Recent Studies

2010

Motherhood: is it good for women's mental health? Holtona S, Fishera J, Rowea H. Journal of Reproductive and Infant Psychology, Volume 28, Issue 3 August 2010 , pages 223 - 239

Abstract

There is ongoing debate regarding whether the child-bearing years, including the postpartum period, are a time of increased risk for mental health problems in women. Comparisons of the mental health of mothers and childless women have inconsistent findings. This is probably attributable to differences in the kinds of mothers and non-mothers investigated, and variations in the conceptualisation of mental health, but suggests that firm conclusions about the relationship between motherhood and women's mental health remain less clear than claimed. This study investigated the relationship between motherhood and mental health in a population-based, cross-sectional survey of a broadly representative sample of 569 women aged 30-34 years living in Victoria, one Australian state, in 2005. It was found that the rates of mental health conditions in mothers, including those who had given birth in the preceding year, were no higher than in women without children. Further, mothers reported significantly better subjective well-being and greater life satisfaction than childless women. These data suggest that being a mother is associated with enhanced mental health for women, and challenge the view that the child-bearing years are a period of diminished psychological well-being for women.

Long term follow-up of emotional experiences after termination of pregnancy: women's views at menopause. Dykesa K, Sladeb P; Haywood A. Journal of Reproductive and Infant Psychology,, First published on: 20 October 2010

Abstract

The objective was to explore women’s long-term experiences and perspectives on their terminations of pregnancy (TOP) when perimenopausal. Eight women attending a menopause clinic who had experienced termination a minimum of 10 years previously (mean 24 years) completed semi-structured interviews. Transcripts were analysed using Template Analysis. Five TOP themes were identified: ‘Impression left’ involved sadness, regret, and guilt which affected women’s self-perceptions. ‘Judgement’ encompassed judgement on themselves and how censure was feared from others. ‘Growth and development’ noted the development of resilience and compassion for others. ‘Coming to terms and managing effects’ identified beliefs in the correctness of the decision, but effortful avoidance of thoughts still intruding into life. ‘Contradictions’ identified dramatic inconsistencies within almost all individual accounts indicating lack of resolution and full acceptance. Considering menopause and TOP together revealed a further three themes; Changes to thinking, Menopause as a time of reflection and Linkages or separateness. For some women termination may be continually reappraised in their changing life context and remain an active yet hidden feature managed through active avoidance. Menopause was viewed as a time of vulnerability to TOP-related negative thoughts, especially where wishes for more children were unfulfilled. Accessibility of post-termination counselling throughout life is recommended.

Young age and termination of pregnancy during the second trimester are risk factors for repeat second-trimester abortion. Mentula MJ, Niinimäki M, Suhonen S, Hemminki E, Gissler M, Heikinheimo O. Am J Obstet Gynecol. 2010 Aug;203(2):107.e1-7.

OBJECTIVE: The objective of the study was to characterize women undergoing a termination of pregnancy (TOP) during the second trimester and to evaluate the risk factors and timing of repeat TOP.

STUDY DESIGN: This nationwide retrospective cohort study investigated 41,750 women who underwent TOP during the first (n = 39,850) or second (n = 1900) trimester in Finland in 2000-2005. The follow-up time was until repeat TOP or until Dec. 31, 2006.

RESULTS: TOP during the second trimester increases the risk of repeat TOP (hazard ratio [HR], 1.4; 95% confidence interval [CI], 1.3-1.6), repeat second-trimester TOP (HR, 3.8; 95% CI, 2.9-5.1), and repeat TOP after 16 weeks of gestation (HR, 5.0; 95% CI, 3.3-7.7). The other risk factor for these is young age (HR, 7.0, 95% CI, 5.3-9.3; and HR, 12.5; 95% CI, 3.1-50.4 for age <20 years).

CONCLUSION: Second-trimester TOP and young age are risk factors for repeat second-trimester TOP. Special focus on these women might be effective in decreasing repeat abortions.

Use of psychotropic drugs before pregnancy and the risk for induced abortion: population-based register-data from Finland 1996-2006 Gissler M, Artama M, Ritvanen A, Wahlbeck K. BMC Public Health. 2010 Jun 30;10:383.

(ABSTRACT)

Background Some, though not all studies have reported an increased risk for mental health problems after an induced abortion. Problems with design and data have compromised these studies and the generalisation of their results.

Methods The Finnish Medication and Pregnancy database (N = 622 671 births and 114 518 induced abortions for other than fetal reasons) in 1996-2006 was utilised to study the use of psychotropic drugs in the three months before a pregnancy ending in a birth or an induced abortion.

Results In total 2.1% of women with a birth and 5.1% of women with an induced abortion had used a psychotropic medicine 0-3 months before pregnancy. Psychotropic drug users terminated their pregnancies (30.9%) more often than other pregnant women (15.5%). Adjustment for background characteristics explained one third of this elevated risk, but the risk remained significantly increased among users of psychotropic medicine (OR 1.94, 95% confidence intervals 1.87-2.02). A similar risk was found for first pregnancies (30.1% vs. 18.9%; adjusted OR 1.53, 95% confidence intervals 1.42-1.65). The rate for terminating pregnancy was the highest for women using hypnotics and sedatives (35.6% for all pregnancies and 29.1% for first pregnancies), followed by antipsychotics (33.9% and 36.0%) and antidepressants (32.0% and 32.1%).

Conclusions The observed increased risk for induced abortion among women with psychotropic medication highlights the importance to acknowledge the mental health needs of women seeking an induced abortion. Further studies are needed to establish the impact of pre-existing differences in mental health on mental health outcomes of induced abortions compared to outcomes of pregnancies ending in a birth.

Do Depression and Low Self-Esteem Follow Abortion Among Adolescents? Evidence from a National Study Perspectives on Sexual and Reproductive Health, 42(4):230–235, (2010) Warren, Harvey, and Henderson.

Abstract

METHODS: Data from the National Longitudinal Study of Adolescent Health were used to examine whether abortion in adolescence was associated with subsequent depression and low self-esteem. In all, 289 female respondents reported at least one pregnancy between Wave 1 (1994–1995) and Wave 2 (1996) of the survey. Of these, 69 reported an induced abortion. Population-averaged lagged logistic regression models were used to assess associations between abortion and depression and low self-esteem within a year of the pregnancy and approximately five years later, at Wave 3 (2001–2002).

RESULTS: Abortion was not associated with depression or low self-esteem at either time point. Socioeconomic and demographic characteristics did not substantially modify the relationships between abortion and the outcomes.

CONCLUSIONS: Adolescents who have an abortion do not appear to be at elevated risk for depression or low self esteem in the short term or up to five years after the abortion.

EDITOR'S COMMENTS

1. This journal is published by the pro-abortion Alan Guttmacher Institute which was founded by Planned Parenthood.
2. The sample of women who aborted was very small (n= 69) reducing the statistical power.
   1. This is very important because with small sample size it is much more likely that one will not find any statistically significant results.
   2. The authors acknowledge on page 234 that “The lack of association between abortion and our outcomes could reflect other factors including insufficient sample size to detect an effect.”
   3. Very few control variables were employed despite the fact that this data set contains dozens of personal history, personality, relationship, situational, familial, and demographic variables that could have been controlled to isolate the effect of abortion.
   4. A common tactic of researchers trying to prove "no association" between A and B is to report results based on a small sample and may also include the use of only those control variables which reduce the statistical association.
   5. The 95% confidence interval reported by the authors (.027-2.09) indicates that it is 95% likely that the true risk of depression following abortion may be anywhere between 27% and 209% of depression rate found among teens who have not been pregnant. In other words, these findings do not contradict research showing higher rates of depression associated with abortion. Given the small sample size, this broad confidence interval is fully consistent with studies using larger populations which find the range of depression to be in the range of 110% to 200% higher than for women without a history of abortion.
   6. The findings fail to show any benefit from abortion. When abortion was legalized, it was argued that abortion would decrease the rate of depression and mental health problems because it would spare women the difficulties associated with an unplanned pregnancy and unwanted parenthood. Since the study does not show any statistically significant benefits or risks, it is actually a study that tells us nothing because the range of risk is just way to broad to be informative.

1. The outcome measures were superficial assessments. Specifically, the measure of depression was an abbreviated 9 item scale and self-esteem was measure with only 4 items.
2. The choice of the comparison group is suspect. The comparison group could have been unintended pregnancy carried to term since the data is available in ADD Health, but the researchers chose the broader “no pregnancy” group as their control group. Another study published regarding the same data set which did use unintended pregnancy delivered as the control group found significant associations between abortion history and marijuana usage, having received counseling for psychological or emotional problems, and sleep difficulties. Seeking professional counseling services is a much more valid measure of psychological distress than abbreviated self-report measures, one of which is merely “predictive of depression”. (See Coleman, P. K. (2006). Resolution of unwanted pregnancy during adolescence through abortion versus childbirth: Individual and family predictors and psychological consequences. The Journal of Youth and Adolescence, 35, 903-911.)

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

(Abstract)

The primary aim of this study was to compare the experience of an early abortion (1st trimester) to a late abortion (2nd and 3rd trimester) relative to Posttraumatic Stress Disorder (PTSD) symptoms after controlling for socio-demographic and personal history variables. Online surveys were completed by 374 women who experienced either a 1st trimester abortion (up to 12 weeks gestation) or a 2nd or 3rd trimester abortion (13 weeks gestation or beyond). Most respondents (81%) were U.S. citizens.

Later abortions were associated with higher Intrusion subscale scores and with a greater likelihood of reporting disturbing dreams, reliving of the abortion, and trouble falling asleep. Reporting the pregnancy was desired by one’s partner, experiencing pressure to abort, having left the partner prior to the abortion, not disclosing the abortion to the partner, and physical health concerns were more common among women who received later abortions. Social reasons for the abortion were linked with significantly higher PTSD total and subscale scores for the full sample.

Women who postpone their abortions may need more active professional intervention before securing an abortion based on the increased risks identified herein. More research with diverse samples employing additional measures of mental illness is needed.

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

Associations Between Abortion, Mental Disorders, and Suicidal Behaviour in a Nationally Representative Sample.Mota NP, Burnett M, Sareen J. The Canadian Journal of Psychiatry, Vol 55, No 4, April 2010,

Methods: Data came from the National Comorbidity Survey Replication (n = 3310 women, aged 18 years and older). The World Health Organization–Composite International Diagnostic Interview was used to assess mental disorders based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria and lifetime abortion in women. Multiple logistic regression analyses were employed to examine associations between abortion and lifetime mood, anxiety, substance use, eating, and disruptive behaviour disorders, as well as suicidal ideation and suicide attempts. We calculated the percentage of respondents whose mental disorder came after the first abortion. The role of violence was also explored. Population attributable fractions were calculated for significant associations between abortion and mental disorders.

Results: After adjusting for sociodemographics, abortion was associated with an increased likelihood of several mental disorders—mood disorders (adjusted odds ratio [AOR] ranging from 1.75 to 1.91), anxiety disorders (AOR ranging from 1.87 to 1.91), substance use disorders (AOR ranging from 3.14 to 4.99), as well as suicidal ideation and suicide attempts (AOR ranging from 1.97 to 2.18). Adjusting for violence weakened some of these associations. For all disorders examined, less than one-half of women reported that their mental disorder had begun after the first abortion. Population attributable fractions ranged from 5.8% (suicidal ideation) to 24.7% (drug abuse).

Conclusions: Our study confirms a strong association between abortion and mental disorders. Possible mechanisms of this relation are discussed.

Editor Notes Regarding Key Findings: Among the most notable findings women who had abortions had:

• 59 percent increased risk for suicidal thoughts
• 61 percent increased risk for mood disorders
• 61 percent increased risk for social anxiety disorders
• 261 percent increased risk for alcohol abuse
• 280 percent increased risk for any substance use disorder
• The researchers concluded that approximately 6 percent of suicidal ideation cases among women nationwide and 25 percent of cases of drug use could be related to abortion.

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

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 Regarding Key Findings: 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.

First-time pregnant women's experience of the decision-making process related to completing or terminating pregnancy - a phenomenological study. Scand J Caring Sci. 2010 Jul 7. Kjelsvik M, Gjengedal E.

(Abstract)

Every year about 30,000 women in Norway become unexpectedly pregnant and have to decide whether to complete or terminate the pregnancy. Few studies have been performed of these women's experiences. The aim of this qualitative study was to get new and more extensive information regarding women's experiences relating to their considerations of whether to terminate a pregnancy in the first trimester.

In-depth interviews with four participants between 25 and 32 years were conducted. None of them had previously given birth or had had an abortion. Each woman was interviewed twice during a period of 2 weeks. The first interview took place between 7 and 11 weeks into the pregnancy. None of the women had reached a decision on whether to complete or terminate the pregnancy. All the women described an increased awareness of their body and a struggle to make 'the right decision'. They described a desire for autonomy as well as a need for understanding and acknowledgement from significant others and health care providers. They experienced a tension between their pregnant body and the surrounding world, between their own body and the foetus and between their own choice and the opinions of others.

One consequence of a woman's right to choose can be an unwanted loneliness or giving in to other people's choices. There is consequently a need for professionals who are able to exercise skilled judgement and who are aware of their own power in the relationship so as to assure that the pregnant woman does in fact makes her own decision.

2009

Immediate complications after medical compared with surgical termination of pregnancy. Niinimäki M, Pouta A, Bloigu A, Gissler M, Hemminki E, Suhonen S, Heikinheimo O. Obstet Gynecol. 2009 Oct;114(4):795-804. OBJECTIVE: To estimate the immediate adverse events and safety of medical compared with surgical abortion using high-quality registry data.

METHODS: All women in Finland undergoing induced abortion from 2000-2006 with a gestational duration of 63 days or less (n=42,619) were followed up until 42 days postabortion using national health registries. The incidence and risk factors of adverse events after medical (n=22,368) and surgical (n=20,251) abortion were compared. Univariable and multivariable association models were used to analyze the risk of the three main complications (hemorrhage, infection, and incomplete abortion) and surgical (re)evacuation.

RESULTS: The overall incidence of adverse events was fourfold higher in the medical compared with surgical abortion cohort (20.0% compared with 5.6%, P<.001). Hemorrhage (15.6% compared with 2.1%, P<.001) and incomplete abortion (6.7% compared with 1.6%, P<.001) were more common after medical abortion. The rate of surgical (re)evacuation was 5.9% after medical abortion and 1.8% after surgical abortion (P<.001). Although rare, injuries requiring operative treatment or operative complications occurred more often with surgical termination of pregnancy (0.6% compared with 0.03%, P<.001). No differences were noted in the incidence of infections (1.7% compared with 1.7%, P=.85), thromboembolic disease, psychiatric morbidity, or death.

CONCLUSION: Both methods of abortion are generally safe, but medical termination is associated with a higher incidence of adverse events. These observations are relevant when counseling women seeking early abortion.

LEVEL OF EVIDENCE: II.

Reactions to abortion and subsequent mental health. Fergusson DM, Horwood LJ, Boden JM. Br J Psychiatry. 2009 Nov;195(5):420-6.

Abstract

BACKGROUND: There has been continued interest in the extent to which women have positive and negative reactions to abortion.

AIMS: To document emotional reactions to abortion, and to examine the links between reactions to abortion and subsequent mental health outcomes.

METHOD: Data were gathered on the pregnancy and mental health history of a birth cohort of over 500 women studied to the age of 30.

RESULTS: Abortion was associated with high rates of both positive and negative emotional reactions; however, nearly 90% of respondents believed that the abortion was the right decision. Analyses showed that the number of negative responses to the abortion was associated with increased levels of subsequent mental health disorders (P<0.05). Further analyses suggested that, after adjustment for confounding, those having an abortion and reporting negative reactions had rates of mental health disorders that were approximately 1.4-1.8 times higher than those not having an abortion.

CONCLUSIONS: Abortion was associated with both positive and negative emotional reactions. The extent of negative emotional reactions appeared to modify the links between abortion and subsequent mental health problems.

Excerpt of Researchers Conclusions Regarding Key Findings:

• Combining the findings of our two studies leads to the following generalisations about the links between unwanted pregnancy, abortion and mental health in this birth cohort.

• (a) First, unwanted pregnancy terminated by abortion was associated with modestly increased risks of common mental health problems for women who reported significant distress about the abortion (RR = 1.4–1.8).
• (b) Second, unwanted pregnancy terminated by abortion was not associated with significantly increased risks of mental health problems for women who did not report significant distress about the abortion (RR = 1.14–1.24).
• (c) Third, unwanted pregnancy that came to term was not associated with significant increases in mental health problems (RR = 1.05–1.11).
• (d) Finally, any associations between unwanted pregnancy, abortion and mental health problems were small to moderate, with adjusted relative risks in the region of 1.1–1.8. Estimates of the population attributable risk suggested that exposure to unwanted pregnancy terminated by abortion accounted for fewer than 5% of the mental health problems experienced by women in this cohort.

"Inadequate Preabortion Counseling and Decision Conflict as Predictors of Subsequent Relationship Difficulties and Psychological Stress in Men and Women"[1] 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.

Editor's Notes Regarding Key Findings: Overall, 54 percent of the women and 43 percent of the men reported all the symptoms for a clinical diagnosis of post-traumatic stress disorder. Approximately 80 percent of women and 77 percent of men had at least one symptom of PTSD, and nearly 80 percent of women and 60 percent of men reported that the abortion experience was highly or overwhelmingly stressful.

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.

Editor's Notes Regarding Key Findings: 22 percent of women were diagnosed with a psychiatric disorder after abortion, compared to 18 percent of women who gave birth to a baby with very low-birth-weight (VLBW) and 6 percent of women who had a healthy full-term pregnancy.

While the three groups of women "did not differ significantly" on psychiatric disorders prior to abortion or delivery, the researchers noted a difference afterwards, with women who had abortions having the highest rates of psychiatric disorders. Further, 16 percent of women who had abortions had psychiatric disorders 14 months later, compared to 7 percent of women with preterm births and none of the women with healthy pregnancies.

The disorders found among women who had abortions included acute stress disorders, eating disorders, affective disorders and anxiety disorders, with depression and anxiety predominating over time. Just over 64 percent of aborting women in the study developed symptoms of post-traumatic stress disorder.

The authors reported that for most women, abortions in the 2nd or 3rd trimester after a negative fetal diagnosis "are major life events" that can cause ongoing problems even months after the event. They called for more resources and better screening to help identify those who might be at risk for problems after abortion and need psychological support.

Violence in the lives of women in Italy who have an elective abortion. Romito P, Escribà-Agüir V, Pomicino L, Lucchetta C, Scrimin F, Molzan Turan J. Womens Health Issues. 2009 Sep-Oct;19(5):335-43.

Abstract

BACKGROUND: Violence is an important health problem for pregnant women, with numerous studies showing that it may compromise maternal and infant health. Many women who seek an elective abortion (EA) live in difficult personal and social circumstances, in which violence often has a central role, yet few studies have analyzed the relationships between violence and having an EA. OBJECTIVES: To analyze the role of family and partner violence among women seeking an EA, exploring the role of women's age, and controlling for sociodemographic factors. METHODS: An unmatched, case-control study was carried out in the Trieste Public Hospital, including all consecutive EAs (n=445) and live births (n=438). With an anonymous questionnaire, we collected information on sociodemographic characteristics, current violence (psychological, physical, and sexual) perpetrated by a partner or by other family members, and past violence. RESULTS: Compared with postpartum women, EA women were significantly more likely to report any type of current and past violence. Among women younger than 30 years old, adjusting for relevant social factors, partner psychological violence and family violence were strongly associated with EA, whereas among women 30 years old or older, there was no association with partner and family violence after adjustment. CONCLUSION: These results highlight the role of violence in the lives of women, especially younger women, seeking an abortion, and the need for sensitive screening for partner and family violence among these women. Health professionals should be able to recognize violence among women seeking an EA and to support them.

Rates of follow-up and repeat pregnancy in the 12 months after first-trimester induced abortion. Madden T, Westhoff C. Obstet Gynecol. 2009 Mar;113(3):663-8.

OBJECTIVE: To estimate the proportion of women who returned for a routine follow-up visit after elective abortion and to identify factors associated with repeat pregnancy in the subsequent year.

METHODS: We performed a historical cohort study of 865 women who underwent first-trimester surgical abortion at a hospital-based family planning clinic between March 2003 and February 2004. We collected demographic and clinical data from procedure notes and a computerized hospital patient database. We used univariable and multivariable logistic regression to analyze associations between patient characteristics and repeat pregnancy within 1 year.

RESULTS: There were a total of 865 women in our cohort. Of these, 753 (87%) returned to the medical center for care; 485 women returned on time, 268 women returned late, and 112 had no further visit. There were 161 repeat pregnancies; 87 (17.9%) in the on-time group and 74 (27.6%) in the late group (P<.001). There were 85 repeat abortions; 42 (8.7%) in the on-time group and 43 (16.0%) in the late group (P<.001). Multivariable analysis demonstrated that on-time follow-up was associated with a reduction in repeat pregnancy (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.37-0.77) and repeat abortion (OR 0.53, 95% CI 0.33-0.86). A total of 130 women received injectable depot medroxyprogesterone acetate (DMPA) at the time of abortion. The rates of repeat pregnancy and abortion in these women were 13.7% and 6.2%, respectively. Women who received DMPA had a decrease in rates of repeat pregnancy (OR 0.41, 95% CI 0.23-0.73) and repeat abortion (OR 0.45, 95% CI 0.20-0.99).

CONCLUSION: Timely follow-up and immediate administration of DMPA are associated with a decrease in repeat pregnancy in the 12 months after first-trimester elective abortion.

Editor's Notes: Overall, at least 21% became pregnant again within one year. OF those who became pregnant again, 53% had another abortion and 47% continued their "replacement" pregnancy. Another way of looking at it is that within one year, about 1 in 10 women became pregnant and decided against a second abortion. The abortion didn't "buy" them much time to change their lives and so it is likely they would not agree that the abortion made their lives better. DMPA is a contraceptive injection that lasts approximately 3 months.

'Termination of pregnancy: a review of psychological effects on women.' Lipp A. Nurs Times. 2009 Jan 13-19;105(1):26-9.

Abstract

Termination of pregnancy may have psychological consequences that are greater than its physical impact. Following a literature search and appraisal, this article explores some of the main themes arising from studies on the psychological impact. The results demonstrate that negative psychological effects are more likely in certain high-risk women. A table of indicators has been developed which could assist nurses in recognising whether a woman is at risk of negative psychological effects after termination.

Editor's Notes Regarding Key Findings: This is not a true literature review, but is rather simply a review of key information useful for nurses.

Lipp's identified the following risk factors may elicit greater risk of psychological effects (Source of evidence)

• Demographics - termination being in conflict with ethnic group, religion, socioeconomic group (Harris 2004; Bonevski and Adams 2001]
• Foetal abnormality (Bonevski and Adams 2001)
• Second trimester caused by delay in accessing services (Harris 2004)
• Low self-esteem (Bonevski and Adams 2001)
• Lack of social support (Major and Gramzow 1999); Cozzarelli et al 1998)
• Difficulty making decision (Shusterman 1979)
• Suicide in the family (Thorp et al 2002)
• History of self-harm (Thorp et al 2002)
• History of depression (Thorp et al 2002)
• History of psychiatric illness (Broen et al 2005b; Bonevski and Adams 2001)
• Undue influence from male partner (Broen et al 2005a; Pope et al 2001)

'Induced abortion and intimate relationship quality in the Chicago Health and Social Life Survey.' Coleman PK, Rue VM, Coyle CT. Public Health. 2009 Apr;123(4):331-8. Epub 2009 Mar 26. Abstract

OBJECTIVES: To examine associations between abortion and relationship functioning. STUDY DESIGN: Independent variables included abortion in a previous relationship and abortion in a current relationship. Perceptions of quality-of-life changes associated with terminating the relationship, conflict, aggressiveness and sexual dysfunction were the outcome measures. METHODS: Data were derived from interviews with an ethnically diverse urban sample of men (n=658) and women (n=906). Surveys were conducted in person using computer-assisted personal interview technology by the National Opinion Research Center affiliated with the University of Chicago, USA. RESULTS: For men and women, the experience of an abortion in a previous relationship was related to negative outcomes in the current relationship; perceptions of improved quality of life if the current relationship also ended and intimate partner violence. Experience of an abortion within a current relationship was associated with 116% and 196% increased risk of arguing about children for women and men, respectively. Among females, experience of an abortion within a current relationship was associated with increased risk for various forms of sexual dysfunction (122-182%), increased risk of arguments about money (75%), increased risk of conflict about the partner's relatives (80%), and increased risk of arguing about the respondent's relatives (99%). Men whose current partners had experienced an abortion were more likely to report jealousy (96% greater risk) and conflict about drugs (385% greater risk). CONCLUSION: Abortion may play a vital role in understanding the aetiology of relationship problems.

'Induced abortion and anxiety, mood, and substance abuse disorders: isolating the effects of abortion in the national comorbidity survey.' Coleman PK, Coyle CT, Shuping M, Rue VM. J Psychiatr Res. 2009 May;43(8):770-6. Epub 2008 Nov 28.

Abstract

The purpose of this study was to examine associations between abortion history and a wide range of anxiety (panic disorder, panic attacks, PTSD, Agoraphobia), mood (bipolar disorder, mania, major depression), and substance abuse disorders (alcohol and drug abuse and dependence) using a nationally representative US sample, the national comorbidity survey. Abortion was found to be related to an increased risk for a variety of mental health problems (panic attacks, panic disorder, agoraphobia, PTSD, bipolar disorder, major depression with and without hierarchy), and substance abuse disorders after statistical controls were instituted for a wide range of personal, situational, and demographic variables. Calculation of population attributable risks indicated that abortion was implicated in between 4.3% and 16.6% of the incidence of these disorders. Future research is needed to identify mediating mechanisms linking abortion to various disorders and to understand individual difference factors associated with vulnerability to developing a particular mental health problem after abortion.

2008

'Abortion and mental health disorders: evidence from a 30-year longitudinal study.'Fergusson DM, Horwood LJ, Boden JM. Br J Psychiatry. 2008 Dec;193(6):444-51.

Background: Research on the links between abortion and mental health has been limited by design problems and relatively weak evidence.

Aims: To examine the links between pregnancy outcomes and mental health outcomes. METHOD: Data were gathered on the pregnancy and mental health history of a birth cohort of over 500 women studied to the age of 30.

Results: After adjustment for confounding, abortion was associated with a small increase in the risk of mental disorders; women who had had abortions had rates of mental disorder that were about 30% higher. There were no consistent associations between other pregnancy outcomes and mental health. Estimates of attributable risk indicated that exposure to abortion accounted for 1.5% to 5.5% of the overall rate of mental disorders.

Conclusions: The evidence is consistent with the view that abortion may be associated with a small increase in risk of mental disorders. Other pregnancy outcomes were not related to increased risk of mental health problems.

'Abortion and mental health' Fergusson, DM. The Psychiatrist (2008) 32: 321-324. (editorial)

In this editorial, Fergusson, a noted researcher in the field, praises the thoughtful position of Royal College of Psychiatrists (RCP) which was issued in 2008 in which the RCP concluded:

‘The specific issue of whether or not induced abortion has harmful effects on women’s mental health remains to be fully resolved. The current research evidence base is inconclusive - some studies indicate no evidence of harm while other studies identify a range of mental disorders following abortion.’

According to Fergusson: "This careful and hedged position contrasts starkly with the confident statement made by the Royal College of Psychiatrists in 1994 (Royal College of Psychiatrists, 1994)" which stated:

‘The Royal College of Psychiatrists finds the risks to psychological health from termination of pregnancy in the first trimester much less than the risks associated with proceeding with a pregnancy that is clearly harming the mother’s mental health. There is no evidence in such cases of major psychiatric risk or long-lasting psychological distress.’

He notes the change is due to a growing body of evidence that abortion is associated with negative mental health effects. He also goes on to note that this is especially problematic for British law which only allows abortion in cases where the risks of childbirth are greater than the risks of abortion. The problem is that there is no evidence of when, if ever, this is actually the case.

"Although decisions on whether to proceed with induced abortion are made on the basis of clinical assessments of the extent to which abortion poses a risk to maternal mental health, these clinical assessments are not currently supported by population-level evidence showing the provision of abortion reduces mental health risks for women having unwanted pregnancy."