Psychological Reactions to Second and Third Trimester Abortion

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

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Studies relating to abortions in the second and third trimester.

Fetal Anomolies--Better Coping Without Abortion

Pregnancy continuation and organizational religious activity following prenatal diagnosis of a lethal fetal defect are associated with improved psychological outcome. Cope H, Garrett ME, Gregory S, Ashley-Koch A. Prenat Diagn. 2015 Aug;35(8):761-8. doi: 10.1002/pd.4603. Epub 2015 May 26.

OBJECTIVE: The aim of the article is to examine the psychological impact, specifically symptoms of grief, post-traumatic stress and depression, in women and men who either terminated or continued a pregnancy following prenatal diagnosis of a lethal fetal defect.

METHOD: This project investigated a diagnostically homogeneous group composed of 158 women and 109 men who lost a pregnancy to anencephaly, a lethal neural tube defect. Participants completed the Perinatal Grief Scale, Impact of Event Scale - Revised and Beck Depression Inventory-II, which measure symptoms of grief, post-traumatic stress and depression, respectively. Demographics, religiosity and pregnancy choices were also collected. Gender-specific analysis of variance was performed for instrument total scores and subscales.

RESULTS: Women who terminated reported significantly more despair (p = 0.02), avoidance (p = 0.008) and depression (p = 0.04) than women who continued the pregnancy. Organizational religious activity was associated with a reduction in grief (Perinatal Grief Scale subscales) in both women (p = 0.02, p = 0.04 and p = 0.03) and men (p = 0.047).

CONCLUSION: There appears to be a psychological benefit to women to continue the pregnancy following a lethal fetal diagnosis. Following a lethal fetal diagnosis, the risks and benefits, including psychological effects, of termination and continuation of pregnancy should be discussed in detail with an effort to be as nondirective as possible.

Most Recent

This section includes studies related to eugenic abortions and therapeutic abortions.

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.

METHODS: Medical TOP (MTOP) using mifepristone and misoprostol or surgical TOP (STOP) by vacuum aspiration at <15 weeks of gestation, and by dilatation and evacuation at 15 or more weeks of gestation.

MAIN OUTCOME MEASURES: Distress 2 weeks after TOP, measured by the impact of events scale (IES), and acceptability, measured by the proportion of women who would opt for the same procedure again.

RESULTS: One hundred and twenty two women were randomised: 60 to the MTOP group and 62 to the STOP group. Twelve women opted to continue their pregnancy. Follow-up rates were low (n=66/110; 60%). At 2 weeks post-procedure there was no difference in total IES score between groups. However, compared with women undergoing STOP, women undergoing MTOP had a higher score on the IES intrusion subscale (mean difference 6.6; 95% CI 1.4-11.8), and a higher score on the general health questionnaire (GHQ) (P=0.033). Women found STOP more acceptable: compared with MTOP, more women would opt for the same procedure again (100% versus 53%, P≤0.001), and fewer women found the experience to be worse than expected (0% versus 53%, P=0.001). Women who had MTOP experienced more bleeding (P=0.003), more pain on the day of the procedure (P=0.008), and more days of pain (P=0.020). Of the 107 women who declined to participate, 58 (67%) preferred a STOP.

CONCLUSIONS: Randomised trials of women requesting midtrimester TOP are challenging. Women found STOP less painful and more acceptable than MTOP.

Editor Comments: The closer a woman comes to "experiencing" versus "submitting" to an abortion, the more likely she is to readily experience intrusive symptoms characteristic of posttraumatic stress. One large French abortion clinic director put it this way:

"The difference between a surgical and a medical abortion is the difference between experiencing and submitting (un avortement médical est vécu; un avortement chirugical est subi). With a medical abortion, the woman usually experiences contractions, bleeding, waiting, and finally the sight of the expulsion. She participates, whereas with a surgical abortion it's over in two minutes and she has done nothing but submit to the physician . . ." 1

Also, the study is important to be aware of since there is a major transformation occurring both here and worldwide from surgical to medical abortions. Consider the following:

"Medical termination of pregnancy with mifepristone was approved in the United States in 2000 and is used in 31 countries worldwide. Approximately half of all abortions are performed with this method."2

The average IES scores reported for both surgical abortion (30.1) and medical abortion (36.8) indicate a significant likelihood of PTSD. An IES score over 26 is considered a "Powerful Impact Event—you are certainly affected."1 for which there is a 75% chance of PTSD.1

An IES score over 33 is considered a good cutoff score for probable PTSD.[1

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.

Neural Activation Underlying Acute Grief in Women After the Loss of an Unborn Child' Kersting A., et al. Am J Psychiatry. 2009 Dec;166(12):1402-10. Epub 2009 Nov 2.

OBJECTIVE: The traumatic loss of an unborn child by induced termination of pregnancy because of fetal malformation is a major life event that causes intense maternal grief. Increasing evidence supports the hypothesis that the same neural structures involved in the experience of physical pain are involved in the experience of social pain and loss. METHOD: To investigate neural activation patterns related to acute grief, the authors conducted a functional MRI study of 12 post-termination women and 12 noninduced women who delivered a healthy child. Brain activation was measured while participants viewed pictures of happy baby, happy adult, and neutral adult faces. RESULTS: Relative to comparison women, post-termination women showed greater activation in the middle and posterior cingulate gyrus, the inferior frontal gyrus, the middle temporal gyrus, the thalamus, and the brainstem in response to viewing happy baby faces. Functional connectivity between the cingulate gyrus and the thalamus during the processing of happy baby faces was significantly stronger in post-termination women. CONCLUSIONS: Overall, acute grief after the loss of an unborn child was closely related to the activation of the physical pain network encompassing the cingulate gyrus, the inferior frontal gyrus, the thalamus, and the brainstem. To the authors’ knowledge, the stronger functional thalamocingulate connectivity in post-termination women is the first in vivo demonstration of an involvement of the neural maternal attachment network in grief after the loss of an unborn child.

"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, Kroker K, Steinhard J, Hoernig-Franz I, Wesselmann U, Luedorff K, Ohrmann P, Arolt V, Suslow T. Arch Womens Ment Health. 2009 Aug;12(4):193-201. Epub 2009 Mar 6.

"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."

Older Studies

"Why Do Women Have Abortions?" A Torres and JD Forrest, Family Planning Perspectives 20(4): 169, 1988.

An Alan Guttmacher Institute survey in 1987 who obtained abortions at 16 gestational weeks or later are significantly more likely to be teenagers under the age of 18, black women, unemployed women, or women covered by Medicaid. Abortions at 16 gestational weeks or more were more apt to be performed if the reason was possible fetal health problems, if the woman's parents wanted her to have an abortion, or if the pregnancy resulted from rape or incest. Women were significantly less likely to have an abortion at 16 gestational weeks or later if they were age 30 or older, if they had no religious affiliation, if they were having health problems, or if their husband or partner wanted them to have an abortion.

Induced Terminations of Pregnancy: Reporting States, 1988 KD Kochenek, National Center for Health Statistics, Monthly Vital Statistics Report 39(12) Supplement, April 30, 1991

Twenty-five percent of young women age 14 had abortions at 13 gestational weeks or greater compared to 19% of women age 16, 13.8% of women age 18, and 11.2% of women age 20-24.

Emotional Patterns Related to Delay in Decision to Seek Legal Abortion. N Kaltreider, Cal Med 118:23, 1973.

Women who have abortions in the second trimester are more likely to use the word " baby" to describe what is in her womb compared to women who have abortions in the first trimester who are more likely to use words such as " this pregnancy" or " this condition."

"Abortion Surveillance-United States, 1996," Koonin et al, MMWR 48/No.SS-4, July 30, 1999

11.0% of U.S. white women had abortions at 13 gestational weeks or more compared to 14.2% of black women, and 12.3% of Hispanic women.

"Psychodynamic aspects of delayed abortion decisions," JA Cancelmo et al, Br J Medical Psychology 65:333, 1992.

A study of New York City women found that abortion at later gestational ages was significantly associated with a greater disturbance of the basic sense of self due to gender/sexual conflict and lower levels of internalized striving or ambition.

"Delayed Abortion in an Area of Easy Accessibility," WA Burr, KF Schulz, JAMA 244 (1): 44, 1980.

Women with moral objections to abortion were more likely to have a late abortion compared to an early abortion. These moral conflicts included opposition of the woman to abortion as well as conflicted decisions.

Psycho-Social Stress Following Abortion, Anne Speckhard, (Kansas City, MO: Sheed&Ward, 1987)

A study of women with long term stress reactions following induced abortion had an overrepresentation of women who had abortions in the second trimester.

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

A religiously based postabortion recovery group had an overrepresentation of women with second or third trimester abortions.

"Psycho-Social Aspects of Late Term Abortions," Thomas Strahan, Association for Interdisciplinary Research in Values and Social Change Research Bulletin 14(4): 108, Jan/Feb 2000

Review Article

"Very and moderate preterm births: are the risk factors different?," Pierre-Yves Ancel et al, Br J Obstet Gynaecol 106: 1162-1170, Nov, 1999.

A study of preterm birth in 15 European countries found that among women with a previous second trimester abortion there was a 3.67 increased relative risk for very preterm birth (22-32 gestational weeks) and a 2.33 increased relative risk for moderate preterm birth (33-36 gestational weeks). Among women with a previous first trimester abortion there was a 1.86 increased relative risk for very preterm birth and a 1.58 increased risk for moderate preterm birth.

"Induced Abortion and Subsequent Pregnancy Duration," W Zhou et al, Obstet Gynecol 94:948-953, 1999.

A Danish study using national registries found that one evacuation had an overall increased relative risk of 2.27 for preterm birth compared to 1.82 for one vacuum aspiration abortion. Two evacuations had an overall increased relative risk of 12.55 for preterm birth compared to 2.45 overall increased relative risk for two vacuum aspirations. Ed Note: evacuations would most likely occur in the second trimester, while vacuum aspirations would occur in the first trimester.