Abortion Decision-Making

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

General Background Studies

Informing abortion counseling: An examination of evidence-based practices used in emotional care for other stigmatized and sensitive health issues. Upadhyay UD, Cockrill K, Freedman LR. Patient Educ Couns. 2010 Oct 4

Abstract

OBJECTIVE: Emotional care is an important component of abortion services. Evidence-based counseling for other stigmatized and sensitive health issues may be informative for the improvement of abortion counseling.

METHODS: We searched the literature for practices used in emotional care for stigmatized and sensitive health issues. We made analytic choices for the selection of articles using the "constant comparative method," a grounded theory technique. We selected practices that were effective in supporting coping and improving psychosocial adjustment. Findings were synthesized and analyzed to draw evidence-based implications for abortion counseling.

RESULTS: We uncovered nine practices used in emotional care for stigmatized and sensitive health issues that have been shown to support coping or improve psychological adjustment. The techniques and interventions identified were: self-awareness assessments, peer counseling, decision aids, encouraging active client participation, supporting decision satisfaction, support groups, Internet-based support, ongoing telephone counseling, and public artistic expression.

CONCLUSION: A variety of patient-centered, evidence-based interventions used for other health issues are applicable in emotional care for abortion. Evaluation of these practices in the abortion counseling setting can determine their appropriateness and effectiveness.

PRACTICE IMPLICATIONS: Abortion care providers may be able to integrate additional patient-centered practices to support coping or improve psychological adjustment after abortion.

Excerpt: "Decision aids are commonly used to make choices in a variety of stigmatized or sensitive health issues including mental health treatment, breast cancer surgeryand pre natal genetic screening A Cochrane review of 55 randomized controlled trials concluded that patient decision aids lead to better decision-making. The review found that decision aids result in greater patient knowledge and lower decisional conflict due to feeling uninformed or unclear about personal values. They also reduce passive decision-making and indecision regarding treatments."

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)

Pregnant and ambivalent. First-time pregnant women's experience of the decision-making process related to completing or terminating pregnancy - a phenomenological study 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.

"Abortion Counseling," M Kahn-Edrington, The Counseling Psychologist 8(1): 37- 38, 1979

The following knowledge is recommended for effective abortion counseling: (1) Aware of the definition, prevalence, myths, types of procedures, risks and sequels of abortion. (2) aware of alternatives to problem pregnancy: abortion, adoption, marriage. (3) Have information about sexuality, contraception, and community resources. (4) Have knowledge of value systems of other cultures and religions. Counselors should have crisis intervention and problem solving skills. (Ed Note: This model lacks any recognition of the fetus as a patient, treats abortion and childbirth as moral equivalents , concentrates on the technique of abortion or contraception, and views the counselors role as no more than a facilitator.)

"Differential Impact on Abortion on Adolescents and Adults," W Franz and D Reardon, Adolescence 105:162-172, 1992

Women who aborted as teenagers compared to women who aborted at 20 years of age or older, were less satisfied with services at the time of the abortion, were more likely to feel forced by circumstances to have the abortion, were more likely to report being misinformed, more often reported severs psychological distress, and more often wanted to give birth and keep the baby.

"Interview Follow-up of Abortion Applicant Dropouts," M Swiger et al, Social Psychiatry 11:135-143, 1976

Women who originally sought abortion and then elected to carry to term were studied. Factors most important in influencing the decision were religious or moral objections; partner desires baby; fear of abortion procedure; abortion equated with loss of part of self; single, getting married; and response to family's push for abortion.

"Emergence and Resolution of Ambivalence in Expectant Mothers," P Trad, Am J Psychotherapy 44(4): 577-589, Oct 1990

Therapists should help the expectant mother work through her ambivalent feelings toward her infant in order that a more adapting and accepting attitude is achieved.

"Unwanted Pregnancy-A Neurotic Attempt of Conflict-Solving? An Analysis of the Conflict Situations of 228 Women Immediately Before Legal Abortion," P Goebel, Zscr. Psychosom Med 28:280-299, 1982

A German study of women seeking abortion evaluated the psycho-social situation at the time of conception. Several conflict situations were determined in which the "unwanted pregnancy" was an attempt to overcome actual neurotic needs.

"Partnership and Pregnancy Conflict," H Roeder et al, Psychother Psychosom Med Psychol 44(5): 153-158, 1994

A German study found that whether or not a child is aborted depends on the general commitment of the man involved with the relationship, the compatibility of a child with the professional situation of the pregnant woman, and their relationship with their own mother. The relationship with their mother is combined with the pregnant woman's trust in her own motherly competence.

"Abortion, adoption, or motherhood: An empirical study of decision-making during pregnancy," MB Bracken et al, Am J Obstet Gynecol 130(3): 251, Feb 1978

Women delivering were in significantly longer relationships with partners who had also been less cooperative about contraception. Discussion with significant others occurred more often in decisions to deliver and greater support was received for that option. For many women, the abortion decision, and to a lesser degree, the decision to deliver, was conflictual, options evenly balanced, and considerable indecision reported.

"Psychological Factors Involved in Request for Elective Abortion," M Blumenfield, The Journal of Clinical Psychiatry, 1978 pp. 17-25

Contraceptive failure in women seeking a first or repeat abortion was not because women did not have access to adequate contraception, but occurred because of underlying psychological conflicts in the female and sometimes the male. Frequent depression in women at the time of pregnancy was noted. Many males had a strong wish to father a child. In many cases, women attributed the failure to use contraceptives on medical factors, but such a factor was used as a form of rationalization to abandon contraception when the woman had an emotional need to become pregnant. The request for repeat abortion indicates that the ambivalence has persisted, and is acted out once again or a new circumstance has awakened underlying conflicts.

"Outcome and Management of Crisis Pregnancy Counseling," A Brett, W. Brett, New Zealand Medical Journal 105:7, 1992.

Counseling in a New Zealand crisis pregnancy center consisted of 1.5 hours of personal interviews separated in time and location from the abortion procedure, providing visual material on the development of the fetus and a waiting period of I to 2 weeks for reflection on the decision. Among 18 women who had planned to continue their pregnancies, 2 elected to terminate their pregnancies after the counseling. Among 72 women who had originally decided to terminate their pregnancies, 14 decided to continue their pregnancy after the counseling. Among 49 women regarded as ambivalent, 9 chose to terminate their pregnancies and 35 elected to continue their pregnancies. The study concluded that such counseling clearly affects the original decision about the continuation or termination in a substantial proportion of women in a "crisis" pregnancy.

"Abortion Counseling - A New Component of Medical Care," Uta Landy, Clinics in Obstetrics and Gynecology 13 (l):33, March, 1986.

This article by the former national director of the National Abortion Federation describes conflicts with partner, ambivalence, guilt, anger, fear of pain and concern about suitable birth control as major themes which consistently appear in counseling. ( Ed Note: This article is frank and revealing.)

"Abortions: Predicting the Complexity of the Decision-Making Process," M.L. Friedlander, T.J. Kaul and C.A .Stirnel, Women and Health 9(l):43-54. Spring, 1984.

Existing beliefs about oneself and morality tend to be inadequate guide for decision- making in the face of an abortion dilemma, and in order to overcome this disequilibrium often will require the woman to develop new cognitive constructions of the situation. Citing the writings of Carol Gilligan.

Crisis Theory

Crisis Counseling, Howard W. Stone, (Minneapolis: Fortress Press, 1976).

Comments by author:

One of the worst things a person can do who is in crisis is to become isolated. Isolation often leads to bouts of depression and self-pity.

Crisis behavior includes tiredness and exhaustion, lethargy, feelings of helplessness and inadequacy, sense of confusion, anxiety, disorganization and poor functioning in work relationship, possible anger or hostility.

People in crisis are often less in touch with reality and are more vulnerable to change than they are in non-crisis periods.

Irrespective of how the client depicts the problem, all crises are religious at their core: they involve ultimate issues with which one must come to terms if one's life is to be fulfilling.

One of the most important things a person can offer an individual in a crisis is a relationship through which is communicated the sense that life has meaning, purpose and hope.

The more seriously threatening an individual's appraisal of an event, the more primitive or regressive his or her coping resources will likely be. A result of this regression to primitive coping methods is increased suggestibility and diminished trust, leading to what is referred to as "heightened psychological accessibility." This is probably the most unique and important concept within the theory of crisis intervention.

Principles of Preventive Psychiatry, Gerald Caplan, (New York: Basic Books, 1964).

Heightened psychological accessibility has obvious and important implications when it comes to counseling a person in crisis. The author states: "A relatively minor force, acting for a relatively short time, can switch the whole balance to one side or to the other-to the side of mental health or to the side of ill-health."

"Crisis Theory: A Definitional Study," Howard Halpern, Community Mental Health Journal, 9(4): 342, 349, Winter, 1973.

The author has verified this heightened psychological accessibility in his research on the defensiveness of people in crisis. He found that they tend to protect themselves less than other people and are more open to outside help and assistance toward change.

"Theory of Crisis Intervention," Wilbur E. Morley, Pastoral Psychology 21:203 (April 1970), p. 16.

A person in crisis is in a state of "upsetness" or cognitive dissonance. Much less of the personality is firmly planted on the line between stability and instability. The individual wants to reestablish stability, and is therefore very susceptible to any influence from the inside or outside which will aid in resolving the crisis. With a minimal effort on the part of the minister, mental health professional, or family member, a maximum amount of leverage may be exerted upon the individual.

Pregnancy as a Crisis

"Some Considerations of the Psychological Processes in Pregnancy," Grete L. Bibring, Psychoanalytic Study of the Child, 14:113-121, (1959)

Comments by author: Pregnancy, like puberty or menopause, is a period of crisis involving profound psychological as well as somatic changes.

These crises are equally the testing ground of psychological health, and we find that under unfavorable conditions they tend toward more or less severe neurotic solutions.

Stress is inherent in all areas: in the endocrinological changes, in the activation of unconscious psychological conflicts pertaining to the factors involved in pregnancy, and in the intra-psychic reorganization of becoming a mother. A new organization of all forces must be made, and this necessity leads to the crisis of pregnancy. Within this crisis, of course, individual problems and neurotic conflicts of significance are highlighted.

As the modern family becomes isolated, and as other important group memberships break down, the individual must rely increasingly on the nuclear family, especially on the marital relationship, and this unit is rarely equipped to replace all these figures in their varied supportive functions.

The enormous improvement in medical management, (and) in lessening the physical dangers of pregnancy, has contributed to a waning concern with the concomitant psychological changes on the part of society in general. This waning concern stands in marked contrast to the unchanged, conservative, inner psychological processes and anxieties, especially of the primigravida.

What was once a crisis with carefully worked out traditional customs of giving support to the woman passing through this crisis period , has become at this time a crisis with no mechanisms within the society for helping the woman involved in this profound change of conflict solutions and adjustive tasks.

"A Study of the Psychological Processes in Pregnancy and of the Earliest Mother- Child Relationship," G. Bibring, T. Dwyer, D. Huntington, and A. Valenstein, Psychoanalytic Study of the Child 16:9 (1961).

An example of a young pregnant woman whose family did not initially support her pregnancy and her subsequent ambivalence; whereas a social worker's simple appreciation of her role as an expectant mother dramatically changed her attitude toward her pregnancy. This is a good example of how an apparent minor comment makes a big difference to someone in a crisis situation. Any normal girl, though she might have intense wishes for a child and though she might love the man who is the father of the child, still must make a major developmental move in becoming a mother. At any point along this line of integration and adjustment complications may arise; be it from relation to the husband, or men in general; be it from the modes of receiving, retaining or releasing which the woman has established as a result of her own infantile development and her leading libidinal positions; be it from the emotional change of her object relationship which may be prevalently positive or ambivalent or destructively hostile; be it from her relationship to herself as compared or contrasted with that to the external world and its objects. All these will be reflected in the signs of crisis.

"Outcome and management of crisis pregnancy counseling," A Brett and W Brett, New Zealand Medical Journal 105:7-9, 1992

A study of women in crisis pregnancy situations informed women about the physical and emotional effects of pregnancy, normal fetal development, and options that were available over about a 1.5 hour period. Overall, 47% of the women changed an initial decision or reached a final decision regarding their pregnancy, and 46% ultimately continued with their pregnancies. The authors concluded that the study provided support for considering the crisis pregnancy as an obstetric emergency.

"Informed Consent in Crisis Pregnancy and Abortion," W Brett and A Brett, Journal of Christian Health Care 5(1) : 3-10, March, 1992.

This article reviewed the ethical basis of informed consent during pregnancy where the doctor has an ethical duty to both the woman and the fetus. Principles of autonomy, veracity, beneficience, non-maleficience, and justice were discussed. The authors concluded that, "disturbingly and quite inappropriately, the ethical responsibilities implicit in the doctor-fetus relationship may also be neglected in the crisis pregnancy."

"The Spectrum of Fetal Abuse in Pregnant Women," JT Condon, The Journal of Nervous and Mental Disease 174(9):509, Sept, 1986.

The fetus, whose intrapsychic representation is a curious admixture of fantasy and reality, is a recipient "par excellence" for projection and displacement.

"Pregnancy, Miscarriage and Abortion," Dinora Pines, International Journal of Psychoanalysis 71:301, 1990

For some women, the fetus is not represented as a baby in fantasy, dreams, or reality, but rather as an aspect of the bad self or as a bad internal object that must be expelled. Analysis of such patients reveals an early relationship with the mother which is suffused with frustration, rage, disappointment, and guilt. Loss of the fetus is experienced as a relief rather than a loss, as if the continuing internal bad mother had not given permission to become a mother herself.

"Therapeutic Abortion Clinical Aspects," Edward Senay, Archives of General Psychiatry, 23:408-415, November 1970

Even brief exposure to this population should serve to convince the skeptic that the frequent reports of insomnia, somatic complaints, intense anxiety, depressive feelings, suicide ideation and intense preoccupation with the problem of getting rid of the unwanted pregnancy define a population of people in crisis.

"The experiences of women who face abortions "V Slonim-Nevo, Health Care for Women International 12(3): 283-292, 1991

Israeli women who were about to have abortions were interviewed and found to be in crisis as evidenced by intense emotions of sadness, ambivalence, confusion, and fear. The women were dependent upon the professional counselor for technical and emotional support.

"Paternalistic vs. egalitarian physician styles: the treatment of patients in crisis," S LeBaron, J Reyher, JM Stack, Journal of Family Practice 21(1)): 56-62, July, 1985.

Among women who had elective abortions, those who were treated in a paternalistic manner had significantly higher responsiveness to suggestibility compared to those treated in an egalitarian interpersonal style.) (Ed Note: This study demonstrates how individuals in crisis are susceptible to influence from others.

"Emotional Crises of School-Age Girls During Pregnancy and Early Motherhood," Maurine LaBarre, Journal of the American Academy of Child Psychiatry 11(3): 537-557 (1972).

The theoretical concepts we have found most useful in studying and working with pregnant girls are those of "crisis." These young girls are experiencing concurrently a triple crisis of maturational or developmental phases of feminine life. They have not yet completed adolescent development when they are experiencing their first pregnancy, and they are struggling with adjustments to new roles as wives or mothers-to-be. In some cases the discovery of the pregnancy or other life events precipitates an acute episode of shock, stress, and anxiety, disrupting the previous adjustment and requiring the reorganization or development of new coping methods to deal with the trauma.

"Life Situation Associated with the Onset of Pregnancy," N. Greenberg, J. Loesch and M. Lakin, Psychosomatic Medicine 21:296(1959).

In approximately two thirds of the cases studied, loss of a meaningful relationship or separation from a loved person occurred within six months of the onset of the woman's pregnancy.

"Unwed Mothers: A Study of 100 Girls in Melbourne. Australia N," Shanmugan and C. Wood, Australian and New Zealand Journal of Sociology 6:51(1970).

More than a quarter of the girls had lost fathers by death or divorce, and only 10 percent of all girls felt they were very close to either parent.

Pregnancy Reactions/Unwanted Pregnancy

“ Cultural practices and social support of pregnant women in a northern New Mexico community”, EW Domian, J Nursing Scholarship 33(4):331-336, 2001

Among Hispanic mothers in this community pregnancy outcomes were positive because of a socialization process that helped mothers and family members to adapt to support the pregnancy. This mutual sharing helped reinforce the family structure, integrate cultural beliefs, and define roles for mother and family members and define the nature of mother-child and family-child relationships.

"Psycho-Social Aspect of Induced Abortion," B Raphael, Medical Journal of Australia 2:35-40, July 1, 1972

Tremendous variation exists in motivations for becoming pregnant, and influences may range from the mature and natural fulfillment of an adult, loving and involved marital relationship to the neurotic, repeatedly illegitimate pregnancies of the immature teenager. Self-punishment or self-destructive tendencies may operate so that either the pregnancy itself or the abortion represents a way of punishing herself for unrecognized feelings of guilt. Guilt may derive from earlier events in the woman's life, e.g. a previous abortion, a sadistic or rejecting act, or it may be related to deep-seated conflict concerning her sexuality which she may perceive as being bad, sinful, dirty or uncomfortable. Women may become pregnant while they are depressed. Passivity and failure to care may make them casual in their contraceptive practice. Or they may unconsciously believe that a pregnancy may make them feel better, filling the emptiness inside or giving them the sense of worth and fulfillment they so desperately need in their depressive mood. A second or third undesired conception may represent a rather pathetic attempt to undo previous failure-to relive the situation of the last abortion, the previous pregnancy, more satisfactorily. But the woman driven by deep neurotic motives rarely achieves such reparation even if she carries to term, and instead repeats once more her abnormal patterns of behavior, reinforcing again her guilt, anxiety and conflict. It is vitally important for any doctor dealing with a woman who may come to him seeking termination of pregnancy to recognize the possibility of such influencing factors. Only in this way can he help her deal with the crisis that continuing the pregnancy or terminating it may mean to her.

"Elective Abortion: Woman in Crisis," Naomi Leiter, New York State Journal of Medicine 2908-2910, December 1, 1972.

A woman may have an unwanted pregnancy because of (1) an acting out against and in defiance of the parent and a wish to get away from home, (2) loneliness and a desire to get closer to a man and have a baby to love as the person wishes to be loved, and (3) loss or threatened loss of a significant person in one's life. his loss or threat of loss may be real or fantasied.

"The Mental Health of Women 6 Months After They Gave Birth to an Unwanted Baby: A Longitudinal Study," JM Najman et al, Social Science Med 32(3):241-247, 1991

An Australian study found that mothers proceeding with an unwanted pregnancy, on the whole, manifest few subsequent mental health problems.

"Unwanted Conceptions.Research on undesirable consequences," E. Pohlman, Eugenics Quarterly 14:143, 1967.

We think, not in terms of dichotomies such as ‘wanted' and ‘unwanted', but of a continuum of feelings ranging from total rejection to to nearly total acceptance." Conscious rejection may (1) continue and remain conscious; (2) continue but become repressed and unconscious; (3) decrease in intensity as positive aspects become more apparent-with resulting ambivalence; (4) become submerged by positive feelings, even at the unconscious level; (5) be only a superficial façade, perhaps in order to conform to social ideas. In this last instance, the pregnancy fills needs and is not rejected: here it is the acceptance of pregnancy that is repressed and concealed beneath a conscious façade of rejection.

"Children Born to Women Denied Abortion," Z Dytrych et al, Family Planning Perspectives 7(4): 165, July/Aug 1975; "Follow-up Study of Children Born to Women Denied Abortion," Z Matejek et al, Ciba Foundation Symposium 115, 1985, 136,148.

A Czech study of children born where their mothers were twice refused a request for abortion reported that " by and large the mothers did move from initial rejection to ultimate acceptance in the 9 year interval" since the birth. Thirty-eight percent of the mothers subsequently denied ever seeking an abortion; some said they hated the commission for refusing their request; others said they were now very grateful the commission had refused; fourteen percent of the mothers refused induced abortion reported a spontaneous abortion (early miscarriage).

"The effect of pregnancy intention on child development," TJ Joyce et al, Demography 37(1): 83-94, Feb 2000.

Based on data from the National Longitudinal Survey of Youth it was found that unwanted pregnancy is associated with prenatal and postpartum behaviors that adversely affect infant and child health, but that unwanted pregnancy has little effect with birth weight and child cognitive outcomes. Estimates of the association between unwanted pregnancy and maternal behaviors were greatly reduced after controls for unmeasured family background were included in the model. There were also no significant differences in maternal berhaviors or child outcomes between mistimed and wanted pregnancies.

"Defining dimensions of pregnancy intendedness," JB Stanford et al, Maternal Child Health Journal 4(3): 183-189, Sept 2000.

Women indicated that their partners had a strong influence on preconception and postconception desire for pregnancy.

"Pregnancy Resolution Decisions: What If Abortions Were Banned?" J Murphy, B Symington, S Jacobson, The Journal of Reproductive Medicine 28(11): 789-797, 1983.

The availability of another person to help with an unplanned child was most closely associated with the decision to carry the baby to term or abort it.

"Life Events and Acceptance of Pregnancy," MM Helper et al, Journal of Psychosomatic Research 12:183-188, 1968.

This study determined what life events are judged by women to impose difficulties in adjustment to pregnancy.

"L'interruption volontaire de grossesse a repetition," I Tamian-Kunegel, Gynecol Obstet Fertil 28:137-140, 2000.

Repetitive abortions reveal an ambivalence towards contraception. The desire for pregnancy does not always go along with a desire for motherhood. It is a neurotic expression full of guilt that shows that these women did not overcome a childish rivalry with their mothers, and remain within a symbiotic relationship with them.

"The effects of termination of pregnancy: A follow-up study of psychiatric patients," R Schmidt and RG Priest, Br J Medical Psychology 54:267-276, 1981.

In a British study of women seeking abortion for mental health reasons, many women described considerable difficulties in current relationships at the time of their abortion request. Some women had used the pregnancy in the hope that the men would remain with them. Many had unresolved conflicts in their family of origin. It was concluded that the unwanted pregnancy may represent for women a vehicle for the restorative and reparative wishes as well as for their destructive wishes.

"Abortion-Pain or Pleasure," Howard W. Fisher in The Psychological Aspects of Abortion, Ed. D Mall and W Watts, (Washington, D.C.: University Publications of America, 1979) 39-51.

Confusion of sexual identity (can) lead to attempts to "prove" femininity with sexual acting out and resultant pregnancy. This is why contraception ‘fails'. Actually, the pregnancy is not totally ‘unwanted' The author concludes that abortion has both masochistic and sadistic components.

Personality Changes Shortly Before Abortion

Very pronounced psychological, psychiatric , and cognitive changes occur in a majority of women shortly before they undergo an induced abortion. The following studies are illustrative.

"Coping with Abortion," L Cohen and S Roth, Journal of Human Stress 140, Fall, 1984.

A generalized stress response syndrome was found in women upon arrival at an abortion facility similar to responses of bereaved populations.

"Grief and Elective Abortions:Breaking the Emotional Bond?" Larry Peppers, Omega 18(1): 1, 1987-88.

An intense grief response was found in women at a pre-abortion counseling session. A wide range of responses was observed.

"The Effects of Termination of Pregnancy: A Follow-up Study of Psychiatric Referrals," R Schmidt and Priest, Br J Medical Psychology 54:267, 1981.

Prior to abortion, the mean score on hostility (predominately self-criticism and guilt) was about two standard deviations above the normal mean which is similar to psychiatric populations.

"Psychiatric Morbidity and Acceptability Following Medical and Surgical Methods of Induced Abortion," DR Urquhart and AA Templeton, Br J Obstetrics and Gynecology 98:396, 1991

Two days before the abortion, 60% of women had high scores for anxiety and depression which was compatible with psychiatric morbidity.

"Testing a Model of the Psychological Consequences of Abortion," Warren B Miller, David J Pasta, Catherine L Dean in The New Civil War. The Psychology, Culture and Politics of Abortion, Ed. Linda J. Beckman and S Marie Harvey, (Washington, D.C.:American Psychological Association, 1998) 235-267

Women who participated in a clinical trial of Mifepristone abortion exhibited acute pre- abortion stress which was dominated by high avoidance, intrusion, and anxiety. The authors concluded that, "what appears to be happening is that the women are trying to control their response to the unwanted pregnancy/abortion by avoiding thinking about it."

"Psychological consequences of induced abortion," L Schleiss et al, Ugeskr Laeger 159(23):3603-3606, 1997

Fifty-two percent of Danish women were psychologically influenced before the abortion to an extent which indicated severe crisis or actual psychiatric illness.

"Family Relationships and Depressive Symptoms Preceding Induced Abortion, D Bluestein and CM Rutledge," Family Practice Research Journal 13(2): 149, 1993

Women about to undergo induced abortion had depressive symptoms which were moderate to severe in intensity which were strongly associated with unsatisfactory family relationships. Depressive symptoms increased as dissatisfaction with choosing abortion increased.

The Ambivalence of Abortion, Linda Bird Francke. (New York: Random House, 1978) 93.

The author cites a Canadian study of married couples which found in many cases that the wife exhibited "great stress" and underwent a temporary personality change. The effect of the unwanted pregnancy was sufficiently great to swamp whatever personality similarities the women had previously shared with their husbands.

"Counselling of Patients Requesting an Abortion," Joyce Dunlop, The Practitioner 220:847-851, June, 1978

This article quotes a psychiatric counselor who said, "the 24 hour period prior to the woman obtaining an abortion is a period of intense anxiety and ambivalence."

Attitude Toward Pregnancy

A positive orientation toward early motherhood is associated with unintended pregnancy among New Orleans youth. Afable-Munsuz A, Speizer I, Magnus JH, Kendall C. Matern Child Health J. 2006 May;10(3):265-76.

OBJECTIVE: Characterizing young women's willingness to enter motherhood is critical to understanding the high rates of unintended pregnancy among women under 20 years. Our objectives were to discuss a measure called Positive Orientation towards Early Motherhood (POEM), and investigate its association with self-reported unintended pregnancy experience.

METHODS: We used data from 332 African-American women 13-19 years old recruited at public family planning and prenatal clinics in New Orleans. Using a series of ANOVAs and multinomial logistic regression, we assessed differences in POEM between four different outcome groups: women who were never pregnant and those who had only intended pregnancies, only unintended pregnancies and both unintended and intended pregnancies.

RESULTS: The data suggested that young women perceive pregnancy as an opportunity to assert responsibility, become closer with their families and achieve greater intimacy with their boyfriends. Multiple regression analysis indicated that this positive orientation toward early motherhood independently raised the likelihood that young women experienced unintended pregnancies. In particular, the perception that a pregnancy makes a young woman feel more responsible was associated with an increased likelihood that a young woman had only unintended pregnancies compared to no pregnancies at all. Interestingly, this perception did not differentiate young women who had only intended pregnancies from those who were never pregnant.

CONCLUSION: When interpreting reports of unintended pregnancy, more attention should be given to young women's orientation toward early motherhood. Doing so will inform policies that address both personal and structural factors that contribute to persistently high rates of unintended pregnancy among adolescents.

Attitudes of Doctors and Counselors

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

Numerous attitudes of abortion providers and counselors may influence tendency to discount risks of abortion or reluctance of woman to have an abortion.

Physicians Recommend Different Treatments for Patients Than They Would Choose for Themselves Ubel PA, Angott AM, Zikmund-Fisher BJ. Arch Intern Med. 2011;171(7):630-634

Background Patients facing difficult decisions often ask physicians for recommendations. However, little is known regarding the ways that physicians' decisions are influenced by the act of making a recommendation.

Methods We surveyed 2 representative samples of US primary care physicians—general internists and family medicine specialists listed in the American Medical Association Physician Masterfile—and presented each with 1 of 2 clinical scenarios. Both involved 2 treatment alternatives, 1 of which yielded a better chance of surviving a fatal illness but at the cost of potentially experiencing unpleasant adverse effects. We randomized physicians to indicate which treatment they would choose if they were the patient or they were recommending a treatment to a patient.

Results Among those asked to consider our colon cancer scenario (n = 242), 37.8% chose the treatment with a higher death rate for themselves but only 24.5% recommended this treatment to a hypothetical patient (21 = 4.67, P = .03). Among those receiving our avian influenza scenario (n = 698), 62.9% chose the outcome with the higher death rate for themselves but only 48.5% recommended this for patients (21 = 14.56, P < .001).

Conclusions The act of making a recommendation changes the ways that physicians think regarding medical choices. Better understanding of this thought process will help determine when or whether recommendations improve decision making.

Characteristics of Women Having Induced Abortion

"Abortion Surveillance-United States. 1992," L.M. Koonin et. al., MMWR 45, No, 55- 3:1, May 3 1996

For 1992, 1,359,145 legal abortions were reported to CDC, representing a 2.1% decline overall, from the number reported for 1991. 45.8% of women were repeating abortion with 26.9% reporting a second abortion, 10.8% (third), and 6.4% having four or more abortions. The abortion ratio was more than nine times greater for unmarried women than for married women. The abortion rate for white women was 15 per 1000 white women compared to 41 per 1000 black women and 32 per 1000 Hispanic women.

The Long Term Psychological Effects of Abortion, Catherine A. Barnard, (Portsmouth N.H. : Institute For Pregnancy Loss, 1990) see also "Stress Reactions in Women Related to Induced Abortion," Association For Interdisciplinary Research Newsletter 3(4):1-3, Winter 1991

A study of 80 women (3-5 years post abortion) who had abortions at a Baltimore area clinic in 1984-86 using the Millon clinical Multi-Axial Inventory (MCMI) found that women had significantly higher scores in areas of histrionic, narcissistic and anti-social characteristics compared to the sample on which the test had been normed. They also exhibited higher levels of anxiety and paranoia.

"Abortion and Subsequent Pregnancy," C. Bradley, Canadian Journal of Psychiatry29: 494, Oct. 1984.

A Canadian study on married women who had recently given birth to a child found that women with a history of induced abortion were more likely to describe themselves as self- reliant, independent, rebellious and to enjoy being unattached and not tied to people, places or things, they were also much more likely to work outside the home following the birth of their baby.

"The Characteristics and Prior Contraceptive Use of U.S. Abortion patients," S. Henshaw and Silverman, Family Planning Perspectives 20(4): 158-168, July/Aug. 1988.

In a 1987 survey of 9480 women at 103 hospitals, clinics and doctors offices women undergoing abortion were more likely to be non-white than women generally, be eligible for medical assistance, be enrolled in school, never married, cohabitating, divorced or supported and with lower family income. 42.9% reportedly were repeating abortion.

"Gestation, Birth-Weight, and Spontaneous Abortion in Pregnancy After Induced Abortion," Report of Collaborative Study by World Health Organization Task Force on Sequelae of Abortion, The Lancet, January 20, 1979, pp. 142-145.

Women who have had an induced abortion are not a random sample of the population, but the degree to which they deviate from the norm varies with the attitude of their society. In general, the study suggests that they were more likely to smoke, to have had failed contraception, and to be uncertain of menstrual dates when compared with primigravidae of similar age or with women who had a previous spontaneous abortion. See also Bulletin World Health Organization, S. Harlap, A. Davies, 52(149) 1975.

"Motivational Factors in Abortion Patients," F.J. Kane, P. Lachenbruch, M. Lipton, and D. Baram, American Journal of Psychiatry, 130(3): 290-293, March, 1973.

Forty percent were found to have motivational factors that may have influenced the outcome of the pregnancy, such as guilt over the use of contraception, a severe acting out of a character disorder, or a reaction to loss.

"Prospective Study of Spontaneous Fetal Losses After Induced Abortions," S. Harlap, P. Shiono, S. Ramcharan, New England Journal of Medicine, 301(13): 677-681, September 27,1979.

Women with previous induced abortions were more likely to be unmarried, black, regular drinkers and smokers.

Abortion Decision Making - Role of Males

Passage Through Abortion, Mary K. Zimmerman (New York: Praeger Publishers, 1977).

In an in-depth study of 40 U.S. women undergoing abortion in 1973 The male partner played a central role in the abortion experience for 38 out of 40 women. In 20% of the cases resulting in abortion the woman initially wanted to have the baby, but the man was opposed. In addition, 16 males stated they agreed with the decision of abortion while 8 disagreed with the decision of abortion. Opposition by the male was disruptive for the woman. Fifty percent terminated their relationship with the man involved in the pregnancy. Abortion appeared to assist in a decision for marriage in 3 cases. Six women reported no change in their relationships.

Women overwhelmingly denied their own responsibility in having the abortion in an attempt to view themselves as "moral" persons. Two out of 3 said they had "no choice" in the matter of abortion or were "forced" to have an abortion.

"The Relationship of Social Support and Social Networks to Anxiety During Pregnancy," Joan Jurich, Ph.D. Dissertation, Purdue University, 1986, Dissertation Abstracts International 48(1), July 1987, Order No. DA 8709818.

In a study of 65 women receiving prenatal care from Methodist Hospital of Indiana, the most consistent predictors of anxiety at each point of inquiry throughout pregnancy were the woman's need for emotional support and their satisfaction with their relationship with their partner. Informational support was found to be relevant to anxiety only at the outset. Material support was not significantly related to anxiety at any point during pregnancy.

"Psychologic and Emotional Consequences of Elective Abortion: A Review," G.S. Walter, Obstetrics and Gynecology 36(3):482-491, September 1970.

It is known that women seeking abortion may do so at the insistence of partners whose neurotic behavior is being acted out upon their wives. Citing several studies.

"Why Do Women Have Abortions?," Aida Torres and Jacqueline Forrest, Family Planning Perspectives 20(4): 169-176, July/August 1988.

In a survey by the Alan Guttmacher Institute in 1987 of women at abortion facilities, lifestyle change, can't afford baby now, problems with relationships-or avoidance of single parenthood or not ready for responsibility, doesn't want others to know she has had sex or is pregnant or thought she is not mature enough to have a child were the primary reasons cited by the self-report of the women based upon the questions posed.

A Study of Abortion in Primitive Societies, George Deveraux, (New York: The Julian Press, 1955), p. 136.

Anthropologist George Deveraux, in his study of abortion in primitive societies, observed that female attitudes toward maternity appear to be largely determined by masculine attitude toward paternity. He found that the romanticization of the maternal role the Madonna complex is conspicuously absent in primitive societies, even where children are ardently desired and where fertile women are much esteemed ... and even when women abort of their own free will, and including instances where they abort from spite or as a result of a domestic quarrel, they do so under the impact of a genuine or expected masculine attitude.

"Life Events and Acceptance of Pregnancy," M. Helper, R. Cohen, E. Beitenman and L. Eaton, Journal of Psychosomatic Research 12:183-188(1968).

The attitude of the father is an important factor in the degree of stress related to a pregnancy. In a study at the University of Nebraska on women from wide ranging backgrounds, it was found that the most stressful events occurring during pregnancy were, "The woman is pregnant out of wedlock and receives no help from the father of the baby, " and "The husband doesn't want the baby she is carrying.")

Men and Abortion. Lessons. Losses and Love, Arthur Shostak and Gary McLouth, (New York: Praeger, 1984).

Sociologist Arthur Shostak, in his study of 1, 000 U.S. men interviewed at abortion clinics, found that a sizable bloc (45%) recalled urging abortion (37% of the married men, 48% of the unwed males). The vast majority were pro-choice with only 9% favoring a law to outlaw abortion (83% were opposed). Men emphasized their belief that pregnancy was a distinct trauma for their sex partner and one that required and justified the location of 51% or more of the decision making power in their hands alone.

"Husbands of Abortion Applicants: A Comparison With Husbands of Women Who Complete Their Pregnancies," F. Lieh-Mak., Y. Tam and S. Ng, Social Psychiatry 14:59- 64(1979).

In a Hong Kong study of 130 husbands of women seeking abortions, 44% of the husbands instigated the abortion with economic reasons being predominant. Characteristics of husbands of women seeking abortion were compared to husbands of women who delivered. More abortion husbands reported poor relationships with either or both parents. 27% of the abortion husbands reported psychiatric illness in the family compared to 8% of the controls; abortion husbands had a higher prevalence of alcoholism, drug dependency, neurosis and compulsive gambling compared to controls. An unhappy childhood was reported by 20% of abortion husbands versus 5% for controls. 70% of the abortion husbands reported they used contraception compared to 35% for controls. Abortion husbands tended to use unreliable contraceptive methods such as withdrawal (18% vs. 6%) or reliance upon a "safe" period (12% vs. 4%). The authors concluded, "Our study has served to emphasize the important role that the husband plays in abortion seeking and fertility regulation behavior. It is high time we should give substance to the shadowy figure that we call the male partner."

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

In a study of 252 women members of Women Exploited by Abortion, 51% reported they were encouraged to have an abortion by a husband or boyfriend.

"Psychosis in Males Related Parenthood," R. Towne and J. Afterman, Bulletin of the Menninger Clinic (1955), pp. 19-26.

The child may be seen as a rival by the father and a target for unconscious aggressive feelings.

"Abortion in Relationship Context," Vincent M. Rue, International Review of Natural Family Planning 9:95-121, Summer 1985

Abortion serves well the erotically compulsive male or one with such tendencies, who strives to maintain his self-esteem and to gratify narcissistic needs through sexual achievement. Typically, this Don Juan male is minimally involved in the personality of his partner since his capacity to love is sharply limited. His sexual activity is invested in countering feelings of inferiority by proving erotic successes. After such a conquest he loses interest in the chosen woman and reacts with hostility towards her, since he devalues her after the successful conquest. Abortion is a handy passport for such adventure.

"Husband's Attitudes Towards Abortion and Canadian Abortion Law," Osborn and Silkey, Journal of Biosocial Science 12:21-30(1980).

This study found that religious affiliation is strongly related to male opinions about abortion. Permissive attitude toward abortion was associated with the use of highly effective contraceptive methods and with prior use of abortion.

Expectant Fathers, S Bittman and S. Zalk, (New York: Hawthorn, 1978, 1980).

A man may have guilt feelings or anger during his wife's pregnancy which may occur if his wife has had a previous miscarriage or abortion. The male may feel somehow responsible and if so there is a good chance that he will resent the baby and his wife that much more. The authors state, "[This is] not an auspicious way to begin family life.") p. 134 (After the first pregnancy and childbirth experience, many fears of the man dissipate on the second pregnancy. pp. 148-149

"Attitudes of Adolescent Males Toward Pregnancy and Fatherhood," Marcia A. Redmond, Family Relations, Journal of Applied Family and Child Studies 34(3):337-341, July 1985.

In a study of 74 adolescent males in Ontario, Canada of their attitudes toward adolescent pregnancy and fatherhood, all males wished to be told if a pregnancy occurred, whether or not they were in a casual or serious dating relationship. Male attitudes toward abortion were markedly different depending on the type of relationship. Some 32% of the casual daters believed the desired pregnancy outcome should be abortion compared to only 13% of the serious daters. Most males wished to be included in the decision-making process and receive emotional and social support during this time. When not included they felt confused and neglected. Males were a factor in the decision-making process even when ignored by professionals. The study concluded, "In regard to teenage pregnancy, it seems appropriate for professionals to recognize the male sexual partner as part of the problem as well as part of the solution."

Adoption as An Option

"Hispanic Adolescent Pregnancy Testers: A Comparative Analysis of Negative Testers, Childbearers and Aborters," DK Berger, Adolescence 26(104): 951 (1991)

In a sample of pregnant Hispanic adolescents, none chose adoption.

"Abortion, adoption, or motherhood: An empirical study of decision-making during pregnancy," MB Bracken and LV Klerman, Am J Obstet Gynecol 130(3):251 (1978)

Adoption was not considered among population of pregnant young black women.

"The Adoption Alternative for Pregnany Adolescents: Decision Making, Consequences, and Policy Implications," MP Sobol and KJ Daly, Journal of Social Issues 48(3):143 (1992)

The authors estimated that only 3% of U.S. adolescents who carry to term place their infant for adoption and that there an estimated 50,000 unrelated adoptions each year in the U.S. Among adolescents who placed for adoption, parents were more likely to have been involved in the decision.

"Adoption as an Option for Unmarried Pregnant Teens," Marcia Custer, Adolescence 29(112): 891 (1993)

Societal sanctions, low level of knowledge, anticipated psychological discomfort, and lack of support from helping professions were found to be barriers to adoption.

"Physician's Preferences for Adoption, Abortion and Keeping a Child Among Adolescents," V Powell, et al Research in the Sociology of Health Care 9:33 (1991)

Physicians were generally supportive of adoption

"Adoption, Adoption Seeking, and Relinquishment for Adoption in the United States," Advance Data, No. 306, Centers for Disease Control, May 11, 1999

This study found that 232,000 ever married U.S. women were currently taking active steps toward adoption in 1995.

Ethical Obligations for Medical Decision Making

According to Dr. Philip Ney, in his response to the 2011 NCCMH – Royal College of Psychiatrists request for comments:

If a woman has a right to good medical treatment that may include having an abortion on her physician’s recommendation, then the physician must be prepared to answer all of these questions:

a) Indication Is there a pathological process in pregnant women in general and this patient in particular that warrants having an abortion? (It must be recognized that pregnancy is not a disease.)

b) Benefit What is the evidence that an abortion will benefit women with this condition (pregnancy) and this patient in particular?

c) Harms. What are the adverse effects from an abortion and if there are some, do they outweigh the anticipated benefit?

d) Other options. Have all less invasive, more reversible treatments been offered, tried and failed before an abortion is recommended?

e) In good faith. Is the physician who is providing this procedure doing so in good faith? Has the abortionist carefully studied to relevant literature in order to practice evidence based medicine, honed his/her skills and performed a careful followed up on his/her ex-abortion patients to know personally that he/she will be providing good treatment?

f) Adoption etc. Has the physician facilitated all options to abortion of a truly unwanted child? i.e., adoption, fostering etc.

g) Informed consent. Has the physician made a clear recommendation to the patient with evidence to support that recommendation, options available, potential benefits and hazards, and shown the ambivalent woman the ultrasound of her fetus? Has he/she been given fully informed consent which requires the patient have full opportunity to ask questions, get a 2nd opinion and make a decision with enough time to do so and without pressure from mate, family, IPPF, physician, etc.?

It must be remembered that until any treatment is well proven, it must be considered as experimental and constrained as such.

Moreover the burden of proof rests with the performing physician, his/her supporters and those who fund this activity to show abortion is necessary, beneficial etc. not on those who question abortion is a valid treatment to show it is harmful.

Duty of Doctor to Refuse Contraindicated Procedure

Judge Ellen I. Picard & Gerald B. Robertson: “... However, this does not mean that the doctor has a duty to provide (and the patient a correlative right to receive) whatever treatment the patient may request. If a patient requests treatment which the doctor considers to be inappropriate and potentially harmful, the doctor's overriding duty to act in the patient's best interests dictates that the treatment must be withheld. A doctor who accedes to a patient's request (or demand) and performs treatment which he or she knows, or ought to know, is contra-indicated and not in the patient's best interests, may be held liable for any injury which the patient suffers as a result of treatment.....” (Picard & Robertson, Legal Liability Of Doctors And Hospitals In Canada, Carswell, Toronto, Canada, pp. 264-265, 1996)