Impact on Subsequent Pregnancies

A history of abortion may effect subsequent pregnancies both emotionally and physically. It may contribute to how soon a woman become pregnant via a [Replacement Pregnancies/Rapid Repeat Pregnancies After Abortion |replacement pregnancy], or it may lead to difficulties becoming pregnant due to physical effects on fertility and the capability to carry to term, and it may also impact the woman's ability to cope with pregnancy and increase the risk of psychological difficulties both during and subsequent to the later pregnancy.

Mental Health Impact During Later Pregnancies

Previous pregnancy loss has an adverse impact on distress and behaviour in subsequent pregnancy. McCarthy F, Moss-Morris R, Khashan A, et al.BJOG An Int J Obstet Gynaecol. 2015;122(13):1757-1764. doi:10.1111/1471-0528.13233.

Objective: To investigate whether women with previous miscarriages or terminations have higher levels of anxiety, depression, stress, and altered behaviours in a subsequent pregnancy.

Design:A retrospective analysis of 5575 women recruited into the Screening for Pregnancy Endpoints (SCOPE) study, a prospective cohort study.

Setting:Auckland, New Zealand, Adelaide, Australia, Cork, Ireland, and Manchester, Leeds, and London, UK.

Population:Healthy nulliparous women with singleton pregnancies.

Methods: Outcomes were recorded at 15 and 20 weeks of gestation.

Main outcome measures: Short-form State–Trait Anxiety Inventory (STAI) score, Perceived Stress Scale score, Edinburgh Postnatal Depression Scale score, and pregnancy-related behaviour measured using behavioural responses to pregnancy score.

Results: Of the 5465 women included in the final analysis, 559 (10%) had one and 94 (2%) had two previous miscarriages, and 415 (8%) had one and 66 (1%) had two previous terminations of pregnancy. Women with one previous miscarriage had increased anxiety (adjusted mean difference 1.85; 95% confidence interval, 95% CI 0.61–3.09), perceived stress (adjusted mean difference 0.76; 95% CI 0.48–1.03), depression (adjusted odds ratio, aOR 1.26; 95% CI 1.08–1.45), and limiting/resting behaviour in pregnancy (adjusted mean difference 0.80; 95% CI 0.62–0.97). In women with two miscarriages, depression was more common (aOR 1.65; 95% CI 1.01–2.70) and they had higher scores for limiting/resting behaviour in pregnancy (adjusted mean difference 1.70; 95% CI 0.90–2.53) at 15 weeks of gestation.

Women with one previous termination displayed elevated perceived stress (adjusted mean difference 0.65; 95% CI 0.08–1.23) and depression (aOR 1.25; 95% 1.08–1.45) at 15 weeks of gestation. Women with two previous terminations displayed increased perceived stress (adjusted mean difference 1.43; 95% CI 0.00–2.87) and depression (aOR 1.67; 95% 1.28–2.18).

Conclusions: This study highlights the psychological implications of miscarriage and termination of pregnancy.

Identifying the women at risk of antenatal anxiety and depression: A systematic review Biaggi A, Conroy S, Pawlby S, Pariante CM. J Affect Disord. 2015 Nov 18;191:62-77.

BACKGROUND: Pregnancy is a time of increased vulnerability for the development of anxiety and depression. This systematic review aims to identify the main risk factors involved in the onset of antenatal anxiety and depression.

METHODS: A systematic literature analysis was conducted, using PubMed, PsychINFO, and the Cochrane Library. Original papers were included if they were written in English and published between 1st January 2003 and 31st August 2015, while literature reviews and meta-analyses were consulted regardless of publication date. A final number of 97 papers were selected.

RESULTS: The most relevant factors associated with antenatal depression or anxiety were: lack of partner or of social support; history of abuse or of domestic violence; personal history of mental illness; unplanned or unwanted pregnancy; adverse events in life and high perceived stress; present/past pregnancy complications; and pregnancy loss.

LIMITATIONS: The review does not include a meta-analysis, which may have added additional information about the differential impact of each risk factor. Moreover, it does not specifically examine factors that may influence different types of anxiety disorders, or the recurrence or persistence of depression or anxiety from pregnancy to the postpartum period.

CONCLUSIONS: The results show the complex aetiology of antenatal depression and anxiety. The administration of a screening tool to identify women at risk of anxiety and depression during pregnancy should be universal practice in order to promote the long-term wellbeing of mothers and babies, and the knowledge of specific risk factors may help creating such screening tool targeting women at higher risk.

The Impact of Prior Abortion on Anxiety and Depression Symptoms During a Subsequent Pregnancy: Data From a Population-Based Cohort Study in China Huang Z, et al. Bulletin of Clinical Psychopharmacology 2012;22(1):51-8

Objective: The aim of the study was to assess anxiety and depression in women with history of spontaneous abortion or induced abortion during a subsequent pregnancy.

Methods: The data were consecutively obtained from seven maternal and child health (MCH) Centers in the Anhui Province of China. The sociodemographic characteristics of the women, the number of previous pregnancies, number of living children, and gestational age of the current pregnancy were ascertained at the time of the interview.

Results: The pregnant women who were in the first trimester of their pregnancy reported significantly higher scores than those in the second trimester both on SAS (Zung’s Self-Rating Anxiety Scale) and CES-D (The Center for Epidemiologic Studies-Depression Scale) (SAS score means: 32.11 vs 31.68, P=0.000; CES-D score means: 4.59 vs 4.06, P=0.012). The women with a history of induced abortions were significantly more likely to report more “cases” of depression (OR = 1.543, 95% CI = 1.055- 254) and more “cases” of anxiety (OR = 2.142, 95% CI = 1.294-3.561) during the first trimester than those with no history of abortion. Controlling for confounding variables yielded similar results. However, “cases” of depression and “cases” of anxiety were equally common in women with history of spontaneous abortions and in those with no abortion history.

Conclusions: These results suggest women who have experienced a previous induced abortion have omnipresent anxiety and depression symptoms during a subsequent pregnancy, specially during the first trimester.

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

A study of 254 pregnant women in Victoria, B.C. were followed from the second trimester of their pregnancy until 12 months post-partum. Twenty-eight women had a prior induced abortion and 216 had no prior induced abortion. Women who had a prior abortion had significantly higher levels of depressive effect in the third trimester of pregnancy (35 weeks gestation) and also at intervals of I month, 6 months and 12 months in the post- partum period. A Depressive Adjective Checklist developed by other researchers was used as the evaluation tool. Women with prior abortions also described themselves as less well-adjusted during the prenatal period and had lower self-esteem in the post- partum period than those without any abortion history. The author suggested that it may have been those factors which were related to their depressive mood.

"The Relationship Between Previous Elective Abortions and Postpartum," Depressive Reactions. N.E. Devore, Journal of Obstetric Gynecologic and Neonatal Nursing, July/August 1979, pp-237-240

In a study of 73 women among the obstetrical population at the Hospital of Albert Einstein College during 1975-76, 25 pregnant women who had one abortion and 48 women who were pregnant for the first time were interviewed 6-8 weeks postpartum. Seventy-one percent of the women with abortion history reported they were depressed at the time of the abortion, yet only 12% reported that they had received emotional counseling at the time of the abortion. The range of time from the earlier abortion to the current pregnancy was 2-8 years, mean 3.9 years. Using the Beck Depression Inventory, the study found postpartum moderate depression in 16% of women with a prior abortion compared to 12% of the women without any abortion. Eighty percent of the women with abortion history compared to 56% without abortion history reported the "baby blues." The study suggested that a few women who have had a previous elective abortion will still experience feelings of guilt or depression in connection with it. Spontaneous comment from the women with abortion history suggested that anxiety during pregnancy concurring the infants health was a greater source of discomfort than was post-partum depression.

"Previous induced abortion and ante-natal depression in primipare: preliminary report of a survey of mental health in pregnancy," R. Kumar, K. Robson, Psychological Medicine8:711-715, 1978

A British study of 119 pregnant women found an association between a previous abortion (legal or illegal) and depression and anxiety in an early subsequent pregnancy. An intensification of fears of fetal abnormality was noted in women having had a prior abortion. The study concluded that "unresolved feelings of guilt, grief and loss may remain dormant long after an abortion until they are apparently re-awakened by another pregnancy. Normal anxieties about the now desired fetus are intensified and such fears are often spontaneously interpreted in terms of retribution."

A Prospective Study of Emotional Disorders in Childbearing Women, R Kumar, K Robson, Brit J Psychiat 144:35-47, 1984

Prior induced abortion was associated with ante-natal depression and anxiety; thoughts about obtaining abortion was associated with both ante-natal and post-natal depression and anxiety.

"Psychiatric Morbidity in a Pregnant Population in Nigeria," OA Abiodun et. al General Hospital Psychiatry 15: 125-128, 1993

A previous history of induced abortion was significantly associated with psychiatric morbidity (mostly anxiety and neurotic depression) among 240 married Christian and Muslim women attending an antenatal clinic.

"Psychological and social correlates of the onset of affective disorders among pregnant women," T Kitamura et al, Psychological Medicine 23:967-975, 1993

A Japanese study found that among women with previous pregnancy, pregnancy-related affective disorder was recognized among 27% of those expecting their first baby where there had been a previous termination of pregnancy compared to 3% of women who had no previous termination of pregnancy.

Substance Use

History of induced abortion in relation to substance abuse during subsequent pregnancies carried to term, PK Coleman et al, Am J Obstet Gynecol 187: 1673-1678, 2002.

A nationally representative sample of women using data from the National Pregnancy and Health Survey found that, compared to women who had given birth, women who had had an induced abortion were significantly more likely to use marijuana (OR 10.29,95%CI, 3.47-30.56) , various illicit drugs (OR 5.60, 95%CI, 2.39-13.10) , and alcohol (OR 2.22,95%CI, 1.31-3.76) during their next pregnancy. An average of 5 years had elapsed since a prior abortion; an average of 3.42 years had elapsed since a prior birth.

Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy. Coleman P., Reardon D., Cougle J. Br J Health Psychol 2005; 10: 255–68.

Abstract

OBJECTIVE: The primary objectives of this study were to explore maternal history of perinatal loss and pregnancy wantedness as correlates of substance use during pregnancy.

METHOD: The research design involved interviewing women who gave birth in Washington DC hospitals during 1992. Interview data included pregnancy history (prior births, induced abortions, miscarriages, and stillbirths), desire for the pregnancy (wanted, not wanted, mistimed), socio-demographic information, timing of onset of prenatal care, and substance use (cigarettes, alcohol, and drugs) during pregnancy.

RESULTS: A history of induced abortion was associated with elevated risk for maternal substance use of various forms; whereas other forms of perinatal loss (miscarriage and stillbirth) were not related to substance use. Unwanted pregnancy was associated with cigarette smoking during pregnancy, but not with any other forms of substance use.

CONCLUSIONS: Reproductive history information may offer insight to professionals pertaining to the likelihood of women using substances in a later pregnancy.

"Patterns of Alcohol and Cigarette Use in Pregnancy," J. Kuzma and D. Kissinger, Neurobehavioral Toxicology and Teratology 3:211-221(1981).

In a California study of more than 12,000 women during 1975-1977, of those having a history of two or more abortions, virtually all (98.5%) consumed alcohol throughout the entire 9 months of a subsequent pregnancy and at higher levels than any of the other categories studied (up to 3 oz. per day) Overall, 51% of the women drank and 35% smoked during the pregnancy.

Impact of induced abortions on subsequent pregnancy outcome: the 1995 French national perinatal pregnancy survey, L Henriet, M Kaminski, Br J Obstet Gynaecol 108:1036-1042, 2001

A 1995 French national survey of women who delivered a singleton birth found that 23.6% of the women smoked during the third trimester of pregnancy where there was no induced abortion history compared to 34.5% for women with a history of one induced abortion, and 42% of women with a history of two or more induced abortions. Women with abortion history were also more likely to be heavier smokers compared to women with no abortion history.

"Induced abortion is not a cause of subsequent pre-term delivery in teenage pregnancies," TT Lao and LF Ho, Human Reproduction 13(3): 758, 1998.

In a Hong Kong study, 39% of teenage mothers with a history of induced abortion who delivered were smokers compared to 14.4% of teenage mothers who delivered but had no induced abortion history.

"A study on the effects of induced abortion on subsequent pregnancy outcome," C. Madore, W.E. Hawes, F. Many, A.C. Hexter, Am. J. Obstet. Gynecol. 139: 516, 1981.

A California case-control study in 1976-78 of women with a history of one or more previous induced abortions compared to control subjects without a history of abortion found that 11.8% of women with an abortion history smoked 1 pack of cigarettes per day compared to 8.1% of controls which was statistically significant.

Postpartum Depression

Increased risk for postpartum psychiatric disorders among women with past pregnancy loss. Giannandrea SA, Cerulli C, Anson E, Chaudron LH. J Womens Health (Larchmt). 2013 Sep;22(9):760-8. doi: 10.1089/jwh.2012.4011.

Abstract Background: Scant literature exists on whether prior pregnancy loss (miscarriage, stillbirth, and/or induced abortion) increases the risk of postpartum psychiatric disorders-specifically depression and anxiety-after subsequent births. This study compares: (1) risk factors for depression and/or anxiety disorders in the postpartum year among women with and without prior pregnancy loss; and (2) rates of these disorders in women with one versus multiple pregnancy losses.

Methods: One-hundred-ninety-two women recruited at first-year pediatric well-child care visits from an urban pediatric clinic provided demographic information, reproductive and health histories. They also completed depression screening tools and a standard semi-structured psychiatric diagnostic interview.

Results: Almost half of the participants (49%) reported a previous pregnancy loss (miscarriage, stillbirth, or induced abortion). More than half of those with a history of pregnancy loss reported more than one loss (52%). Women with prior pregnancy loss were more likely to be diagnosed with major depression (p=0.002) than women without a history of loss. Women with multiple losses were more likely to be diagnosed with major depression (p=0.047) and/or post-traumatic stress disorder (Fisher's exact [FET]=0.028) than women with a history of one pregnancy loss. Loss type was not related to depression, although number of losses was related to the presence of depression and anxiety.

Conclusions: Low-income urban mothers have high rates of pregnancy loss and often have experienced more than one loss and/or more than one type of loss. Women with a history of pregnancy loss are at increased risk for depression and anxiety, including post-traumatic stress disorder (PTSD), after the birth of a child. Future research is needed to understand the reasons that previous pregnancy loss is associated with subsequent postpartum depression and anxiety among this population of women.

"Predictors of postpartum post-traumatic stress disorder in primiparous mothers.[Article in French] Montmasson H1, Bertrand P, Perrotin F, El-Hage W. J Gynecol Obstet Biol Reprod (Paris). 2012 Oct;41(6):553-60. doi: 10.1016/j.jgyn.2012.04.010. Epub 2012 May 21.

A history of abortion was associated with a six fold increased risk of subsequent postpartum PTSD.

Fear of childbirth predicts postpartum depression: a population-based analysis of 511 422 singleton births in Finland. Räisänen S, Lehto SM, Nielsen HS, Gissler M, Kramer MR, Heinonen S. BMJ Open. 2013 Nov 28;3(11):e004047. doi: 10.1136/bmjopen-2013-004047.

Abstract

OBJECTIVES: To study how reproductive risks and perinatal outcomes are associated with postpartum depression treated in specialised healthcare defined according to the International Classification of Diseases (ICD)-10 codes, separately among women with and without a history of depression.

DESIGN: A retrospective population-based case-control study.

SETTING: Data gathered from three national health registers for the years 2002-2010.

PARTICIPANTS: All singleton births (n=511 422) in Finland.

PRIMARY OUTCOME MEASURES: Prevalence of postpartum depression and the risk factors associated with it.

RESULTS: In total, 0.3% (1438 of 511 422) of women experienced postpartum depression, the prevalence being 0.1% (431 of 511 422) in women without and 5.3% (1007 of 18 888) in women with a history of depression. After adjustment for possible covariates, a history of depression was found to be the strongest risk factor for postpartum depression. Other strong predisposing factors for postpartum depression were fear of childbirth, caesarean birth, nulliparity and major congenital anomaly. Specifically, among the 30% of women with postpartum depression but without a history of depression, postpartum depression was shown to be associated with fear of childbirth (adjusted OR (aOR 2.71, 95% CI 1.98 to 3.71), caesarean birth (aOR 1.38, 95% CI 1.08 to 1.77), preterm birth (aOR 1.65, 95% CI 1.08 to 2.56) and major congenital anomaly (aOR 1.67, 95% CI 1.15 to 2.42), compared with women with no postpartum depression and no history of depression.

CONCLUSIONS: A history of depression was found to be the most important predisposing factor of postpartum depression. Women without previous episodes of depression were at an increased risk of postpartum depression if adverse events occurred during the course of pregnancy, especially if they showed physician-diagnosed fear of childbirth.

Editor's Note: Women with a history of abortion were 41% more likely to have post-partum depression compared to both women without any history of prior depression (OR=1.41; CI 1.08 to 1.84) and compared women with a prior history of depression (OR=1.41; CI = 1.21 to 1.67), as shown in Table 4. Prior miscarriage was not significantly associated with a higher risk of post-partum depression.

Re-analysis of Table 1, indicates that among the subset of all women without a prior history of depression, those who had a history of abortion were 49% more likely to experience post-partum depression (95% CI 1.15 to 1.93; incident rate per 100,000 of 123 versus 82.)

Identification of Factors Associated with Postpartum Depression among Saudi Females in Riyadh City Nesreen Al-Shami. King Saud University College of Nursing, Department of Maternal and Child Health Nursing. June 2, 2010.

A study of 200 women drawn from four hospitals in Riyadh City all of whom had reported postpartum depression. Survey instruments were used to measure socioeconomic factors, gynecological and obstetric history, life stressor events, and post-partum depression symptoms.

Risk factors for postpartum depression include first birth, ambivalence about the pregnancy, lack of social support, economical problems, history of abortion, died infant, gender of infant, medical or surgical history, number of pregnancies, type of delivery, life stressor event, lack of partner, and a history of depression or another depression illness.

"The Relationship Between Previous Elective Abortions and Postpartum, Depressive Reactions." N.E. Devore, Journal of Obstetric Gynecologic and Neonatal Nursing, July/August 1979, pp-237-240

In a study of 73 women among the obstetrical population at the Hospital of Albert Einstein College during 1975-76, 25 pregnant women who had one abortion and 48 women who were pregnant for the first time were interviewed 6-8 weeks postpartum. Seventy-one percent of the women with abortion history reported they were depressed at the time of the abortion, yet only 12% reported that they had received emotional counseling at the time of the abortion. The range of time from the earlier abortion to the current pregnancy was 2-8 years, mean 3.9 years. Using the Beck Depression Inventory, the study found postpartum moderate depression in 16% of women with a prior abortion compared to 12% of the women without any abortion. Eighty percent of the women with abortion history compared to 56% without abortion history reported the "baby blues." The study suggested that a few women who have had a previous elective abortion will still experience feelings of guilt or depression in connection with it. Spontaneous comment from the women with abortion history suggested that anxiety during pregnancy concurring the infants health was a greater source of discomfort than was post-partum depression.

Increased risk for postpartum psychiatric disorders among women with past pregnancy loss. Giannandrea SA, Cerulli C, Anson E, Chaudron LH. J Womens Health (Larchmt). 2013 Sep;22(9):760-8. doi: 10.1089/jwh.2012.4011.

Abstract Background: Scant literature exists on whether prior pregnancy loss (miscarriage, stillbirth, and/or induced abortion) increases the risk of postpartum psychiatric disorders-specifically depression and anxiety-after subsequent births. This study compares: (1) risk factors for depression and/or anxiety disorders in the postpartum year among women with and without prior pregnancy loss; and (2) rates of these disorders in women with one versus multiple pregnancy losses.

Methods: One-hundred-ninety-two women recruited at first-year pediatric well-child care visits from an urban pediatric clinic provided demographic information, reproductive and health histories. They also completed depression screening tools and a standard semi-structured psychiatric diagnostic interview.

Results: Almost half of the participants (49%) reported a previous pregnancy loss (miscarriage, stillbirth, or induced abortion). More than half of those with a history of pregnancy loss reported more than one loss (52%). Women with prior pregnancy loss were more likely to be diagnosed with major depression (p=0.002) than women without a history of loss. Women with multiple losses were more likely to be diagnosed with major depression (p=0.047) and/or post-traumatic stress disorder (Fisher's exact [FET]=0.028) than women with a history of one pregnancy loss. Loss type was not related to depression, although number of losses was related to the presence of depression and anxiety.

Conclusions: Low-income urban mothers have high rates of pregnancy loss and often have experienced more than one loss and/or more than one type of loss. Women with a history of pregnancy loss are at increased risk for depression and anxiety, including post-traumatic stress disorder (PTSD), after the birth of a child. Future research is needed to understand the reasons that previous pregnancy loss is associated with subsequent postpartum depression and anxiety among this population of women.

Pregnancy loss and anxiety and depression during subsequent pregnancies: data from the C-ABC study. Gong X, Hao J, Tao F, Zhang J, Wang H, Xu R. Eur J Obstet Gynecol Reprod Biol. 2013 Jan;166(1):30-6. doi: 10.1016/j.ejogrb.2012.09.024. Epub 2012 Nov 10.Source School of Public Health, Anhui Medical University, Hefei, Anhui, China.

OBJECTIVE: Previous studies have shown that pregnancy loss may affect the mental health of women in subsequent pregnancies. The China Anhui Birth Defects and Child Development cohort study therefore aimed to investigate the influence of pregnancy loss on anxiety and depression in subsequent pregnancies.

STUDY DESIGN: In total, 20,308 pregnant women provided written informed consent and completed the study questionnaire. The Self-rating Anxiety Scale and Center for Epidemiologic Studies-Depression Scale were used to evaluate anxiety and depression in pregnant women. Pearson's χ(2) test and binary logistic regression were used for statistical analyses.

RESULTS: Of 20,308 pregnant women, 1495 (7.36%) had a history of miscarriage and 7686 (37.85%) had a history of induced abortion. The binary logistic regression model found that pregnant women with a history of miscarriage had a significantly higher risk of anxiety and depression in the first trimester than primigravidae after stratified analysis according to the timing of the first prenatal visit (p<0.05). Compared with pregnant women with no history of miscarriage, women who had a history of miscarriage and an interpregnancy interval of less than 6 months had increased risk of anxiety symptoms (p<0.05) and depression symptoms (p<0.05) during the first trimester. Women with an interpregnancy interval of 7-12 months had a 2.511-fold higher risk of depression (p<0.05) than women with no history of miscarriage. These findings were not changed after adjustment for maternal age, maternal education, family income, place of residence and pre-pregnancy body mass index.

CONCLUSIONS: Women with a history of miscarriage experienced significant anxiety and depression during their next pregnancy. A short interpregnancy interval and the first trimester are risk factors for adverse mental health