Validity of Studies

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

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

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Validity of Studies

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Qualitative Studies

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

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

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

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

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

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

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

Risk Factors for Adverse Emotional Consequences of Abortion

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

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

See also Risk_factors

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

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

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

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

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

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

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

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

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

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

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

Background

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Variation in Propensity to PTSD

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

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

"A Marker for PTSD in Women?"

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

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

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

What Increases Risk for PTSD in Military Service Members?

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

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

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

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

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

Smaller Brain Linked to Soldiers' PTSD Risk

U.S. Military Studying PTSD Risk Factors

Research Validating Abortion Associated PTSD

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

Abstract

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

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

Method: Eighty-six women were approached a few hours after the abortion and then 6 weeks later. Several questionnaires were completed: the Impact of Event Scale Revised (IES-R), the Multidimensional Scale of Social Support (MSPSS), the Peritraumatic Dissociative Experience Questionnaire (PDEQ), the Peritraumatic Emotions List (PEL), the Hospital Anxiety and Depression Scale (HADS), the Perinatal Grief Scale (PGS) and the Texas Grief Inventory (TGI).

Results: Six weeks after the abortion, 38% of women reported a potential PTSD and a significant decrease of the anxious symptomatology was also highlighted. Peritraumatic dissociation and peritraumatic emotions were the main predictors of the intensity of post-abortum PTSD symptoms. Compared to surgical abortion, medical abortion was associated with increasing the risk of developing a possible PTSD.

Conclusion: By providing evidence on some of the main risk factors, this study highlights the need for psychological support for women and strategies of prevention to be developed.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinical examples of abortion related post traumatic stress disorder.

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

This study reported that 6 of 442 women ( 1.36%) reported PTSD two years postabortion according to DSM-IV criteria. An increasing number of women had negative emotional reactions with the passage of time. In this study it appears that the standard for identifying a case of abortion-related PTSD was set to exceptionally high level. First, women were required to the cause of each symptom as having been directly related to the abortion. Nightmares that they did not associate to their abortion, for example, would not have been included as an intrusive symptom. In addition, it appears that only women who rated the degree of the reaction at the highest level, for every PTSD symptom, were included. Women with a moderate level of distress in one symptom area, for example, were not counted as having PTSD. This high standard is useful for verifying with a high degree of certainty that abortion is the direct cause of PTSD in at least some cases. On the other hand, because the standard appears to be set higher than is normally the case in population studies of PTSD, the findings may under represent the actual incidence rate.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

6. The rates of depression and anxiety were high both pre-abortion and at three months post-abortion, but were not significantly higher. Regarding depression, at pre-termination 21.9% of the sample had high depression scores compared to 20% at 1 and 3 months. 'High' state anxiety (STAI) at pre-abortion was reported by 63.9%, and this dropped to 56.3% of women at both 1 and 3 months. Note: Pre-depresssion and anxiety scores are measured at the height of the crisis when the woman is about to have an abortion. It does not reflect pre-pregnancy scores. In addition, the high attrition rate and short time frame (3 months) must also be considered in properly interpreting this data.

7. "[W]omen with PTSD 3 months after termination were further along in their pregnancy than those without PTSD (gestational age: With PTSD: 13.2 ± 3.3; Without PTSD: 9.7 ± 4.2; p = 0.023)."

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

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

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

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

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

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

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

Case Study of PTSD Treatment

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

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

Related Information

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

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

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

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