Validity of Studies

Thomas W. Strahan Memorial Library
Index
Standard of Care for Abortion
Abortion Decision-Making
Psychological Effects of Abortion
Social Effects and Implications
Physical Effects of Abortion
Abortion and Maternal Mortality
Adolescents and Abortion
Definition of Terms
Women's Health After Abortion
Material Yet to be Cataloged
Strahan Summary Articles

Sub-Index
Psychological Effects
Validity of Studies
Reviews
Risk Factors
PTSD
Grief and Loss
Guilt
Ambivalence or Inner Conflict
Anxiety
Intrusion / Avoidance / Nightmares
Denial
Dissociation
Narcissism
Self-Image
Self Punishment
Depression
Psychiatric Treatment
Self-Destructive Behavior
Substance Abuse
Long-Terms Effects of Abortion
Replacement Pregnancies
Sterilization
Impact of Abortion On Others
Violence
Rape, Incest, Sexual Assault
After Late Term Abortion

Please Submit New Material for This Protected Page Here

Validity of Studies

Women’s Health after Abortion.The Medical and Psychological Evidence, E Ring-Cassidy, I Gentiles (Toronto: The deVeber Institute for Bioethics and Social Research, 2002) 255.

Research on the effects of abortion on women’s health, especially in North America, is highly prone to the problem of selective citation. Some researchers refer only to previous studies with which they agree and do not consult, or mention those studies whose conclusions differ from their own.

"The Psychological Complications of Therapeutic Abortion," G Zolese and CVR Blacker, Br J Psychiatry 160: 724, 1992

Women who choose abortion are not amenable to endless questions on how they feel, are less likely to return for follow-up, and baseline assessments before they become pregnant are impossible. Most psychological studies were conducted when standardized psychiatric instruments were not available or used self-devised questionnaires without proven reliability.

From the Patient’s Perspective - Quality of Abortion Care, Picker Institute. (1999). Boston, MA.

A survey of 2,215 abortion patients in 12 abortion clinics in the US found that two out of three women do not return for follow-up appointments at the abortion clinic. (comment: Poor followup may result in underestimation of the problem of significant adjustment problems post-abortion.)

"Emotional Sequelae of Elective Abortion," I Kent et al, British Columbia Medical Journal 20:118, 1978

Sharp discrepancies were noted between data derived from a questionnaire survey administered through a general practice with the responses of women in a therapy group with deep and painful feelings not emerging in a questionnaire survey.

Aborted Women: Silent No More, David C Reardon, (Chicago: Loyola University Press, 1987

In a survey of long-term effects of abortion on women, over 70% reported there was a time when they would have denied the existence of any reactions from their abortion. For some, denial lasted only a few months; for others it lasted over 10-15 years. Subsequently, they were able to share the severe adverse effects of abortion on their lives.

"Underreporting Sensitive Behaviors: The Case of Young Women's Willingness to Report Abortion," LB Smith et al, Health Psychology 18(1): 37, 1999

U.S. young women were likely not to disclose prior induced abortion when interviewed. They were more likely to disclose smoking habits than abortion history.

"Some Problems Caused by Not Having a Conceptual Foundation for Health Research: An Illustration From Studies of the Psychological Effects of Abortion," EJ Posavac and TQ Miller, Psychology and Health 5:13, 1990

The authors reviewed 24 empirical studies and concluded that psychological research was of poor quality, failed to state the basis of the theory to be tested, failed to track women over time, and made superficial assessments.

"Psychological Impact of Abortion: Methodological and Outcomes Summary of Emperical Research Between 1966 and 1988," JL Rogers et al, Health Care for Women Int'l10:347,1989.

Concludes that the literature on the psychological sequelae is seriously flawed and makes suggestions for critique of the literature. The authors conclude that both advocates and opponents of abortion can prove their points by judiciously referring only to articles supporting their political agenda.

"Mental Health and Abortions: Review and Analysis," Philip G. Ney and A. Wickett, Psychiatric Univ. Ottawa 14(4): 506-516, (1989)

A review of the literature shows a need for more long-term, in-depth studies; there's no satisfactory evidence that abortion improves the psychological state of those not mentally ill; mental ill-health is worsened by abortion; there is an alarming rate of post-abortion complications such as pelvic inflammatory disease and subsequent infertility.

"Psychiatric Aspects of Therapeutic Abortion," B. Doane and B. Quigley, CMA Journal 125:427-432, September 1, 1981

Concludes that a search of the literature on the psychiatric aspects of abortion reveal poor study design, lack of clear criteria for decisions for or against abortion, poor definition of psychologic symptoms experienced by patients, absence of control groups in clinical studies, indecisiveness and uncritical attitudes in writers from various disciplines. The study also concludes that "there is little evidence that differences in abortion legislation account for significant differences in the psychologic reactions of patients to abortion."

"Psychological and Social Aspects of Induced Abortion," J.A. Handy, British Journal of Clinical Psychology, February 21, 1982, Part I, pp. 29-41

A good summary of prior studies on the effects of abortion; states that a variety of methodological faults makes the results of many studies difficult to interpret.

"Interpreting Literature on Abortion," (letter), WL Larimore, DB Larson, KA Sherrill, American Family Physician 46(3):665-666, Sept 1992

Various review articles on abortion share few of the same references, interpretation of the same article differs between reviewers.

"Abortion: A Social-Psychological Perspective," Nancy Adler, Journal of Social Issues 35(l): 100-119 (1979)

Concludes there is a need for continuing research on the negative effects of abortion and for intervention designed to diminish those negative effects for all concerned.

"Psychiatric Sequelae of Induced Abortion," Mary Gibbons, Journal of the Royal College of General Practitioners 34:146-150(1984)

Observes that many studies concluding that few psychiatric problems follow induced abortion were deficient in methodology, material or length of follow-up. It concludes that a large amount of the previously reported research on the psychiatric indications of abortion may be unreliable.

Qualitative Studies

Social Sources of Women's Emotional Difficulty After Abortion: Lessons from Women's Abortion Narratives. Kimport, K., Foster, K. and Weitz, T. A. (2011), Perspectives on Sexual and Reproductive Health, 43: 103–109.

CONTEXT: The experiences of women who have negative emotional outcomes, including regret, following an abortion have received little research attention. Qualitative research can elucidate these women’s experiences and ways their needs can be met and emotional distress reduced.

METHODS: Twenty-one women who had emotional difficulties related to an abortion participated in semi-structured, in-depth telephone interviews in 2009. Of these, 14 women were recruited from abortion support talklines; seven were recruited from a separate research project on women’s experience of abortion. Transcripts were analyzed using the principles of grounded theory to identify key themes.

RESULTS: Two social aspects of the abortion experience produced, exacerbated or mitigated respondents’ negative emotional experience. Negative outcomes were experienced when the woman did not feel that the abortion was primarily her decision (e.g., because her partner abdicated responsibility for the pregnancy, leaving her feeling as though she had no other choice) or did not feel that she had clear emotional support after the abortion. Evidence also points to a division of labor between women and men regarding pregnancy prevention, abortion and childrearing; as a result, the majority of abortion-related emotional burdens fall on women. Experiencing decisional autonomy or social support reduced respondents’ emotional distress.

CONCLUSIONS: Supporting a woman’s abortion decision-making process, addressing the division of labor between women and men regarding pregnancy prevention, abortion and childrearing, and offering nonjudgmental support may guide interventions designed to reduce emotional distress after abortion.

Editor comments: This may be the first study ever published by the Guttmacher Institute on emotional problems post-abortion. While it is a very limited study that is qualitative in nature with a very small sample size, what is useful are the admissions that:

1. post-abortion psychological problems are not religiously based;
2. a woman seeking an abortion needs nonjudgmental support in the decision making process;
3. secret abortions are likely to cause emotional difficulties;
4. relationship counseling services are needed echoing our previous research; and
5. disengaging partner, family and friends during the abortion decision making stage is ill-advised.

Risk Factors for Adverse Emotional Consequences of Abortion

Abortion decisions and the duty to screen: clinical, ethical, and legal implications of predictive risk factors of post-abortion maladjustment. Reardon DC. The Journal of Contemporary Health Law & Policy J Contemp Health Law Policy. 2003 Winter;20(1):33-114

A comprehensive review of the literature on risk factors associated with abortion. Includes tables with over 40 statistically validated risk factors and citations to the studies identifying and validating these risk factors. The complete text of Abortion Decisions and the Duty to Screen is available through this link.

See also Risk_factors

"Complicated Mourning: Dynamics of Impacted Pre and Post-Abortion Grief," Anne Speckland, Vincent Rue, Pre and Perinatal Psychology Journal 8(81 ):5, Fall, 1993.

Emotional harm from abortion is more likely when one or more of the following risk factors are present: prior history of mental illness; immature interpersonal relationships; unstable, conflicted relationship with one's partner; history of negative relationship with one's mother; ambivalence regarding abortion; religious and cultural background hostile to abortion; single status especially if no born children; adolescent; second-trimester abortion; abortion for genetic reason; pressure and coercion to abort; prior abortion; prior children; maternal orientation.

"Adolescent Abortion Option," G. Zakus, S. Wilday, Social Work in Health Care, 12(4):77, Summer, 1987.

Certain categories of women are much more likely to have post-abortion problems sometimes many months or years later. These include: being forced or coerced into abortion; women who place great emphasis on future fertility plans; women with pre- existing psychiatric problems; women suffering from unresolved grief reactions or women with a history of sexual abuse, including incest, molestation or rape.

"Outcome Following Therapeutic Abortion," R.C. Payne, A.R. Kravitz, M.T. Notman, J.V. Anderson, Arch. Gen. Psychiatry 33:725, June, 1976.

This study measured short- term outcomes of anxiety, depression, anger, guilt and shame following abortion. The authors concluded that women who are most vulnerable to difficulty are those who are single and nulliparous, those with previous history of serious emotional problems, conflicted relationships to lovers, past negative relationships to mother, ambivalence toward abortion or negative religious or cultural attitudes about abortion.

"The Decision-Making Process and the Outcome of Therapeutic Abortion, C," Friedman, R. Greenspan and F. Mittleman, American Journal of Psychiatry 131(12): 1332-1337, December 1974.

There is high risk for post-abortion psychiatric illness when there is (1) Strong ambivalence; (2) Coercion; (3) Medical indication; (4) Concomitant psychiatric illness and (5) A woman feeling the decision was not her own.

"Women's Emotions One Week After Receiving or Being Denied an Abortion in the United States." Rocca CH, Kimport H, Gould H, Foster DG. Perspectives on Sexual and Reproductive Health, 45(3)(2013).

Methods: Baseline data from a longitudinal study of women seeking abortion at 30 U.S. facilities between 2008 and 2010 were used to examine emotions among 843 women who received an abortion just prior to the facility's gestational age limit, were denied an abortion because they presented just beyond the gestational limit or obtained a first-trimester abortion. Multivariable analyses were used to compare women's emotions about their pregnancy and about their receipt or denial of abortion after one week, and to identify variables associated with experiencing primarily negative emotions postabortion.

Results: Compared with women who obtained a near-limit abortion, those denied the abortion felt more regret and anger (scoring, on average, 0.4–0.5 points higher on a 0–4 scale), and less relief and happiness (scoring 1.4 and 0.3 points lower, respectively). Among women who had obtained the abortion, the greater the extent to which they had planned the pregnancy or had difficulty deciding to seek abortion, the more likely they were to feel primarily negative emotions (odds ratios, 1.2 and 2.5, respectively). Most (95%) women who had obtained the abortion felt it was the right decision, as did 89% of those who expressed regret.

Conclusions: Difficulty with the abortion decision and the degree to which the pregnancy had been planned were most important for women's postabortion emotional state. Experiencing negative emotions postabortion is different from believing that abortion was not the right decision.

Editor comments: Despite a low participation rate (38%), this study reported: 53% of women who aborted felt guilt, 41% regret, 64% sadness and 31% anger. And this was only one week post-abortion! Interestingly, only one out of four pregnancy partners wanted the abortion. As to decision difficulty for the women, more than one out of two (56%) indicated the abortion decision was “somewhat or very difficult.”

Prior History of Psychiatric Illness

Incidence and recurrence of common mental disorders after abortion: Results from a prospective cohort study. van Ditzhuijzen J, Ten Have M, de Graaf R, Lugtig P, van Nijnatten CH, Vollebergh WA. J Psychiatr Res. 2017 Jan;84:200-206. doi: 10.1016/j.jpsychires.2016.10.006. Epub 2016 Oct 11.

Abstract: Research in the field of mental health consequences of abortion is characterized by methodological limitations. We used exact matching on carefully selected confounders in a prospective cohort study of 325 women who had an abortion of an unwanted pregnancy and compared them 1-to-1 to controls who did not have this experience. Outcome measures were incidence and recurrence of common DSM-IV mental disorders (mood, anxiety, substance use disorders, and the aggregate measure 'any mental disorder') as measured with the Composite International Diagnostic Interview (CIDI) version 3.0, in the 2.5-3 years after the abortion. Although non-matched data suggested otherwise, women in the abortion group did not show significantly higher odds for incidence of 'any mental disorder', or mood, anxiety and substance use disorders, compared to matched controls who were similar in background variables but did not have an this experience. Having an abortion did not increase the odds for recurrence of the three disorder categories, but for any mental disorder the higher odds in the abortion group remained significant after matching. It is unlikely that termination of an unwanted pregnancy increases the risk on incidence of common mental disorders in women without a psychiatric history. However, it might increase the risk of recurrence among women with a history of mental disorders.

NOTES: Main problems: This study used a very small number of women and therefore had very low statstical power, resulting in very wide confidence intervals which could clearly include much higher rates of psychological illness.

Second, the control group doubtlessly includes women concealing abortion history.

Third, the abortion group has highly self-censured indicating that women at greatest risk of negative reactions excluded themselves from the study sample or dropped out. 56% of the 2443 initially asked to participate refused outright. By the time the first interview (20-40 days after the abortion) was scheduled, 22% of those previously agreeing refused and another 42% could not be contacted (perhaps gave false contact info or otherwise avoided the interview. As a result, only 35.8% of those who initially they were willing to participate, and 13% of those eligible to participate, actually did participate at the T0 interview. The T1 interview, three years post-abortion, saw a drop out rate of 19%, from 325 to 264 participants. Thus, the T1 data represented just 29% of those who agreed to be studied and just 11% of the eligible sample. (See van Ditzhuijzen 2013 for a complete flow chart of participation and drop outs from invite through T0.)

It is also notable that recurrent 20.7% of women having abortions reported recurrent substance use disorders at three years post-abortion compared to 0% for their matched control group. This was not discussed by the study's authors. Notably, substance use is one of the most frequent problems.

Psychiatric history of women who have had an abortion. van Ditzhuijzen J, ten Have M, de Graaf R, van Nijnatten CH, Vollebergh WA. J Psychiatr Res. 2013 Nov;47(11):1737-43. doi: 10.1016/j.jpsychires.2013.07.024.

Abstract. Prior research has focused primarily on the mental health consequences of abortion; little is known about mental health before abortion. In this study, the psychiatric history of women who have had an abortion is investigated. 325 Women who recently had an abortion were compared with 1902 women from the population-based Netherlands Mental Health Survey and Incidence Study (NEMESIS-2). Lifetime prevalence estimates of various mental disorders were measured using the Composite International Diagnostic Interview 3.0. Compared to the reference sample, women in the abortion sample were three times more likely to report a history of any mental disorder (OR = 3.06, 95% CI = 2.36–3.98). The highest odds were found for conduct disorder (OR = 6.97, 95% CI = 4.41–11.01) and drug dependence (OR = 4.96, 95% CI = 2.55–9.66). Similar results were found for lifetime-minus-last-year prevalence estimates and for women who had first-time abortions only. The results support the notion that psychiatric history may explain associations that have been found between abortion and mental health. Psychiatric history should therefore be taken into account when investigating the mental health consequences of abortion.

The impact of psychiatric history on women's pre- and postabortion experiences. van Ditzhuijzen J, Ten Have M, de Graaf R, van Nijnatten CH, Vollebergh WA. Contraception. 2015 Sep;92(3):246-53. doi: 10.1016/j.contraception.2015.05.003.

OBJECTIVE: The objective of this study is to investigate to what extent psychiatric history affects preabortion decision difficulty, experienced burden, and postabortion emotions and coping. Women with and without a history of mental disorders might respond differently to unwanted pregnancy and subsequent abortion.

STUDY DESIGN: Women who had an abortion (n=325) were classified as either with or without a history of mental disorders, using the Composite International Diagnostic Interview version 3.0. The two groups were compared on preabortion doubt, postabortion decision uncertainty, experienced pressure, experienced burden of unwanted pregnancy and abortion, and postabortion emotions, self-efficacy and coping. The study was conducted in the Netherlands. Data were collected using structured face-to-face interviews and analyzed with regression analyses.

RESULTS: Compared to women without prior mental disorders, women with a psychiatric history were more likely to report higher levels of doubt [odds ratio (OR)=2.30; confidence interval (CI)=1.29-4.09], more burden of the pregnancy (OR=2.23; CI=1.34-3.70) and the abortion (OR=1.93; CI=1.12-3.34) and more negative postabortion emotions (β=.16; CI=.05-.28). They also scored lower on abortion-specific self-efficacy (β=-.11; CI=-.22 to .00) and higher on emotion-oriented (β=.22; .11-.33) and avoidance-oriented coping (β=.12; CI=.01-.24). The two groups did not differ significantly in terms of experienced pressure, decision uncertainty and positive postabortion emotions.

CONCLUSIONS: Psychiatric history strongly affects women's pre- and postabortion experiences. Women with a history of mental disorders experience a more stressful pre- and postabortion period in terms of preabortion doubt, burden of pregnancy and abortion, and postabortion emotions, self-efficacy and coping.

IMPLICATIONS: Negative abortion experiences may, at least partially, stem from prior or underlying mental health problems.

[Is underage abortion associated with adverse outcomes in early adulthood? A longitudinal birth cohort study up to 25 years of age.] Leppälahti S, Heikinheimo O, Kalliala I, Santalahti P, Gissler M. Hum Reprod. 2016 Sep;31(9):2142-9. doi: 10.1093/humrep/dew178.

STUDY QUESTION: Is underage abortion associated with adverse socioeconomic and health outcomes in early adulthood when compared with underage delivery?

SUMMARY ANSWER: Underage abortion was not found to be associated with mental health problems in early adulthood, and socioeconomic outcomes were better among those who experienced abortion compared with those who gave birth.

WHAT IS KNOWN ALREADY: Teenage motherhood has been linked with numerous adverse outcomes in later life, including low educational levels and poor physical and mental health. Whether abortion at a young age predisposes to similar consequences is not clear.

STUDY DESIGN, SIZE, DURATION: This nationwide, retrospective cohort study from Finland, included all women born in 1987 (n = 29 041) and followed until 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS: We analysed socioeconomic, psychiatric and risk-taking-related health outcomes up to 25 years of age after underage (<18 years) abortion (n = 1041, 3.6%) and after childbirth (n = 394, 1.4%). Before and after conception analyses within the study groups were performed to further examine the association between abortion and adverse health outcomes. A group with no pregnancies up to 20 years of age (n = 25 312, 88.0%) served as an external reference group.

MAIN RESULTS AND THE ROLE OF CHANCE: We found no significant differences between the underage abortion and the childbirth group regarding risks of psychiatric disorders (adjusted odds ratio 0.96 [0.67-1.40]) or suffering from intentional or unintentional poisoning by medications or drugs (1.06 [0.57-1.98]). Compared with those who gave birth, girls who underwent abortion were less likely to achieve only a low educational level (0.41 [95% confidence interval 0.31-0.54]) or to be welfare-dependent (0.31 [0.22-0.45]), but more likely to suffer from injuries (1.51 [1.09-2.10]). Compared with the external control group, both pregnancy groups were disadvantaged already prior to the pregnancy. Psychiatric disorders and risk-taking-related health outcomes, including injury, were increased in the abortion group and in the childbirth group similarly on both sides of the pregnancy.

LIMITATIONS, REASONS FOR CAUTION: The retrospective nature of the study remains a limitation. The identification of study subjects in order to collect additional data was not allowed for ethical reasons. Therefore further confounding factors, such as the intentionality of the pregnancy, could not be checked.

WIDER IMPLICATIONS OF THE FINDINGS: Previous studies have found that abortion is not harmful to mental health in the majority of adult women. Our study adds to the current understanding in suggesting that this is also the case concerning underage girls. Furthermore, women with a history of underage abortion had better socioeconomic outcomes compared with those who gave birth. These findings can be generalized to settings of high-quality social and health-care services, where abortion is accessible and affordable to all citizens. Social and health-care professionals who care for and counsel underage girls facing unplanned pregnancy should acknowledge this information.

STUDY FUNDING/COMPETING INTERESTS: This study was financially supported by the Finnish Cultural Foundation and the Päivikki and Sakari Sohlberg Foundation. The researchers are independent of funders and the funders had no role in the study design, in the collection, analysis and interpretation of data, in the writing of the report or in the decision to submit the article for publication. The authors have no competing interests.

Induced abortions and birth outcomes of women with a history of severe psychosocial problems in adolescence. Lehti V, Gissler M, Suvisaari J, Manninen M. Eur Psychiatry. 2015 Sep;30(6):750-5. doi: 10.1016/j.eurpsy.2015.05.005

OBJECTIVE: To increase knowledge on the reproductive health of women who have been placed in a residential school, a child welfare facility for adolescents with severe psychosocial problems.

METHODS: All women (n=291) who lived in the Finnish residential schools on the last day of the years 1991, 1996, 2001 and 2006 were included in this study and compared with matched general population controls. Register-based information on induced abortions and births was collected until the end of the year 2011.

RESULTS: Compared to controls, women with a residential school history had more induced abortions. A higher proportion of their births took place when they were teenagers or even minors. They were more often single, smoked significantly more during pregnancy and had a higher risk of having a preterm birth or a baby with a low birth weight.

CONCLUSIONS: The findings have implications for the planning of preventive and supportive interventions that aim to increase the well-being of women with a residential school history and their offspring.

Prior History of Abortion

A study of psychiatric morbidity during second trimester of pregnancy subsequent to abortion in the previous pregnancy. Chalana H, Sachdeva JK. Asian J Psychiatr. 2012 Sep;5(3):215-9. doi: 10.1016/j.ajp.2011.11.006.

INTRODUCTION: Pregnancy plays a unique role in the transformation of women towards completeness. For those women who have had a previous unsuccessful outcome, pregnancy may bring a lot of inevitable negative emotions. We studied psychiatric morbidity during second trimester of pregnancy subsequent to abortion in the previous pregnancy.

METHODS: The study was carried out in Dayanand Medical College and Hospital, Ludhiana, India. A total of 120 patients were divided into 4 groups depending on their pregnancy status. All the groups were compared with each other regarding their psychiatric morbidities, which were measured using various rating scales such as Hamilton Depression rating scale, Hamilton Anxiety Rating Scale, State Trait Anxiety Inventory, Presumptive Stressful Life events Scale, and Brief Psychotic Rating Scale.

RESULTS: We found that subjects with history of previous abortion, whether single or more had significantly higher mean depression and anxiety score than primigravida or subjects with history of previous successful pregnancy; depression and anxiety scores decreased with increase in time gap between abortion and current pregnancy. High anxiety was found in 36.67%(11) of females with history of previous abortion. We also found that 36.67%(11) of subjects with previous single abortion and 30%(9) of subjects with previous 2 or more abortions were suffering from depressive episode. None of the female suffered from psychotic disorder.

CONCLUSIONS: The incidence of depression and anxiety is high in pregnancy after previous abortion and more in subjects who conceive earlier after previous abortion. These results warrant the need for screening all pregnancies for psychiatric morbidity after a previous abortion.

Postpartum Disorder Following Pregnancy Loss

Increased risk for postpartum psychiatric disorders among women with past pregnancy loss. Giannandrea SA, Cerulli C, Anson E, Chaudron LH. J Womens Health (Larchmt). 2013 Sep;22(9):760-8. doi: 10.1089/jwh.2012.4011.

Abstract Background: Scant literature exists on whether prior pregnancy loss (miscarriage, stillbirth, and/or induced abortion) increases the risk of postpartum psychiatric disorders-specifically depression and anxiety-after subsequent births. This study compares: (1) risk factors for depression and/or anxiety disorders in the postpartum year among women with and without prior pregnancy loss; and (2) rates of these disorders in women with one versus multiple pregnancy losses.

Methods: One-hundred-ninety-two women recruited at first-year pediatric well-child care visits from an urban pediatric clinic provided demographic information, reproductive and health histories. They also completed depression screening tools and a standard semi-structured psychiatric diagnostic interview.

Results: Almost half of the participants (49%) reported a previous pregnancy loss (miscarriage, stillbirth, or induced abortion). More than half of those with a history of pregnancy loss reported more than one loss (52%). Women with prior pregnancy loss were more likely to be diagnosed with major depression (p=0.002) than women without a history of loss. Women with multiple losses were more likely to be diagnosed with major depression (p=0.047) and/or post-traumatic stress disorder (Fisher's exact [FET]=0.028) than women with a history of one pregnancy loss. Loss type was not related to depression, although number of losses was related to the presence of depression and anxiety.

Conclusions: Low-income urban mothers have high rates of pregnancy loss and often have experienced more than one loss and/or more than one type of loss. Women with a history of pregnancy loss are at increased risk for depression and anxiety, including post-traumatic stress disorder (PTSD), after the birth of a child. Future research is needed to understand the reasons that previous pregnancy loss is associated with subsequent postpartum depression and anxiety among this population of women.

"Predictors of postpartum post-traumatic stress disorder in primiparous mothers.[Article in French] Montmasson H1, Bertrand P, Perrotin F, El-Hage W. J Gynecol Obstet Biol Reprod (Paris). 2012 Oct;41(6):553-60. doi: 10.1016/j.jgyn.2012.04.010. Epub 2012 May 21.

A history of abortion was associated with a six fold increased risk of subsequent postpartum PTSD.

Previous prenatal loss as a predictor of perinatal depression and anxiety. Blackmore ER, Côté-Arsenault D, Tang W, Glover V, Evans J, Golding J, O'Connor TG. Br J Psychiatry. 2011 May;198(5):373-8. doi: 10.1192/bjp.bp.110.083105. Epub 2011 Mar 3.

Results: Generalised estimating equations indicated that the number of previous miscarriages/stillbirths significantly predicted symptoms of depression (β = 0.18, s.e. = 0.07, P<0.01) and anxiety (β = 0.14, s.e. = 0.05, P<0.01) in a subsequent pregnancy, independent of key psychosocial and obstetric factors. This association remained constant across the pre- and postnatal period, indicating that the impact of a previous prenatal loss did not diminish significantly following the birth of a healthy child.

Conclusions: Depression and anxiety associated with a previous prenatal loss shows a persisting pattern that continues after the birth of a subsequent (healthy) child. Interventions targeting women with previous prenatal loss may improve the health outcomes of women and their children.

Other Studies Suggestive of Psychiatric Stress During Subsequent Pregnancies

A history of induced abortion in relation to substance use during subsequent pregnancies carried to term. Coleman PK, Reardon DC, Rue VM, Cougle J. Am J Obstet Gynecol. 2002 Dec;187(6):1673-8.

Hospitalization for mental illness among parents after the death of a child. Li J, Laursen TM, Precht DH, Olsen J, Mortensen PB. N Engl J Med. 2005;352(12):1190-1196. doi:10.1056/NEJMoa033160.

Abortion Compared to Birth or Miscarriage

Psychological Impact on Women of Miscarriage Versus Induced Abortion: A 2-Year follow-up study. Broen AN, Moum T, Bödtker AS, Ekeberg O. Psychosomatic Medicine, 2004, 66:265-271.

"The feeling relief (at T1) had no significant influence on the IES scores at T3, unadjusted or adjusted." (p 268) This supports an argument that researchers who place too much emphasis on measure of relief may be missing the full picture.

p270, "mental health before the event suprisingly had no significant independent influence on IES scores."

Reasons for induced abortion and their relation to women's emotional distress: a prospective, two-year follow-up study. Broen AN, Moum T, Bodtker AS, Ekeberg O. Gen Hosp Psychiatry 2005, 27:36-43.

OBJECTIVE: The present study aimed to identify the most important reasons for induced abortion and to examine their relationship to emotional distress at follow-up. METHODS: Eighty women were included in the study. The women were interviewed 10 days, 6 months (T2) and 2 years (T3) after they underwent an abortion. At all time points, the participants completed the Impact of Event Scale and a questionnaire about feelings connected to the abortion. RESULTS: Reasons related to education, job and finances were highly rated. Also, "a child should be wished for," "male partner does not favour having a child at the moment," "tired, worn out" and "have enough children" were important reasons. "Pressure from male partner" was listed as the 11th most important reason. When the reasons for abortion and background variables were included in multiple regression analyses, the strongest predictor of emotional distress at T2 and T3 was "pressure from male partner." CONCLUSION: Male pressure on women to have an induced abortion has a significant, negative influence on women's psychological responses in the 2 years following the event. Women who gave the reason "have enough children" for choosing abortion reported slightly better psychological outcomes at T3.

The course of mental health after miscarriage and induced abortion: a five-year follow-up study. Broen AN, Moum T, Bødtker AS, Ekeberg O. BMC Medicine 2005, 3:18 (12 December 2005)

Broen et al.'s results show that women who had a miscarriage suffer more mental distress up until six months after the event than women who had an abortion. Women who had an abortion, however, experienced more mental distress long after the event - two and five years afterwards - than women who had a miscarriage. Women who experienced induced abortion had significantly greater IES scores for avoidance and for the feelings of guilt, shame and relief than the miscarriage group at two and five years after the pregnancy termination (IES avoidance means: 3.2 vs 9.3 at T3, respectively, p < 0.001; 1.5 vs 8.3 at T4, respectively, p < 0.001). Compared with the general population, women who had undergone induced abortion had significantly higher HADS anxiety scores at all four interviews (p < 0.01 to p < 0.001), while women who had had a miscarriage had significantly higher anxiety scores only at T1 (p < 0.01).

Predictors of anxiety and depression following pregnancy termination: a longitudinal five-year follow-up study. Broen AN, Moum T, Bödtker AS, Ekeberg O. Acta Obstet Gynecol Scand. 2006;85(3):317-23.

BACKGROUND: The aims of the study were to assess anxiety and depression in women who had experienced either a miscarriage or an induced abortion, to compare the women's level of distress with that of a general population sample, and to find predictors of anxiety and depression six months and five years after the event.

METHODS: A prospective, longitudinal follow-up study. Women who experienced miscarriage (n = 40) and induced abortion (n = 80) were interviewed ten days (T1), six months (T2), two years (T3), and five years (T4) after the event. On each occasion, they completed the Hospital Anxiety and Depression Scale and the Life Events Scale. Paired-sample t-test, logistic regression, and multiple linear regression statistical tests were used.

RESULTS: Women with miscarriage had significantly more anxiety and depression at T1 than the general population, while women with induced abortion had significantly more anxiety at all time points and more depression at T1 and T2. In both groups, important predictors of anxiety and depression at T2 and T4 were recent life events and poor former psychiatric health. Childbirth events between T1 and T4 had no significant influence on the scores. For women with induced abortion, doubt about the decision to abort was related to depression at T2 (p <0.05), while a negative attitude towards induced abortion was associated with anxiety at T2 (p <0.05) and T4 (p <0.05).

CONCLUSION: Correlates of anxiety and depression may be used to better identify women who are at risk of negative psychological responses following pregnancy termination.

"Psychological impact on women after second and third trimester termination of pregnancy due to fetal anomalies versus women after preterm birth—a 14-month follow up study" Kersting A, et al. Arch Womens Ment Health. 2009 Aug;12(4):193-201. Epub 2009 Mar 6.

(ABSTRACT) The objective of this study was to compare psychiatric morbidity and the course of posttraumatic stress, depression, and anxiety in two groups with severe complications during pregnancy, women after termination of late pregnancy (TOP) due to fetal anomalies and women after preterm birth (PRE). As control group women after the delivery of a healthy child were assessed. A consecutive sample of women who experienced a) termination of late pregnancy in the 2nd or 3rd-trimester (N = 62), or b) preterm birth (N = 43), or c) birth of a healthy child (N = 65) was investigated 14 days (T1), 6 months (T2), and 14 months (T3) after the event. At T1, 22.4% of the women after TOP were diagnosed with a psychiatric disorder compared to 18.5% women after PRE, and 6.2% in the control group. The corresponding values at T3 were 16.7%, 7.1%, and 0%. Shortly after the event, a broad spectrum of diagnoses was found; however, 14 months later only affective and anxiety disorders were diagnosed. Posttraumatic stress and clinician-rated depressive symptoms were highest in women after TOP. The short-term emotional reactions to TOP in late pregnancy due to fetal anomaly appear to be more intense than those to preterm birth. Both events can lead to severe psychiatric morbidity with a lasting

psychological impact.

Trauma and grief 2-7 years after termination of pregnancy because of fetal anomalies-a pilot study. Kersting A, et al. J of Psychosomatic Obstetrics & Gynecology 2005; 26(1): 9-14.

The aim of the study was to obtain information on the long-term posttraumatic stress response and grief several years after termination of pregnancy due to fetal malformation. We investigated 83 women who had undergone termination of pregnancy between 1995 and 1999 and compared them with 60 women 14 days after termination of pregnancy and 65 women after the spontaneous delivery of a full-term healthy child. Women 2-7 years after termination of pregnancy were expected to show a significantly lower degree of traumatic experience and grief than women 14 days after termination of pregnancy. Contrary to the hypothesis, however, the results showed no significant intergroup differences with respect to the degree of traumatic experience. With the exception of one subscale (fear of loss), this also applied to the grief reported by the women. However, both groups differed significantly in their posttraumatic stress response from women who had given spontaneous birth to a full-term healthy child. The results indicate that termination of pregnancy is to be seen as an emotionally traumatic major life event which leads to severe posttraumatic stress response and intense grief reactions that are still detectable some years later.

Increased risk for postpartum psychiatric disorders among women with past pregnancy loss. Giannandrea SA, Cerulli C, Anson E, Chaudron LH. J Womens Health (Larchmt). 2013 Sep;22(9):760-8. doi: 10.1089/jwh.2012.4011.

Abstract Background: Scant literature exists on whether prior pregnancy loss (miscarriage, stillbirth, and/or induced abortion) increases the risk of postpartum psychiatric disorders-specifically depression and anxiety-after subsequent births. This study compares: (1) risk factors for depression and/or anxiety disorders in the postpartum year among women with and without prior pregnancy loss; and (2) rates of these disorders in women with one versus multiple pregnancy losses.

Methods: One-hundred-ninety-two women recruited at first-year pediatric well-child care visits from an urban pediatric clinic provided demographic information, reproductive and health histories. They also completed depression screening tools and a standard semi-structured psychiatric diagnostic interview.

Results: Almost half of the participants (49%) reported a previous pregnancy loss (miscarriage, stillbirth, or induced abortion). More than half of those with a history of pregnancy loss reported more than one loss (52%). Women with prior pregnancy loss were more likely to be diagnosed with major depression (p=0.002) than women without a history of loss. Women with multiple losses were more likely to be diagnosed with major depression (p=0.047) and/or post-traumatic stress disorder (Fisher's exact [FET]=0.028) than women with a history of one pregnancy loss. Loss type was not related to depression, although number of losses was related to the presence of depression and anxiety.

Conclusions: Low-income urban mothers have high rates of pregnancy loss and often have experienced more than one loss and/or more than one type of loss. Women with a history of pregnancy loss are at increased risk for depression and anxiety, including post-traumatic stress disorder (PTSD), after the birth of a child. Future research is needed to understand the reasons that previous pregnancy loss is associated with subsequent postpartum depression and anxiety among this population of women.

Abortion in young women and subsequent mental health. Fergusson DM, John Horwood L, Ridder EM. J Child Psychol Psychiatry. 2006 Jan;47(1):16-24.

Background: The extent to which abortion has harmful consequences for mental health remains controversial. We aimed to examine the linkages between having an abortion and mental health outcomes over the interval from age 15-25 years. Methods: Data were gathered as part of the Christchurch Health and Development Study, a 25-year longitudinal study of a birth cohort of New Zealand children. Information was obtained on: a) the history of pregnancy/abortion for female participants over the interval from 15-25 years; b) measures of DSM-IV mental disorders and suicidal behaviour over the intervals 15-18, 18-21 and 21-25 years; and c) childhood, family and related confounding factors. Results: Forty-one percent of women had become pregnant on at least one occasion prior to age 25, with 14.6% having an abortion. Those having an abortion had elevated rates of subsequent mental health problems including depression, anxiety, suicidal behaviours and substance use disorders. This association persisted after adjustment for confounding factors. Conclusions: The findings suggest that abortion in young women may be associated with increased risks of mental health problems.

Women's experiences in relation to stillbirth and risk factors for long-term post-traumatic stress symptoms: a retrospective study. Gravensteen IK, Helgadóttir LB, Jacobsen EM, Rådestad I, Sandset PM, Ekeberg O. BMJ Open. 2013 Oct 22;3(10):e003323. doi: 10.1136/bmjopen-2013-003323.

OBJECTIVES: (1) To investigate the experiences of women with a previous stillbirth and their appraisal of the care they received at the hospital. (2) To assess the long-term level of post-traumatic stress symptoms (PTSS) in this group and identify risk factors for this outcome.

DESIGN: A retrospective study.

SETTING:Two university hospitals.

PARTICIPANTS: The study population comprised 379 women with a verified diagnosis of stillbirth (≥23 gestational weeks or birth weight ≥500 g) in a singleton or twin pregnancy 5-18 years previously. 101 women completed a comprehensive questionnaire in two parts.

PRIMARY AND SECONDARY OUTCOME MEASURES: The women's experiences and appraisal of the care provided by healthcare professionals before, during and after stillbirth. PTSS at follow-up was assessed using the Impact of Event Scale (IES).

RESULTS: The great majority saw (98%) and held (82%) their baby. Most women felt that healthcare professionals were supportive during the delivery (85.6%) and showed respect towards their baby (94.9%). The majority (91.1%) had received some form of short-term follow-up. One-third showed clinically significant long-term PTSS (IES ≥ 20). Independent risk factors were younger age (OR 6.60, 95% CI 1.99 to 21.83), induced abortion prior to stillbirth (OR 5.78, 95% CI 1.56 to 21.38) and higher parity (OR 3.46, 95% CI 1.19 to 10.07) at the time of stillbirth. Having held the baby (OR 0.17, 95% CI 0.05 to 0.56) was associated with less PTSS.

CONCLUSIONS: The great majority saw and held their baby and were satisfied with the support from healthcare professionals. One in three women presented with a clinically significant level of PTSS 5-18 years after stillbirth. Having held the baby was protective, whereas prior induced abortion was a risk factor for a high level of PTSS.

Posttraumatic stress and posttraumatic stress disorder after termination of pregnancy and reproductive loss: a systematic review. Daugirdaitė V, van den Akker O, Purewal S. J Pregnancy. 2015;2015:646345. doi: 10.1155/2015/646345. Epub 2015 Feb 5.

OBJECTIVE: The aims of this systematic review were to integrate the research on posttraumatic stress (PTS) and posttraumatic stress disorder (PTSD) after termination of pregnancy (TOP), miscarriage, perinatal death, stillbirth, neonatal death, and failed in vitro fertilisation (IVF).

METHODS:Electronic databases (AMED, British Nursing Index, CINAHL, MEDLINE, SPORTDiscus, PsycINFO, PubMEd, ScienceDirect) were searched for articles using PRISMA guidelines.

RESULTS: Data from 48 studies were included. Quality of the research was generally good. PTS/PTSD has been investigated in TOP and miscarriage more than perinatal loss, stillbirth, and neonatal death. In all reproductive losses and TOPs, the prevalence of PTS was greater than PTSD, both decreased over time, and longer gestational age is associated with higher levels of PTS/PTSD. Women have generally reported more PTS or PTSD than men. Sociodemographic characteristics (e.g., younger age, lower education, and history of previous traumas or mental health problems) and psychsocial factors influence PTS and PTSD after TOP and reproductive loss.

CONCLUSIONS: This systematic review is the first to investigate PTS/PTSD after reproductive loss. Patients with advanced pregnancies, a history of previous traumas, mental health problems, and adverse psychosocial profiles should be considered as high risk for developing PTS or PTSD following reproductive loss.

Psychiatric admissions of low income women following abortion and childbirth. Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Can Med Assoc J. 2003; 168(10):1253-7

Background: Controversy exists about whether abortion or childbirth is associated with greater psychological risks. We compared psychiatric admission rates of women in time periods from 90 days to 4 years after either abortion or childbirth.

Methods: We used California Medicaid (Medi-Cal) records of women aged 13–49 years at the time of either abortion or childbirth during 1989. Only women who had no psychiatric admissions or pregnancy events during the year before the target pregnancy event were included (n = 56 741). Psychiatric admissions were examined using logistic regression analyses, controlling for age and months of eligibility for Medi-Cal services.

Results: Overall, women who had had an abortion had a significantly higher relative risk of psychiatric admission compared with women who had delivered for every time period examined. Significant differences by major diagnostic categories were found for adjustment reactions (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.1–4.1), single-episode (OR 1.9, 95% CI 1.3–2.9) and recurrent depressive psychosis (OR 2.1, 95% CI 1.3–3.5), and bipolar disorder (OR 3.0, 95% CI 1.5–6.0). Significant differences were also observed when the results were stratified by age.

Interpretation: Subsequent psychiatric admissions are more common among low-income women who have an induced abortion than among those who carry a pregnancy to term, both in the short and longer term.

NOTES:

• Tables showing when the psychiatric hospitalization occurred illustrate a marked peak closer to the time of the pregnancy event, providing support for a causal interpretation.
• Using the same population, the authors also examined outpatient treatment for psychiatric disorders and also found higher rates of outpatient treatment following abortion. See next entry below
• The abortion group had 160% more total in-patient mental health claims than the birth group. Percentages equaled 120%, 90%, 110%, 60%, and 50% for the first 180 days, one year, two years, three years, and four years respectively.
• Across the four years, the abortion group had 70% more in-patient mental health claims than the birth group. Percentages equaled 90%, 110%, and 200% for depressive psychosis, single episode, depressive psychosis, recurrent episode, and bipolar disorder, respectfully

State-funded abortions vs. deliveries: A comparison of outpatient mental health claims over five years. Coleman PK, Reardon DC, Rue VM, Cougle JR. American Journal of Orthopsychiatry, 2002; 72(1):141–52.

(Abstract) In this record-based study, rates of 1st-time outpatient mental health treatment for 4 years following an abortion or a birth among women (aged 13-49 yrs) receiving medical assistance through the state of California were compared. After controlling for preexisting psychological difficulties, age, months of eligibility, and the number of pregnancies, the rate of care was 17% higher for the abortion group (n = 14,297) in comparison with the birth group (n = 40,122). Within 90 days after the pregnancy, the abortion group had 63% more claims than the birth group, with the percentages equaling 42%, 30%, and 16% for 180 days, 1 year, and 2 years, respectively. Additional comparisons between the abortion and birth groups were conducted on the basis of claims for specific types of disorders and age.

"Postabortion or Postpartum Psychotic Reactions," H David et al, Family Planning Perspectives 13(2): 892, 1981

A Danish register linkage study over a three month period found that the rate of psychiatric hospital admissions was 18.4 per 10,000 postabortion women, 12.0 pr 10,000 postpartum women, and 7.5 per 10,000 women of childbearing age generally.

Post-Traumatic Stress Disorder / Post-Abortion Syndrome / PTSD

The observation that abortion may cause or aggravate traumatic reactions, including post-traumatic stress disorder has been very controversial. Psychologist Vincent Rue was the first to propose this association and he was the first to use the term post-abortion syndrome to describe PTSD resulting from abortion.

See also Dr. Anne Speckhard's comments Women's Perspectives on Abortion Relative to PTSD

Background

Postpartum Post-Traumatic Stress Disorder symptoms: The Uninvited Birth Companion Inbal Shlomi Polachek, MD, Liat Huller Harari, MD, Micha Baum, MD and Rael D. Strous, MD. IMAJ 2011: 14: June: 347-353

Genetic changes show up in people with PTSD" Nathan Seppa, Science News, Web edition : Monday, May 3rd, 2010

"The team found that the people with PTSD showed less methylation in several immune system genes and more methylation in genes linked to the growth of brain cells. 'There is evidence that PTSD is involved in immune dysfunction, and we suggest that that’s part of a larger process,' Galea says. Although previous studies have also suggested a PTSD link to immune gene activation, the connection is unclear."

"The Conception of the Repetition-Compulsion," E. Bibring, Psychoanalytic Quarterly 12:486-519(1943).

Repetition-compulsion is a regulating mechanism with the task of discharging tensions caused by traumatic experiences after they have been bound in fractional amounts.

"Two cases of post-abortion psychosis," W. Pasini and H. Stockhammer, Annales Medico Psichologiques [Paris] 128(4): 555-564 (1973).

Two cases of post-abortion psychosis are presented. One resulted in suicide while the other thought a nurse was attempting to poison her. One abortion was illegal, the other legal. A possible neurological basis for post-abortion psychological problems was presented. (French)

Psycho-Social Stress Following Induced Abortion, Anne Speckhard, (Kansas City: Sheed and Ward, 1987).

A study of 30 women who reported stress following their abortion found grief reactions, fear and anxiety, changes in sexual relationships, unresolved fertility issues, increased drug and alcohol use, changes in eating behaviors, increased isolation, lowered self-worth and suicide ideation and attempts.

Diagnostic and Statistical Manual of Mental Disorders-Revised, DSM-III-R 309.89 (Post Traumatic Stress Disorder), (Washington, D.C.: American Psychiatric Press, 1987), pp. 20, 250.

Abortion is included as a possible psychosocial stressor under physical injury or illness. (Ed Note: Abortion as a possible psychosocial stressor was not included in DSM-IV manual)

The Long-Term Psycho-social Effects of Abortion, Catherine A. Barnard (Portsmouth, N.H.: Institute For Pregnancy Loss, 1990).

Some 18.8% of women who had undergone induced abortion 3-5 years previously reported all Post Traumatic Stress Syndrome criteria (DSM-III R). Some 39-45% of women still had sleep disorders, hyper-vigilance and flashbacks of the abortion experience. Some 16.9% had high intrusion scores and 23.4% had high avoidance scores on the Impact of Events Scale. Women showed elevated scores on the MCMI test in areas of histrionic, anti-social narcissism, paranoid personality disorder and elevated anxiety compared with the sample on which the test had been normed.

The Mourning After Help for Post Abortion Syndrome, Terry L. Selby with Marc Bockman (Grand Rapids: Baker Book House, 1990).

Designed for the clinical counselor. It has valuable chapters on subjects such as grief, denial the importance of faith and detailed case histories which provide valuable insights.

Post-Abortion Trauma: 9 Steps to Recovery, Jeanette Vought, (Grand Rapids: Zondervan, 1991)

Experiences of men and women in a religiously-based postabortion recovery group.

"Post Abortion Syndrome. An Emerging Public Health Concern," Anne C. Speckhard and Vincent M. Rue, Journal of Social Issues, Vol. 48(3):95-119, 1992.

Concludes that post abortion syndrome is a type of Post Traumatic Stress Disorder composed of the following basic components (a) exposure to or participation in an abortion experience, which is perceived as the traumatic and intentional destruction of one's unborn child; (b) uncontrolled negative re-experiencing of the abortion event; (c) unsuccessful attempts to avoid or deny painful abortion recollections, resulting in reduced responsiveness; and (d) experiencing associated symptoms not present before the abortion, including guilt and surviving.

"Post-Trauma Sequelae Following Abortion and Other Traumatic Events," J.O. Brende, Association for Interdisciplinary Research in Values and Social Change 7(1): 1-8, July/August 1994

Case studies include a lonely woman with a history of multiple traumas, including sexual assault. After a divorce, she moved in with a man who promised to take care of her but eventually began to abuse her. When she became pregnant, he abandoned her, and she had an abortion. Severely depressed, she began to rely heavily on sleeping pills and alcohol to sleep because of nightmares and a repetitive dream about reaching for an infant that floated beyond her reach. One night, she overdosed on her pills but telephoned a friend who called for help. Her suicide was prevented and she was admitted to a psychiatric hospital for treatment. It was during this hospitalization that she received help, the first step toward breaking her victimization cycle.

A second case study involved a 21- year old woman who visited an abortion facility to obtain an abortion. However, the abortion was incomplete and she had bleeding, cramping and a low grade fever. She was admitted to a hospital where an intact fetus was observed on ultrasound. An abortion was performed and fetal parts were removed. Predisposing factors for trauma included her impulsive decision to have the abortion and poor treatment by the doctor at the abortion facility. She sought counseling 3 ½ months after the abortion, after six months, and again 9 ½ months after the abortion when her depression worsened and she overdosed on medications. She then had six counseling sessions and was diagnosed with Post-Traumatic Stress Disorder. After 2 ½ years she had intrusive images, flashbacks, and reliving experiences; anger at the doctor and others; grief; distractibility; selective concentration; vivid memory of the abortion; numbing and detachment; startle reactions; fear of men and of having sex ; physical symptoms including abdominal and stomach pain.

"Fragmentation of the Personality Associated with Post-Abortion Trauma," J.O. Brende, Association for Interdisciplinary Research in Values and Social Change 8(3): 1-8, July/August 1995

People enduring extreme stress often suffer profound rupture in the very fabric of the self. Severity of fragmentation is dependent upon several variables (1) the degree to which the trauma is experienced as a violation, (2) the presence or absence of support, (3) the presence of shame or self-blame, and (4) the loss of idealism and purpose.

"Methodological considerations in empirical research on abortion," RL Anderson et al in Post-Abortion Syndrome: Its Wide Ramifications, Ed Peter Doherty, (Portland: Four Courts Press, 1995) 103-115

A study at an psychiatric outpatient service, compared women who presented with a history of elective abortion and sought psychiatric services in response to negative adjustment to abortion, with women with a history of elective abortion who presented seeking outpatient services for reasons that were not abortion-related. A second control group consisted of women who sought outpatient services but denied any abortion history. 73% of the abortion- distressed group met the criteria for DSM-IIIR. Abortion distressed women reported more frequently that they believed abortion to be morally wrong and had fewer recent adverse life events than abortion non-distressed women.

"Post-Abortion Perceptions: A Comparison of Self-Identified Distressed and Non-distressed Populations," G. Kam Congleton, L.G. Calhoun. The Int'l J. Social Psychiatry 39(4): 255-265, 1993

Women reporting distress were more often currently affiliated with conservative churches and reported a lower degree of social support and confidence in the abortion decision. They were also more likely to recall experiencing feelings of loss immediately postabortion.

Posttraumatic Stress Disorder Symptoms and Food Addiction in Women by Timing and Type of Trauma Exposure Susan M. Mason, PhD, Alan J. Flint, DPH, MD, Andrea L. Roberts, PhD, et al. JAMA Psychiatry. Published online September 17, 2014. doi:10.1001/jamapsychiatry.2014.1208

While this study did not report on abortion, it did find that "The prevalence of food addiction increased with the number of lifetime PTSD symptoms, and women with the greatest number of PTSD symptoms (6-7 symptoms) had more than twice the prevalence of food addiction as women with neither PTSD symptoms nor trauma histories (prevalence ratio, 2.68; 95% CI, 2.41-2.97). Symptoms of PTSD were more strongly related to food addiction when symptom onset occurred at an earlier age."

Variation in Propensity to PTSD

Toward the Predeployment Detection of Risk for PTSD Douglas L. Delahanty, Ph.D. Am J Psychiatry 168:9-11, January 2011

A summary of several studies identifying biological markers that can be used to identify persions who are at greater risk of developing PTSD in reaction to a traumatic experience.

"[1]"

"Only a small minority of people who fall victim to a violent attack or witness a bloody accident suffer the recurring nightmares, hypervigilance, and other symptoms of posttraumatic stress disorder (PTSD). Women seem to be twice as susceptible as men, but otherwise researchers know virtually nothing about who is most at risk or why. Now a study has linked a genetic mutation and blood levels of a particular peptide—a compound made from a short string of the same building blocks that make up proteins—to the severity of PTSD symptoms in women. The finding could lead to tests to identify people who may need extra help after a traumatic event."

Stress-related disorders, pituitary adenylate cyclase-activating peptide (PACAP)ergic system, and sex differences. Ramikie TS, Ressler KJ. Dialogues Clin Neurosci. 2016 Dec;18(4):403-413.

Study may help curb cases of combat-stress disorder: UT examining genes, reactions of Fort Hood troops to find risk factors.

http://www.nasw.org/determining-soldiers-vulnerability-ptsd-and-anxiety-disorders

What Increases Risk for PTSD in Military Service Members?

Agaibi, C.E., & Wilson, J.P. (2005). Trauma, PTSD, and resilience: A review of the literature. Trauma, Violence, and Abuse, 6, 195-216.

Brailey, K., Vasterling, J.J., Proctor, S.P., Constans, J.I., & Friedman, M.J. (2007). PTSD symptoms, life events, and unit cohesion in U.S. soldiers: Baseline findings from the Neurocognition Deployment Health Study. Journal of Traumatic Stress, 20, 495-503.

Erbes, C., Westermeyer, J., Engdahl, B., & Johnsen, E. (2007). Post-traumatic stress disorder and service utilization in a sample of service members from Iraq and Afghanistan. Military Medicine, 172, 359-363.

Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I., & Koffman, R.L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13-22.

Ozer, E.J., Best, S.R., Lipsey, T.L., & Weiss, D.S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129, 52-73.

Smaller Brain Linked to Soldiers' PTSD Risk

U.S. Military Studying PTSD Risk Factors

Research Validating Abortion Associated PTSD

The Severity of Post-abortion Stress in Spontaneous, Induced and Forensic Medical Center Permitted Abortion in Shiraz, Iran, in 2018. Alipanahpour S, Zarshenas M, Ghodrati F, Akbarzadeh M. Iran J Nurs Midwifery Res. 2019 Dec 27;25(1):84-90.

Background: Abortion and loss of pregnancy in the first trimester may affect maternal mortality and morbidity. This study aimed to determine the severity of post-abortion stress in spontaneous abortion, induced abortion, and Forensic Medical Center (FMC) referral abortions immediately after abortion and after 1 month of follow-up in Shiraz, Iran, in 2018.

Materials and methods: This cross-sectional study was conducted on 104 mothers selected through convenience sampling method in 2018. The data collection tools included a demographic characteristics questionnaire and the Mississippi Post-Traumatic Stress Disorder (M-PTSD) Scale that were filled out by mothers immediately and 1 month after the abortion. Data were analyzed using one-way ANOVA and post-hoc LSD test in SPSS software. Moreover, p < 0.05 was considered as statistically significant.

Results: The mean (SD) of post-traumatic stress scores was 83.87 (18.35) and 77.40 (9.88) in spontaneous abortion, 82.28 (13.27) and 75.71 (14.73) in FMC permitted abortions, and 86.66 (10.10) and 74.98 (12.99) in induced abortions immediately and 1 month after abortion, respectively. Stress was reduced in the three groups of mothers, after one month of severe value. The score for frequency of stress was 3.10% in FMC-permitted abortions and 5.10% in induced abortions; moreover, no stress was observed in the spontaneous abortion cases.

Conclusions: Stress was gradually reduced over time. The level of PTSD was lower after 1 month in women who had experienced spontaneous abortion. Given that 1 month after abortion, women are still often moderately stressed, follow-up care, and appropriate counseling for these women are necessary.

Does abortion increase women's risk for post-traumatic stress? Findings from a prospective longitudinal cohort study. Biggs MA, Rowland B, McCulloch CE, Foster DG. BMJ Open. 2016;6(2)

7% of the Turnaway Study attributed their PTSS symptoms to their abortions.

The Severity of Post-abortion Stress in Spontaneous, Induced and Forensic Medical Center Permitted Abortion in Shiraz, Iran, in 2018. Alipanahpour S1, Zarshenas M2, Ghodrati F3, Akbarzadeh M4. Iran J Nurs Midwifery Res. 2019 Dec 27;25(1):84-90. doi: 10.4103/ijnmr.IJNMR_36_19. eCollection 2020 Jan-Feb.

BACKGROUND: Abortion and loss of pregnancy in the first trimester may affect maternal mortality and morbidity. This study aimed to determine the severity of post-abortion stress in spontaneous abortion, induced abortion, and Forensic Medical Center (FMC) referral abortions immediately after abortion and after 1 month of follow-up in Shiraz, Iran, in 2018.

MATERIALS AND METHODS: This cross-sectional study was conducted on 104 mothers selected through convenience sampling method in 2018. The data collection tools included a demographic characteristics questionnaire and the Mississippi Post-Traumatic Stress Disorder (M-PTSD) Scale that were filled out by mothers immediately and 1 month after the abortion. Data were analyzed using one-way ANOVA and post-hoc LSD test in SPSS software. Moreover, p < 0.05 was considered as statistically significant.

RESULTS: The mean (SD) of post-traumatic stress scores was 83.87 (18.35) and 77.40 (9.88) in spontaneous abortion, 82.28 (13.27) and 75.71 (14.73) in FMC permitted abortions, and 86.66 (10.10) and 74.98 (12.99) in induced abortions immediately and 1 month after abortion, respectively. Stress was reduced in the three groups of mothers, after one month of severe value. The score for frequency of stress was 3.10% in FMC-permitted abortions and 5.10% in induced abortions; moreover, no stress was observed in the spontaneous abortion cases.

CONCLUSIONS: Stress was gradually reduced over time. The level of PTSD was lower after 1 month in women who had experienced spontaneous abortion. Given that 1 month after abortion, women are still often moderately stressed, follow-up care, and appropriate counseling for these women are necessary

Neuroticism-related personality traits are associated with posttraumatic stress after abortion: findings from a Swedish multi-center cohort study. Wallin Lundell I1,2, Sundström Poromaa I3, Ekselius L4, Georgsson S5,6, Frans Ö7, Helström L8, Högberg U3, Skoog Svanberg A3. BMC Womens Health. 2017 Oct 2;17(1):96. doi: 10.1186/s12905-017-0417-8.

BACKGROUND: Most women who choose to terminate a pregnancy cope well following an abortion, although some women experience severe psychological distress. The general interpretation in the field is that the most consistent predictor of mental disorders after induced abortion is the mental health issues that women present with prior to the abortion. We have previously demonstrated that few women develop posttraumatic stress disorder (PTSD) or posttraumatic stress symptoms (PTSS) after induced abortion. Neuroticism is one predictor of importance for PTSD, and may thus be relevant as a risk factor for the development of PTSD or PTSS after abortion. We therefore compared Neuroticism-related personality trait scores of women who developed PTSD or PTSS after abortion to those of women with no evidence of PTSD or PTSS before or after the abortion.

METHODS: A Swedish multi-center cohort study including six Obstetrics and Gynecology Departments, where 1294 abortion-seeking women were included. The Screen Questionnaire-Posttraumatic Stress Disorder (SQ-PTSD) was used to evaluate PTSD and PTSS. Measurements were made at the first visit and at three and six month after the abortion. The Swedish universities Scales of Personality (SSP) was used for assessment of Neuroticism-related personality traits. Multiple logistic regression analyses were performed to investigate the risk factors for development of PTSD or PTSS post abortion.

RESULTS: Women who developed PTSD or PTSS after the abortion had higher scores than the comparison group on several of the personality traits associated with Neuroticism, specifically Somatic Trait Anxiety, Psychic Trait Anxiety, Stress Susceptibility and Embitterment. Women who reported high, or very high, scores on Neuroticism had adjusted odds ratios for PTSD/PTSS development of 2.6 (CI 95% 1.2-5.6) and 2.9 (CI 95% 1.3-6.6), respectively.

CONCLUSION: High scores on Neuroticism-related personality traits influence the risk of PTSD or PTSS post abortion. This finding supports the argument that the most consistent predictor of mental disorders after abortion is pre-existing mental health status.

• Editor Note: Among 512 women with no prior PTSD symptoms, 9.4% experienced all the criteria necessary for a PTSD diagnosis by the three or six month post-abortion assessment. Pre-abortion screening for higher neuroticism-related personality traits can be used to identify the women at greatest risk of abortion associated PTSD. This finding is consistent with other studies showing neurotisicm being associated with greater susceptibility to PTSD.

Posttraumatic stress and posttraumatic stress disorder after termination of pregnancy and reproductive loss: a systematic review. Daugirdaitė V, van den Akker O, Purewal S. J Pregnancy. 2015;2015:646345. doi: 10.1155/2015/646345. Epub 2015 Feb 5.

OBJECTIVE: The aims of this systematic review were to integrate the research on posttraumatic stress (PTS) and posttraumatic stress disorder (PTSD) after termination of pregnancy (TOP), miscarriage, perinatal death, stillbirth, neonatal death, and failed in vitro fertilisation (IVF).

METHODS: Electronic databases (AMED, British Nursing Index, CINAHL, MEDLINE, SPORTDiscus, PsycINFO, PubMEd, ScienceDirect) were searched for articles using PRISMA guidelines.

RESULTS: Data from 48 studies were included. Quality of the research was generally good. PTS/PTSD has been investigated in TOP and miscarriage more than perinatal loss, stillbirth, and neonatal death. In all reproductive losses and TOPs, the prevalence of PTS was greater than PTSD, both decreased over time, and longer gestational age is associated with higher levels of PTS/PTSD. Women have generally reported more PTS or PTSD than men. Sociodemographic characteristics (e.g., younger age, lower education, and history of previous traumas or mental health problems) and psychsocial factors influence PTS and PTSD after TOP and reproductive loss.

CONCLUSIONS: This systematic review is the first to investigate PTS/PTSD after reproductive loss. Patients with advanced pregnancies, a history of previous traumas, mental health problems, and adverse psychosocial profiles should be considered as high risk for developing PTS or PTSD following reproductive loss.

"Predictors of postpartum post-traumatic stress disorder in primiparous mothers.[Article in French] Montmasson H1, Bertrand P, Perrotin F, El-Hage W. J Gynecol Obstet Biol Reprod (Paris). 2012 Oct;41(6):553-60. doi: 10.1016/j.jgyn.2012.04.010. Epub 2012 May 21.

A history of abortion was associated with a six fold increased risk of subsequent postpartum PTSD.

Previous experience of spontaneous or elective abortion and risk for posttraumatic stress and depression during subsequent pregnancy. Hamama L, Rauch SA, Sperlich M, Defever E, Seng JS. Depress Anxiety. 2010 Jun 23.

Abstract

Background: Few studies have considered whether elective and/or spontaneous abortion (EAB/SAB) may be risk factors for mental health sequelae in subsequent pregnancy. This paper examines the impact of EAB/SAB on mental health during subsequent pregnancy in a sample of women involved in a larger prospective study of posttraumatic stress disorder (PTSD) across the childbearing year (n=1,581). Methods: Women expecting their first baby completed standardized telephone assessments including demographics, trauma history, PTSD, depression, and pregnancy wantedness, and religiosity. Results: Fourteen percent (n=221) experienced a prior elective abortion (EAB), 13.1% (n=206) experienced a prior spontaneous abortion (SAB), and 1.4% (n=22) experienced both. Of those women who experienced either an EAB or SAB, 13.9% (n=220) appraised the EAB or SAB experience as having been "a hard time" (i.e., potentially traumatic) and 32.6% (n=132) rated it as their index trauma (i.e., their worst or second worst lifetime exposure). Among the subset of 405 women with prior EAB or SAB, the rate of PTSD during the subsequent pregnancy was 12.6% (n-51), the rate of depression was 16.8% (n=68), and 5.4% (n-22) met criteria for both disorders. Conclusions: History of sexual trauma predicted appraising the experience of EAB or SAB as "a hard time." Wanting to be pregnant sooner was predictive of appraising the experience of EAB or SAB as the worst or second worst (index) trauma. EAB or SAB was appraised as less traumatic than sexual or medical trauma exposures and conveyed relatively lower risk for PTSD. The patterns of predictors for depression were similar

Psychological problems sequalae in adolescents after artificial abortion. Zulčić-Nakić V, Pajević I, Hasanović M, Pavlović S, Ljuca D. J Pediatr Adolesc Gynecol. 2012 Aug;25(4):241-7. doi: 10.1016/j.jpag.2011.12.072.

STUDY AND OBJECTIVES: Controversy exists over psychological risks associated with unwanted pregnancy and consecutive abortion. The aim of this study was to assess the psychological health of female adolescents following artificial abortion up to 12(th) week of pregnancy. DESIGN: The control case study. SETTING: The study was carried out in the Department of Gynecology and Obstetrics, University Clinical Center Tuzla, in Bosnia-Herzegovina.

PARTICIPANTS: We assessed 120 female adolescents. The mean (SD) age of the patients was 17.7 (1.5) years experiencing sexual intercourse in the age of 14-19 years for trauma experiences, presence of posttraumatic stress symptoms, depression and anxiety as state, and anxiety as trait. Sixty adolescents had intentional artificial abortion and 60 had sexual intercourse but did not become pregnant. MAIN OUTCOME MEASURES: We used the PTSD Questionnaire, the Beck Depression Inventory, and the Spielberger State Trait Anxiety Inventory (Form Y) for assessment of anxiety in adolescents. Basic socio-demographic data were also collected. RESULTS: PTSD presented significantly more often in adolescents who aborted pregnancy (30%), than in adolescents who did not abort (13.3%) (odds ratio = 4.91 (95%CI 0.142-0.907) P = 0.03). Anxiety as state and as trait were significantly higher in the abortion group, as the mean (SD) anxiety score of patients was 59.8 (8.9), 57.9 (9.7) respectively, than in non-abortion group 49.5 (8.8), 47.3 (9.9) respectively (t = 6.392, P < 0.001; t = 5.914, P < 0.001, respectively). Adolescents who aborted pregnancy had significantly higher depression symptoms severity 29.2 (5.6) than controls 15.2 (3.3) (t = 8.322, P < 0.001), and they presented significantly more often depression (75%), than adolescents who did not abort (10%) (χ(2) = 53.279, P < 0.001). Logistic regression showed that only experience of life threatening(s) and injury of other person(s) reliably predicted PTSD, whereas abortion and experience of life threatening(s) reliably predicted depression. CONCLUSION: Adolescents who aborted pregnancy presented significantly greater prevalence of PTSD and depression, and significantly greater depression severity and anxiety as state and trait than those who did not abort. Abortion predicted depression only, and did not predict PTSD.

'The Characteristics and Severity of Psychological Distress After Abortion Among University Students.'Curley M, Johnston C. J Behav Health Serv Res. 2013 Apr 12. [Epub ahead of print]

Abstract

Controversy over abortion inhibits recognition and treatment for women who experience psychological distress after abortion (PAD). This study identified the characteristics, severity, and treatment preferences of university students who experienced PAD. Of 151 females, 89 experienced an abortion. Psychological outcomes were compared among those who preferred or did not prefer psychological services after abortion to those who were never pregnant. All who had abortions reported symptoms of post-traumatic stress disorder (PTSD) and grief lasting on average 3 years. Yet, those who preferred services experienced heightened psychological trauma indicative of partial or full PTSD (Impact of Event Scale, M = 26.86 versus 16.84, p < .05), perinatal grief (Perinatal Grief Scale, M 62.54 versus 50.89, p < 0.05), dysthymia (BDI M = 11.01 versus 9.28, p < 0.05), (M = 41.86 versus 39.36, p < 0.05), and co-existing mental health problems. PAD appeared multi-factorial, associated with the abortion and overall emotional health. Thus, psychological interventions for PAD need to be developed as a public health priority.

Comparison of pain, cortisol levels, and psychological distress in women undergoing surgical termination of pregnancy under local anaesthesia versus intravenous sedation. Suliman S, Ericksen T, Labuschgne P, de Wit R, Stein DJ, Seedat S. BMC Psychiatry. 2007 Jun 12;7:24.

Examining symptom domains preabortion, and 1 and 3 months later, the authors evaluated 155 women who had abortions in Cape Town, South Africa. They reported:

1. “High rates of PTSD characterize women who have undergone voluntary pregnancy termination.” p. 8 (almost one fifth of the sample met criteria for PTSD)

2. The percent of women who met PTSD criteria increased by 61% from pre-abortion baseline to 3 months post-abortion (11.3 to 18.2)

3. Women who met PTSD criteria pre-abortion experienced significantly more physical pain post-abortion

4. “Thus it would follow that screening women pre-termination for PTSD and disability and post-termination for high levels of dissociation is important in order to help identify women at risk of PTSD and to provide follow-up care.” p. 6

5. "[t]here was a high rate of attrition over the course of the study leaving a small final sample (37% of the original sample). It might be that participants who were lost to follow-up were lost because of their higher levels of postabortion distress (i.e. PTSD and other psychopathology)."

6. The rates of depression and anxiety were high both pre-abortion and at three months post-abortion, but were not significantly higher. Regarding depression, at pre-termination 21.9% of the sample had high depression scores compared to 20% at 1 and 3 months. 'High' state anxiety (STAI) at pre-abortion was reported by 63.9%, and this dropped to 56.3% of women at both 1 and 3 months. Note: Pre-depresssion and anxiety scores are measured at the height of the crisis when the woman is about to have an abortion. It does not reflect pre-pregnancy scores. In addition, the high attrition rate and short time frame (3 months) must also be considered in properly interpreting this data. 7. "[W]omen with PTSD 3 months after termination were further along in their pregnancy than those without PTSD (gestational age: With PTSD: 13.2 ± 3.3; Without PTSD: 9.7 ± 4.2; p = 0.023)."

Posttraumatic Stress Disorder and psychological distress following medical and surgical abortion. C. Rousset, C. Brulfert, N. Séjourné, N. Goutaudier & H. Chabrol Journal of Reproductive and Infant Psychology, (2011) Volume 29(5), 506-517.

Method: Eighty-six women were approached a few hours after the abortion and then 6 weeks later. Several questionnaires were completed: the Impact of Event Scale Revised (IES-R), the Multidimensional Scale of Social Support (MSPSS), the Peritraumatic Dissociative Experience Questionnaire (PDEQ), the Peritraumatic Emotions List (PEL), the Hospital Anxiety and Depression Scale (HADS), the Perinatal Grief Scale (PGS) and the Texas Grief Inventory (TGI). Results: Six weeks after the abortion, 38% of women reported a potential PTSD and a significant decrease of the anxious symptomatology was also highlighted. Peritraumatic dissociation and peritraumatic emotions were the main predictors of the intensity of post-abortum PTSD symptoms. Compared to surgical abortion, medical abortion was associated with increasing the risk of developing a possible PTSD. Conclusion: By providing evidence on some of the main risk factors, this study highlights the need for psychological support for women and strategies of prevention to be developed.

The prevalence of post-abortion syndrome in patients presenting at Kalafong hospital's family medicine clinic after having a termination of pregnancy. van Rooyen M, Smith S. South African Family Practice (2004) 46 (5), pp 21-24.

Background: Post-abortion syndrome (PAS) is said to be the emotional, psychological, physical and spiritual trauma caused by an abortion, which is an event outside the normal range of human experience. Post-abortion syndrome is a type of post-traumatic disorder and is characterised by a stressor (the abortion), the event being re-experienced, avoidance and/or numbing of general responsiveness, and physical symptoms such as insomnia and depression. The question was asked whether the patients at Kalafong Hospital experienced any of the after-effects of a termination of pregnancy and whether these effects would fulfill the criteria of post-abortion syndrome.

Method: A prospective descriptive study was done over a six-month period. All female patients presenting at the Family Medicine Clinic of Kalafong Hospital who were known to have had a previous abortion on request were asked to participate in the study. After obtaining informed consent, a structured questionnaire on their psychological symptoms was completed by the participants with the help of the researcher. The questionnaire contained demographic data, as well as questions on the above-mentioned symptoms of PAS. To fulfill the criteria of PAS, the symptoms should have been present for more than a month and must have affected the subject’s daily functioning.

Results: Of the 48 woman recruited, 16 (33%) fulfilled the criteria of PAS, and more than 50% of the women had had some or other emotional or psychological after-effect.

Conclusion: This study showed that one out of every three women presenting at Kalafong Hospital after abortion fulfilled the criteria of PAS. Since family physicians are committed to their patients and regard it as their duty to address problems prevalent in the community they serve, it is necessary to investigate further the possible link between termination of pregnancy and the emotional problems identified. It is imperative that women requesting termination of pregnancy receive comprehensive counseling prior to the procedure, as well as support thereafter,to ensure that they are not unnecessarily traumatised.

Note: Other reactions were insomnia (23%), irritability (69%) feeling of being more alert (46%), being startled more easily (79%), depressed mood (75%), suicidal thoughts (40%), feelings of guilt (67%), low self esteem (54%) substance abuse (2%), change in eating habits (23%) and decreased libido (79%).

Late-Term Elective Abortion and Susceptibility to Posttraumatic Stress Symptoms. Journal of Pregnancy Volume 2010 (2010)Coleman PK, Coyle CT, Rue VM

An average of 15 years after their abortions, 52.5% of women with a history of a first trimester abortion and 67.4% with a history of a second or third trimester abortion, met the DSM-IV symptom criteria for PTSD.

Previous experience of spontaneous or elective abortion and risk for posttraumatic stress and depression during subsequent pregnancyHamama L, et al. Depression and Anxiety Published Online: 23 Jun 2010

(Abstract)Background: Few studies have considered whether elective and/or spontaneous abortion (EAB/SAB) may be risk factors for mental health sequelae in subsequent pregnancy. This paper examines the impact of EAB/SAB on mental health during subsequent pregnancy in a sample of women involved in a larger prospective study of posttraumatic stress disorder (PTSD) across the childbearing year (n=1,581).

Methods: Women expecting their first baby completed standardized telephone assessments including demographics, trauma history, PTSD, depression, and pregnancy wantedness, and religiosity.

Results: Fourteen percent (n=221) experienced a prior elective abortion (EAB), 13.1% (n=206) experienced a prior spontaneous abortion (SAB), and 1.4% (n=22) experienced both. Of those women who experienced either an EAB or SAB, 13.9% (n=220) appraised the EAB or SAB experience as having been a hard time (i.e., potentially traumatic) and 32.6% (n=132) rated it as their index trauma (i.e., their worst or second worst lifetime exposure). Among the subset of 405 women with prior EAB or SAB, the rate of PTSD during the subsequent pregnancy was 12.6% (n-51), the rate of depression was 16.8% (n=68), and 5.4% (n-22) met criteria for both disorders.

Conclusions: History of sexual trauma predicted appraising the experience of EAB or SAB as a hard time. Wanting to be pregnant sooner was predictive of appraising the experience of EAB or SAB as the worst or second worst (index) trauma. EAB or SAB was appraised as less traumatic than sexual or medical trauma exposures and conveyed relatively lower risk for PTSD. The patterns of predictors for depression were similar. Depression and Anxiety

Editor Notes: Among women having an elective abortion, 28.6 percent rated it as the first or second worst lifetime experience. During the subsequent pregnancy, among women with a history of elective abortion 12.5% met the criteria for a PTSD diagnosis, 17.9 percent experienced major depression in the past year, and 4.5 percent had both PTSD and depression. Among those reporting that they had a "hard time" with their abortion or miscarriage, 32% were diagnosed with PTSD and 28 percent had major depression, and 17.3% had both.

"Inadequate Preabortion Counseling and Decision Conflict as Predictors of Subsequent Relationship Difficulties and Psychological Stress in Men and Women" Catherine T. Coyle, Priscilla K. Coleman, and Vincent M. Rue, Traumatology first published on November 16, 2009 as doi:10.1177/1534765609347550

(Abstract)The purpose of this study was to examine associations between perceptions of preabortion counseling adequacy and partner congruence in abortion decisions and two sets of outcome variables involving relationship problems and individual psychological stress. Data were collected through online surveys from 374 women who had a prior abortion and 198 men whose partners had experienced elective abortion. For women, perceptions of preabortion counseling inadequacy predicted relationship problems, symptoms of intrusion, avoidance, and hyperarousal, and meeting full diagnostic criteria for posttraumatic stress disorder (PTSD) with controls for demographic and personal/situational variables used. For men, perceptions of inadequate counseling predicted relationship problems and symptoms of intrusion and avoidance with the same controls used. Incongruence in the decision to abort predicted intrusion and meeting diagnostic criteria for PTSD among women with controls used, whereas for men, decision incongruence predicted intrusion, hyperarousal, meeting diagnostic criteria for PTSD, and relationship problems. Findings suggest that both perceptions of inadequate preabortion counseling and incongruence in the abortion decision with one’s partner are related to adverse personal and interpersonal outcomes.

"Psychological impact on women after second and third trimester termination of pregnancy due to fetal anomalies versus women after preterm birth—a 14-month follow up study" Kersting A, et al. Arch Womens Ment Health. 2009 Aug;12(4):193-201. Epub 2009 Mar 6.

(ABSTRACT) The objective of this study was to compare psychiatric morbidity and the course of posttraumatic stress, depression, and anxiety in two groups with severe complications during pregnancy, women after termination of late pregnancy (TOP) due to fetal anomalies and women after preterm birth (PRE). As control group women after the delivery of a healthy child were assessed. A consecutive sample of women who experienced a) termination of late pregnancy in the 2nd or 3rd-trimester (N = 62), or b) preterm birth (N = 43), or c) birth of a healthy child (N = 65) was investigated 14 days (T1), 6 months (T2), and 14 months (T3) after the event. At T1, 22.4% of the women after TOP were diagnosed with a psychiatric disorder compared to 18.5% women after PRE, and 6.2% in the control group. The corresponding values at T3 were 16.7%, 7.1%, and 0%. Shortly after the event, a broad spectrum of diagnoses was found; however, 14 months later only affective and anxiety disorders were diagnosed. Posttraumatic stress and clinician-rated depressive symptoms were highest in women after TOP. The short-term emotional reactions to TOP in late pregnancy due to fetal anomaly appear to be more intense than those to preterm birth. Both events can lead to severe psychiatric morbidity with a lasting psychological impact.

Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: a randomised controlled trial. Kelly T, Suddes J, Howel D, Hewison J, Robson S. BJOG. 2010 Nov;117(12):1512-20. OBJECTIVE: To compare the psychological impact, acceptability and clinical effectiveness of medical versus surgical termination of pregnancy (TOP) at 13-20 weeks of gestation.

One hundred and twenty two women were randomised: 60 had medical (drug induced) abortions (MTOP) and 62 had surgical abortions. Twelve women opted to continue their pregnancy. Follow-up rates were low (n=66/110; 60%). At 2 weeks post-procedure the average IES scores reported for surgical abortion was 30.1 and for medical abortion was 36.8. For scores over 26, there is a 75% chance of PTSD. 1 and the event may be classified as a "Powerful Impact Event—you are certainly affected."1 An IES score over 35 is considered a good cutoff score for probable PTSD. 1 With means of 30.1 and 36.8, it would appear that a high percentage of women in both the MTOP and STOP group exceeded the cutoff score for probable PTSD.

Also, given the fact there was a 60% non-participation rate in this study, it is likely that the mean IES scores reported here are much lower than they would have been with 100% participation since it is likely that women who were most disturbed by the abortion were least likely to participate.

"Past trauma and Present Functioning of Patients Attending a Women's Psychiatric Clinic," EFM Borins, PJ Forsythe, Am J Psychiatry 142(4) :460, 1985

In a Canadian study, abortion correlated significantly with three or more trauma factors.

"Iatrogenic Post-Traumatic Stress Disorder," (letter), R. Fisch and 0. Tadmor, The Lancet, December 9, 1989, p. 1397.

PTSD following induced abortion with post-abortion complications was reported. Soon after the abortion the patient exhibited severe anxiety, depression, recurrent intrusive thoughts and images related to the abortion, insomnia, recurrent nightmares, avoidance behavior along with other social problems continuing over two and a half years without much remission.

"Obsessive-Compulsive Disorder Apparently Related to Abortion," Ronald K. McGraw, American Journal of Psychotherapy 43(2):269-276, April 1989.

A married woman with a history of three abortions was obsessed with the idea she would become pregnant by someone other than her husband although she was not sexually active outside her marriage, and she compulsively underwent repeated pregnancy tests although there was no sign of pregnancy. If she became pregnant she thought she would die in childbirth. It was concluded that the obsessive-compulsive disorder was precipitated by routine medical tests that brought back memories of the prior abortions with associated guilt and fear of punishment.

"Incidence of complicated grief and post-traumatic stress in a post-abortion population," Leslie M. Butterfield, Ph.D. Dissertation, Virginia Commonwealth University (1988), Dissertation Abstracts International 49(8): 3431-B, February 1989, Order No. DA 8813540.

Stress responses were found in 55% of women six months following first trimester abortion. Posttraumatic stress was heightened by loss of partner and wishful thinking. Social support seeking and problem-focused coping was negatively associate with post- traumatic stress and grief. Women consistently showed death anxiety on the Grief Experience Inventory (GEI).

"Abortion Trauma: Application of a Conflict Model," R.C. Erikson, Pre and Perinatal Psychology Journal 8(l): 33. Fall, 1993.

Elective abortion is a potentially traumatizing event. Clinic experience indicates the symptoms and development of post traumatic stress disorder following abortion. A conflict model of trauma is presented with the woman as both victim and aggressor.

"Post Traumatic Stress Disorders in Women Following Abortion: Some Considerations and Implications for Martial/Couple Therapy," D Bagarozzi, Int'l Journal of Family and Marriage (Delhi, India) 1 (2): 51, 1993

Clinical examples of abortion related post traumatic stress disorder.

"Psychological Responses of Women After First-Trimester Abortion," B Major et al, Arch Gen Psychiatry 57:777, 2000

This study reported that 6 of 442 women ( 1.36%) reported abortion related PTSD two years postabortion according to DSM-IV criteria as assessed with a modified measure asking specifically about abortion. A history of depression was significantly associated with a higher risk of experience abortion related PTSD.

An increasing number of women had negative emotional reactions with the passage of time. In this study it appears that the standard for identifying a case of abortion-related PTSD was set to exceptionally high level. First, women were required to the cause of each symptom as having been directly related to the abortion. Nightmares that they did not associate to their abortion, for example, would not have been included as an intrusive symptom. In addition, it appears that only women who rated the degree of the reaction at the highest level, for every PTSD symptom, were included. Women with a moderate level of distress in one symptom area, for example, were not counted as having PTSD. This high standard is useful for verifying with a high degree of certainty that abortion is the direct cause of PTSD in at least some cases. On the other hand, because the standard appears to be set higher than is normally the case in population studies of PTSD, the findings may under represent the actual incidence rate.

Posttraumatic stress disorder and pregnancy complications. Seng JS, Oakley DJ, Sampselle CM, Killion C, Graham-Bermann S, Liberzon I. Obstetrics and gynecology. 2001 Jan; 97(1): 17-22

OBJECTIVE: To assess the associations between specific pregnancy complications and posttraumatic stress disorder based on neurobiologic and behavioral characteristics, using Michigan Medicaid claims data from 1994-1996.

METHODS: Two thousand, two hundred nineteen female recipients of Michigan Medicaid who were of childbearing age had posttraumatic stress disorder on the basis of International Classification of Diseases, 9th Revision (ICD-9) codes. Twenty percent (n = 455) of those recipients and 30% of randomly selected comparison women with no mental health diagnostic codes (n = 638; P <.001) had ICD-9 diagnostic codes for pregnancy complications. We used multiple logistic regression to investigate associations between specific pregnancy complications and posttraumatic stress disorder, controlling for demographic and psychosocial variables. Obstetric complications were hypothesized based on high-risk behaviors and neurobiologic alterations in stress axis function in posttraumatic stress disorder.

RESULTS: After controlling for demographic and psychosocial factors, women with posttraumatic stress disorder had higher odds ratios (ORs) for ectopic pregnancy (OR 1.7, 95% confidence interval [CI] 1.1, 2.8), spontaneous abortion (OR 1.9, 95% CI 1.3, 2.9), hyperemesis (OR 3.9, 95% CI 2.0, 7.4), preterm contractions (OR 1.4, 95% CI 1.1, 1.9), and excessive fetal growth (OR 1.5, 95% CI 1.0, 2.2). Hypothesized labor differences were not confirmed and no differences were found for complications not thought to be related to traumatic stress.

CONCLUSIONS: Pregnant women with posttraumatic stress disorder might be at higher risk for certain conditions, and assessment and treatment for undiagnosed posttraumatic stress might be warranted for women with those obstetric complications. Prospective studies are needed to confirm present findings and to determine potential biologic mechanisms. Treatment of traumatic stress symptoms might improve pregnancy morbidity and maternal mental health.

NOTE: women's most common attribution for PTSD was violence and the second most common attribution was for prior pregnancy loss.

Trauma and grief 2-7 years after termination of pregnancy because of fetal anomalies-a pilot study. Kersting A, et al. J of Psychosomatic Obstetrics & Gynecology 2005; 26(1): 9-14.

The aim of the study was to obtain information on the long-term posttraumatic stress response and grief several years after termination of pregnancy due to fetal malformation. We investigated 83 women who had undergone termination of pregnancy between 1995 and 1999 and compared them with 60 women 14 days after termination of pregnancy and 65 women after the spontaneous delivery of a full-term healthy child. Women 2-7 years after termination of pregnancy were expected to show a significantly lower degree of traumatic experience and grief than women 14 days after termination of pregnancy. Contrary to the hypothesis, however, the results showed no significant intergroup differences with respect to the degree of traumatic experience. With the exception of one subscale (fear of loss), this also applied to the grief reported by the women. However, both groups differed significantly in their posttraumatic stress response from women who had given spontaneous birth to a full-term healthy child. The results indicate that termination of pregnancy is to be seen as an emotionally traumatic major life event which leads to severe posttraumatic stress response and intense grief reactions that are still detectable some years later.

Assessing traumatic reactions of abortion with the emotional stroop. Toledano, Levana. Dissertation Abstracts International: Section B: The Sciences & Engineering, Vol 64(9-B), 2004. pp. 4639.

Two groups of women were included in this study: 59 women who had undergone an abortion and a control group of 28 women who had comparable surgical procedures. The mean age of the participants was 29.82, with ages ranging from 18 to 50 years. Symptoms of PTSD were assessed using the Posttraumatic Diagnostic Scale (PDS), the Impact of Event Scale (IES), and the Emotional Stroop paradigm. The Emotional Stroop procedure utilized was a color-naming task comprised of abortion-relevant words (i.e., sex, pregnant, fetus), positive words, neutral words, and obsessive-compulsive disorder (OCD) words. Levels of depression and anxiety were assessed with the Beck Depression Inventory-II (BDI-II), and the State-Trait Anxiety Inventory (STAI). The role of social support at the time of abortion was measured via the Multidimensional Scale of Perceived Social Support (MSPSS). Background variables such as religiosity, the presence or absence of coercion, marital status, gestational length, number of children, and age were also explored as possible risk factors mediating responses to abortion. Multivariate tests indicated the presence of PTSD in both groups of women, but to a greater extent in the post-abortion group. The two groups reported similarly elevated scores for anxiety. Post-abortion women exhibited significantly longer response latencies on the Stroop for abortion/trauma-relevant stimuli as compared to the control group. There were no significant differences found between groups on measures of depression. Significant risk factors included low levels of perceived social support, younger age, and the presence of coercion. Implications for community and clinical psychology are outlined.

Postabortion Grief: Evaluating the Possible Efficacy of a Spiritual Group Intervention. SD Layer, C Roberts, K Wild, J Walters. Research on Social Work Practice, Vol. 14, No. 5, 344-350 (2004)

Objective: Although not every woman is negatively affected by an abortion, researchers have identified a subgroup of women susceptible to grief and trauma. The primary providers for postabortion grief (PAG) groups are community faith-based agencies. Principle features of PAG are shame and post-traumatic stress disorder (PTSD) symptoms. Method: This study measured the efficacy of a spiritually based grief group intervention for women grieving an abortion. Thirty-five women completed the Impact of Event Scale-Revised(IES-R) and the Internalized Shame Scale (ISS) pre- and postintervention along with posttest open-ended questions. Results: Postintervention measures indicated significant decrease in shame (p < .000) and PTSD symptoms (p < .002). More than 80% reported their religious beliefs and the spiritual intervention played a strong to very strong role in the group. Conclusion: Social workers need to screen for PAG with a postabortive woman and when appropriate refer her to agencies offering such groups.

Abortion in young women and subsequent mental health. Fergusson DM, John Horwood L, Ridder EM. J Child Psychol Psychiatry. 2006 Jan;47(1):16-24.

Background: The extent to which abortion has harmful consequences for mental health remains controversial. We aimed to examine the linkages between having an abortion and mental health outcomes over the interval from age 15-25 years. Methods: Data were gathered as part of the Christchurch Health and Development Study, a 25-year longitudinal study of a birth cohort of New Zealand children. Information was obtained on: a) the history of pregnancy/abortion for female participants over the interval from 15-25 years; b) measures of DSM-IV mental disorders and suicidal behaviour over the intervals 15-18, 18-21 and 21-25 years; and c) childhood, family and related confounding factors. Results: Forty-one percent of women had become pregnant on at least one occasion prior to age 25, with 14.6% having an abortion. Those having an abortion had elevated rates of subsequent mental health problems including depression, anxiety, suicidal behaviours and substance use disorders. This association persisted after adjustment for confounding factors. Conclusions: The findings suggest that abortion in young women may be associated with increased risks of mental health problems.

Induced abortion and traumatic stress: A preliminary comparison of American and Russian women. Rue VM, Coleman PK, Rue JJ, Reardon DC. Med Sci Monit, 2004 10(10): SR5-16.

BACKGROUND: Individual and situational risk factors associated with negative postabortion psychological sequelae have been identified, but the degree of posttraumatic stress reactions and the effects of culture are largely unknown.

MATERIAL/METHODS: Retrospective data were collected using the Institute for Pregnancy Loss Questionnaire (IPLQ) and the Traumatic Stress Institute's (TSI) Belief Scale administered at health care facilities to 548 women (331 Russian and 217 American) who had experienced one or more abortions, but no other pregnancy losses.

RESULTS: Overall, the findings here indicated that American women were more negatively influenced by their abortion experiences than Russian women. While 65% of American women and 13.1% of Russian women experienced multiple symptoms of increased arousal, re-experiencing and avoidance associated with posttraumatic stress disorder (PTSD), 14.3% of American and 0.9% of Russian women met the full diagnostic criteria for PTSD. Russian women had significantly higher scores on the TSI Belief Scale than American women, indicating more disruption of cognitive schemas. In this sample, American women were considerably more likely to have experienced childhood and adult traumatic experiences than Russian women. Predictors of positive and negative outcomes associated with abortion differed across the two cultures.

CONCLUSIONS: Posttraumatic stress reactions were found to be associated with abortion. Consistent with previous research, the data here suggest abortion can increase stress and decrease coping abilities, particularly for those women who have a history of adverse childhood events and prior traumata. Study limitations preclude drawing definitive conclusions, but the findings do suggest additional cross-cultural research is warranted.

Increased risk for postpartum psychiatric disorders among women with past pregnancy loss. Giannandrea SA, Cerulli C, Anson E, Chaudron LH. J Womens Health (Larchmt). 2013 Sep;22(9):760-8. doi: 10.1089/jwh.2012.4011.

Abstract Background: Scant literature exists on whether prior pregnancy loss (miscarriage, stillbirth, and/or induced abortion) increases the risk of postpartum psychiatric disorders-specifically depression and anxiety-after subsequent births. This study compares: (1) risk factors for depression and/or anxiety disorders in the postpartum year among women with and without prior pregnancy loss; and (2) rates of these disorders in women with one versus multiple pregnancy losses.

Methods: One-hundred-ninety-two women recruited at first-year pediatric well-child care visits from an urban pediatric clinic provided demographic information, reproductive and health histories. They also completed depression screening tools and a standard semi-structured psychiatric diagnostic interview.

Results: Almost half of the participants (49%) reported a previous pregnancy loss (miscarriage, stillbirth, or induced abortion). More than half of those with a history of pregnancy loss reported more than one loss (52%). Women with prior pregnancy loss were more likely to be diagnosed with major depression (p=0.002) than women without a history of loss. Women with multiple losses were more likely to be diagnosed with major depression (p=0.047) and/or post-traumatic stress disorder (Fisher's exact [FET]=0.028) than women with a history of one pregnancy loss. Loss type was not related to depression, although number of losses was related to the presence of depression and anxiety.

Conclusions: Low-income urban mothers have high rates of pregnancy loss and often have experienced more than one loss and/or more than one type of loss. Women with a history of pregnancy loss are at increased risk for depression and anxiety, including post-traumatic stress disorder (PTSD), after the birth of a child. Future research is needed to understand the reasons that previous pregnancy loss is associated with subsequent postpartum depression and anxiety among this population of women.

Women's experiences in relation to stillbirth and risk factors for long-term post-traumatic stress symptoms: a retrospective study. Gravensteen IK, Helgadóttir LB, Jacobsen EM, Rådestad I, Sandset PM, Ekeberg O. BMJ Open. 2013 Oct 22;3(10):e003323. doi: 10.1136/bmjopen-2013-003323.

OBJECTIVES: (1) To investigate the experiences of women with a previous stillbirth and their appraisal of the care they received at the hospital. (2) To assess the long-term level of post-traumatic stress symptoms (PTSS) in this group and identify risk factors for this outcome.

DESIGN: A retrospective study.

SETTING:Two university hospitals.

PARTICIPANTS: The study population comprised 379 women with a verified diagnosis of stillbirth (≥23 gestational weeks or birth weight ≥500 g) in a singleton or twin pregnancy 5-18 years previously. 101 women completed a comprehensive questionnaire in two parts.

PRIMARY AND SECONDARY OUTCOME MEASURES: The women's experiences and appraisal of the care provided by healthcare professionals before, during and after stillbirth. PTSS at follow-up was assessed using the Impact of Event Scale (IES).

RESULTS: The great majority saw (98%) and held (82%) their baby. Most women felt that healthcare professionals were supportive during the delivery (85.6%) and showed respect towards their baby (94.9%). The majority (91.1%) had received some form of short-term follow-up. One-third showed clinically significant long-term PTSS (IES ≥ 20). Independent risk factors were younger age (OR 6.60, 95% CI 1.99 to 21.83), induced abortion prior to stillbirth (OR 5.78, 95% CI 1.56 to 21.38) and higher parity (OR 3.46, 95% CI 1.19 to 10.07) at the time of stillbirth. Having held the baby (OR 0.17, 95% CI 0.05 to 0.56) was associated with less PTSS.

CONCLUSIONS: The great majority saw and held their baby and were satisfied with the support from healthcare professionals. One in three women presented with a clinically significant level of PTSS 5-18 years after stillbirth. Having held the baby was protective, whereas prior induced abortion was a risk factor for a high level of PTSS.

Voluntary and involuntary childlessness in female veterans: associations with sexual assault. Ryan GL, Mengeling MA, Booth BM, Torner JC, Syrop CH, Sadler AG. Fertil Steril. 2014 Aug;102(2):539-47. doi: 10.1016/j.fertnstert.2014.04.042. Epub 2014 May 27.

In a sample of 1,004 female veterans enrolled at VA medical centers, 620 had a history of at least one attempted or completed sexual assault. Those with a history of sexual assault were "more often self-reported a history of pregnancy termination (31% vs. 19%) and infertility (23% vs. 12%), as well as sexually transmitted infection (42% vs. 27%), posttraumatic stress disorder (32% vs. 10%), and postpartum dysphoria (62% vs. 44%). Lifetime sexual assault was independently associated with termination and infertility in multivariate models; sexually transmitted infection, posttraumatic stress disorder, and postpartum dysphoria were not. The LSA by period of life was as follows: 41% of participants in childhood, 15% in adulthood before the military, 33% in military, and 13% after the military (not mutually exclusive). Among the 511 who experienced a completed LSA, 23% self-reported delaying or foregoing pregnancy because of their assault."

Investigation of risk factors for acute stress reaction following induced abortion. Vukelić J, Kapamadzija A, Kondić B. [Article in Serbian] Med Pregl. 2010 May-Jun;63(5-6):399-403.

INTRODUCTION: Termination of pregnancy-induced abortion is inevitable in family planning as the final solution in resolving unwanted pregnancies. It can be the cause of major physical and phychological consequences on women's health. Diverse opinions on psychological consequences of induced abortion can be found in literature.

MATERIAL AND METHODS: A prospective study was performed in order to predict acute stress disorder (ASD) after the induced abortion and the possibility of post-traumatic stress disorder (PTSD). Seven days after the induced abortion, 40 women had to fill in: (1) a special questionnaire made for this investigation, with questions linked to some risk factors inducing stress, (2) Likert's emotional scale and 3. Bryant's acute stress reaction scale.

RESULTS: After an induced abortion 52.5% women had ASD and 32.5% women had PTSD. Women with ASD after the abortion developed more sense of guilt, irritability, shame, self-judgement, fear from God and self-hatred. They were less educated, had lower income, they were more religious, did not approve of abortion and had worse relationship with their partners after the abortion in comparison to women without ASD. Age, number of previous abortions and decision to abort did not differ between the two groups.

DISCUSSION: Induced abortion represents a predisposing factor for ASD and PTSD in women. Some psycho-social factors contribute to the development of stress after abortion. Serbia has a task to reduce the number of abortions which is very high, in order, to preserve reproductive and psychological health of women.

[2] Wallin Lundell I, Georgsson Öhman S, Frans Ö, Helström L, Högberg U, Nyberg S, Sundström Poromaa I, Sydsjö G, Östlund I, Skoog Svanberg A. BMC Womens Health. 2013 Dec 23;13:52. doi: 10.1186/1472-6874-13-52. See also: Induced Abortions and Posttraumatic Stress - Is there any relation? A Swedish multi-centre study INGER WALLIN LUNDELL 2014 Dissertation.

Background: Induced abortion is a common medical intervention. Whether psychological sequelae might follow induced abortion has long been a subject of concern among researchers and little is known about the relationship between posttraumatic stress disorder (PTSD) and induced abortion. Thus, the aim of the study was to assess the prevalence of PTSD and posttraumatic stress symptoms (PTSS) before and at three and six months after induced abortion, and to describe the characteristics of the women who developed PTSD or PTSS after the abortion.

Methods: This multi-centre cohort study included six departments of Obstetrics and Gynaecology in Sweden. The study included 1457 women who requested an induced abortion, among whom 742 women responded at the three-month follow-up and 641 women at the six-month follow-up. The Screen Questionnaire-Posttraumatic Stress Disorder (SQ-PTSD) was used for research diagnoses of PTSD and PTSS, and anxiety and depressive symptoms were evaluated by the Hospital Anxiety and Depression Scale (HADS). Measurements were made at the first visit and at three and six months after the abortion. The 95% confidence intervals for the prevalence of lifetime or ongoing PTSD and PTSS were calculated using the normal approximation. The chi-square test and the Student’s t-test were used to compare data between groups.

Results: The prevalence of ongoing PTSD and PTSS before the abortion was 4.3% and 23.5%, respectively, concomitant with high levels of anxiety and depression. At three months the corresponding rates were 2.0% and 4.6%, at six months 1.9% and 6.1%, respectively. Dropouts had higher rates of PTSD and PTSS. Fifty-one women developed PTSD or PTSS during the observation period. They were young, less well educated, needed counselling, and had high levels of anxiety and depressive symptoms. During the observation period 57 women had trauma experiences, among whom 11 developed PTSD or PTSS and reported a traumatic experience in relation to the abortion.

Conclusion: Few women developed PTSD or PTSS after the abortion. The majority did so because of trauma experiences unrelated to the induced abortion. Concomitant symptoms of depression and anxiety call for clinical alertness and support.

Case Study of PTSD Treatment

The Assessment and Treatment of Post-Abortion Syndrome: A Systematic Case Study From Southern Africa Boulind M, Edward D. Journal of Psychology in Africa 2008 18(4); 539-548.

Abstract: This article reports a clinical case study of “Grace”, a black Zimbabwean woman with post-abortion syndrome (PAS), a form of post-traumatic stress disorder precipitated by aborting an unwanted pregnancy. She was treated by a middle class white South African trainee Clinical Psychologist. The case narrative documents the assessment and the course of treatment which was guided by ongoing case formulation based on current evidence-based models. Factors that made her vulnerable to developing PTSD included active suppression of the memory of the event and lack of social support. An understanding of these factors was used to guide an effective intervention. In spite of the differences in culture and background between client and therapist, there was considerable commonality in their experience as young women and students who each had to balance personal and occupational priorities. The narrative also highlights the commonalities of Grace’s experiences with those reported in the literature on post-abortion syndrome, which is mostly from the U. S. A. and Europe.

Related Information

How women perceive abortion care: A study focusing on healthy women and those with mental and posttraumatic stress.Wallin Lundell I1, Öhman SG, Sundström Poromaa I, Högberg U, Sydsjö G, Skoog Svanberg A. Eur J Contracept Reprod Health Care. 2015 Feb 9:1-12.

Abstract: Objectives To identify perceived deficiencies in the quality of abortion care among healthy women and those with mental stress.

Methods: This multi-centre cohort study included six obstetrics and gynaecology departments in Sweden. Posttraumatic stress (PTSD/PTSS) was assessed using the Screen Questionnaire-Posttraumatic Stress Disorder; anxiety and depressive symptoms, using the Hospital Anxiety Depression Scale; and abortion quality perceptions, using a modified version of the Quality from the Patient's Perspective questionnaire. Pain during medical abortion was assessed in a subsample using a visual analogue scale.

Results: Overall, 16% of the participants assessed the abortion care as being deficient, and 22% experienced intense pain during medical abortion. Women with PTSD/PTSS more often perceived the abortion care as deficient overall and differed from healthy women in reports of deficiencies in support, respectful treatment, opportunities for privacy and rest, and availability of support from a significant person during the procedure. There was a marginally significant difference between PTSD/PTSS and the comparison group for insufficient pain alleviation.

Conclusions: Women with PTSD/PTSS perceived abortion care to be deficient more often than did healthy women. These women do require extra support, relatively simple efforts to provide adequate pain alleviation, support and privacy during abortion may improve abortion care.

Posttraumatic stress among women after induced abortion: a Swedish multi-centre cohort study. Wallin Lundell I, Georgsson Öhman S, Frans O, Helström L, Högberg U, Nyberg S, Sundström Poromaa I, Sydsjö G, Ostlund I, Skoog Svanberg A. BMC Womens Health. 2013 Dec 23;13(1):52.

BACKGROUND: Induced abortion is a common medical intervention. Whether psychological sequelae might follow induced abortion has long been a subject of concern among researchers and little is known about the relationship between posttraumatic stress disorder (PTSD) and induced abortion. Thus, the aim of the study was to assess the prevalence of PTSD and posttraumatic stress symptoms (PTSS) before and at three and six months after induced abortion, and to describe the characteristics of the women who developed PTSD or PTSS after the abortion.

METHODS: This multi-centre cohort study included six departments of Obstetrics and Gynaecology in Sweden. The study included 1457 women who requested an induced abortion, among whom 742 women responded at the three-month follow-up and 641 women at the six-month follow-up. The Screen Questionnaire-Posttraumatic Stress Disorder (SQ-PTSD) was used for research diagnoses of PTSD and PTSS, and anxiety and depressive symptoms were evaluated by the Hospital Anxiety and Depression Scale (HADS). Measurements were made at the first visit and at three and six months after the abortion. The 95% confidence intervals for the prevalence of lifetime or ongoing PTSD and PTSS were calculated using the normal approximation. The chi-square test and the Student's t-test were used to compare data between groups.

RESULTS: The prevalence of ongoing PTSD and PTSS before the abortion was 4.3% and 23.5%, respectively, concomitant with high levels of anxiety and depression. At three months the corresponding rates were 2.0% and 4.6%, at six months 1.9% and 6.1%, respectively. Dropouts had higher rates of PTSD and PTSS. Fifty-one women developed PTSD or PTSS during the observation period. They were young, less well educated, needed counselling, and had high levels of anxiety and depressive symptoms. During the observation period 57 women had trauma experiences, among whom 11 developed PTSD or PTSS and reported a traumatic experience in relation to the abortion.

CONCLUSION: Few women developed PTSD or PTSS after the abortion. The majority did so because of trauma experiences unrelated to the induced abortion. Concomitant symptoms of depression and anxiety call for clinical alertness and support

Reviewer Comments (Donna Harrison, MD)

But what does the data in the paper actually demonstrate?

“Response rates were 742/1381 (54%) at the three-month follow-up and 641/1381 (46%) at the six-month assessment (Figure 1).” So, less than half of the study respondents actually completed the study. Let’s look at these dropouts a little closer:

“Dropouts at the three-month assessments were younger, more often born outside Sweden, had a lower level of education, reported tobacco use more often but less alcohol use, had more anxiety and depressive symptoms and were more often using antidepressant treatment. In addition, they had more often had a previous abortion and had less often received counselling before the abortion (Table 1), and they also had higher rates of lifetime PTSD, ongoing PTSD and PTSS at the baseline assessment than the responders (Table 2). Dropouts at the six month assessment had lower levels of education and had more often had a previous induced abortion (Table 1), but did not differ from responders in rates of lifetime PTSD, ongoing PTSD or PTSS (Table 2)”

So, in the baseline assessment, prior to the abortion being studied, there is a subset of women who later became dropouts of this study. This subset of women, who had higher PTSD scores, more anxiety and depression, and were more often using antidepressants had one additional characteristic which distinguished them from the responders: “they had more often had a previous abortion”.

A reasonable researcher might ask why the experience of a previous abortion would correlate with the presence of higher PTSD scores, more anxiety and depression and greater frequency of use of antidepressants BEFORE the abortion being studied.

A reasonable researcher might also ask whether this loss of half of the study population might affect the statistical conclusions of the study.

A reasonable researcher might also wonder why a 3month and 6 month follow up time interval was chosen for an outcome such as PTSD which has been well established to occur much later; years after the event? In fact, the “baseline” PTSD data, which collected information on abortion history BEFORE THE ABORTION IN THE STUDY, might actually shed more light on the long term psychological outcome, than a 3 and 6 month follow up.

This study is an excellent illustration of what pro-abortion researchers call “Research for Advocacy” and what the rest of the world calls “spin”. As pro-life physicians, we are called to read further than the abstract and conclusion, and to really consider the scientific data being presented. We need to look at whether or not the data actually supports the published conclusions.

Another analysis using the same data set was published by the same research team: "The prevalence of posttraumatic stress among women requesting induced abortion."

Posttraumatic stress disorder following medical illness and treatment. JE Tedstone, N Tarrier. Clin Psychol Rev. 2003 May;23(3):409-48.

Studies describing posttraumatic stress disorder (PTSD) as a result of physical illness and its treatment were reviewed. PTSD was described in studies investigating myocardial infarction (MI), cardiac surgery, haemorrhage and stroke, childbirth, miscarriage, abortion and gynaecological procedures, intensive care treatment, human immunodeficiency virus (HIV) infection, awareness under anaesthesia, and in a group of miscellaneous conditions. Cancer medicine was not included as it had been the subject of a recent review in this journal. Studies were reviewed in terms of the prevalence rates for PTSD, intrusive and avoidance symptoms, predictive and associated factors and the consequences of PTSD on healthcare utilization and outcome.

Which Medical Conditions Account For The Rise In Health Care Spending? Kenneth E. Thorpe, Curtis S. Florence, Peter Joski. Health Affairs, 10.1377/hlthaff.w4.437

Between 1987 and 2000, the 15 costliest medical conditions were heart disease, mental disorders, lung disease, cancer, trauma, high blood pressure, diabetes, back problems, arthritis, stroke and other brain blockages, skin disorders, pneumonia, infectious disease, hormone disorders, and kidney disease. For their study, Thorpe and colleagues used two U.S. government surveys -- the 1987 National Medical Expenditure Survey of 34,000 people and the 2000 Medical Expenditure Panel Survey of 25,000 people New patients accounted for 59 percent of the rise in spending on mental disorders, the report found. While mental disorders did not become more common, twice as many people sought treatment for them between 1987 and 2000.

Prevalence and prediction of re-experiencing and avoidance after elective surgical abortion: a prospective study. van Emmerik AA, Kamphuis JH, Emmelkamp PM. Clin Psychol Psychother. 2008 Nov-Dec;15(6):378-85. doi: 10.1002/cpp.586.

OBJECTIVE: This study investigated short-term re-experiencing and avoidance after elective surgical abortion. In addition, it was prospectively investigated whether peritraumatic dissociation and pre-abortion dissociative tendencies and alexithymia predict re-experiencing and avoidance.

METHOD: In a prospective observational design, Dutch-speaking women presenting for first trimester elective surgical abortion completed self-report measures for dissociative tendency and alexithymia. Peritraumatic dissociation was measured immediately post-abortion. Re-experiencing and avoidance were measured 2 months post-abortion.

RESULTS: Participants reported moderately elevated levels of re-experiencing and avoidance that exceeded a clinical cut-off point for 19.4% of the participants. Peritraumatic dissociation predicted intrusion and avoidance at 2 months. In addition, avoidance was predicted by the alexithymic aspect of difficulty describing feelings.

CONCLUSIONS: Re-experiencing and avoidance after elective surgical abortion represent a significant clinical problem that is predicted by peritraumatic dissociation and alexithymia. Psychological screening and intervention might be a useful adjunct to elective abortion procedures.

Adjustment to termination of pregnancy for fetal anomaly: a longitudinal study in women at 4, 8, and 16 months. Korenromp MJ1, Page-Christiaens GC, van den Bout J, Mulder EJ, Visser GH. Am J Obstet Gynecol. 2009 Aug;201(2):160.e1-7. doi: 10.1016/j.ajog.2009.04.007. Epub 2009 Jun 26.Author information

OBJECTIVE: We studied psychological outcomes and predictors for adverse outcome in 147 women 4, 8, and 16 months after termination of pregnancy for fetal anomaly.

STUDY DESIGN: We conducted a longitudinal study with validated self-completed questionnaires.

RESULTS: Four months after termination 46% of women showed pathological levels of posttraumatic stress symptoms, decreasing to 20.5% after 16 months. As to depression, these figures were 28% and 13%, respectively. Late onset of problematic adaptation did not occur frequently. Outcome at 4 months was the most important predictor of persistent impaired psychological outcome. Other predictors were low self-efficacy, high level of doubt during decision making, lack of partner support, being religious, and advanced gestational age. Strong feelings of regret for the decision were mentioned by 2.7% of women.

CONCLUSION: Termination of pregnancy for fetal anomaly has significant psychological consequences for 20% of women up to > 1 year. Only few women mention feelings of regret.

Abortion and anxiety: what's the relationship? Steinberg JR1, Russo NF. Soc Sci Med. 2008 Jul;67(2):238-52. doi: 10.1016/j.socscimed.2008.03.033. Epub 2008 May 28.

"[M]ultiple abortions were found to be associated with much higher rates of PTSD and social anxiety," though the author, pro-choice activits, insist "this relationship was largely explained by pre-pregnancy mental health disorders and their association with higher rates of violence."

Systematic Reviews

Posttraumatic stress and posttraumatic stress disorder after termination of pregnancy and reproductive loss: a systematic review. Daugirdaitė V, van den Akker O, Purewal S. J Pregnancy. 2015;2015:646345. doi: 10.1155/2015/646345. Epub 2015 Feb 5.

OBJECTIVE: The aims of this systematic review were to integrate the research on posttraumatic stress (PTS) and posttraumatic stress disorder (PTSD) after termination of pregnancy (TOP), miscarriage, perinatal death, stillbirth, neonatal death, and failed in vitro fertilisation (IVF).

METHODS:Electronic databases (AMED, British Nursing Index, CINAHL, MEDLINE, SPORTDiscus, PsycINFO, PubMEd, ScienceDirect) were searched for articles using PRISMA guidelines.

RESULTS: Data from 48 studies were included. Quality of the research was generally good. PTS/PTSD has been investigated in TOP and miscarriage more than perinatal loss, stillbirth, and neonatal death. In all reproductive losses and TOPs, the prevalence of PTS was greater than PTSD, both decreased over time, and longer gestational age is associated with higher levels of PTS/PTSD. Women have generally reported more PTS or PTSD than men. Sociodemographic characteristics (e.g., younger age, lower education, and history of previous traumas or mental health problems) and psychsocial factors influence PTS and PTSD after TOP and reproductive loss.

CONCLUSIONS: This systematic review is the first to investigate PTS/PTSD after reproductive loss. Patients with advanced pregnancies, a history of previous traumas, mental health problems, and adverse psychosocial profiles should be considered as high risk for developing PTS or PTSD following reproductive loss.

Sleep Disorders

Sleep disorders are associated with PTSD and increased risk of suicide See Sleep Disorders