants in this study resumed their daily activities the day after surgery, including going back to school. Taiwanese women believe that post-abortion care should be the same as postpartum care of a term delivery to preserve future fertility and good health; however, postabortion care was widely overlooked by those participants. They stated that they felt fine after abortion and did not see the need to access post-abortion care. Sometimes, it was difficult for them to obtain a parental signed request for leaving from school, as most did not mention the procedure to their parents. Health professionals' attitude toward abortion is another reason why participants were reluctant to do followup care because some of the professionals perceived abortion as a crime and a sin (Gesteira et al., 2008). Post-abortion care is very important in reproductive health care (Cappiello et al., 2011). Further education on health care after abortion is needed.
Research from previous studies has shown the role of family members in decision making regarding teenage abortion (Halldén et al., 2005;Kalyanwala et al., 2010;Kjelsvik and Gjengedal, 2011). The mother is often the main person to consult with decisions for or against abortion for unmarried teenagers. However, in the current study, partners, friends, classmates, siblings, and grandmothers were the major persons these teenagers talked to. Two explanations might contribute to this finding. First, pregnancy before marriage has a stigma that is perceived to ruin a family's reputation in Taiwan (Hung, 2010;Yu, 2012). Second, a distant relationship existed between parents and teenagers. Participants in this study were afraid of possible punishments from parents, so they turned to siblings or grandparents for emotional or financial assistance, in addition to seeking help from partners, friends, and classmates.
Thirteen out of 20 participants had separated with their partners before the interview because most participants were dissatisfied with the attitudes and actions of their partners. Previous studies found that unmarried pregnant girls aged 13 to 18 cared about the views of their male partners, but few partners were willing to make an abortion decision with them (Kalyanwala et al., 2010;Kjelsvik & Gjengedal, 2011) or provide financial support because they had their own difficulties (Hung, 2010). Some of the participants in this study described their partners' non-supportive and nonunderstanding attitude about their thoughts and feelings. They also commented on their partners' failure in using contraception as the reason why they got pregnant. After introspection about their experience, they thought they should choose appropriate contraceptives and use them consistently to protect themselves from future pregnancy.
Although it is illegal in Taiwan for a girl under 18 years of age to get an abortion without parental or guardian's consent, some clinics do perform the procedure on those adolescents. In this study, three participants were under the age of 18 and their adult family members' consent was obtained. It is not our intention to discuss why those clinics went against the abortion law. However, an issue raised by this study is how abortion became a preferred method for adolescents to solve the problem of unwanted pregnancy in Taiwan. Several scholars (Collison, 2011) attributed the reason to the liberal abortion law and the ready availability of the abortion drug RU-486. They suggested that the government tighten the law and create an environment that facilitates adoption to encourage teenagers to continue their pregnancy.

Limitations and Suggestions
A major limitation of this study was the small sample size. Findings must therefore be interpreted with caution. All participants in this study underwent a legal abortion and the findings might not apply to those who have an illegal abortion. Furthermore, the ages of most participants in this study were above 18 years; the results might be different with those whose ages are much younger. Future studies using longterm follow-up to explore the effects of adolescent abortion are recommended. Inclusion of male partners in the investigation is also recommended to produce additional insights into teenagers' experiences.

Conclusion and Relevance to Clinical Practice
This qualitative study adds helpful insights into the experience of adolescent women undergoing abortion in Taiwan and helps health professionals understand the decisionmaking processes of those young women. More relevant sex education programs are needed to educate teenagers about the importance of safe sex. Such programs can also provide information on post-abortion care. A friendly and nonjudgmental abortion consultation center (Cappiello et al., 2011) or "talk line" resources specified for adolescents might be a good way to emphasize the importance of safe sex and post-abortion care in Taiwan or anywhere.
The development and refinement of appropriate web pages would also be helpful as young women frequently use the Internet to obtain sensitive information. The current web pages of professional medical organizations, schools, and health bureaus should be refined to provide useful and accurate information on sexuality and interpersonal relationships. Enhancement of these web pages would enable teenagers to obtain information anonymously.
This research showed that adolescent women experience tremendous social and moral pressure from the traditional Taiwanese social-cultural environment, which implies that nurses need to consider cultural diversity and assess spiritual needs when caring for patients who undergo an abortion. Nurses may provide a source of compassion for pregnant teenagers in a time of emotional difficulty. They can also provide resources and information as well as refer the adolescent to psychological counseling, while respecting the privacy and decision of each patient. In addition, hospitals should consider providing teenage girls and their partners with a convenient location where a ceremony for the aborted fetus can be held in a quiet environment, which may help to relieve the guilt after abortion.