Risk factors

COMPLETE LIST OF RISK FACTORS IDENTIFIED IN THE 2008 APA TASK FORCE REPORT

(see pages 5, 11, and 92 of the Report of the APA Task Force on Mental Health and Abortion)

1. terminating a pregnancy that is wanted or meaningful
2. perceived pressure from others to terminate a pregnancy
3. perceived opposition to the abortion from partners, family, and/or friends
4. lack of perceived social support from others
5. various personality traits (e.g., low self-esteem, a pessimistic outlook, low-perceived control over life)
6. a history of mental health problems prior to the pregnancy
7. feelings of stigma
8. perceived need for secrecy
9. exposure to antiabortion picketing
10. use of avoidance and denial coping strategies
11. Feelings of commitment to the pregnancy
12. ambivalence about the abortion decision
13. low perceived ability to cope with the abortion
14. history of prior abortion
15. late term abortion
16. By parsing of the APA summary conclusion that "adult women who have an unplanned pregnancy the relative risk of mental health problems is no greater if they have a single elective first-trimester abortion than if they deliver that pregnancy," it also appears that the APA is identifying the following as risk factors

• being an adolescent (not an adult)
• having a non-elective, "therapeutic" abortion

COMPLETE LIST OF RISK FACTORS IDENTIFIED IN THE NAF's "A Clinician's Guide to Medical and Surgical Abortion"

Predisposing Factors for Negative Reactions

(Excerpted from Chapter 3, p29 - Table 3-2.

1. Low self-efficacy: expecting depression, severe grief or guilt, and regret after the abortion
2. Low self-esteem prior to the abortion
3. An existing mental illness or disorder prior to the abortion
4. Significant ambivalence about the decision
5. Lack of emotional support and receiving criticism from significant people in their lives
6. Perceived coercion to have the abortion
7. Belief that a fetus is the same as a 4-year-old human and that abortion is murder
8. Fetal abnormality or other medical indications for the abortion
9. Usual coping style is repressing thoughts or denial
10. Unresolved past losses and perceptions of abortion as a loss
11. Experiencing social stigma and antiabortion demonstrators on the day of the abortion
12. Commitment to the pregnancy

Risk Factors for Physical Complications

(Excerpted from Chapter 5, "Medical Evaluation and Management")

1. Prior History of anemeia, siezures, asthma, diabetes, mellitus, heart disease, infectious diseases, and conditions that necessitate chronic steroid use
2. History of bleeding disorders
3. Current symptoms of respiratory illness
4. Current medications
5. Medical allergies
6. History of sexually transmitted disease
7. Previous surgical procedures
8. Previous history of induced abortion
9. Recent or current substance abuse
10. Previous reactions to anesthetics
11. History of sexual abuse or domestic/partner violence
12. History of contraceptive use
13. History of cervical dysplasia
14. Rho(D) antigen status
15. Anatomic variation of the female genital tract
16. Genital tract infection
17. Urinary tract infection
18. HIV infection or AIDS
19. Hypertension

Most Complete List of Risk Factors for Negative Psychological Reactions to Abortion

The lists of risk factors chosen by the APA and the National Abortion Federation is based on a subjective judgments and do not include a complete list of risk factors that have been statistically validated in peer reviewed medical literature.

For a more comprehensive list of risk factors for psychological reactions to abortion, including citations to all the studies for each risk factor, see see Identifying High Risk Abortion Patients here.

For an even more complete treatment of why these risk factors have been identified and why it is important to screen for them, download Abortion decisions and the duty to screen: clinical, ethical, and legal implications of predictive risk factors of post-abortion maladjustment.

Four Types of Women

According to Philip Ney, from a clinical perspective there are four groups of women having abortion:

1. Tough and committed. Those who insist that abortion is a woman’s right.
2. Vulnerable. Those who are basically unstable who are pushed into a definable mental illness by the trauma of abortion.
3. Sensitive. Those who are reasonably mentally healthy but because of their sensitivities, they are deeply hurt by having an abortion and develop psychiatric symptoms which a researcher defines as an illness.
4. Resilient. Those who choose abortion as the least worst alternative and don’t appear to be affected for years until poor health or stressful circumstance undermine their ego defenses.

Additional Research Regarding Risk Factors for Adverse Emotional Consequences of Abortion

Neuroticism-related personality traits are associated with posttraumatic stress after abortion: findings from a Swedish multi-center cohort study. Wallin Lundell I1,2, Sundström Poromaa I3, Ekselius L4, Georgsson S5,6, Frans Ö7, Helström L8, Högberg U3, Skoog Svanberg A3. BMC Womens Health. 2017 Oct 2;17(1):96. doi: 10.1186/s12905-017-0417-8.

Among 512 women with no PTSD symptoms, 9.4% experienced all the criteria necessary for a PTSD diagnosis by the three or six month post-abortion assessment. Pre-abortion screening for higher neuroticism-related personality traits can be used to identify the women at greatest risk of abortion associated PTSD.

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

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

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

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

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

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

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

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

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.

Pressure from the male partner was significantly associated with more negative emotional reactions following an abortion.

Risk Factors for Multiple Abortions

Characteristics of women undergoing repeat induced abortion.] Fisher WA, Singh SS, Shuper PA, Carey M, Otchet F, MacLean-Brine D, et al. CMAJ 2005;172(5):637-41

Background: Although repeat induced abortion is common, data concerning characteristics of women undergoing this procedure are lacking. We conducted this study to identify the characteristics, including history of physical abuse by a male partner and history of sexual abuse, of women who present for repeat induced abortion.

Methods: We surveyed a consecutive series of women presenting for initial or repeat pregnancy termination to a regional provider of abortion services for a wide geographic area in southwestern Ontario between August 1998 and May 1999. Self-reported demographic characteristics, attitudes and practices regarding contraception, history of relationship violence, history of sexual abuse or coercion, and related variables were assessed as potential correlates of repeat induced abortion. We used χ2 tests for linear trend to examine characteristics of women undergoing a first, second, or third or subsequent abortion. We analyzed significant correlates of repeat abortion using stepwise multivariate multinomial logistic regression to identify factors uniquely associated with repeat abortion.

Results: Of the 1221 women approached, 1145 (93.8%) consented to participate. Data regarding first versus repeat abortion were available for 1127 women. A total of 68.2%, 23.1% and 8.7% of the women were seeking a first, second, or third or subsequent abortion respectively. Adjusted odds ratios for undergoing repeat versus a first abortion increased significantly with increased age (second abortion: 1.08, 95% confidence interval [CI] 1.04–1.09; third or subsequent abortion: 1.11, 95% CI 1.07–1.15), oral contraceptive use at the time of conception (second abortion: 2.17, 95% CI 1.52–3.09; third or subsequent abortion: 2.60, 95% CI 1.51–4.46), history of physical abuse by a male partner (second abortion: 2.04, 95% CI 1.39–3.01; third or subsequent abortion: 2.78, 95% CI 1.62–4.79), history of sexual abuse or violence (second abortion: 1.58, 95% CI 1.11–2.25; third or subsequent abortion: 2.53, 95% CI 1.50–4.28), history of sexually transmitted disease (second abortion: 1.50, 95% CI 0.98–2.29; third or subsequent abortion: 2.26, 95% CI 1.28–4.02) and being born outside Canada (second abortion: 1.83, 95% CI 1.19–2.79; third or subsequent abortion: 1.75, 95% CI 0.90–3.41).

Interpretation: Among other factors, a history of physical or sexual abuse was associated with repeat induced abortion. Presentation for repeat abortion may be an important indication to screen for a current or past history of relationship violence and sexual abuse.

Screening for Coercion

The American College of Obstetricians and Gynecologists recommends that their members screen all patients for intimate partner violence, including during prenatal visits.

"Women of all ages experience intimate partner violence, but it is most prevalent among reproductive-age women," Dr. Maureen Phipps, chair of the college's Committee on Health Care for Underserved Women, said in the news release. "We have a prime opportunity to identify and help women who are being abused by incorporating this screening into our routine office visits with each and every patient."

Clearly, this recommendation should extend to abortion providers as there is ample evidence that pregnant women are more likely to face coercion to have an unwanted abortion which can escalate to acts of violence.

Pre-Abortion and Post-Abortion Screening Recommendations

• Miller WB, Pasta DJ, Dean CL. Testing a model of the psychological consequences of abortion. In: The New Civil War: The Psychology, Culture, and Politics of Abortion. Vol ; 1998:235-267. doi:10.1037/10302-010.

• Steinberg JR, McCulloch CE, Adler NE. Abortion and mental health: findings from the national comorbidity survey-replication. Obstet Gynecol. 2014;123(2 Pt 1):263-270. doi:10.1097/AOG.0000000000000092.

"Women seeking abortions may be at higher risk of prior untreated mental health disorders and the abortion care setting may be an important intervention point for mental health screening and referrals."

• Lask B. Short term psychiatric sequelae to therapeutic termination of pregnancy. Br J Psychiatry. 1975;126(2):173-177. http://www.scopus.com/inward/record.url?eid=2-s2.0-0016745377&partnerID=tZOtx3y1.

• Major B, Cozzarelli C. Psychosocial predictors of adjustment to abortion. J Soc Issues. 1992. http://onlinelibrary.wiley.com/doi/10.1111/j.1540-4560.1992.tb00900.x/abstract. Accessed November 30, 2016.

• Belsey EM, Greer HS, Lal S, Lewis SC, Beard RW. Predictive factors in emotional response to abortion: King’s termination study--IV. Soc Sci Med. 1977;11(2):71-82. http://www.ncbi.nlm.nih.gov/pubmed/594780. Accessed December 20, 2016.

Recommendations for Funding Major Longitudinal Studies

• Miller WB, Pasta DJ, Dean CL. Testing a model of the psychological consequences of abortion. In: The New Civil War: The Psychology, Culture, and Politics of Abortion. Vol ; 1998:235-267. doi:10.1037/10302-010.

• Fergusson, David.

Recommendation for Routine Psychological Screening of Pregnant Women

Effects of posttraumatic stress disorder on pregnancy outcomes. Rogal SS1, Poschman K, Belanger K, Howell HB, Smith MV, Medina J, Yonkers KA. J Affect Disord. 2007 Sep;102(1-3):137-43. Epub 2007 Feb 8.

Associations between PTSD, depression and substance use in pregnant women and preterm and low birth weight delivery "support the utility of screening for mental health disorders in pregnancy."

Pregnant Women With Posttraumatic Stress Disorder and Risk of Preterm Birth. Yonkers KA1, Smith MV2, Forray A3, Epperson CN4, Costello D3, Lin H5, Belanger K5. JAMA Psychiatry. 2014 Jun 11. doi: 10.1001/jamapsychiatry.2014.558.

"Women with likely diagnoses of both PTSD and a major depressive episode are at a 4-fold increased risk of preterm birth; this risk is greater than, and independent of, antidepressant and benzodiazepine use and is not simply a function of mood or anxiety symptoms."

ACOG also recommends routine psychosocial screening of pregnant women: "Psychosocial screening of all women seeking pregnancy evaluation or prenatal care should be performed regardless of social status, educational level, or race and ethnicity." (See ACOG Committee Opinion No. 343: psychosocial risk factors: perinatal screening and intervention. Obstet Gynecol. 2006 Aug;108(2):469-77.)

Proposed Statute to Require Physicians to Screen for Risk Factors

See StopForcedAbortions.org

Other Literature Identifying Risk Factors

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

An excellent literature review of risk factors identified in the literature through 2003.

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

"Certain groups are especially at risk from adverse psychological sequelae; these include those with a past psychiatric history, younger women, those with poor social support, the multiparous, and those belonging to sociocultural groups antagonistic to abortion. ... A better understanding of the nature of the risk factors would enable clinicians to identify vulnerable women for whom some form of psychological intervention might be beneficial." Women who choose abortion are not amenable to endless questions on how they feel, are less likely to return for follow-up, and baseline assessments before they become pregnant are impossible.

Psychosocial consequences of therapeutic abortion. King's termination study III. Greer HS, Lal S, Lewis SC, Belsey EM, Beard RW. Br J Psychiatry 1976;128:74-9.

Other Medical Procedures Preceded by Screening

See Screening For Other Elective Surgeries