Long-Terms Effects of Abortion

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

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

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Review Papers

Abortion and subsequent mental health: Review of the literature. Bellieni CV, Buonocore G. Psychiatry Clin Neurosci. 2013 Jul;67(5):301-10. doi: 10.1111/pcn.12067.

Abstract

The risk that abortion may be correlated with subsequent mental disorders needs a careful assessment, in order to offer women full information when facing a difficult pregnancy. All research papers published between 1995 and 2011, were examined, to retrieve those assessing any correlation between abortion and subsequent mental problems. A total of 36 studies were retrieved, and six of them were excluded for methodological bias. Depression, anxiety disorders (e.g. post-traumatic stress disorder) and substance abuse disorders were the most studied outcome. Abortion versus childbirth: 13 studies showed a clear risk for at least one of the reported mental problems in the abortion group versus childbirth, five papers showed no difference, in particular if women do not consider their experience of fetal loss to be difficult, or if after a fetal reduction the desired fetus survives. Only one paper reported a worse mental outcome for childbearing. Abortion versus unplanned pregnancies ending with childbirth: four studies found a higher risk in the abortion groups and three, no difference. Abortion versus miscarriage: three studies showed a greater risk of mental disorders due to abortion, four found no difference and two found that short-term anxiety and depression were higher in the miscarriage group, while long-term anxiety and depression were present only in the abortion group. In conclusion, fetal loss seems to expose women to a higher risk for mental disorders than childbirth; some studies show that abortion can be considered a more relevant risk factor than miscarriage; more research is needed in this field.

Does abortion reduce the mental health risks of unwanted or unintended pregnancy? A re-appraisal of the evidence. Fergusson DM, Horwood LJ, Boden JM. Aust N Z J Psychiatry. 2013 Apr 3.

Objective:There have been debates about the linkages between abortion and mental health. Few reviews have considered the extent to which abortion has therapeutic benefits that mitigate the mental health risks of abortion. The aim of this review was to conduct a re-appraisal of the evidence to examine the research hypothesis that abortion reduces rates of mental health problems in women having unwanted or unintended pregnancy.

Methods:Analysis of recent reviews (Coleman, 2011; National Collaborating Centre for Mental Health, 2011) identified eight publications reporting 14 adjusted odds ratios (AORs) spanning five outcome domains: anxiety; depression; alcohol misuse; illicit drug use/misuse; and suicidal behaviour. For each outcome, pooled AORs were estimated using a random-effects model.

Results:There was consistent evidence to show that abortion was not associated with a reduction in rates of mental health problems (p>0.75). Abortion was associated with small to moderate increases in risks of anxiety (AOR 1.28, 95% CI 0.97-1.70; p<0.08), alcohol misuse (AOR 2.34, 95% CI 1.05-5.21; p<0.05), illicit drug use/misuse (AOR 3.91, 95% CI 1.13-13.55; p<0.05), and suicidal behaviour (AOR 1.69, 95% CI 1.12-2.54; p<0.01).Conclusions:There is no available evidence to suggest that abortion has therapeutic effects in reducing the mental health risks of unwanted or unintended pregnancy. There is suggestive evidence that abortion may be associated with small to moderate increases in risks of some mental health problems.

Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009. Coleman PK. Br J Psychiatry. 2011 Sep;199(3):180-6. doi: 10.1192/bjp.bp.110.077230.

BACKGROUND: Given the methodological limitations of recently published qualitative reviews of abortion and mental health, a quantitative synthesis was deemed necessary to represent more accurately the published literature and to provide clarity to clinicians.

AIMS: To measure the association between abortion and indicators of adverse mental health, with subgroup effects calculated based on comparison groups (no abortion, unintended pregnancy delivered, pregnancy delivered) and particular outcomes. A secondary objective was to calculate population-attributable risk (PAR) statistics for each outcome.

METHOD: After the application of methodologically based selection criteria and extraction rules to minimise bias, the sample comprised 22 studies, 36 measures of effect and 877 181 participants (163 831 experienced an abortion). Random effects pooled odds ratios were computed using adjusted odds ratios from the original studies and PAR statistics were derived from the pooled odds ratios.

RESULTS: Women who had undergone an abortion experienced an 81% increased risk of mental health problems, and nearly 10% of the incidence of mental health problems was shown to be attributable to abortion. The strongest subgroup estimates of increased risk occurred when abortion was compared with term pregnancy and when the outcomes pertained to substance use and suicidal behaviour.

CONCLUSIONS: This review offers the largest quantitative estimate of mental health risks associated with abortion available in the world literature. Calling into question the conclusions from traditional reviews, the results revealed a moderate to highly increased risk of mental health problems after abortion. Consistent with the tenets of evidence-based medicine, this information should inform the delivery of abortion services.

Abortion and mental health: Evaluating the evidence. Major B, Appelbaum M, Beckman L, Dutton MA, Russo NF, West C.A m Psychol. 2009 Dec;64(9):863-90. doi: 10.1037/a0017497.

ABSTRACT: The authors evaluated empirical research addressing the relationship between induced abortion and women's mental health. Two issues were addressed: (a) the relative risks associated with abortion compared with the risks associated with its alternatives and (b) sources of variability in women's responses following abortion. This article reflects and updates the report of the American Psychological Association Task Force on Mental Health and Abortion (2008). Major methodological problems pervaded most of the research reviewed. The most rigorous studies indicated that within the United States, the relative risk of mental health problems among adult women who have a single, legal, first-trimester abortion of an unwanted pregnancy is no greater than the risk among women who deliver an unwanted pregnancy. Evidence did not support the claim that observed associations between abortion and mental health problems are caused by abortion per se as opposed to other preexisting and co-occurring risk factors. Most adult women who terminate a pregnancy do not experience mental health problems. Some women do, however. It is important that women's varied experiences of abortion be recognized, validated, and understood.

NOTE: This is an abbreviated version of the 2008 APA Task Force Report on Abortion and Mental Health and the strengths and weaknesses of this report should be reviewed here.

Induced Abortion and Mental Health, NCCMH Published December 2011

See NCCMH Review for summary and comments.

Abortion and long-term mental health outcomes: a systematic review of the evidence. Authors: Vignetta E. Charles, Chelsea B. Polis, Srinivas K. Sridhara, Robert W. Blum Contraception 78(2008) 436-450

See Charles_et_al for summary and comments.

Experiences of abortion: a narrative review of qualitative studies. Lie ML, Robson SC, May CR.BMC Health Serv Res. 2008 Jul 17;8:150. doi: 10.1186/1472-6963-8-150.

• "Feelings of ambivalence in the decision-making process were highlighted in a Swedish study [26], where women felt positive towards the right to abortion, but negative about their own decision to abort."
• "Complex emotional experiences appear to be integral to TOP. These include regret and guilt [17,22], distress and anxiety [17,22,27] and grief, loss, emptiness and suffering [21]."

Psychiatric complications of abortion. [Article in Spanish] Gurpegui M1, Jurado D. Cuad Bioet. 2009 Sep-Dec;20(70):381-92.

INTRODUCTION: The psychiatric consequences of induced abortion continue to be the object of controversy. The reactions of women when they became aware of conception are very variable. Pregnancy, whether initially intended or unintended, may provoke stress; and miscarriage may bring about feelings of loss and grief reaction. Therefore, induced abortion, with its emotional implications (of relief, shame and guilt) not surprisingly is a stressful adverse life event.

METHODOLOGICAL CONSIDERATIONS: There is agreement among researchers on the need to compare the mental health outcomes (or the psychiatric complications) with appropriate groups, including women with unintended pregnancies ending in live births and women with miscarriages. There is also agreement on the need to control for the potential confounding effects of multiple variables: demographic, contextual, personal development, previous or current traumatic experiences, and mental health prior to the obstetric event. Any psychiatric outcome is multi-factorial in origin and the impact of life events depend on how they are perceived, the psychological defence mechanisms (unconscious to a great extent) and the coping style. The fact of voluntarily aborting has an undeniable ethical dimension in which facts and values are interwoven.

RESULT: No research study has found that induced abortion is associated with a better mental health outcome, although the results of some studies are interpreted as <<neutral>> or <<mixed.>> Some general population studies point out significant associations with alcohol or illegal drug dependence, mood disorders (including depression) and some anxiety disorders. Some of these associations have been confirmed, and nuanced, by longitudinal prospective studies which support causal relationships.

CONCLUSION: With the available data, it is advisable to devote efforts to the mental health care of women who have had an induced abortion. Reasons of the woman's mental health by no means can be invoked, on empirical bases, for inducing an abortion.

Abortion among young women and subsequent life outcomes. Casey PR. Best Pract Res Clin Obstet Gynaecol. 2010 Aug;24(4):491-502. doi: 10.1016/j.bpobgyn.2010.02.007. Epub 2010 Mar 20.

This article will discuss the nature of the association between abortion and mental health problems. Studies arguing about both sides of the debate as to whether abortion per se is responsible will be presented. The prevalence of various psychiatric disorders will be outlined and where there is dispute between studies, these will be highlighted. The impact of abortion on other areas such as education, partner relationships and sexual function will also be considered. The absence of specific interventions will be highlighted. Suggestions for early identification of illness will be made.

Psychiatric or Psychological Hospitalization or Consultation

Induced First-Trimester Abortion and Risk of Mental Disorder. Trine Munk-Olsen, Ph.D., Thomas Munk Laursen, Ph.D., Carsten B. Pedersen, Dr.Med.Sc., Øjvind Lidegaard, Dr.Med.Sc., and Preben Bo Mortensen, Dr.Med.Sc. N Engl J Med 2011;364:332-9.

Background:Concern has been expressed about potential harm to women’s mental health in association with having an induced abortion, but it remains unclear whether induced abortion is associated with an increased risk of subsequent psychiatric problems.

Methods:We conducted a population-based cohort study that involved linking information from the Danish Civil Registration system to the Danish Psychiatric Central Register and the Danish National Register of Patients. The information consisted of data for girls and women with no record of mental disorders during the 1995–2007 period who had a first-trimester induced abortion or a first childbirth during that period. We estimated the rates of first-time psychiatric contact (an inpatient admission or outpatient visit) for any type of mental disorder within the 12 months after the abortion or childbirth as compared with the 9-month period preceding the event.

Results:
The incidence rates of first psychiatric contact per 1000 person-years among girls and women who had a first abortion were 14.6 (95% confidence interval [CI], 13.7 to 15.6) before abortion and 15.2 (95% CI, 14.4 to 16.1) after abortion. The corresponding rates among girls and women who had a first childbirth were 3.9 (95% CI, 3.7 to 4.2) before delivery and 6.7 (95% CI, 6.4 to 7.0) post partum. The relative risk of a psychiatric contact did not differ significantly after abortion as compared with before abortion (P = 0.19) but did increase after childbirth as compared with before childbirth (P<0.001).

Conclusions: The finding that the incidence rate of psychiatric contact was similar before and after a first-trimester abortion does not support the hypothesis that there is an increased risk of mental disorders after a first-trimester induced abortion.

Editor's Note: Please see the extended review of this study for a more detailed discussion of the methodological limitations which slanting of the study design.

Psychiatric admissions of low income women following abortion and childbirth. Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Can Med Assoc J. 2003; 168(10):1253-7

Background: Controversy exists about whether abortion or childbirth is associated with greater psychological risks. We compared psychiatric admission rates of women in time periods from 90 days to 4 years after either abortion or childbirth.

Methods: We used California Medicaid (Medi-Cal) records of women aged 13–49 years at the time of either abortion or childbirth during 1989. Only women who had no psychiatric admissions or pregnancy events during the year before the target pregnancy event were included (n = 56 741). Psychiatric admissions were examined using logistic regression analyses, controlling for age and months of eligibility for Medi-Cal services.

Results: Overall, women who had had an abortion had a significantly higher relative risk of psychiatric admission compared with women who had delivered for every time period examined. Significant differences by major diagnostic categories were found for adjustment reactions (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.1–4.1), single-episode (OR 1.9, 95% CI 1.3–2.9) and recurrent depressive psychosis (OR 2.1, 95% CI 1.3–3.5), and bipolar disorder (OR 3.0, 95% CI 1.5–6.0). Significant differences were also observed when the results were stratified by age.

Interpretation: Subsequent psychiatric admissions are more common among low-income women who have an induced abortion than among those who carry a pregnancy to term, both in the short and longer term.

NOTES:

• Tables showing when the psychiatric hospitalization occurred illustrate a marked peak closer to the time of the pregnancy event, providing support for a causal interpretation.
• Using the same population, the authors also examined outpatient treatment for psychiatric disorders and also found higher rates of outpatient treatment following abortion. See next entry below
• The abortion group had 160% more total in-patient mental health claims than the birth group. Percentages equaled 120%, 90%, 110%, 60%, and 50% for the first 180 days, one year, two years, three years, and four years respectively.
• Across the four years, the abortion group had 70% more in-patient mental health claims than the birth group. Percentages equaled 90%, 110%, and 200% for depressive psychosis, single episode, depressive psychosis, recurrent episode, and bipolar disorder, respectfully

State-funded abortions vs. deliveries: A comparison of outpatient mental health claims over five years. Coleman PK, Reardon DC, Rue VM, Cougle JR. American Journal of Orthopsychiatry, 2002; 72(1):141–52.

(Abstract) In this record-based study, rates of 1st-time outpatient mental health treatment for 4 years following an abortion or a birth among women (aged 13-49 yrs) receiving medical assistance through the state of California were compared. After controlling for preexisting psychological difficulties, age, months of eligibility, and the number of pregnancies, the rate of care was 17% higher for the abortion group (n = 14,297) in comparison with the birth group (n = 40,122). Within 90 days after the pregnancy, the abortion group had 63% more claims than the birth group, with the percentages equaling 42%, 30%, and 16% for 180 days, 1 year, and 2 years, respectively. Additional comparisons between the abortion and birth groups were conducted on the basis of claims for specific types of disorders and age.

Report of the Committee on the Abortion Law, RF Badgley et al, (Ottawa:Supply and Services, 1977) pp. 313-321

A Saskatchewan, Canada study found that postabortion women had "mental disorders" 40.8% more often than postpartum women. An Alberta, Canada study found that among women who had abortions, 24% made visits to psychiatrists compared to 3% in the general population.

'[http://www.scribd.com/doc/132704966/Virginia-DMAS-analysis-of-health-claims-following-abortion-and-childbirth Virginia DMAS analysis of health claims following abortion and childbirth. Nelson J. Department of Medical Assistance Services. Richmond, VA. March 21, 1997. Reply to request by Delegate Bob Marshall.

This was an exploratory investigation by the Virginia Department of Medical Assistance Services (DMAS) to compare health claims of women who aborted and women who had normal births. The study examined medicaid claims paid by DMAS over a three year period for 122 women who had a first live birth and 122 women with a first abortion.

In this study population, women who had abortions had statistically significant 62% percent increase in subsequent mental health claims (43% higher costs), and a 12% increase in claims (53% higher costs) for treatments resulting from accidents. They were 275% more likely to undergo a subsequent clinical psychiatric evaluation and 206% more likely to receive individual medical psychotherapy, and were 720% more likely to receive pharmacologic management in association with minimal psychotherapy.

"Health Services Utilization After Induced Abortion in Ontario: A Comparison Between Community Clinics and Hospitals," T Ostbye et al, Am J Medical Quality 16(3):99-106, 2001

In Canada, a study of Ontario Health Insurance Plan claims in 1995 found that women who were three months postabortion from hospital day surgery had a rate of hospitalization for psychiatric problems of 5.2 per 1000 vs. 1.1 per 1000 for age matched controls without induced abortions. Three month postabortion women who had abortions at a community clinic had a rate of hospitalization for psychiatric problems of 1.9 per 1000 vs. 0.60 per 1000 for age-matched controls who did not have induced abortions. The incidence of postabortion psychiatric hospitalization was significantly higher if there had been preabortion hospitalization for psychiatric problems, preabortion emergency room consultation, or preabortion hospital admissions. Ed. Note: Flaws in the available data and study design limit the value of this study.

"Postabortion or Postpartum Psychotic Reactions," H David et al, Family Planning Perspectives 13(2): 892, 1981

A Danish register linkage study over a three month period found that the rate of psychiatric hospital admissions was 18.4 per 10,000 postabortion women, 12.0 pr 10,000 postpartum women, and 7.5 per 10,000 women of childbearing age generally.

"Risk of Admission to Psychiatric Institutions among Danish Women Who Experienced Induced Abortion: An Analysis Based on A National Record Linkage," Ronald Somers, Dissertation Abstracts Int'l, Public Health 2621-B, 1979

The age-adjusted incidence of psychiatric hospitalization was 3.42%, 4.06%, and 6.0% for women with one, two, and three induced abortions respectively compared with 2.56%, 1.97% and 2.15% for women with one, two and three live births respectively. The age- adjusted percentage of psychiatric hospitalization for aborting women was 1.49% for married women, 2.38%for single women, 4.21% for separated women, and 5.16% for divorced women. Aborting women under 30 years of age exhibited higher overall and diagnosis specific psychiatric hospital admission rates than women of this age in general. Teenagers who had abortions had 2.9 times the rate of psychiatric hospital admissions compared to teenage women in general. The highest rate of psychiatric hospital admissions was 9.45% among women age 35-39 with more than one abortion during the study period.

"State-funded abortions vs. deliveries: A comparison of subsequent mental health claims over 6 years," PK Coleman and D Reardon, Poster session presented at the American Psychological Society 12th Annual Convention, Miami, FL, June, 2000

In a study of California women who received state funded medical care and who either had an abortion or gave birth in 1989, postabortion women were more than twice as likely to have from two to nine treatments for mental health as women who carried to term.

"Psychosocial Characteristics of Psychiatric Inpatients with Reproductive Losses," T Thomas et al, Journal of Health Care for the Poor and Underserved 7(1):15, 1996

Postabortion women were more likely to require psychiatric hospitalization, have been subjected to sexual abuse, and be diagnosed for psychoactive substance abuse disorder compared to childless women.

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

In a Canadian study of women attending a hospital based women's psychiatric clinic, a past abortion correlated significantly with three or more trauma factors.

Proceedings of the Conference on Psycho-Social Factors in Transnational Planning, W Pasini and J Kellerhals, (Washington D.C.: American Institute for Research, 1970) p.44

A three fold increase in previous psychiatric consultations was found in women seeking repeat abortions compared to maternity patients.

2010

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

Abstract

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

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

Abstract

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

Conduct disorder symptoms and subsequent pregnancy, child-birth and abortion: A population-based longitudinal study of adolescents. Pedersen W, Mastekaasa A. J Adolesc. 2010 Dec 9.

Abstract: Research on teenage pregnancy and abortion has primarily focused on socio-economic disadvantage. However, a few studies suggest that risk of unwanted pregnancy is related to conduct disorder symptoms. We examined the relationship between level of conduct disorder symptoms at age 15 and subsequent pregnancy, child-birth and abortion. A population-based, representative sample of Norwegian adolescent girls (N = 769) was followed from early adolescence until their mid-20s. Even with control for socio-demographic and family variables, conduct disorder symptoms at age 15 were strongly associated with pregnancy in the 15-19 age group, and a weaker association persisted in the 20-28 age group. Similar results were obtained for abortions, but here a strong relationship with conduct disorder symptoms was found even after age 20. After adjustment, no significant association between conduct disorder symptoms and subsequent child-birth was observed. More targeted preventive programmes aimed at girls with conduct disorder symptoms may be warranted.

Turn Away Study

Decision Rightness and Emotional Responses to Abortion in the United States: A Longitudinal Study Rocca CH, Kimport K, Roberts SC, Gould H, Neuhaus J, Foster DG. PLoS One. 2015 Jul 8;10(7):e0128832. doi: 10.1371/journal.pone.0128832. eCollection 2015.

Abstract

BACKGROUND: Arguments that abortion causes women emotional harm are used to regulate abortion, particularly later procedures, in the United States. However, existing research is inconclusive. We examined women's emotions and reports of whether the abortion decision was the right one for them over the three years after having an induced abortion.

METHODS: We recruited a cohort of women seeking abortions between 2008-2010 at 30 facilities across the United States, selected based on having the latest gestational age limit within 150 miles. Two groups of women (n=667) were followed prospectively for three years: women having first-trimester procedures and women terminating pregnancies within two weeks under facilities' gestational age limits at the same facilities. Participants completed semiannual phone surveys to assess whether they felt that having the abortion was the right decision for them; negative emotions (regret, anger, guilt, sadness) about the abortion; and positive emotions (relief, happiness). Multivariable mixed-effects models were used to examine changes in each outcome over time, to compare the two groups, and to identify associated factors.

RESULTS: The predicted probability of reporting that abortion was the right decision was over 99% at all time points over three years. Women with more planned pregnancies and who had more difficulty deciding to terminate the pregnancy had lower odds of reporting the abortion was the right decision (aOR=0.71 [0.60, 0.85] and 0.46 [0.36, 0.64], respectively). Both negative and positive emotions declined over time, with no differences between women having procedures near gestational age limits versus first-trimester abortions. Higher perceived community abortion stigma and lower social support were associated with more negative emotions (b=0.45 [0.31, 0.58] and b=-0.61 [-0.93, -0.29], respectively).

CONCLUSIONS: Women experienced decreasing emotional intensity over time, and the overwhelming majority of women felt that termination was the right decision for them over three years. Emotional support may be beneficial for women having abortions who report intended pregnancies or difficulty deciding.

Comments:

1. This study's findings and conclusions are overreaching due to self-selection and high drop out rates. To quote from the study: "Overall, 37.5% of eligible women consented to participate, and 85% of those completed baseline interviews (n = 956). Among the Near-Limit and First-Trimester Abortion groups, 92% completed six-month interviews, and 69% were retained at three years; 93% completed at least one follow-up interview." This means 62.5% of women refused to participate in the study.

1. With 62.5% of eligible women refusing to participate in the study, it is improper for the authors to suggest that their findings reflect the general experiences of most women. There are numerous risk factors which have been identified as predicting which women will have the most severe post-abortion reactions. One of these risk factors, for example, is ambivalence about having an abortion or carrying to term. Another is the expectation that one will have more negative feelings about the abortion. In a similar post-abortion interview study by Soderberg, the author reported that in interviews with those declining to participate "the reason for non-participation seemed to be a sense of guilt and remorse that they did not wish to discuss. An answer often given was: ' Do do not want to talk about it. I just want to forget.'"

1. It is very likely that the self-selected 37.5% of women agreeing to participate were more highly confident of their decision to abort prior to their abortions and anticipated fewer negative outcomes. This concern about selection bias is highlighted by the study's own finding that "women feeling more relief and happiness at baseline were less likely to be lost [to follow-up]." Clearly, due to the large numbers of women choosing not to be questioned about their experience, and the large drop out of those who did agree, this sample is not representative of the national population of women having abortions.

1. Despite the initial selection bias, 15% of those agreeing to be interviewed subsequently opted out of the baseline interview and another 31% opted out within the three year followup period. This indicates that even among women who expected little or no negative reactions, the stress of participating in follow up interviews lead to a change of mind. The authors also make much of the claim that 93% of the participants "completed at least one follow up interview" which the media outlets incorrectly reported as meaning "Only 7% of the participants dropped out of the study during follow-up."

1. The bias of the research team is made clear in press releases and a infographic purporting to summarize the study. In these "summaries" the research group conceals the details regarding the high non-participation rate and boldly claims "95% of women who had abortions felt it was the right decision, both immediately and over 3 years," omitting the fact that 62.5% refused to answer the question at the time of their abortion and of those interviewed at the time 31% were out of the study by the third year.

Notably, the claim of declining regret and declining negative reactions is at odds with Brenda Major's two year longitudinal study, which also had high drop out rates, which found that there was a trend in decline in relief and increase in negative emotions over the two year period among those who did not drop out of her study. (See Major B, et al. Psychological responses of women after first-trimester abortion. Archives of General Psychiatry. 2000: 57(8), 777-84.)

Another oddity, the authors report that in the final group analyzed, average age 25, 62% were raising children. This would appear to be a very high rate that is not typical of national averages for women seeking abortion. Also, the sample included 413 women who had an abortion near the end of the second trimester compared to only 254 women having an abortion in the first trimester.

Additionally, the authors do not report on any assessment of whether women experiencing negative emotions sought any post-abortion psychological or spiritual counseling. In other words, it is unclear if the women reporting a decline in negative emotions experienced this decline because of intervention (counseling) or reconciliation (spiritual effort) or whether the decline is "natural" as the authors suggest.

Yet another problem is that the questionnaire used by the authors focused on just five emotional reactions which the women attributed to their abortions: relief, happiness, regret, guilt, anger. (Why "sadness" was omitted is unclear.) The "decision rightness" measure was based on a single question of whether or not the "abortion was right for them."

But there is clear evidence from other studies that many women experience symptoms of post-traumatic stress disorder which includes symptoms of denial and avoidance behavior. In a study by Rue, for example, among women reporting intrusive memories and dreams related to their abortion, only half attributed these thoughts to their abortions. In other words, half were in such denial that while on one hand they could report certain intrusive thoughts half denied that these thoughts had anything to to do with their abortions. Therefore, women reporting less "anger" relative to their abortion may in fact have more feelings of anger in their lives but may not be attributing this anger to their abortions, but rather to other problems, though perhaps in counseling, they might discover their increased feelings of anger were projected on other issues but are related to unresolved hurt over the past abortion.

Older Papers Regarding Long-Term Effects

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

BACKGROUND: There has been continued interest in the extent to which women have positive and negative reactions to abortion. AIMS: To document emotional reactions to abortion, and to examine the links between reactions to abortion and subsequent mental health outcomes.

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

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

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

Broen AN, Moum T, Bodtker AS, Ekeberg O: Reasons for induced abortion and their relation to women's emotional distress: a prospective, two-year follow-up study. Gen Hosp Psychiatry 2005, 27:36-43.

OBJECTIVE: The present study aimed to identify the most important reasons for induced abortion and to examine their relationship to emotional distress at follow-up. :

METHODS: Eighty women were included in the study. The women were interviewed 10 days, 6 months (T2) and 2 years (T3) after they underwent an abortion. At all time points, the participants completed the Impact of Event Scale and a questionnaire about feelings connected to the abortion.

RESULTS: Reasons related to education, job and finances were highly rated. Also, "a child should be wished for," "male partner does not favour having a child at the moment," "tired, worn out" and "have enough children" were important reasons. "Pressure from male partner" was listed as the 11th most important reason. When the reasons for abortion and background variables were included in multiple regression analyses, the strongest predictor of emotional distress at T2 and T3 was "pressure from male partner."

CONCLUSION: Male pressure on women to have an induced abortion has a significant, negative influence on women's psychological responses in the 2 years following the event. Women who gave the reason "have enough children" for choosing abortion reported slightly better psychological outcomes at T3.

Psychological Impact on Women of Miscarriage Versus Induced Abortion: A 2-Year follow-up study. Broen AN, Moum T, Bödtker AS, Ekeberg O. Psychosomatic Medicine, 2004, 66:265-271.

"The feeling relief (at T1) had no significant influence on the IES scores at T3, unadjusted or adjusted." (p 268) This supports an argument that researchers who place too much emphasis on measure of relief may be missing the full picture.

p270, "mental health before the event suprisingly had no significant independent influence on IES scores."

The course of mental health after miscarriage and induced abortion: a five-year follow-up study. Broen AN, Moum T, Bødtker AS, Ekeberg O. BMC Medicine 2005, 3:18 (12 December 2005)

Broen et al.'s results show that women who had a miscarriage suffer more mental distress up until six months after the event than women who had an abortion. Women who had an abortion, however, experienced more mental distress long after the event - two and five years afterwards - than women who had a miscarriage. Women who experienced induced abortion had significantly greater IES scores for avoidance and for the feelings of guilt, shame and relief than the miscarriage group at two and five years after the pregnancy termination (IES avoidance means: 3.2 vs 9.3 at T3, respectively, p < 0.001; 1.5 vs 8.3 at T4, respectively, p < 0.001). Compared with the general population, women who had undergone induced abortion had significantly higher HADS anxiety scores at all four interviews (p < 0.01 to p < 0.001), while women who had had a miscarriage had significantly higher anxiety scores only at T1 (p < 0.01).

Predictors of anxiety and depression following pregnancy termination: a longitudinal five-year follow-up study. Broen AN, Moum T, Bödtker AS, Ekeberg O. Acta Obstet Gynecol Scand. 2006;85(3):317-23.

BACKGROUND: The aims of the study were to assess anxiety and depression in women who had experienced either a miscarriage or an induced abortion, to compare the women's level of distress with that of a general population sample, and to find predictors of anxiety and depression six months and five years after the event. METHODS: A prospective, longitudinal follow-up study. Women who experienced miscarriage (n = 40) and induced abortion (n = 80) were interviewed ten days (T1), six months (T2), two years (T3), and five years (T4) after the event. On each occasion, they completed the Hospital Anxiety and Depression Scale and the Life Events Scale. Paired-sample t-test, logistic regression, and multiple linear regression statistical tests were used. RESULTS: Women with miscarriage had significantly more anxiety and depression at T1 than the general population, while women with induced abortion had significantly more anxiety at all time points and more depression at T1 and T2. In both groups, important predictors of anxiety and depression at T2 and T4 were recent life events and poor former psychiatric health. Childbirth events between T1 and T4 had no significant influence on the scores. For women with induced abortion, doubt about the decision to abort was related to depression at T2 (p <0.05), while a negative attitude towards induced abortion was associated with anxiety at T2 (p <0.05) and T4 (p <0.05). CONCLUSION: Correlates of anxiety and depression may be used to better identify women who are at risk of negative psychological responses following pregnancy termination.

"Induced Elective Abortion and Perinatal Grief," Gail B. Williams, Dissertation Abstracts Int'l. 53(3): 1296B, Sept. 1992.

A study of 83 white women with one first trimester abortion, no documented psychiatric history and no self-reported prenatal losses in the last 5 years an average of 11 years postabortion. The Grief Experience Inventory was used as a test instrument and found a range of scores from 27-82. 50 represents at least minimal grief on 12 bereavement/research scales. Various scales measured included anger/hostility, social isolation, loss of control, death anxiety, loss of vigor, physical symptoms, dependency, somatization, sleep disturbance, loss of appetite, optimism/despair, denial. It was concluded that some women experienced persistence of various aspects of grief for long periods of time following induced abortion.

The Psycho-Social Aspects of Stress Following Abortion, Anne C. Speckhard, (Kansas City: Sheed and Ward, 1987)

In a study of 30 women stressed by abortion after 5-10 years following their abortion, women reported feelings of sadness, regret, remorse or a sense of loss [100 percent]; feelings of depression [92 percent]; feelings of anger [92 percent]; feelings of guilt [92 percent]; fear that others would learn of the pregnancy and abortion experience [89 percent]; many expressed surprise at the intensity of the emotional reaction to the abortion [85 percent]; Other adverse reactions included feelings of lowered self-worth [81 percent]; feelings of victimization [81 percent]; preoccupation with the characteristics of the aborted child [81 percent]; feelings of depressed effect or suppressed ability to experience pain [73 percent]; and feelings of discomfort around infants and small children [73 percent]. In this study the most common behavioral reactions included frequent crying [81 percent]; inability to communicate with others concerning the pregnancy and abortion experience [77 percent]; flashbacks of the abortion experience [73 percent]; sexual inhibition [69 percent]; suicide ideation [65 percent] and increased alcohol use [61 percent].

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

In a detailed study of 252 women with prior abortions who are members of Women Exploited by Abortion approximately 10 years after their abortion, 95% were now dissatisfied with the abortion choice and 94% attributed negative psychological effects to their abortion.

"Mental Disorders After Abortion," B. Jansson, Acta Psychiatrica Scandinavica41:87 (1965).

In a Swedish study of 57 women with prior psychiatric problems who subsequently had induced abortions, three committed suicide as determined by long-term follow-up studies 8-13 years after their abortion. In contrast, of 195 women with previous psychiatric problems who carried children to term, none committed suicide.

"Risk of Admission to Psychiatric Institutions Among Danish Women Who Experience induced Abortion," Ronald L. Somers, Ph.D. Thesis/ UCLA (1979)

Among women with 2 or more abortions the rate of psychiatric admissions among women 35-39 (approx. 9%) was about 4 times higher than women 25-29 years of age (approx. 2.3%) and 8-18 times higher than women 20-24 years of age (0.5-1.1%) during 1973- 1975.

"Psychological Aspects of Abortion," Edna Ortof in Psychological Aspects of Pregnancy, Birthing and Bonding, ed. Barbara L. Blum (New York: Human Sciences Press, 1980)

Several examples of post-abortion dreams are provided. One woman had the following dream 11, years after a self-induced abortion:

"I was in my old home town with two girlfriends and about to go horseback riding... (but) we couldn't get a horse. Then some lady came over and handed me a bundle wrapped in a sheet and blankets/ like a baby. I was delighted to hold it... when I opened the bundle ... there was a kid there and it looked like it was shrinking. Like it was wasting away and I wanted the mother to come and take it away before it would die in my arms... The more I looked, the more anxious I got." The therapist reported this woman had an enormous sense of unfinished business about the pregnancy and abortion. She still had periodic intercourse without use of contraceptives with the prospective father hoping to "undo" that event. At times her guilt was overwhelming and her sense of loss increased with the passing years.

A Survey of Post-Abortion Reactions, David C. Reardon, (Springfield, Illinois: Elliot Institute, 1987)

A 1987 survey of 100 women an average of 11 years post-abortion who were contacted through state Women Exploited by Abortion chapters found that only 54% felt they had fully reconciled their abortion experience; 62% experienced the majority of their negative experience one year or more post-abortion; 97% regretted having the abortion; 62% said they felt more callused and hardened; 70% felt a need to stifle feelings; 45% said they had feelings of relief after abortion; 42% became sexually promiscuous; 50% reported aversion to sexual intercourse or sexual unresponsiveness; 54% thought the abortion choice was inconsistent with their own ideals; 64% ended the relationship with their sexual partner following the abortion (41% within one month, 9% more within 6 months and 14% more within one year.

The Long-Term Psychological Effects of Abortion, Catherine A Barnard, (Portsmouth, NH: Institute for Pregnancy Loss, 1990) Summarized in Association for Interdisciplinary Research in Values and Social Change Newsletter 3(4):1 (1991)

A random sample of 984 women who had abortions during 1984-84 at a clinic in Baltimore, Maryland were selected for study. However, only 160 women could be contacted 3-5 years later, Of the 160 contacted only 80 actually completed the research packets. Research instruments used were the DSM-IIIR, Impact of Events Scale, and the Millon Clinical Mulitaxial Inventory. The prevalence of Post Traumatic Disorder was 18.8%. High stress levels ranging from 39-45% were prevalent in such areas as sleep disorers, hypervigalence, or flashbacks. The variables that predicted high stress reactions were: a negative relationship with mother, a past history of emotional problems in the family of origin, a conflictual relationship with the father of the child, and poor aftercare at the clinic. The number of reported prior abortions did not predict the incidence of PTSD. 30% of the women had abortions between 14-18 years of age and few were religious at the time of their abortion.

"Methodological considerations in empirical research on abortion," RL Anderson et al in Post-Abortion Syndrome. Its Wide Ramifications, ed. Peter Doherty (1995) 103

A study at Pine Rest Christian Hospital in Grand Rapids, Michigan which provided psychiatric outpatient services, compared women who presented with a history of elective abortion and sought psychiatric outpatient services in response to a negative adjustment to abortion ( the abortion distressed group), to a control group which also had a history of elective abortion but who presented for outpatient psychiatric services for reasons which were not abortion related. (the abortion non-distressed group). The average length of time from the abortion to the time of the study was 9 years. Seventy-three percent (73%) of the abortion distressed group met the criteria for Post Traumatic Stress Disorder (DSM-IIIR) which was significantly higher than the abortion non-distressed group. Women in the abortion distressed group more often reported they believed abortion to be morally wrong compared to the abortion non-distressed group. There were no significant differences among groups in psychopathology as measured by MMPI-2, on overall social support, or religiosity. Abortion distressed women experienced fewer recent adverse life events compared to abortion non-distressed women.

Canonical variates of postabortion syndrome, Helen P Vaughan, (Portsmouth, NH: Institute for Pregnancy Loss, 1990)

Questionnaires were distributed nationwide to 62 crisis pregnancy centers to women who had reported symptoms of postabortion syndrome and 232 questionnaires were returned. The mean length of time from their abortion was 11 years. It was found that postabortion syndrome was comprised of anger, guilt, grief, depression, and stress reactions. Two different dimensions of negative postabortion adjustment were noted. One dimension included high levels of anger and guilt, with a significant absence of any grief feelings. The second dimension showed high guilt and stress with a significant absence of anger. The various personality characteristics and circumstances of women in each dimension were discussed.

" Psychological Profile of dysphoric women postabortion," KN Franco et al, Journal of the American Medical Women's Association 44(4): 113, 1989

Eighty-one women in a patient-led postabortion support group years who described themselves as having poorly assimilated their abortion experience 1-15 years postabortion were studied. 78% were single at the time of their abortion and only 19% married the father of the child. The Bech Depression Inventory for women with one abortion was 4.7(none to minimal depression) and for women with multiple abortions was 9.4(moderate depression). The Millon Clinical Mulitaxial Inventory (MCMI) suggested personal pathology in the form of anxiety (48%), somatoform disorders (58%), and dysthymia (36%). Those with multiple abortions scored on the borderline personality subscales. Some 48% of the group underwent psychotherapy after their abortion; 50% of women with multiple abortions made a suicide attempt sometime after their abortions; anniversary reactions were clearly reported by 42% of the sample. For additional studies on this sample of postabortion women see "Anniversary Reactions and Due Date Responses Following Abortion," K Franco et al, Psychother Psychosom 52:151, 1989; "Abortion in Adolescence," NB Campbell et al, Adolescence, 23(92), 1988

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

In a study of women in a religiously-based postabortion recovery group 10-15 years post- abortion, 90% reported guilt and shame related to their abortion, 74% feelings of isolation, 60% expressed anger toward others, 24% were more fearful of sexual intercourse after their abortion, 31% tried to avoid pregnant women, 53% said they desired to get pregnant again to compensate for their loss; 76% suffered from depression, 78% struggled with low self-esteem and 49% said they felt alienated from God. Following their abortion, women reported insomnia (25%), negative and hurtful relationships with men (38%, abortion had a negative effect on parenting (32.4%), frequent alcohol use (17.8%), frequent drug use (9.2%) as well as other negative personal or relational problems.

"Physical and Psychological Injury Following Abortion: Akron Pregnancy Services Survey," L.H. Gsellman, Association For Interdisciplinary Research Newsletter 5(4):1-8, Sept/Oct 1993.

In a questionnaire study of 344 post-abortal women receiving a variety of services at a pregnancy service center an average of 6 years following their abortion, 66% expressed guilt, 54% expressed regret or remorse, 46% had an inability to forgive self, 57% reported crying or depression, 38% reported lower self-esteem and 36% reported anger or rage, 16% reported suicidal impulses and 7% made suicide attempts. 18.4% of the abortions were at 13 weeks gestation or more; 22% reported two abortions and 4.3% reported three or more abortions.

"Prolonged Grieving After Abortion. A Descriptive Study," D Brown et al, The Journal of Clinical Ethics 4(2):118, 1993.

Upon request, women from a large protestant congregation in Florida wrote descriptive letters on the negative effects of abortion. 45 letters contained sufficient information to compile statistical information, 81% were first trimester abortions and 71% occurred after Roe v Wade was decided. 42% reported negative emotional sequelae that lasted over 10 years. Frequently mentioned long term experiences included guilt feelings (73.3%), fantasizing about the aborted fetus( 57.8%), masking their experience with the appearance of well-being (35.5%), suicide ideation (15.5%), recurrent nightmares(15.5%), marital discord (15.5%), phobic responses to infants (13.3%), as well as fear of men (8.9%) and disinterest in sex (6.7%).