Söderberg, H., Janzon, L., & Sjöberg, N-O. (1998). Emotional distress following induced abortion: A study of its incidence and determinants among abortees in Malmo, Sweden. European Journal of Obstetrics & Gynecology and Reproductive Biology, 79:173-178.

Abstract

OBJECTIVE: To study incidence and determinants of emotional distress following induced abortion.

SETTING: Department of Obstetrics and Gynecology, Lund University, University Hospital Malmö, Sweden.

SUBJECTS: A series of 854 participants at 12-month postabortion follow-up, representing 66.5% of the 1285 women undergoing induced abortion at Malmö, 1989.

METHODS: Analysis of data elicited at a semistructured interview 1 year after induced abortion, risk factors for emotional distress being determined in a "case" subgroup (n = 139) of women satisfying all the inclusion criteria (i.e., postabortion emotional distress, doubts about abortion decision, would not consider abortion again), as compared with a control group (n = 114) satisfying none of the inclusion criteria. The study design is a retrospective study.

RESULTS: In the subgroup with emotional distress (duration ranging from 1 month to still present at 12-month follow-up), the following risk factors were identified: living alone, poor emotional support from family and friends, adverse postabortion change in relations with partner, underlying ambivalence or adverse attitude to abortion, and being actively religious.

CONCLUSIONS: Thus, 50-60% of women undergoing induced abortion experienced some measure of emotional distress, classified as severe in 30% of cases. The risk factors identified suggest that it may be possible to ameliorate or even prevent such distress.

Söderberg H, Andersson C, Janzon L, Sjöberg NO. Selection bias in a study on how women experienced induced abortion. Eur J Obstet Gynecol Reprod Biol. 1998 Mar;77(1):67-70. Abstract OBJECTIVE: One third of the women who had an induced abortion at the department of gynecology and obstetrics in Malmö 1989 refused to participate in an interview a year later to explore their experience and the care they had received. Using data from the mandatory preoperative visit it was then possible to compare participants with non-participants with regard to socio-demographic characteristics. reproductive history and stated reason for abortion. By continued follow-up of medical records it has furthermore been possible to ascertain how many women conceived within a year, and how many of them applied for another abortion and how many elected to continue the pregnancy to term.

SETTING: Department of Obstetrics and Gynecology, Lund University, University Hospital, Malmö Sweden. This is the sole referral hospital serving the population of Malmö (approx. 230000).

SUBJECTS: All 1285 women who underwent induced abortion at the department in 1989.

STUDY DESIGN: In each case information on socio-demographic characteristics, reproductive history and stated reasons for abortion was collected at the mandatory clinical visit prior to the abortion. This information was used for comparison of participants and non-participants in the planned 1-year follow-up interview.

RESULTS: Young, unmarried women of low educational status and without full-time employment or studying were overrepresented in the non-participant group. The proportion of women with children was however smaller in that group. Within 12 months after the abortion, 118 women 66 (7.7%) of the participants in the follow-up interview and 52 (12%) of the non-participants conceived again but elected to continue the pregnancy to term (P<0.05). whereas 124 of the women 80 (9.5%) and 44 (10.2%) of the respective subgroups again applied for abortion within 12 months.

CONCLUSION: One third of the women who underwent induced abortion did not wish to be interviewed about their emotional and somatic experience of the abortion 1 year later. Non-participation at the follow-up interview was associated with socio-demographic factors which in studies about other medical problems have been shown to be associated with increased vulnerability and morbidity. Non-participation was also associated with an increased childbirth rate during the following 2 years. The large proportion of non-participants is a matter for concern as to some extent it reflects inability of the health care system to establish trustful relationships with these women. How the participants in the follow-up study experienced this relationship will soon be published in our next paper. Support from the women's surroundings and the adviser the women met at the public health care system clearly influenced the women's psychological reactions after the abortion. It is therefore important to ascertain to what extent the management of abortion applicants in fact fulfils their individual needs and expectations.

Söderberg H, Andersson C, Janzon L, Sjöberg NO. Continued pregnancy among abortion applications. A study of women having a change of mind. Acta Obstet Gynecol Scand. 1997 Nov;76(10):942-7. Abstract OBJECTIVE: A certain proportion of women applying for legal abortion later change their minds. The present study was designed to ascertain whether such women differ from those who choose to terminate their pregnancy, with regard to age, civil status, other demographic characteristics, or reproductive history.

SETTING: Department of Obstetrics and Gynecology, University Hospital Malmö, Lund University, Sweden.

SUBJECTS: All 1,446 abortion applicants attending the abortion clinic at University Hospital Malmö, in 1989.

STUDY DESIGN: A comparison of the women who continued the pregnancy and those who underwent abortion, with regard to the above mentioned factors.

METHODS: Semistructured interviews and statistical analysis. RESULTS: Of this series of urban abortion applicants, almost one in ten underwent a change of mind. Women who chose to continue their pregnancy differed from those who held fast to their initial decision above all with regard to age and family situation. Less important was education, reproductive history, and stated reasons for abortion.

CONCLUSIONS: To answer the question why some women continue an unwanted pregnancy after a closer consideration is not easy. The complexity of a woman's feeling in the matter seems to be moderated by the kind of support and stability she has in her life situation and also of the stability in relation to her partner. An equally important question is whether this change of mind is associated with a changed attitude to the expected baby (i.e., does an unwanted child become a wanted one?).

Söderberg H. Abortions in Malmö--problems and prevention. Acta Obstet Gynecol Scand Suppl. 1997;164:60-2. Abstract Since 1975, women living in Sweden have had after counseling, free access to legal abortion until the 18th week of pregnancy. During the past decade, the abortion number remained around 34-38,000 per year, but since 1989 it has been decreasing continuously. This means an abortion rate ranging from 19.8 to 21.5 per 1,000 women aged 15-44. The largest towns in Sweden have the highest abortion rates, Malmö leading with 26.5-30.4 per 1,000 women.

Söderberg H. Urban Women applying for induced abortion. Studies of epidemiology, attitudes, and emotional reactions. Malmö, 1998. Doctoral Disseration. Department of Obstetrics and Gynecology and Community Medicine, Lund University, University Hospital, Malmö, Sweden. The basis for the studies Söderberg published in the above journal articles. There is a little extra information not found in the above.

• She reports that 33.5 percent declined to participate in the follow up interview. "For many of the women, the reason for non-participation seemed to be a sense of guilt and remorse that they did not wish to discuss. An answer often given was: ' Do do not want to talk about it. I just want to forget.'" (p 15) The demographic and first interview characteristics of the women refusing to participate were consistent with factors associated with higher rates of morbidity and mortality. (p25)

• Of 854 women, 59% had some measure of emotional distress, classified as severe for 16%." (p 26) "Slight emotional distress was defined as the occurrence of mild depression or remorse, guilt feelings, a tendency to cry without cause, discomfort upon meeting children, or recurrent fantasizing about the child that might have been (its gender, looks, etc.) Women who had needed help from a psychiatrist or a psychologist, or who could not work because of depression, were considered to have serious emotional problems..." (p 25)

• Risk factors for emotional distress included women who were actively religious, those with negative attitudes toward abortion, and those who ambivalent about their decision. Women at less risk were characterized by an over representation of women who had been intoxicated when they became pregnant. (p26)

• "Of the 854 women interviewed about a year after the abortion, not less than 650 (76.1%) said they would never consider an abortion if they became unwanted pregnant again, and 169 (19.8%) were still undecided as to whether or not their decision had been the right one." (p 37)

• 28.3 percent of the women (n=242) became pregnant again within 12 months of their abortions. About half carried to term and the rest had another abortion. (p 24)

• 18.9 percent of the 1,277 women who had abortions (n=242) became pregnant again within 12 months of their abortions. About half carried to term and the rest had another abortion. Women who refused to participate in the followup interview were significantly more likely to carry the subsequent pregnancy to term. (p 24)

Summary

Specifically, Söderberg conducted extensive structured interviews with 1,446 abortion applicants one year after they sought an abortion. 1,285 of the women had abortions and 161 changed their mind and did not abort.

Among those who had abortions, 50-60% of women undergoing induced abortion experienced some measure of emotional distress, classified as severe in 30% of cases. The following risk factors were identified: living alone, poor emotional support from family and friends, adverse postabortion change in relations with partner, underlying ambivalence or adverse attitude to abortion, and being actively religious. Söderberg also reported that about one-third declined to participate in the follow-up interview and that and that analysis of socio-demographic characteristics indicated that those who declined most closely matched the profile of women who reported more negative reactions.

Most notably, no emotional distress was reported in Söderberg’s analysis of the 161 women who changed their mind. This indicates that it may be easier to adjust to the birth of an unplanned and unwanted child than to adjust to an abortion. While Söderberg’s report on women who changed their mind does not discuss their emotional adjustments, it is clear that if she had detected high rates of emotional problems associated with a decision not to go through with an abortion, this would have been reported.

In short, while these studies do not provide a statistical comparison of, for example, depression scores between those who aborted and those who changed their minds, the researchers did do careful interviews with women from both groups and the absence of such an analysis, especially in light of the high rates of distress among the women who aborted, speaks volumes.

Because these are the only known studies comparing women who abort to women who sought an abortion but subsequently changed their minds, these studies are very unique and valuable. Due to their unique nature, these are important studies which should be at least briefly discussed in this review. It would also be worth seeking the raw data and encouraging similar research in the future.