Looking at pregnancy terminations from the opposite side: the perspective of healthcare professionals

Looking at pregnancy terminations from the opposite side: the perspective of healthcare professionals | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Looking at pregnancy terminations from the opposite side: the perspective of healthcare professionals Arzu Akpınar, Yasemin Turgut, Hatice Yangın This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3256516/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background It is already known that the woman and the family can be affected in various ways psychologically and physiologically during the termination of pregnancy, but the healthcare professionals who manage the process can also be affected while being effective on the process. We aimed to determine the opinions and experiences of the healthcare professionals regarding pregnancy terminations with this qualitative study. Methods A hermeneutic phenomenological design was used in this qualitative study. Data collection were obtained through face-to-face and individual in-depth interviews using a semi-structured interview guide between December 2018 - April 2019. The sample of the study consisted of 26 participants from different professions who have encountered pregnancy termination process. Results Data were grouped under two themes with seven three sub-themes. First theme about how health professionals were affected by the process has been defined as ''How are healthcare professionals affected during the termination process?''. Second theme about how they acted in the process has been defined as ''What do healthcare professionals do in the termination process?''. Conclusions As a result of our study, it was determined that health professionals working on pregnancy termination were adversely affected and had problems while giving care. In order to prevent adverse effects on healthcare professionals, some facilitator methods are needed to strengthen prevention strategies and facilitate the process for them. Experiences Healthcare Professionals Pregnancy Termination Qualitative Research Figures Figure 1 Background Termination of pregnancy is the process of terminating an existing pregnancy. It is a very traumatic and difficult process for the woman and the family, from the termination decision to the birth and beyond. While the grieving woman and her family experience emotional trauma, they have to overcome the pain and physical difficulties of childbirth [3; 5–7]. At the same time, healthcare professionals who care for women and their families may also be affected differently from this process. Previous studies in different countries [ 1 – 4 ] have shown that participating in pregnancy termination can have adverse effects on healthcare workers. Studies show that healthcare professionals often experience symptoms such as individual grief reactions, self-doubt, depression, and self-blame in cases of perinatal loss [1; 8; 9]. To cope with this situation, health professionals resort to coping methods such as suppressing silence and emotions, seeking support, keeping oneself out of the event, and using belief systems (10). When healthcare professionals who involved in the termination of pregnancy encounter negative experiences due to the emotional burden and the heavyweight of this process, and if they are inadequate in coping, it may reflect in health care. They may react to individuals such as inadequate or excessive care behavior, thus affecting health care. Sometimes, they may even think of quitting the profession due to this emotional weight [2–4; 11]. Depending on how healthcare professionals are affected by this experience, individuals' needs may not be fully met. Besides, although healthcare professionals can cope with these emotions by their environment and colleagues' support in the short term, they may endure severe depression and post-traumatic stress disorder in the long term [1; 4; 6; 11; 12]. It is crucial to support healthcare professionals who will be with the women and the family in health care during the termination process and to determine their experience to improve the approach to the individual’s experiencing termination. It is crucial to support healthcare professionals who will be with the women and the family in health care during the termination process and to determine their experience to improve the approach to the individual’s experiencing termination. We aimed to determine the opinions and experiences of the healthcare professionals regarding pregnancy terminations with this qualitative study. The data we obtained as a result of the study will form the basis for the creation of support programs that will facilitate healthcare professionals to cope with negative effects. Thus, it is aimed to raise the necessary awareness so that health professionals can provide quality and effective health services to women and their families in the termination process. Methods A hermeneutic phenomenological design was used in this qualitative study. Also, this study was reported using consolidated criteria for reporting qualitative research (COREQ) guidelines (Booth et al., 2014). Participants The sample of this study is 26 people work in the field of women's health in a university and a state hospital in A… (City’s name) and who at least once met women undergone pregnancy termination due to fetal anomaly. Participants consist of six Obstetrics / Gynecologist (Ob/Gyn) Assistants (A), five Ob/Gyn specialists, eight Ob/Gyn clinical nurses and seven midwifes. Participants who can speak, read, understand Turkish were included in this study. Data collection and analysis Data collection were obtained through face-to-face and individual in-depth interviews using a semi-structured interview guide. In this study, maximum diversity sampling, one of the purposeful sampling methods, was applied to determine whether health professionals from various professions participating in the termination process due to fetal anomaly possess common or different patterns concerning the termination process. The study was conducted between December 2018 - April 2019. The study's data were collected by an individual in-depth interview technique applying a “Personal Information Form” including age, gender, marital status and duration of experience at obstetric clinics and a “Semi-Structured Interview Form” ( Appendix 1 ) designed by the researchers. During the reassessments in the research process, a question was removed from this form. In addition to the form questions, drilling questions such as "Is there anything else you want to say about this topic?", "What did you feel?" "What did you think?" "Can you explain it more?" "How did .... affect?" were included during the interview to deepen the participant's responses [ 13 ]. Throughout the interview, the questions were asked in a logical sequence. The interviews lasted an average of 20 minutes. The interviews were held in a suitable and quiet environment in the hospitals where the participants worked and were recorded with a voice recorder. All interviews were conducted by same two researchers together. In this process, one of the researchers was the moderator, the other was the observer to increase data reliability, control the recorder and keep the field notes taken. Under the qualitative research nature, the data collection was ended when the data reached the saturation point and started to repeat [ 14 ]. Availability of Data and Materials The datasets generated and/or analysed during the current study are not publicly available due [because our data contains the personal information of our participants] but are available from the corresponding author on reasonable request. Data analysis All interviews were combined with field notes and were transcripted by the researchers. One hundred fifty pages of raw text were obtained from the interviews. The content analysis model of Graneheim and Lundman was applied in the analysis of these data [15]. Data analysis of the transcripts was accomplished by the process outlined below, which was based on Graneheim and Lundman’s techniques for extracting themes [15]: 1- The interviews were read through several times to obtain a sense of the whole. 2- A full text was created by combining the data in order to create analyzes aimed at determining the experiences of healthcare professionals regarding pregnancy terminations due to fetal anomalies. 3- The condensed meaning units were abstracted and labeled with a code. 4- The tentative categories were discussed by researchers and revised. 5- Finally, the underlying meaning, that is, the latent content of the categories, was formulated into a theme. Ethics Ethical approval was obtained from X University Faculty of Medicine Clinical Research Ethics Committee (approval number: X and date of approval: X). At the beginning of the interviews, the participants were given information about the aim, importance, duration, and confidentiality of the interviews. Their informed consent was obtained, and the names of the participants were kept confidential. While reporting the study, only the professional groups of the participants were shown with their initials in the findings section (A: Ob/Gyn Assistant Doctor, M: Midwife, N: Ob/Gyn Clinical Nurse, S: Ob/Gyn Specialist). Results Sociodemographic and professional features of participants are presented in Table 1. Table 1. Sociodemographic and Professional Features of Participants (n=26) Feature Age Mean=32,77 Range=21-52 Gender Female n=22 Male n=4 Marital Status Single n=12 Married n=14 Profession Ob/Gyn Assistant Doctor (A) n=6 Midwife (M) n=7 Ob/Gyn Clinical Nurse (N) n=8 Ob/Gyn Specialist (S) n=5 Duration of Professional Experience at Obstetric Clinics (Years) Mean=7,02 Range=0,3-20 The findings of our study consist of one core category, 2 themes and 7 sub-themes under these themes (Fig.). A. Core Category: The Perspective of Healthcare Professionals about Pregnancy Terminations We preferred to write the results of our study under a core category that includes both how health professionals are affected by the pregnancy termination process and how they behave in the process, because we have seen that these two themes have a structure that affects each other in the process. Depending on the behavior of health professionals, this process may be difficult or easier, and therefore how they are affected may change. 1. How are healthcare professionals affected during the termination process? This theme has been handled as four sub-themes in our study. 1. a. Experiences which increase empathy Many of the study participants stated that participating in this process by managing or observing the termination process enables them to empathize with the situation. Some argue that the gender of the health professional is effective in the creation of empathy. One of the participants, who is a midwife, expressed this situation as follows; “I am also a woman, I empathize with this case [termination of pregnancy] whether I want it or not. So, you think the same thing can happen to you, which is not something improbable, it can happen to anyone” (M). Some of the female participants, beyond empathy, stated that they were afraid that this situation might happen to them or someone around them, “I was always afraid during my pregnancy like if something bad happens, if we lose the baby” (M) and “you can be affected when you look at [the baby with anomaly]; if you are or one of your relatives is pregnant, you may think, if such a thing could happen” (N) expressed this fear with their statements. Although being a woman was associated with empathy in the study, male participants also agreed on empathy. One of the participants, a male assistant doctor, stated the importance of empathy in this process by saying, "empathy, most importantly, putting yourself in the family's shoes" (A). From the data obtained in the study, it was observed that healthcare professionals were able to understand the traumatic experience of the woman and the family who underwent pregnancy termination while empathizing with them during the termination process. Most of the participants stated that throughout this period, the woman and the family encountered two types of traumas due to their babies' loss while waiting to meet a live baby and the pain of labor during the termination process. They stated that they empathized while caring for the woman in the termination process and felt sorry for the family's traumatic experience. Participants stated their observations and experiences with the following expressions; “… Dreams of holding her child come with a psychological trauma when suddenly there is a decision to terminate while dreaming of giving birth. The second trauma is already happening in this painful period of giving birth.” (A) “… As a result of [this process] they will not encounter a living baby; it is a great traumatic situation.” (S) Some of the participants in the study stated that both the family and themselves were affected more emotionally throughout terminations at more advanced gestational ages; “… It is challenging in the advanced weeks, you feel sorry, you wish it didn't grow that big…” (N) “In the early pregnancies, at 8-9 weeks, you may not be affected that much, but sometimes we terminate a pregnancy in an advanced week, so it is a heavy burden for us as well.” (S) In our study, the participants stated the compassion fatigue that develops due to the stress they endured while caring for the individual suffering during the termination process; “… It takes more intellectual time than what you do. This job [termination] is tiring.” (N) “The emotional side of [termination] can also wear us down.” (M) 1.b. Feticide: Facilitator or difficulty? While some of the study participants perceived feticide as an application facilitating termination, some mentioned the difficulty of it. Participants who perceived feticide as a facilitator stated that when feticide is not made, the live-born fetus can sometimes be more traumatic by making a noise or moving for women, the family, and healthcare professionals. They find feticide facilitating because it creates the dilemma of whether or not to intervene in a live-born baby: “The biggest trauma of my assistantship was them [live fetal terminations]… Feticide should be made, trauma decreases when the baby is not alive.” (S) “… Since they do not perform a feticide, the baby may be born with a fetal heartbeat, we both terminate and try to revive, in this sense we are experiencing hard things.” (M) Participants who emphasized the difficulty of feticide, on the other hand, mentioned both the ethical and emotional dimensions of the procedure and the application's complexity. During the feticide procedure, one of the specialist doctors emphasizes the principle of non-harm, which is one of the ethical principles, and said, “It's [feticide] a challenging experience for us too since you're damaging something alive there.” (S). One nurse expressed an application difficulty she observed as follows; “We had a patient; two attempts were made to make feticide but both failed. Both the [practicing] doctor and the patient were distressed.” (N). 1.c. The impact of the individual characteristics of the healthcare professionals In our study, some participants stated that individual characteristics such as personality traits, period of personal professional experience, gender, occupational group, personal termination experience, and beliefs might affect health professionals' termination experience. In contrast, others stated that such characteristics do not affect the health care they provide during the termination process. In the study, it was concluded that health professionals' personality traits are effective in managing the termination process. According to the participants' general opinion, sensitive individuals are more affected, and it is harder for them to overcome the termination process, while those who are cool are less affected. Some of the participants stated their opinions as follows; “Individual characteristics, such as conscience, compassion are important ...” (S) “Not everyone can handle [the termination process]; we also see those who sit and cry. The most important thing is to be calm…” (M) Almost all of the participants said that while their professional experience progressed, they were better at managing the process and were less affected by the termination process. Only one participant stated that professional experience does not affect emotional affection: “I guess I can't change; I will cry even after ten years. Because it is difficult” (N). In our study, several opinions emerged about the effect of health professional's gender on termination process management. While some of the participants argued that women were more affected throughout the termination process due to their maternal impulses and their more emotional nature with following expressions, “Men can hide their emotions… Not in terms of discrimination but in terms of projection, women reflect more.” (S) and “We [women] who have a sense of motherhood are slightly more affected due to effect of our hormones, so it [termination] is more difficult for women.” (S); some stated that gender was not effective as follows; “I don't think gender is effective. In other words, as there are very sensitive and polite men, there are very callous women as well.” (A) In our study, the professional group was generally not found effective in managing the termination process. Participants who argued that the profession they belonged to was not effective in the approach to women and their families in the termination process, stated: “No, it is not related to the profession, but to the character of the person and his/her encountering with these cases for a long time ... It does not matter if you are a doctor or a nurse,” (M) and “It doesn't matter when I consider in terms of profession; physician-nurse, female doctor-male doctor, it doesn't make a difference.” (N). Those who think that the professional group is effective expressed this with, “Sometimes, I see it in nurses, nurses are more emotional rather than professionally approaching it” (S) and “I think, we [midwives] get upset, physicians stay emotionally a little cooler” (M) expressions. Stating that the person's probable personal termination experience will harm the termination process management, the participants expressed their opinions as follows; “It would be awful if we had such an experience.” (N), “There was a friend, for example, she went through the same processes, she would show more attention to the mother because she was so upset.” (N) In our study, some participants stated that their beliefs affect the care they will provide to the woman and the family as “beliefs do affect since I am religious, I approach accordingly... I think it is also effective in my care” (N) or “I think my religious characteristics and respect for human rights, right to live come to the fore; I do not see it professionally, I guess I am moving with my feelings a bit, but of course I do not think that it is harmful at this process to put my feelings into work because the doctor must also have a conscience.” (S); while some others stated that their beliefs did not affect their care as “whatever should be done medically should be done, I do not look at it from a religious point of view.” (S), “No, my [beliefs] are not reflected in my care.” (N). 1.d. Reflection of the characteristics and attitudes of women and family on healthcare professionals In our study, some participants stated that the socio-cultural characteristics of the family experiencing the termination process, or family-related characteristics such as expectation or past experiences concerning pregnancy were effective in overcoming the termination process easily or with difficulty, and this was reflected in the care giving healthcare professional. Participants who stated that families had difficulties in communicating and adapting to the process due to their low socio-cultural levels and that they also had difficulties in reaching such families, expressed this situation as follows; “I have so many patients with low socioeconomic and education level and when I explain it [the termination process] they cannot understand very well, and I have difficulty in helping.” (S) “There can be people with different socio-demographic characteristics; they don't know what it [termination] means. They say, "Well, this baby is alive, why are you killing it?", you explain but they don't understand.” (N) Health professionals stated that they had difficulties in managing the termination process when the baby is the family's first child, a highly desired pregnancy or recurrent loss, as individuals were affected more by termination. In the study, it was determined that the support of a spouse or family member throughout the termination process makes it easier to manage the process; “I think [the patient] should have a relative with her during the birth process. Because then, a person knows, shares her feelings and thoughts, and can be more comfortable.” (M) One of the participants, who was a nurse, stated that the family's desire to see the terminated fetus caused a dilemma and had difficulties in this regard. The participant stated this difficulty as “After the termination process takes place, the family wants to see it; you have a dilemma whether to show or not. You don’t know if it will be right and you have a dilemma about what to do.” (N). 2. What do healthcare professionals do in the termination process? This theme has been handled as three sub-themes in our study. 2.a. Physicians are mechanical, nurses and midwives are compassionate We determined that health professionals use various coping methods to cope with the emotional load during the termination process. These coping methods are professional approach, keeping themselves out of the situation/handling as a job, and suppressing emotions. According to the standard view of many participants, physicians rather use methods such as suppressing or treating emotions. Nurses and midwives, as being mostly women, seem to be less successful in suppressing emotions. As a result of these opinions, it was determined that doctors did their work more mechanically by suppressing their emotions, and nurses and midwives mostly approached women and family more affectionately and sometimes emotionally throughout this process. Participants expressed their opinions as follows; “It's tough when you mix your feelings to this work; we have to do it professionally, without mixing feelings. I am trying to think logically and exclude myself… For example, sometimes nurses approach this [pregnancy termination] with a more emotional focus rather than a professional approach.” (S) “We [midwives] feel sad, the physicians stay a little calm, I think emotionally” (M) “I only practiced on the baby and its anomaly… Thus, I did not get too emotionally connected with those families.” (S) “Physicians generally… see it as a case. Midwives and nurses are not like that.” (N) “It's a normal process, a part of our profession so… Some kind of birth, just smaller.” (A) 2.b. Informing and supporting the women makes work easier for everyone According to the study results, it is commonly seen that communicating well with women and their families, providing them with the right information and support, makes the process easier for both them and healthcare professionals. Some of the participants emphasized the importance of effective communication with the following statements; “After communication, that is, after reaching the patient, the patient recovers more easily, and the grief period passes more easily.” (N) “I think good communication is the most important at this point; communicating with the patient's relative, the patient, that is, to understand her...” (A) Some participants stated that the woman and family in the termination process may sometimes endure lack information and that the lack of information during this process complicates the process. Participants expressed the necessity of understandable, accurate and adequate information and facilitating the process as follows; “… When you give the information about what can be experienced in the treatment protocol, how it can be, in fact the patient feels a little more relaxed.” (N) “The thing that can make it easier is providing proper information to the family, that is, to help them overcome the process.” (S) The majority of the participants stated that they supported the woman and her family in the essential aspects during the termination process. This support facilitated the process for the woman and the family in the termination process. They described their experiences of supporting in this process, the necessity, and importance of the support to be given to women and their families as follows; “Guiding the patient a little more, for example, by explaining how to do breathing exercises when pain comes, to get rid of it as soon as possible” (M) “Sometimes, you have to share her silence ... You cannot say I understand because it is not happening to you, so you are just trying to support.” (N) “We need to support our patients spiritually in this process constantly.” (A) “If psychological support is given at that time, the family can be a little more relaxed or it would be more helpful.” (S) 2.c. Organizing the environment as much as possible Majority of the participants stated that the environment in which the termination took place was influential in the process. Many influential factors such as the area where termination will be performed in the hospital, whether the woman will be alone or with a family member, and other patients who are followed up in the environment have been mentioned. The majority of the participants stated that they seldom had difficulties in the termination process due to unalterable hospital conditions; they stated that the process is handled more efficiently when the environment arrangement is made as much as they can; “The terminations were occurring in the maternity ward; it was not wanted in the delivery room because they see each other while one is born, and the other is a stillbirth. We tried to have it in the service room since she was affected, but her family members were very impressed since they witnessed the incident. I think it should be in a private place, not something to be in the service.” (N) “Physical conditions are important, of course, due to the physical structure of the hospital, the mother feels as if she is alone in a dark, desolate place in an environment she never knows about...” (S) “While serving such patients in our service, we take them to single rooms, we try to help in every matter, and we try to send them to their homes as soon as possible so that they don't waste time here.” (A) Discussion In this study, healthcare professionals' views and experiences involved in termination of pregnancy regarding terminations were examined under a core category and two themes. In the first theme, the reflection of pregnancy termination on health professionals, and in the second theme, health professionals' approaches in this process and strategies to facilitate the process are considered. Although the effects of the termination process on health professionals and the approaches of health professionals in the termination process are basically similar to the results of our study; we also reached some original results in our study. The fact that health professionals show empathy during the termination process and even more negatively affect them by experiencing compassion fatigue is similar to the results of our study, while it is common in many studies from different regions [4; 9; 11; 16-18]. This situation makes us think that health professionals' experiences in the process of fetal loss and pregnancy termination are similar in the terms of empathy regardless of geography or culture. However, if the health professionals themselves have experienced a perinatal loss, it has been emphasized in another study, as in our study, that the emotional impact can be experienced much more severely [19]. It is also among the results obtained in our study that healthcare professionals are more affected by terminations performed in advanced weeks of gestation. This result is also similar to another study conducted before [20]. In our study, the feticide application was perceived as facilitating pregnancy termination. Since the fetus is not born alive thanks to the feticide application performed before pregnancy termination, both women and healthcare professionals are less affected, and the dilemma of whether to resuscitate the live-born fetus is eliminated. Still it was determined that there were application difficulties. In two studies by Graham et al. [21; 22] and a study by Dommergues et al. [23], it is stated that feticide is a facilitating application, and sometimes it is difficult to apply, as in our study. There is no consensus in the literature regarding the effect of health professional's gender and beliefs on the termination process, and in our study, participants expressed different opinions on these issues. In our study, some participants claimed that gender is effective in managing the termination process, while others stated that it is not. In other studies, the comparison results in terms of gender were mostly not reported, as the participants or those working in termination clinics were mostly women [10; 24]. In the study of Farrow et al., where gender comparison was made, it was concluded that psychological effects throughout the termination process were not related to the gender of the doctor involved in the process [8]. When the results of our study are evaluated collectively with other research results, it can be assumed that the effect of gender in the termination process should be evaluated together with the effect of other personal characteristics such as emotionality and cannot be generalized. In our study, similar to the relevant literature, there is no consensus on the reflection of health professionals' beliefs on their being affected by the process. In some studies, on the subject, it has been stated that religious belief is effective in the termination process [10; 24]. Thus, in a study conducted in Lebanon, it is stated by the researchers that the reflection of religious beliefs and faiths of healthcare professionals on daily life can affect their attitude and approach to pregnancy termination. Besides, in the same study, it was stated that Muslims were more heavily wholly opposed to pregnancy termination than Christians [25]. Since almost the entire population of Turkey is Muslim, religion may have reflections on the pregnancy termination processes. Considering the termination of the life of the fetus can be accepted as a sin, the healthcare professional performing this procedure may have moral concerns or feel uncomfortable with the procedure [26]. In our study, along with the supportive findings, opinions arguing the opposite and that belief did not reflect on the termination process were also conducted. Since belief is an individual issue and cannot be generalized to society as a whole, it can be argued that individuals should be considered individually on this matter. As an original aspect of our study, the approaches of health professionals in the termination process were compared according to occupational groups. We determined that doctors took a more mechanical approach, and nurses and midwives mostly managed the process by approaching women and their families more affectionately and sometimes emotionally. Related studies have also demonstrated that nurses can use compassionate care as a coping method for themselves. In the study conducted by Jonas-Simpson et al., the participants stated that providing authentic compassion and quality care in perinatal loss helped them feel better [1]. The nurses participating in the study of Puia et al. also stated that providing excellent care to the patient can make the situation more bearable [11]. Concerning the termination process from the perspective of families, according to Gold et al.'s results, families stated that they received emotional support from nurses rather than doctors [9]. In the study of Gandino et al., it was determined that doctors gave less psychological shock reactions than other health care professionals in case of perinatal loss [27]. These results support the result of our study. In our study common view is that communicating well with women and their families and providing them with accurate information and support facilitates the process for both them and health professionals. Similar to our study, Hutti et al.'s study emphasized that providing the required information and support by establishing good communication in a way that enables health professionals to have the women express their feelings is the best care to be done [17]. In other studies, the importance of empathic communication, information, and psychological support in case of loss is similarly discussed [24; 28; 29]. In our study, most participants stated that the environment in which termination takes place in the hospital could be effective in the process. It has been reported that situations such as the presence of other patients or pregnant women in the environment where the procedure is done or the woman is followed up, or her family's support during the termination process may have different effects. In the guides on this subject, it is generally mentioned that this procedure is performed in a separate clinic and the significance of protecting the woman's privacy [7; 30; 31]. For this reason, it can be assumed that the process can be managed more efficiently by protecting the privacy of the woman and preventing her meeting with other patients as much as possible by arranging the environment where termination will take place and ensuring that her family supports her. Conclusion With this study, we revealed the experiences of healthcare professionals involved in the pregnancy termination process and revealed how they could be affected by this process and what facilitation strategies they adopted. How healthcare professionals are affected by taking part in emotionally heavy processes such as pregnancy termination can be related to variables such as personal characteristics or experience. In order to prevent adverse effects on healthcare professionals, some facilitator methods are needed to strengthen prevention strategies and facilitate the process for them. It is estimated that the results of this study can contribute to the development of these methods. When it comes to the negative impact of health professionals from the termination of pregnancy process, especially psychological support should be provided by establishing units where health professionals can get support whenever they want. Professions and length of experience may be considered when providing this support. In particular, new health professionals can be given support and training on the subject without waiting for their demands. When empowering healthcare professionals to provide health care in case of loss, how they are affected by the loss cases must be considered. Many studies have already revealed how healthcare professionals working on perinatal losses are negatively affected by this process and that they may need professional training and individual support [19; 32-35]. According to the results of our study, similarly, it can be recommended to strengthen healthcare professionals with vocational training and to provide individual support programs that consider personal characteristics. References Jonas-Simpson, C., Pilkington, F. B., MacDonald, C., & McMahon, E. (2013). Nurses’ Experiences of Grieving When There Is a Perinatal Death. SAGE Open , 3 (2), 215824401348611. https://doi.org/10.1177/2158244013486116 Mohamed, A. I., Abd Elati, I. H., & Mahmoud Zaki, M. (2015). Knowledge and attitude of maternity nurses regarding perinatal bereavement care. 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J Obstet Gynecol Neonatal Nurs , 42 (3), 321-331. https://doi.org/10.1111/1552-6909.12040 Doherty, J., Cullen, S., Casey, B., Lloyd, B., Sheehy, L., Brosnan, M., . . . Coughlan, B. (2018). Bereavement care education and training in clinical practice: Supporting the development of confidence in student midwives. Midwifery , 66 , 1-9. https://doi.org/10.1016/j.midw.2018.06.026 Minichiello, V., Aroni, R., & Hays, T. N. (2008). In-depth interviewing: Principles, techniques, analysis. . Pearson Education Australia. Polit, D. F., Beck, C. T., & Hungler, B. P. (2006). Essentials of Nursing Research: Methods, Appraisal, and Utilization. Lippincott Williams and Wilkins. Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today , 24 (2), 105-112. https://doi.org/10.1016/j.nedt.2003.10.001 Mauri, P. A., Ceriotti, E., Soldi, M., & Guerrini Contini, N. N. (2015). Italian midwives' experiences of late termination of pregnancy. A phenomenological-hermeneutic study. Nurs Health Sci , 17 (2), 243-249. https://doi.org/10.1111/nhs.12180 Hutti, M. H., Polivka, B., White, S., Hill, J., Clark, P., Cooke, C., . . . Abell, H. (2016). Experiences of Nurses Who Care for Women After Fetal Loss. J Obstet Gynecol Neonatal Nurs , 45 (1), 17-27. https://doi.org/10.1016/j.jogn.2015.10.010 Williamson, M. G. (2016). Exploring Midwives' Experiences of Managing Patients' Perinatal Loss at a Maternity Hospital in The Western Cape, South Africa University of the Western Cape]. Western Cape. Musodza, W., Sheehan, A., Nicholls, D., & Dahlen, H. (2021). Experiences of Maternity Healthcare Professionals Returning to Work Following a Personal Perinatal Loss: A Scoping Review of the Literature. Omega (Westport) , 30222821991312. https://doi.org/10.1177/0030222821991312 Crowe, L., Graham, R. H., Robson, S. C., & Rankin, J. (2018). A survey of health professionals' views on acceptable gestational age and termination of pregnancy for fetal anomaly. Eur J Med Genet , 61 (9), 493-498. https://doi.org/10.1016/j.ejmg.2018.05.011 Graham, R. H., Mason, K., Rankin, J., & Robson, S. C. (2009). The role of feticide in the context of late termination of pregnancy: a qualitative study of health professionals' and parents' views. Prenat Diagn , 29 (9), 875-881. https://doi.org/10.1002/pd.2297 Graham, R. H., Robson, S. C., & Rankin, J. M. (2008). Understanding feticide: an analytic review. Soc Sci Med , 66 (2), 289-300. https://doi.org/10.1016/j.socscimed.2007.08.014 Dommergues, M., Cahen, F., Garel, M., Mahieu-Caputo, D., & Dumez, Y. (2003). Feticide during second- and third-trimester termination of pregnancy: opinions of health care professionals. Fetal Diagn Ther , 18 (2), 91-97. https://doi.org/10.1159/000068068 Lafarge, C., Mitchell, K., Breeze, A. C., & Fox, P. (2017). Pregnancy termination for fetal abnormality: are health professionals' perceptions of women's coping congruent with women's accounts? BMC Pregnancy Childbirth , 17 (1), 60. https://doi.org/10.1186/s12884-017-1238-3 Zahed, L., Nabulsi, M., & Tamim, H. (2002). Attitudes towards prenatal diagnosis and termination of pregnancy among health professionals in Lebanon. Prenat Diagn , 22 (10), 880-886. https://doi.org/10.1002/pd.429 Görgülü, Ü. (2017). Anomalili Gebeliklerin Sonlandırılmasıyla İlgili Cevaz Fetvalarına Eleştirel Bir Bakış [A Critical Analysis of The Fatwas That Give Authorization for The Termination of Abnormal Pregnancies]. Diyanet İlmi Dergi , 53 (4). Gandino, G., Di Fini, G., Bernaudo, A., Paltrinieri, M., Castiglioni, M., & Veglia, F. (2020). The impact of perinatal loss in maternity units: A psycholinguistic analysis of health professionals' reactions. J Health Psychol , 25 (5), 640-651. https://doi.org/10.1177/1359105317727841 Ellis, A., Chebsey, C., Storey, C., Bradley, S., Jackson, S., Flenady, V., . . . Siassakos, D. (2016). Systematic review to understand and improve care after stillbirth: a review of parents' and healthcare professionals' experiences. BMC Pregnancy Childbirth , 16 , 16. https://doi.org/10.1186/s12884-016-0806-2 Heazell, A. E. P., Siassakos, D., Blencowe, H., Burden, C., Bhutta, Z. A., Cacciatore, J., . . . Budd, J. (2016). Stillbirths: economic and psychosocial consequences. The Lancet , 387 (10018), 604-616. https://doi.org/10.1016/s0140-6736(15)00836-3 RCN. (2017). Termination of Pregnancy, An RCN nursing framework (CLINICAL PROFESSIONAL RESOURCE, Issue. https://www.rcn.org.uk › june › pub-005957 Queensland, C. G. (2019). Termination of Pregnancy . Queensland Government Retrieved from https://www.health.qld.gov.au/__data/assets/pdf_file/0029/735293/g-top.pdf Fernandez-Alcantara, M., Schul-Martin, L., Garcia Caro, M. P., Montoya-Juarez, R., Perez-Marfil, M. N., & Zech, E. (2020). 'In the hospital there are no care guidelines': experiences and practices in perinatal loss in Spain. Scand J Caring Sci , 34 (4), 1063-1073. https://doi.org/10.1111/scs.12816 Ravaldi, C., Carelli, E., Frontini, A., Mosconi, L., Tagliavini, S., Cossu, E., . . . Vannacci, A. (2021). The BLOSSoM study: Burnout after perinatal LOSS in Midwifery. Results of a nation-wide investigation in Italy. Women Birth . https://doi.org/10.1016/j.wombi.2021.01.003 Shorey, S., Andre, B., & Lopez, V. (2017). The experiences and needs of healthcare professionals facing perinatal death: A scoping review. Int J Nurs Stud , 68 , 25-39. https://doi.org/10.1016/j.ijnurstu.2016.12.007 Yenal, K., Tektas, P., Donmez, A., & Okumus, H. (2021). Perinatal Loss: Experiences of Midwives and Nurses. Omega (Westport) , 302228211029143. https://doi.org/10.1177/00302228211029143 Booth, A., Hannes, K., Harden, A., Noyes, J., & Harris, J. (2014). COREQ (consolidated criteria for reporting qualitative studies). https://doi.org/10.1002/9781118715598.ch21 Additional Declarations No competing interests reported. Supplementary Files Appendix1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3256516","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":231522565,"identity":"2d86d168-ac47-4cff-a1fb-d5e62840cbd4","order_by":0,"name":"Arzu Akpınar","email":"","orcid":"","institution":"Akdeniz University Nursing Faculty","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Arzu","middleName":"","lastName":"Akpınar","suffix":""},{"id":231522566,"identity":"4e9d394d-9505-45f5-81d8-fe5c16a40e36","order_by":1,"name":"Yasemin Turgut","email":"data:image/png;base64,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","orcid":"","institution":"Antalya Science University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yasemin","middleName":"","lastName":"Turgut","suffix":""},{"id":231522567,"identity":"78e8cdbc-bf2c-481a-8f1a-cf8b14432fec","order_by":2,"name":"Hatice Yangın","email":"","orcid":"","institution":"Akdeniz University Nursing Faculty","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hatice","middleName":"","lastName":"Yangın","suffix":""}],"badges":[],"createdAt":"2023-08-11 18:44:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3256516/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3256516/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":43008843,"identity":"f5e3e8b1-38b4-4ffb-afb8-cd5e0fab4f18","added_by":"auto","created_at":"2023-09-12 14:22:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":190531,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3256516/v1/3e3d929fd4f4629b1a56b978.png"},{"id":47674353,"identity":"2e2067f0-0f68-460d-967e-91fe6300824f","added_by":"auto","created_at":"2023-12-06 04:07:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":501137,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3256516/v1/15f030bc-257a-40fc-b657-68fc51398801.pdf"},{"id":43007350,"identity":"e717bce1-9c63-4024-afea-ae77481c35dc","added_by":"auto","created_at":"2023-09-12 14:14:09","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23230,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-3256516/v1/418047256f0d49db282a6dcb.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Looking at pregnancy terminations from the opposite side: the perspective of healthcare professionals","fulltext":[{"header":"Background","content":"\u003cp\u003eTermination of pregnancy is the process of terminating an existing pregnancy. It is a very traumatic and difficult process for the woman and the family, from the termination decision to the birth and beyond. While the grieving woman and her family experience emotional trauma, they have to overcome the pain and physical difficulties of childbirth [3; 5\u0026ndash;7]. At the same time, healthcare professionals who care for women and their families may also be affected differently from this process. Previous studies in different countries [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] have shown that participating in pregnancy termination can have adverse effects on healthcare workers.\u003c/p\u003e \u003cp\u003eStudies show that healthcare professionals often experience symptoms such as individual grief reactions, self-doubt, depression, and self-blame in cases of perinatal loss [1; 8; 9]. To cope with this situation, health professionals resort to coping methods such as suppressing silence and emotions, seeking support, keeping oneself out of the event, and using belief systems (10).\u003c/p\u003e \u003cp\u003eWhen healthcare professionals who involved in the termination of pregnancy encounter negative experiences due to the emotional burden and the heavyweight of this process, and if they are inadequate in coping, it may reflect in health care. They may react to individuals such as inadequate or excessive care behavior, thus affecting health care. Sometimes, they may even think of quitting the profession due to this emotional weight [2\u0026ndash;4; 11]. Depending on how healthcare professionals are affected by this experience, individuals' needs may not be fully met. Besides, although healthcare professionals can cope with these emotions by their environment and colleagues' support in the short term, they may endure severe depression and post-traumatic stress disorder in the long term [1; 4; 6; 11; 12].\u003c/p\u003e \u003cp\u003eIt is crucial to support healthcare professionals who will be with the women and the family in health care during the termination process and to determine their experience to improve the approach to the individual\u0026rsquo;s experiencing termination. It is crucial to support healthcare professionals who will be with the women and the family in health care during the termination process and to determine their experience to improve the approach to the individual\u0026rsquo;s experiencing termination. We aimed to determine the opinions and experiences of the healthcare professionals regarding pregnancy terminations with this qualitative study. The data we obtained as a result of the study will form the basis for the creation of support programs that will facilitate healthcare professionals to cope with negative effects. Thus, it is aimed to raise the necessary awareness so that health professionals can provide quality and effective health services to women and their families in the termination process.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA hermeneutic phenomenological design was used in this qualitative study. Also, this study was reported using consolidated criteria for reporting qualitative research (COREQ) guidelines (Booth et al., 2014).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe sample of this study is 26 people work in the field of women's health in a university and a state hospital in A\u0026hellip; (City\u0026rsquo;s name) and who at least once met women undergone pregnancy termination due to fetal anomaly. Participants consist of six Obstetrics / Gynecologist (Ob/Gyn) Assistants (A), five Ob/Gyn specialists, eight Ob/Gyn clinical nurses and seven midwifes. Participants who can speak, read, understand Turkish were included in this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection and analysis\u003c/h2\u003e \u003cp\u003eData collection were obtained through face-to-face and individual in-depth interviews using a semi-structured interview guide. In this study, maximum diversity sampling, one of the purposeful sampling methods, was applied to determine whether health professionals from various professions participating in the termination process due to fetal anomaly possess common or different patterns concerning the termination process. The study was conducted between December 2018 - April 2019. The study's data were collected by an individual in-depth interview technique applying a \u0026ldquo;Personal Information Form\u0026rdquo; including age, gender, marital status and duration of experience at obstetric clinics and a \u0026ldquo;Semi-Structured Interview Form\u0026rdquo; (\u003cspan refid=\"Sec5\" class=\"InternalRef\"\u003eAppendix 1\u003c/span\u003e) designed by the researchers. During the reassessments in the research process, a question was removed from this form. In addition to the form questions, drilling questions such as \"Is there anything else you want to say about this topic?\", \"What did you feel?\" \"What did you think?\" \"Can you explain it more?\" \"How did .... affect?\" were included during the interview to deepen the participant's responses [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Throughout the interview, the questions were asked in a logical sequence. The interviews lasted an average of 20 minutes.\u003c/p\u003e \u003cp\u003e The interviews were held in a suitable and quiet environment in the hospitals where the participants worked and were recorded with a voice recorder. All interviews were conducted by same two researchers together. In this process, one of the researchers was the moderator, the other was the observer to increase data reliability, control the recorder and keep the field notes taken. Under the qualitative research nature, the data collection was ended when the data reached the saturation point and started to repeat [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due [because our data contains the personal information of our participants] but are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll interviews were combined with field notes and were transcripted by the researchers. One hundred fifty pages of raw text were obtained from the interviews. \u0026nbsp;The content analysis model of Graneheim and Lundman was applied in the analysis of these data\u0026nbsp;[15].\u003c/p\u003e\n\u003cp\u003eData analysis of the transcripts was accomplished by the process outlined below, which was based on Graneheim and Lundman\u0026rsquo;s techniques for extracting themes\u0026nbsp;[15]:\u003c/p\u003e\n\u003cp\u003e1- The interviews were read through several times to obtain a sense of the whole.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2- A full text was created by combining the data in order to create analyzes aimed at determining the experiences of healthcare professionals regarding pregnancy terminations due to fetal anomalies.\u003c/p\u003e\n\u003cp\u003e3- The condensed meaning units were abstracted and labeled with a code.\u003c/p\u003e\n\u003cp\u003e4- The tentative categories were discussed by researchers and revised.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e5- Finally, the underlying meaning, that is, the latent content of the categories, was formulated into a theme.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from X University Faculty of Medicine Clinical Research Ethics Committee (approval number: X and date of approval: X). At the beginning of the interviews, the participants were given information about the aim, importance, duration, and confidentiality of the interviews. Their informed consent was obtained, and the names of the participants were kept confidential. While reporting the study, only the professional groups of the participants were shown with their initials in the findings section (A: Ob/Gyn Assistant Doctor, M: Midwife, N: Ob/Gyn Clinical Nurse, S: Ob/Gyn Specialist).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSociodemographic and professional features of participants are presented in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Sociodemographic and Professional Features of Participants (n=26)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.49593495934959%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFeature\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.50406504065041%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.49593495934959%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.50406504065041%\" valign=\"top\"\u003e\n \u003cp\u003eMean=32,77 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Range=21-52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.49593495934959%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.50406504065041%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.49593495934959%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.50406504065041%\" valign=\"top\"\u003e\n \u003cp\u003en=22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.49593495934959%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.50406504065041%\" valign=\"top\"\u003e\n \u003cp\u003en=4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.49593495934959%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.50406504065041%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.49593495934959%\" valign=\"top\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.50406504065041%\" valign=\"top\"\u003e\n \u003cp\u003en=12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.49593495934959%\" valign=\"top\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.50406504065041%\" valign=\"top\"\u003e\n \u003cp\u003en=14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.49593495934959%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfession\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.50406504065041%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.49593495934959%\" valign=\"top\"\u003e\n \u003cp\u003eOb/Gyn Assistant Doctor (A)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.50406504065041%\" valign=\"top\"\u003e\n \u003cp\u003en=6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.49593495934959%\" valign=\"top\"\u003e\n \u003cp\u003eMidwife (M)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.50406504065041%\" valign=\"top\"\u003e\n \u003cp\u003en=7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.49593495934959%\" valign=\"top\"\u003e\n \u003cp\u003eOb/Gyn Clinical Nurse (N)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.50406504065041%\" valign=\"top\"\u003e\n \u003cp\u003en=8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.49593495934959%\" valign=\"top\"\u003e\n \u003cp\u003eOb/Gyn Specialist (S)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.50406504065041%\" valign=\"top\"\u003e\n \u003cp\u003en=5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.49593495934959%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of Professional Experience at Obstetric Clinics (Years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.50406504065041%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMean=7,02 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Range=0,3-20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;The findings of our study consist of one core category, 2 themes and 7 sub-themes under these themes (Fig.).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA. Core Category: The Perspective of Healthcare Professionals about Pregnancy Terminations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe preferred to write the results of our study under a core category that includes both how health professionals are affected by the pregnancy termination process and how they behave in the process, because we have seen that these two themes have a structure that affects each other in the process. Depending on the behavior of health professionals, this process may be difficult or easier, and therefore how they are affected may change.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e1. How are healthcare professionals affected during the termination process?\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme has been handled as four sub-themes in our study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1. a. Experiences which increase empathy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany of the study participants stated that participating in this process by managing or observing the termination process enables them to empathize with the situation. Some argue that the gender of the health professional is effective in the creation of empathy. \u0026nbsp;One of the participants, who is a midwife, expressed this situation as follows;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I am also a woman, I empathize with this case [termination of pregnancy] whether I want it or not. So, you think the same thing can happen to you, which is not something improbable, it can happen to anyone\u0026rdquo; (M). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome of the female participants, beyond empathy, stated that they were afraid that this situation might happen to them or someone around them, \u0026ldquo;I was always afraid during my pregnancy like if something bad happens, if we lose the baby\u0026rdquo; (M) and \u0026ldquo;you can be affected when you look at [the baby with anomaly]; if you are or one of your relatives is pregnant, you may think, if such a thing could happen\u0026rdquo; (N) expressed this fear with their statements.\u003c/p\u003e\n\u003cp\u003eAlthough being a woman was associated with empathy in the study, male participants also agreed on empathy. One of the participants, a male assistant doctor, stated the importance of empathy in this process by saying, \u0026quot;empathy, most importantly, putting yourself in the family\u0026apos;s shoes\u0026quot; (A).\u003c/p\u003e\n\u003cp\u003eFrom the data obtained in the study, it was observed that healthcare professionals were able to understand the traumatic experience of the woman and the family who underwent pregnancy termination while empathizing with them during the termination process. \u0026nbsp;Most of the participants stated that throughout this period, the woman and the family encountered two types of traumas due to their babies\u0026apos; loss while waiting to meet a live baby and the pain of labor during the termination process. They stated that they empathized while caring for the woman in the termination process and felt sorry for the family\u0026apos;s traumatic experience. \u0026nbsp;Participants stated their observations and experiences with the following expressions;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;\u0026hellip; Dreams of holding her child come with a psychological trauma when suddenly there is a decision to terminate while dreaming of giving birth. The second trauma is already happening in this painful period of giving birth.\u0026rdquo; (A)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;\u0026hellip; As a result of [this process] they will not encounter a living baby; it is a great traumatic situation.\u0026rdquo; (S)\u003c/p\u003e\n\u003cp\u003eSome of the participants in the study stated that both the family and themselves were affected more emotionally throughout terminations at more advanced gestational ages;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;\u0026hellip; It is challenging in the advanced weeks, you feel sorry, you wish it didn\u0026apos;t grow that big\u0026hellip;\u0026rdquo; (N)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;In the early pregnancies, at 8-9 weeks, you may not be affected that much, but sometimes we terminate a pregnancy in an advanced week, so it is a heavy burden for us as well.\u0026rdquo; (S)\u003c/p\u003e\n\u003cp\u003eIn our study, the participants stated the compassion fatigue that develops due to the stress they endured while caring for the individual suffering during the termination process;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;\u0026hellip; It takes more intellectual time than what you do. This job [termination] is tiring.\u0026rdquo; (N)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;The emotional side of [termination] can also wear us down.\u0026rdquo; (M)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.b. Feticide: Facilitator or difficulty?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhile some of the study participants perceived feticide as an application facilitating termination, some mentioned the difficulty of it. \u0026nbsp;Participants who perceived feticide as a facilitator stated that when feticide is not made, the live-born fetus can sometimes be more traumatic by making a noise or moving for women, the family, and healthcare professionals. They find feticide facilitating because it creates the dilemma of whether or not to intervene in a live-born baby:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;The biggest trauma of my assistantship was them [live fetal terminations]\u0026hellip; Feticide \u0026nbsp;should be made, trauma decreases when the baby is not alive.\u0026rdquo; (S)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;\u0026hellip; Since they do not perform a feticide, the baby may be born with a fetal heartbeat, we both terminate and try to revive, in this sense we are experiencing hard things.\u0026rdquo; (M)\u003c/p\u003e\n\u003cp\u003eParticipants who emphasized the difficulty of feticide, on the other hand, mentioned both the ethical and emotional dimensions of the procedure and the application\u0026apos;s complexity. During the feticide procedure, one of the specialist doctors emphasizes the principle of non-harm, which is one of the ethical principles, and said, \u0026ldquo;It\u0026apos;s [feticide] a challenging experience for us too since you\u0026apos;re damaging something alive there.\u0026rdquo; (S). One nurse expressed an application difficulty she observed as follows; \u0026ldquo;We had a patient; two attempts were made to make feticide but both failed. Both the [practicing] doctor and the patient were distressed.\u0026rdquo; (N).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.c. The impact of the individual characteristics of the healthcare professionals\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn our study, some participants stated that individual characteristics such as personality traits, period of personal professional experience, gender, occupational group, personal termination experience, and beliefs might affect health professionals\u0026apos; termination experience. In contrast, others stated that such characteristics do not affect the health care they provide during the termination process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the study, it was concluded that health professionals\u0026apos; personality traits are effective in managing the termination process. According to the participants\u0026apos; general opinion, sensitive individuals are more affected, and it is harder for them to overcome the termination process, while those who are cool are less affected. Some of the participants stated their opinions as follows;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Individual characteristics, such as conscience, compassion are important ...\u0026rdquo; (S)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026ldquo;Not everyone can handle [the termination process]; we also see those who sit and cry. The most important thing is to be calm\u0026hellip;\u0026rdquo; (M)\u003c/p\u003e\n\u003cp\u003eAlmost all of the participants said that while their professional experience progressed, they were better at managing the process and were less affected by the termination process. Only one participant stated that professional experience does not affect emotional affection: \u0026ldquo;I guess I can\u0026apos;t change; I will cry even after ten years. Because it is difficult\u0026rdquo; (N).\u003c/p\u003e\n\u003cp\u003eIn our study, several opinions emerged about the effect of health professional\u0026apos;s gender on termination process management. While some of the participants argued that women were more affected throughout the termination process due to their maternal impulses and their more emotional nature with following expressions, \u0026ldquo;Men can hide their emotions\u0026hellip; Not in terms of discrimination but in terms of projection, women reflect more.\u0026rdquo; (S) and \u0026ldquo;We [women] who have a sense of motherhood are slightly more affected due to effect of our hormones, so it [termination] is more difficult for women.\u0026rdquo; (S); some stated that gender was not effective as follows;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I don\u0026apos;t think gender is effective. In other words, as there are very sensitive and polite men, there are very callous women as well.\u0026rdquo; (A)\u003c/p\u003e\n\u003cp\u003eIn our study, the professional group was generally not found effective in managing the termination process. Participants who argued that the profession they belonged to was not effective in the approach to women and their families in the termination process, stated: \u0026ldquo;No, it is not related to the profession, but to the character of the person and his/her encountering with these cases for a long time ... It does not matter if you are a doctor or a nurse,\u0026rdquo; (M) and \u0026ldquo;It doesn\u0026apos;t matter when I consider in terms of profession; physician-nurse, female doctor-male doctor, it doesn\u0026apos;t make a difference.\u0026rdquo; (N). Those who think that the professional group is effective expressed this with, \u0026ldquo;Sometimes, I see it in nurses, nurses are more emotional rather than professionally approaching it\u0026rdquo; (S) and \u0026ldquo;I think, we [midwives] get upset, physicians stay emotionally a little cooler\u0026rdquo; (M) expressions.\u003c/p\u003e\n\u003cp\u003eStating that the person\u0026apos;s probable personal termination experience will harm the termination process management, the participants expressed their opinions as follows; \u0026ldquo;It would be awful if we had such an experience.\u0026rdquo; (N), \u0026ldquo;There was a friend, for example, she went through the same processes, she would show more attention to the mother because she was so upset.\u0026rdquo; (N)\u003c/p\u003e\n\u003cp\u003eIn our study, some participants stated that their beliefs affect the care they will provide to the woman and the family as \u0026ldquo;beliefs do affect since I am religious, I approach accordingly... I think it is also effective in my care\u0026rdquo; (N) or \u0026ldquo;I think my religious characteristics and respect for human rights, right to live come to the fore; I do not see it professionally, I guess I am moving with my feelings a bit, but of course I do not think that it is harmful at this process to put my feelings into work because the doctor must also have a conscience.\u0026rdquo; (S); while some others stated that their beliefs did not affect their care as \u0026ldquo;whatever should be done medically should be done, I do not look at it from a religious point of view.\u0026rdquo; (S), \u0026ldquo;No, my [beliefs] are not reflected in my care.\u0026rdquo; (N).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.d. Reflection of the characteristics and attitudes of women and family on healthcare professionals\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn our study, some participants stated that the socio-cultural characteristics of the family experiencing the termination process, or family-related characteristics such as expectation or past experiences concerning pregnancy were effective in overcoming the termination process easily or with difficulty, and this was reflected in the care giving healthcare professional.\u003c/p\u003e\n\u003cp\u003eParticipants who stated that families had difficulties in communicating and adapting to the process due to their low socio-cultural levels and that they also had difficulties in reaching such families, expressed this situation as follows;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I have so many patients with low socioeconomic and education level and when I explain it [the termination process] they cannot understand very well, and I have difficulty in helping.\u0026rdquo; (S)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;There can be people with different socio-demographic characteristics; they don\u0026apos;t know what it [termination] means. They say, \u0026quot;Well, this baby is alive, why are you killing it?\u0026quot;, you explain but they don\u0026apos;t understand.\u0026rdquo; (N)\u003c/p\u003e\n\u003cp\u003eHealth professionals stated that they had difficulties in managing the termination process when the baby is the family\u0026apos;s first child, a highly desired pregnancy or recurrent loss, as individuals were affected more by termination.\u003c/p\u003e\n\u003cp\u003eIn the study, it was determined that the support of a spouse or family member throughout the termination process makes it easier to manage the process;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I think [the patient] should have a relative with her during the birth process. Because then, a person knows, shares her feelings and thoughts, and can be more comfortable.\u0026rdquo; (M)\u003c/p\u003e\n\u003cp\u003eOne of the participants, who was a nurse, stated that the family\u0026apos;s desire to see the terminated fetus caused a dilemma and had difficulties in this regard. The participant stated this difficulty as \u0026ldquo;After the termination process takes place, the family wants to see it; you have a dilemma whether to show or not. You don\u0026rsquo;t know if it will be right and you have a dilemma about what to do.\u0026rdquo; (N).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2. What do healthcare professionals do in the termination process?\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme has been handled as three sub-themes in our study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.a. Physicians are mechanical, nurses and midwives are compassionate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe determined that health professionals use various coping methods to cope with the emotional load during the termination process. These coping methods are professional approach, keeping themselves out of the situation/handling as a job, and suppressing emotions. According to the standard view of many participants, physicians rather use methods such as suppressing or treating emotions. Nurses and midwives, as being mostly women, seem to be less successful in suppressing emotions. As a result of these opinions, it was determined that doctors did their work more mechanically by suppressing their emotions, and nurses and midwives mostly approached women and family more affectionately and sometimes emotionally throughout this process. Participants expressed their opinions as follows;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;It\u0026apos;s tough when you mix your feelings to this work; we have to do it professionally, without mixing feelings. I am trying to think logically and exclude myself\u0026hellip; For example, sometimes nurses approach this [pregnancy termination] with a more emotional focus rather than a professional approach.\u0026rdquo; (S)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;We [midwives] feel sad, the physicians stay a little calm, I think emotionally\u0026rdquo; (M)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026ldquo;I only practiced on the baby and its anomaly\u0026hellip; Thus, I did not get too emotionally connected with those families.\u0026rdquo; (S)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Physicians generally\u0026hellip; see it as a case. Midwives and nurses are not like that.\u0026rdquo; (N)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;It\u0026apos;s a normal process, a part of our profession so\u0026hellip; Some kind of birth, just smaller.\u0026rdquo; (A)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.b. Informing and supporting the women makes work easier for everyone\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the study results, it is commonly seen that communicating well with women and their families, providing them with the right information and support, makes the process easier for both them and healthcare professionals. Some of the participants emphasized the importance of effective communication with the following statements;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;After communication, that is, after reaching the patient, the patient recovers more easily, and the grief period passes more easily.\u0026rdquo; (N)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I think good communication is the most important at this point; communicating with the patient\u0026apos;s relative, the patient, that is, to understand her...\u0026rdquo; (A)\u003c/p\u003e\n\u003cp\u003eSome participants stated that the woman and family in the termination process may sometimes endure lack information and that the lack of information during this process complicates the process. Participants expressed the necessity of understandable, accurate and adequate information and facilitating the process as follows;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u0026hellip; When you give the information about what can be experienced in the treatment protocol, how it can be, in fact the patient feels a little more relaxed.\u0026rdquo; (N)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026ldquo;The thing that can make it easier is providing proper information to the family, that is, to help them overcome the process.\u0026rdquo; (S)\u003c/p\u003e\n\u003cp\u003eThe majority of the participants stated that they supported the woman and her family in the essential aspects during the termination process. This support facilitated the process for the woman and the family in the termination process. They described their experiences of supporting in this process, the necessity, and importance of the support to be given to women and their families as follows;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Guiding the patient a little more, for example, by explaining how to do breathing exercises when pain comes, to get rid of it as soon as possible\u0026rdquo; (M)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Sometimes, you have to share her silence ... You cannot say I understand because it is not happening to you, so you are just trying to support.\u0026rdquo; (N)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;We need to support our patients spiritually in this process constantly.\u0026rdquo; (A)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If psychological support is given at that time, the family can be a little more relaxed or it would be more helpful.\u0026rdquo; (S)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.c. Organizing the environment as much as possible\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMajority of the participants stated that the environment in which the termination took place was influential in the process. Many influential factors such as the area where termination will be performed in the hospital, whether the woman will be alone or with a family member, and other patients who are followed up in the environment have been mentioned. The majority of the participants stated that they seldom had difficulties in the termination process due to unalterable hospital conditions; they stated that the process is handled more efficiently when the environment arrangement is made as much as they can;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The terminations were occurring in the maternity ward; it was not wanted in the delivery room because they see each other while one is born, and the other is a stillbirth. We tried to have it in the service room since she was affected, but her family members were very impressed since they witnessed the incident. I think it should be in a private place, not something to be in the service.\u0026rdquo; (N)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Physical conditions are important, of course, due to the physical structure of the hospital, the mother feels as if she is alone in a dark, desolate place in an environment she never knows about...\u0026rdquo; (S)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;While serving such patients in our service, we take them to single rooms, we try to help in every matter, and we try to send them to their homes as soon as possible so that they don\u0026apos;t waste time here.\u0026rdquo; (A)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, healthcare professionals\u0026apos; views and experiences involved in termination of pregnancy regarding terminations were examined under a core category and two themes. In the first theme, the reflection of pregnancy termination on health professionals, and in the second theme, health professionals\u0026apos; approaches in this process and strategies to facilitate the process are considered. Although the effects of the termination process on health professionals and the approaches of health professionals in the termination process are basically similar to the results of our study; we also reached some original results in our study. The fact that health professionals show empathy during the termination process and even more negatively affect them by experiencing compassion fatigue is similar to the results of our study, while it is common in many studies from different regions\u0026nbsp;[4; 9; 11; 16-18].\u0026nbsp;This situation makes us think that health professionals\u0026apos; experiences in the process of fetal loss and pregnancy termination are similar in the terms of empathy regardless of geography or culture.\u0026nbsp;However, if the health professionals themselves have experienced a perinatal loss, it has been emphasized in another study, as in our study, that the emotional impact can be experienced much more severely\u0026nbsp;[19].\u0026nbsp;It is also among the results obtained in our study that healthcare professionals are more affected by terminations performed in advanced weeks of gestation. This result is also similar to another study conducted before\u0026nbsp;[20].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our study, the feticide application was perceived as facilitating pregnancy termination. Since the fetus is not born alive thanks to the feticide application performed before pregnancy termination, both women and healthcare professionals are less affected, and the dilemma of whether to resuscitate the live-born fetus is eliminated. Still it was determined that there were application difficulties. \u0026nbsp; \u0026nbsp; In two studies by Graham et al.\u0026nbsp;[21; 22]\u0026nbsp;and a study by Dommergues et al.\u0026nbsp;[23], it is stated that feticide is a facilitating application, and sometimes it is difficult to apply, as in our study.\u003c/p\u003e\n\u003cp\u003eThere is no consensus in the literature regarding the effect of health professional\u0026apos;s gender and beliefs on the termination process, and in our study, participants expressed different opinions on these issues.\u0026nbsp;In our study, some participants claimed that gender is effective in managing the termination process, while others stated that it is not. \u0026nbsp;In other studies, the comparison results in terms of gender were mostly not reported, as the participants or those working in termination clinics were mostly women\u0026nbsp;[10; 24]. In the study of Farrow et al., where gender comparison was made, it was concluded that psychological effects throughout the termination process were not related to the gender of the doctor involved in the process\u0026nbsp;[8]. \u0026nbsp;When the results of our study are evaluated collectively with other research results, it can be assumed that the effect of gender in the termination process should be evaluated together with the effect of other personal characteristics such as emotionality and cannot be generalized.\u003c/p\u003e\n\u003cp\u003eIn our study, similar to the relevant literature, there is no consensus on the reflection of health professionals\u0026apos; beliefs on their being affected by the process. \u0026nbsp;In some studies, on the subject, it has been stated that religious belief is effective in the termination process\u0026nbsp;[10; 24]. Thus, in a study conducted in Lebanon, it is stated by the researchers that the reflection of religious beliefs and faiths of healthcare professionals on daily life can affect their attitude and approach to pregnancy termination. Besides, in the same study, it was stated that Muslims were more heavily wholly opposed to pregnancy termination than Christians\u0026nbsp;[25]. Since almost the entire population of Turkey is Muslim, religion may have reflections on the pregnancy termination processes. \u0026nbsp;Considering the termination of the life of the fetus can be accepted as a sin, the healthcare professional performing this procedure may have moral concerns or feel uncomfortable with the procedure\u0026nbsp;[26]. \u0026nbsp;In our study, along with the supportive findings, opinions arguing the opposite and that belief did not reflect on the termination process were also conducted. Since belief is an individual issue and cannot be generalized to society as a whole, it can be argued that individuals should be considered individually on this matter.\u003c/p\u003e\n\u003cp\u003eAs an original aspect of our study, the approaches of health professionals in the termination process were compared according to occupational groups.\u0026nbsp;We determined that doctors took a more mechanical approach, and nurses and midwives mostly managed the process by approaching women and their families more affectionately and sometimes emotionally. Related studies have also demonstrated that nurses can use compassionate care as a coping method for themselves. In the study conducted by Jonas-Simpson et al., the participants stated that providing authentic compassion and quality care in perinatal loss helped them feel better\u0026nbsp;[1]. The nurses participating in the study of Puia et al. also stated that providing excellent care to the patient can make the situation more bearable\u0026nbsp;[11]. Concerning the termination process from the perspective of families, according to Gold et al.\u0026apos;s results, families stated that they received emotional support from nurses rather than doctors\u0026nbsp;[9]. In the study of Gandino et al., it was determined that doctors gave less psychological shock reactions than other health care professionals in case of perinatal loss\u0026nbsp;[27]. These results support the result of our study.\u003c/p\u003e\n\u003cp\u003eIn our study common view is that communicating well with women and their families and providing them with accurate information and support facilitates the process for both them and health professionals. Similar to our study, Hutti et al.\u0026apos;s study emphasized that providing the required information and support by establishing good communication in a way that enables health professionals to have the women express their feelings is the best care to be done\u0026nbsp;[17]. \u0026nbsp;In other studies, the importance of empathic communication, information, and psychological support in case of loss is similarly discussed\u0026nbsp;[24; 28; 29].\u003c/p\u003e\n\u003cp\u003eIn our study, most participants stated that the environment in which termination takes place in the hospital could be effective in the process. \u0026nbsp;It has been reported that situations such as the presence of other patients or pregnant women in the environment where the procedure is done or the woman is followed up, or her family\u0026apos;s support during the termination process may have different effects. In the guides on this subject, it is generally mentioned that this procedure is performed in a separate clinic and the significance of protecting the woman\u0026apos;s privacy [7; 30; 31]. \u0026nbsp;For this reason, it can be assumed that the process can be managed more efficiently by protecting the privacy of the woman and preventing her meeting with other patients as much as possible by arranging the environment where termination will take place and ensuring that her family supports her.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWith this study, we revealed the experiences of healthcare professionals involved in the pregnancy termination process and revealed how they could be affected by this process and what facilitation strategies they adopted. How healthcare professionals are affected by taking part in emotionally heavy processes such as pregnancy termination can be related to variables such as personal characteristics or experience. In order to prevent adverse effects on healthcare professionals, some facilitator methods are needed to strengthen prevention strategies and facilitate the process for them. It is estimated that the results of this study can contribute to the development of these methods. When it comes to the negative impact of health professionals from the termination of pregnancy process, especially psychological support should be provided by establishing units where health professionals can get support whenever they want. Professions and length of experience may be considered when providing this support. In particular, new health professionals can be given support and training on the subject without waiting for their demands. When empowering healthcare professionals to provide health care in case of loss, how they are affected by the loss cases must be considered. Many studies have already revealed how healthcare professionals working on perinatal losses are negatively affected by this process and that they may need professional training and individual support [19; 32-35]. According to the results of our study, similarly, it can be recommended to strengthen healthcare professionals with vocational training and to provide individual support programs that consider personal characteristics.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJonas-Simpson, C., Pilkington, F. B., MacDonald, C., \u0026amp; McMahon, E. (2013). Nurses\u0026rsquo; Experiences of Grieving When There Is a Perinatal Death. \u003cem\u003eSAGE Open\u003c/em\u003e,\u003cem\u003e 3\u003c/em\u003e(2), 215824401348611. https://doi.org/10.1177/2158244013486116 \u003c/li\u003e\n\u003cli\u003eMohamed, A. I., Abd Elati, I. H., \u0026amp; Mahmoud Zaki, M. (2015). 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The experiences and needs of healthcare professionals facing perinatal death: A scoping review. \u003cem\u003eInt J Nurs Stud\u003c/em\u003e,\u003cem\u003e 68\u003c/em\u003e, 25-39. https://doi.org/10.1016/j.ijnurstu.2016.12.007 \u003c/li\u003e\n\u003cli\u003eYenal, K., Tektas, P., Donmez, A., \u0026amp; Okumus, H. (2021). Perinatal Loss: Experiences of Midwives and Nurses. \u003cem\u003eOmega (Westport)\u003c/em\u003e, 302228211029143. https://doi.org/10.1177/00302228211029143 \u003c/li\u003e\n\u003cli\u003eBooth, A., Hannes, K., Harden, A., Noyes, J., \u0026amp; Harris, J. (2014). COREQ (consolidated criteria for reporting qualitative studies). \u003cstrong\u003ehttps://doi.org/10.1002/9781118715598.ch21\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Experiences, Healthcare Professionals, Pregnancy Termination, Qualitative Research","lastPublishedDoi":"10.21203/rs.3.rs-3256516/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3256516/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIt is already known that the woman and the family can be affected in various ways psychologically and physiologically during the termination of pregnancy, but the healthcare professionals who manage the process can also be affected while being effective on the process. We aimed to determine the opinions and experiences of the healthcare professionals regarding pregnancy terminations with this qualitative study.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA hermeneutic phenomenological design was used in this qualitative study. Data collection were obtained through face-to-face and individual in-depth interviews using a semi-structured interview guide between December 2018 - April 2019. The sample of the study consisted of 26 participants from different professions who have encountered pregnancy termination process.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eData were grouped under two themes with seven three sub-themes. First theme about how health professionals were affected by the process has been defined as ''How are healthcare professionals affected during the termination process?''. Second theme about how they acted in the process has been defined as ''What do healthcare professionals do in the termination process?''.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAs a result of our study, it was determined that health professionals working on pregnancy termination were adversely affected and had problems while giving care. In order to prevent adverse effects on healthcare professionals, some facilitator methods are needed to strengthen prevention strategies and facilitate the process for them.\u003c/p\u003e","manuscriptTitle":"Looking at pregnancy terminations from the opposite side: the perspective of healthcare professionals","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-09-12 14:14:04","doi":"10.21203/rs.3.rs-3256516/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"984c8910-87e6-45ae-9f64-5cf6613cadfd","owner":[],"postedDate":"September 12th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-12-06T03:59:20+00:00","versionOfRecord":[],"versionCreatedAt":"2023-09-12 14:14:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3256516","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3256516","identity":"rs-3256516","version":["v1"]},"buildId":"Ocjqolx5-0U8gK8KHECj2","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}