Recent Studies

2010

Previous experience of spontaneous or elective abortion and risk for posttraumatic stress and depression during subsequent pregnancy. Hamama L, Rauch SA, Sperlich M, Defever E, Seng JS. Depress Anxiety. 2010 Jun 23.

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

Associations Between Abortion, Mental Disorders, and Suicidal Behaviour in a Nationally Representative Sample.Mota NP, Burnett M, Sareen J. The Canadian Journal of Psychiatry, Vol 55, No 4, April 2010,

Methods: Data came from the National Comorbidity Survey Replication (n = 3310 women, aged 18 years and older). The World Health Organization–Composite International Diagnostic Interview was used to assess mental disorders based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria and lifetime abortion in women. Multiple logistic regression analyses were employed to examine associations between abortion and lifetime mood, anxiety, substance use, eating, and disruptive behaviour disorders, as well as suicidal ideation and suicide attempts. We calculated the percentage of respondents whose mental disorder came after the first abortion. The role of violence was also explored. Population attributable fractions were calculated for significant associations between abortion and mental disorders.

Results: After adjusting for sociodemographics, abortion was associated with an increased likelihood of several mental disorders—mood disorders (adjusted odds ratio [AOR] ranging from 1.75 to 1.91), anxiety disorders (AOR ranging from 1.87 to 1.91), substance use disorders (AOR ranging from 3.14 to 4.99), as well as suicidal ideation and suicide attempts (AOR ranging from 1.97 to 2.18). Adjusting for violence weakened some of these associations. For all disorders examined, less than one-half of women reported that their mental disorder had begun after the first abortion. Population attributable fractions ranged from 5.8% (suicidal ideation) to 24.7% (drug abuse).

Conclusions: Our study confirms a strong association between abortion and mental disorders. Possible mechanisms of this relation are discussed.

Editor Notes Regarding Key Findings: Among the most notable findings women who had abortions had:

• 59 percent increased risk for suicidal thoughts
• 61 percent increased risk for mood disorders
• 61 percent increased risk for social anxiety disorders
• 261 percent increased risk for alcohol abuse
• 280 percent increased risk for any substance use disorder
• The researchers concluded that approximately 6 percent of suicidal ideation cases among women nationwide and 25 percent of cases of drug use could be related to abortion.

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

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 Regarding Key Findings: 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.

2009

''"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, Traumatologyfirst 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. :

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

Abstract

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.

Excerpt of Researchers Conclusions Regarding Key Findings:

• Combining the findings of our two studies leads to the following generalisations about the links between unwanted pregnancy, abortion and mental health in this birth cohort.

• (a) First, unwanted pregnancy terminated by abortion was associated with modestly increased risks of common mental health problems for women who reported significant distress about the abortion (RR = 1.4–1.8).
• (b) Second, unwanted pregnancy terminated by abortion was not associated with significantly increased risks of mental health problems for women who did not report significant distress about the abortion (RR = 1.14–1.24).
• (c) Third, unwanted pregnancy that came to term was not associated with significant increases in mental health problems (RR = 1.05–1.11).
• (d) Finally, any associations between unwanted pregnancy, abortion and mental health problems were small to moderate, with adjusted relative risks in the region of 1.1–1.8. Estimates of the population attributable risk suggested that exposure to unwanted pregnancy terminated by abortion accounted for fewer than 5% of the mental health problems experienced by women in this cohort.

"Inadequate Preabortion Counseling and Decision Conflict as Predictors of Subsequent Relationship Difficulties and Psychological Stress in Men and Women"[1] 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.

Editor's Notes Regarding Key Findings: Overall, 54 percent of the women and 43 percent of the men reported all the symptoms for a clinical diagnosis of post-traumatic stress disorder. Approximately 80 percent of women and 77 percent of men had at least one symptom of PTSD, and nearly 80 percent of women and 60 percent of men reported that the abortion experience was highly or overwhelmingly stressful.

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.

Editor's Notes Regarding Key Findings: 22 percent of women were diagnosed with a psychiatric disorder after abortion, compared to 18 percent of women who gave birth to a baby with very low-birth-weight (VLBW) and 6 percent of women who had a healthy full-term pregnancy.

While the three groups of women "did not differ significantly" on psychiatric disorders prior to abortion or delivery, the researchers noted a difference afterwards, with women who had abortions having the highest rates of psychiatric disorders. Further, 16 percent of women who had abortions had psychiatric disorders 14 months later, compared to 7 percent of women with preterm births and none of the women with healthy pregnancies.

The disorders found among women who had abortions included acute stress disorders, eating disorders, affective disorders and anxiety disorders, with depression and anxiety predominating over time. Just over 64 percent of aborting women in the study developed symptoms of post-traumatic stress disorder.

The authors reported that for most women, abortions in the 2nd or 3rd trimester after a negative fetal diagnosis "are major life events" that can cause ongoing problems even months after the event. They called for more resources and better screening to help identify those who might be at risk for problems after abortion and need psychological support.

Violence in the lives of women in Italy who have an elective abortion. Romito P, Escribà-Agüir V, Pomicino L, Lucchetta C, Scrimin F, Molzan Turan J. Womens Health Issues. 2009 Sep-Oct;19(5):335-43.

Abstract

BACKGROUND: Violence is an important health problem for pregnant women, with numerous studies showing that it may compromise maternal and infant health. Many women who seek an elective abortion (EA) live in difficult personal and social circumstances, in which violence often has a central role, yet few studies have analyzed the relationships between violence and having an EA. OBJECTIVES: To analyze the role of family and partner violence among women seeking an EA, exploring the role of women's age, and controlling for sociodemographic factors. METHODS: An unmatched, case-control study was carried out in the Trieste Public Hospital, including all consecutive EAs (n=445) and live births (n=438). With an anonymous questionnaire, we collected information on sociodemographic characteristics, current violence (psychological, physical, and sexual) perpetrated by a partner or by other family members, and past violence. RESULTS: Compared with postpartum women, EA women were significantly more likely to report any type of current and past violence. Among women younger than 30 years old, adjusting for relevant social factors, partner psychological violence and family violence were strongly associated with EA, whereas among women 30 years old or older, there was no association with partner and family violence after adjustment. CONCLUSION: These results highlight the role of violence in the lives of women, especially younger women, seeking an abortion, and the need for sensitive screening for partner and family violence among these women. Health professionals should be able to recognize violence among women seeking an EA and to support them.

Rates of follow-up and repeat pregnancy in the 12 months after first-trimester induced abortion. Madden T, Westhoff C. Obstet Gynecol. 2009 Mar;113(3):663-8.

OBJECTIVE: To estimate the proportion of women who returned for a routine follow-up visit after elective abortion and to identify factors associated with repeat pregnancy in the subsequent year.

METHODS: We performed a historical cohort study of 865 women who underwent first-trimester surgical abortion at a hospital-based family planning clinic between March 2003 and February 2004. We collected demographic and clinical data from procedure notes and a computerized hospital patient database. We used univariable and multivariable logistic regression to analyze associations between patient characteristics and repeat pregnancy within 1 year.

RESULTS: There were a total of 865 women in our cohort. Of these, 753 (87%) returned to the medical center for care; 485 women returned on time, 268 women returned late, and 112 had no further visit. There were 161 repeat pregnancies; 87 (17.9%) in the on-time group and 74 (27.6%) in the late group (P<.001). There were 85 repeat abortions; 42 (8.7%) in the on-time group and 43 (16.0%) in the late group (P<.001). Multivariable analysis demonstrated that on-time follow-up was associated with a reduction in repeat pregnancy (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.37-0.77) and repeat abortion (OR 0.53, 95% CI 0.33-0.86). A total of 130 women received injectable depot medroxyprogesterone acetate (DMPA) at the time of abortion. The rates of repeat pregnancy and abortion in these women were 13.7% and 6.2%, respectively. Women who received DMPA had a decrease in rates of repeat pregnancy (OR 0.41, 95% CI 0.23-0.73) and repeat abortion (OR 0.45, 95% CI 0.20-0.99).

CONCLUSION: Timely follow-up and immediate administration of DMPA are associated with a decrease in repeat pregnancy in the 12 months after first-trimester elective abortion.

Editor's Notes: Overall, at least 21% became pregnant again within one year. OF those who became pregnant again, 53% had another abortion and 47% continued their "replacement" pregnancy. Another way of looking at it is that within one year, about 1 in 10 women became pregnant and decided against a second abortion. The abortion didn't "buy" them much time to change their lives and so it is likely they would not agree that the abortion made their lives better. DMPA is a contraceptive injection that lasts approximately 3 months.

'Termination of pregnancy: a review of psychological effects on women.' Lipp A. Nurs Times. 2009 Jan 13-19;105(1):26-9.

Abstract

Termination of pregnancy may have psychological consequences that are greater than its physical impact. Following a literature search and appraisal, this article explores some of the main themes arising from studies on the psychological impact. The results demonstrate that negative psychological effects are more likely in certain high-risk women. A table of indicators has been developed which could assist nurses in recognising whether a woman is at risk of negative psychological effects after termination.

Editor's Notes Regarding Key Findings: This is not a true literature review, but is rather simply a review of key information useful for nurses.

Lipp's identified the following risk factors may elicit greater risk of psychological effects (Source of evidence)

• Demographics - termination being in conflict with ethnic group, religion, socioeconomic group (Harris 2004; Bonevski and Adams 2001]
• Foetal abnormality (Bonevski and Adams 2001)
• Second trimester caused by delay in accessing services (Harris 2004)
• Low self-esteem (Bonevski and Adams 2001)
• Lack of social support (Major and Gramzow 1999); Cozzarelli et al 1998)
• Difficulty making decision (Shusterman 1979)
• Suicide in the family (Thorp et al 2002)
• History of self-harm (Thorp et al 2002)
• History of depression (Thorp et al 2002)
• History of psychiatric illness (Broen et al 2005b; Bonevski and Adams 2001)
• Undue influence from male partner (Broen et al 2005a; Pope et al 2001)

'Induced abortion and intimate relationship quality in the Chicago Health and Social Life Survey.' Coleman PK, Rue VM, Coyle CT. Public Health. 2009 Apr;123(4):331-8. Epub 2009 Mar 26. Abstract

OBJECTIVES: To examine associations between abortion and relationship functioning. STUDY DESIGN: Independent variables included abortion in a previous relationship and abortion in a current relationship. Perceptions of quality-of-life changes associated with terminating the relationship, conflict, aggressiveness and sexual dysfunction were the outcome measures. METHODS: Data were derived from interviews with an ethnically diverse urban sample of men (n=658) and women (n=906). Surveys were conducted in person using computer-assisted personal interview technology by the National Opinion Research Center affiliated with the University of Chicago, USA. RESULTS: For men and women, the experience of an abortion in a previous relationship was related to negative outcomes in the current relationship; perceptions of improved quality of life if the current relationship also ended and intimate partner violence. Experience of an abortion within a current relationship was associated with 116% and 196% increased risk of arguing about children for women and men, respectively. Among females, experience of an abortion within a current relationship was associated with increased risk for various forms of sexual dysfunction (122-182%), increased risk of arguments about money (75%), increased risk of conflict about the partner's relatives (80%), and increased risk of arguing about the respondent's relatives (99%). Men whose current partners had experienced an abortion were more likely to report jealousy (96% greater risk) and conflict about drugs (385% greater risk). CONCLUSION: Abortion may play a vital role in understanding the aetiology of relationship problems.

'Induced abortion and anxiety, mood, and substance abuse disorders: isolating the effects of abortion in the national comorbidity survey.' Coleman PK, Coyle CT, Shuping M, Rue VM. J Psychiatr Res. 2009 May;43(8):770-6. Epub 2008 Nov 28.

Abstract

The purpose of this study was to examine associations between abortion history and a wide range of anxiety (panic disorder, panic attacks, PTSD, Agoraphobia), mood (bipolar disorder, mania, major depression), and substance abuse disorders (alcohol and drug abuse and dependence) using a nationally representative US sample, the national comorbidity survey. Abortion was found to be related to an increased risk for a variety of mental health problems (panic attacks, panic disorder, agoraphobia, PTSD, bipolar disorder, major depression with and without hierarchy), and substance abuse disorders after statistical controls were instituted for a wide range of personal, situational, and demographic variables. Calculation of population attributable risks indicated that abortion was implicated in between 4.3% and 16.6% of the incidence of these disorders. Future research is needed to identify mediating mechanisms linking abortion to various disorders and to understand individual difference factors associated with vulnerability to developing a particular mental health problem after abortion.

2008

'Abortion and mental health disorders: evidence from a 30-year longitudinal study.'Fergusson DM, Horwood LJ, Boden JM. Br J Psychiatry. 2008 Dec;193(6):444-51.

Background: Research on the links between abortion and mental health has been limited by design problems and relatively weak evidence.

Aims: To examine the links between pregnancy outcomes and 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: After adjustment for confounding, abortion was associated with a small increase in the risk of mental disorders; women who had had abortions had rates of mental disorder that were about 30% higher. There were no consistent associations between other pregnancy outcomes and mental health. Estimates of attributable risk indicated that exposure to abortion accounted for 1.5% to 5.5% of the overall rate of mental disorders.

Conclusions: The evidence is consistent with the view that abortion may be associated with a small increase in risk of mental disorders. Other pregnancy outcomes were not related to increased risk of mental health problems.

'Abortion and mental health' Fergusson, DM. The Psychiatrist (2008) 32: 321-324. (editorial)

In this editorial, Fergusson, a noted researcher in the field, praises the thoughtful position of Royal College of Psychiatrists (RCP) which was issued in 2008 in which the RCP concluded:

‘The specific issue of whether or not induced abortion has harmful effects on women’s mental health remains to be fully resolved. The current research evidence base is inconclusive - some studies indicate no evidence of harm while other studies identify a range of mental disorders following abortion.’

According to Fergusson: "This careful and hedged position contrasts starkly with the confident statement made by the Royal College of Psychiatrists in 1994 (Royal College of Psychiatrists, 1994)" which stated:

‘The Royal College of Psychiatrists finds the risks to psychological health from termination of pregnancy in the first trimester much less than the risks associated with proceeding with a pregnancy that is clearly harming the mother’s mental health. There is no evidence in such cases of major psychiatric risk or long-lasting psychological distress.’

He notes the change is due to a growing body of evidence that abortion is associated with negative mental health effects. He also goes on to note that this is especially problematic for British law which only allows abortion in cases where the risks of childbirth are greater than the risks of abortion. The problem is that there is no evidence of when, if ever, this is actually the case.

"Although decisions on whether to proceed with induced abortion are made on the basis of clinical assessments of the extent to which abortion poses a risk to maternal mental health, these clinical assessments are not currently supported by population-level evidence showing the provision of abortion reduces mental health risks for women having unwanted pregnancy."