If prenatal tests detect a genetic condition or abnormality in the fetus, a pregnant woman may be offered a termination under the serious handicap ground of the Abortion Act 1967, which applies in England, Scotland, and Wales. A termination is legal under this ground provided that "there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped". "Serious handicap" is not defined, and it is healthcare professionals' role to interpret its meaning. Two registered medical practitioners must be of the opinion, "formed in good faith", that the legal criteria have been fulfilled. This thesis aims to further understanding of how healthcare professionals decide whether a fetal condition is sufficiently serious for termination. Two phases of research addressed this aim: 1st phase: A systematic review that identified factors influencing healthcare professionals' viewpoints on whether a fetal condition is sufficiently serious for termination. Two syntheses were conducted; a narrative synthesis of 34 surveys, and a thematic synthesis of 14 qualitative studies. A range of medical and non-medical factors were identified. 2nd phase: Primary empirical research, comprising a context-specific Q-methodological study, which identified and systematically characterised the different ways the serious handicap ground is interpreted by healthcare professionals working in prenatal testing and terminations for fetal abnormality in the UK. Forty-eight participants completed a 36-statement Q-sort. Q-factor analysis produced four statistically independent viewpoints reflecting different interpretations. Findings are synthesised to provide a comprehensive description of how the viewpoints of healthcare professionals on whether a condition is sufficiently serious for termination are constructed. The ambiguities of interpreting the serious handicap ground are discussed. In addition, the implications of variation in interpretation of "seriousness" are considered in light of development of guidelines for healthcare professionals and the Abortion Act, should this ground be amended.

Despite the high public profile of abortion, and the fact that men play a shared role in the creation of any pregnancy, men have been accorded little visibility in research, debates and the media in relation to abortion. This study argues the importance of conducting research with men in relation to (1) the decision-making process to have an abortion, (2) the male role and the provision of support, (3) the psychological responses of men involved in an abortion and (4) the positioning of men with regard to the moral aspects of abortion. A further research aim was to explore how men involved in abortion speak about responsibility in relation to contraception. Data was collected through semi-structured interviews with eight men ranging in age from 25-34 yrs, whose respective partners / ex-partners had undergone a legal abortion for reasons other than foetal abnormality within the last eight years. Interpretative Phenomenological Analysis was employed as the primary method of analysis, while Foucauldian Discourse Analysis was used to address the research aim regarding contraception. The main findings were that in the decision-making process to have an abortion the men experienced feelings of powerlessness, compounded by ineffective communication with their partners. The men tended to feel that they lacked a role in relation to abortion and they appeared somewhat uncomfortable within a support role. There were both positive and negative responses to the abortion, including feeling relief, becoming more responsible, being wary of future relationships and feeling shame. The men appeared to attempt to distance themselves from thinking about the moral aspects of abortion. Finally, men's cultural positioning in relation to contraception (as not responsible and marginalised) was very apparent in their talk about contraception in the context of abortion. The importance of placing psychological research within the social context was discussed and the results suggested that the male participants' experiences of abortion were strongly influenced by dominant societal discourses about men and women. It was argued that abortion is a topic that challenges the traditional gender roles. The possible implications of the research, alongside a continued increase in the visibility of men in relation to abortion, were discussed regarding men's and women's experiences of abortion, further research, service provision and social policy.

Background: Measuring unsafe abortion is essential to understand the magnitude of the problem and monitor progress in women’s reproductive health. However, legal and societal constraints in high-burden contexts foster underreporting of induced abortions which makes obtaining accurate estimates challenging. My PhD examines the methodological challenges around defining and measuring unsafe abortions using Zambia as my country context. Methods: First, I conducted interrupted time series analysis on admissions for abortion-related complications and deaths from 2007-2015 at University Teaching Hospital (UTH), Lusaka to assess the impact of key contextual changes. Second, I collected data from women hospitalized for abortion-related complications in three provinces to estimate the incidence of abortion-related near-miss in 2014. Third, I compared estimates of the incidence of induced abortion in the three provinces using data from 3 methodological approaches. Results: The prevalence of unsafe and induced abortion is high in Zambia. Following the release of clinical guidelines in May 2009, there was an immediate decline in the absolute number of abortion complications by 86 cases (p=0.003). The abortion-related near-miss incidence rate was 72 per 100,000 women, and it was feasible to apply the adapted WHO near-miss criteria in Zambia. Estimates of the incidence of induced abortion per 1000 women ranged from 30 to 80. There was variation in the proportion of women estimated to seek facility care for abortion-related complications in each approach. Conclusion: The burden of unsafe abortion is high in Zambia despite its liberal law. Although there is no gold standard method to measure the burden of unsafe abortion, my findings suggest there is scope to improve use of available data to describe the burden of the most unsafe abortions and evaluate the impact of interventions on abortion-related indicators in restrictive contexts.

Introduction: Prenatal diagnosis for genetic conditions has been available in Pakistan since 1994, however very little is known about this population's attitudes toward prenatal diagnosis or termination of affected pregnancies for different conditions. Advances in molecular biology mean it is possible to offer prenatal diagnosis for an increasing number of conditions and therefore, it is important to assess these attitudes. Objective: To explore Pakistani parents' attitudes toward prenatal diagnosis and termination of affected pregnancies for a range of conditions and the factors that contribute towards such attitudes in parents with and without children affected with conditions. Methodology: Attitudes of 400 parents (200 with affected and 200 with unaffected children) towards diagnosis and termination of pregnancy for 30 different genetic conditions were explored, using a UK questionnaire (Hewison et al., 2007). Factors that affect parents' attitudes towards diagnosis and termination of pregnancy for different genetic conditions were also explored through interviews with 40 parents (20 with affected and 20 with unaffected children). Results: Parents held favourable attitudes to prenatal diagnosis and termination of pregnancy for different conditions. Only 3% of parents wanted no prenatal diagnosis and 13.8% did not want termination of pregnancy at all. Mothers and fathers had similar attitudes towards prenatal diagnosis and termination of pregnancy but mothers had higher acceptability of prenatal diagnosis and termination of pregnancy than fathers. Similarly, parents with affected children were more in favour of prenatal diagnosis and termination of pregnancy than parents with unaffected children. The variation in parents' attitudes showed that there was more acceptability for prenatal diagnosis and termination of pregnancy for conditions perceived to be more severe. The most important factors in most parents' decision about termination of pregnancy were suffering of the child and the family, negative attitudes of society, availability of required resources to care for an affected child and and religious beliefs. There was lack of awareness about Islam's stance on termination of pregnancy. The role of family members and health care providers in decision making related to prenatal diagnosis and termination of pregnancy was considered important by some but not all parents. Conclusion: The findings challenged the stereotypes about the non acceptance of termination of pregnancy for genetic conditions in Muslim populations. There is a need to raise awareness of genetic conditions, Islam's stance on termination of pregnancy and availability of screening and prevention services of genetic conditions in Pakistan. The study also highlighted the need for a comprehensive policy on the offer of testing and termination for genetic conditions in Pakistan to ensure easy access to at-risk parents. Furthermore, clinical guidelines should be developed for healthcare providers to facilitate autonomous decision making through the provision of information for parents on testing and termination issues. Technological advances in the field of genetic testing are not only providing more reproductive choices to parents but are also presenting them with more dilemmas.

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