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Assessing the Mental Health Impact of Induced Abortion Logo-CME

Author:Nada L. Stotland, MD, University of Chicago in Illinois

BackAbstract: Induced abortion is the subject of tremendous political conflict. Anti-abortion activists have frequently asserted that abortion results in major psychiatric sequelae. The evidence, however, clearly indicates that this is not necessarily the case. Studies performed to date confirm that it is possible to identify risk factors, help pregnant women make decisions compatible with their own values, and minimize psychiatric sequelae. [Medscape Women's Health 1(8), 1996. © 1996 Medscape, Inc.]

 Key words: Abortion, induced * Psychiatric * Pregnancy
 
 

Contents

Back Introduction: Historical and Social Context

Induced abortion and its psychiatric concomitants and sequelae are often discussed entirely out of context, as though they occur in a psychological and social vacuum.[1,2] The subject evokes such intense feelings that the alternatives, the history, the scientific realities, and the woman involved are frequently all but forgotten. It is important to put induced abortion into a historical and geographic context, so that we realize we are dealing with forever-asked philosophical, religious, social, and medical questions: When does human life begin? Does the mother or the fetus have priority? Under what circumstances can society intrude into the physician-patient relationship? When, if ever, do we mandate that one person provide his or her body, wholly or in part, to support the life of another?[3]

 Induced abortion, and prohibitions against it, are mentioned in medical documents dating back as long ago as ancient Greece.[4] Anthropologic evidence indicates that every society studied has practiced some method of terminating pregnancies.[5] Motivations vary widely, from the difficulty in caring for children already born, to the unacceptability of the father in the given social circumstances. Abortion has been and is practiced in every country, regardless of legality or medical safety. It is estimated that 20 million illegal and 30 million legal abortions are performed worldwide each year.[6] Where medically induced abortion is illegal and/or unobtainable, abortions may be induced by lay persons or by pregnant women themselves. Complications of these abortions account for most of the maternal morbidity and mortality in the world.[7]

Public debate about induced abortion is prominent and rancorous in the US, and it has become fodder for political campaigns. Elements in the debate include a vast and confusing array of facts and fallacies about adverse medical and psychiatric sequelae of abortion. Surgical, infectious, and other physical complications are, overall, rare and relatively straightforward to address. But even health care providers are much less knowledgeable and perhaps more gullible about psychiatric issues, which they may (incorrectly) perceive as "soft." It is incumbent on health care professionals who work with women to have accurate information about mental health aspects of abortion.

Back Personal and Religious Perspectives

A woman considering abortion struggles with her own circumstances, values, and beliefs. To help her make an informed choice, health care professionals must be aware of common assumptions about induced abortion and their accuracy or inaccuracy.

Personal perspective. When a woman considers an abortion because a current pregnancy represents a problem to her, this is a "problem pregnancy." This term implies nothing more or less than the woman's perception. For example, a teenager may view her pregnancy as a problem because she fears her parents will reject her and her future will be destroyed. A woman who becomes pregnant by an abusive spouse may see the pregnancy as a problem in her plan to extricate herself and any other children from the situation. A woman with a chronic illness that typically is complicated by the dramatic hormonal changes of pregnancy, or a woman who learns that the child carries a genetic defect that has devastated the lives of other family members, may see pregnancy as a problem. Whether, in fact, any of these perceptions are valid and whether the present and future circumstances of the woman, the fetus, or the family are made worse by the pregnancy are not the point.[8] "Problem pregnancy" describes the pregnancy in accordance with the woman's perception of her circumstances and resources for managing her life during and after pregnancy.

Religious perspective. A woman's beliefs about the positions of denominations on terminating pregnancy can have a powerful impact on her emotional reaction. Abortion rhetoric often seems to imply that the fight over abortion is a fight between religion and atheism or heresy. Many assume that all religious groups oppose abortion, and that this opposition is part of the historical fiber of theology. This assumption is not universally accurate. Roman Catholicism, fundamentalist Christianity, and Orthodox Judaism oppose abortion. Islamic positions vary by sect and geographic/political area. The other religions of the Far East tend to be silent on the subject. For example, although the Vedas, the classic Hindu religious text, contains pejorative references to abortion, in contemporary Hindu society abortion is both common and accepted, mainly due to a strong cultural/religious preference for male children.[9]

 Even in religious groups that have a clear position against abortion, history and practice are not consistent. The history of Roman Catholicism reveals that for its first thousand years, the Church did not consider the fetus to have a soul until 7 or 8 weeks of gestation (earlier for a male than a female). Before "ensoulment," abortion was permissible.[4] There is an organization today, Catholics for a Free Choice, that advocates against current Church doctrine.[10]
 
 

Back Linguistic Confusions

Highly emotional issues engender confusing language. Even medical language, which is designed for maximum precision, is imprecise in regard to abortion. Although spontaneous and induced abortions have different etiologies and involve completely different processes, the word abortion does not distinguish between them. The linguistic confusion can also complicate how the health care provider assesses a woman's psychological reactions to her pregnancy and her consideration of terminating it. The words used in casual descriptions of emotions and those used to document the diagnosis of psychiatric illnesses can sound confusingly similar. Anxiety, the ubiquitous emotion of normal life, and anxiety disorders, diagnosable and treatable diseases, are entirely different entities easily confused by the similarity of the words. Depression, used to describe a fleeting mood, also is the diagnosis for a serious, definable psychiatric illness. Such distinctions in terminology are highly relevant in assessing the psychological impact of any decision to terminate pregnancy.
 
 

Back Objectively Weighing the Issues

Any consideration or study of the psychological implications of induced abortion must factor in 2 major, and interrelated, issues: (1) the need to compare the psychological effects of legal, safe abortion versus the effects of continued pregnancy and childbearing or the effects of an illicit abortion that may be medically unsafe and done with little or no anesthesia, and (2) the medical, psychological, and social factors leading up to the pregnancy and surrounding the decision to continue or interrupt a problem pregnancy. Pregnancies can be viewed as problematic because of an array of factors: medical risks and complications, poverty or overwhelming personal responsibilities, ignorance about and lack of access to contraceptive methods, contraceptive methods that fail, treasured intimate relationships that fall apart, and interpersonal pressures that interfere with a woman's ability to protect herself against unplanned conceptions. The emotional reaction to the decision to terminate pregnancy often is a confused mixture of circumstances surrounding the conception and/or the perinatal period, circumstances anticipated after a child is born, and the nature of the abortion procedure itself.
 
 

Back Factors in Problem Pregnancies

Immaturity. Problem pregnancy often occurs among young girls. The psychodynamics include an adolescent vulnerability to peer pressure and ignorance about reproduction and contraception. Traditionally, girls are socially conditioned to acquiesce to the needs and desires of others, especially males, rather than to assert their own preferences and needs. One out of every 10 teenagers in the US becomes pregnant each year.[11,12] Many of these young women are not ready to assume responsibility for a child. Some young girls may seek to continue the pregnancy with little thought as to the responsibilities associated with parenting, while others who recognize their lack of independent resources for handling parenthood at a tender age may seek to terminate the pregnancy.[11] Still others decide to continue the pregnancy and give the infant up for adoption. The primary care physician can play an important role in helping the pregnant adolescent weigh these factors in her decision.

Poverty. Financial need can restrict a woman's access to contraceptive care and products. When the struggle for existence and the care of dependents she already has consumes much or all of her energy, little or none may be left for effective family planning.[13] Although women of all socioeconomic classes experience unplanned pregnancies, women in poverty who already feel overwhelmed by their lack of resources to care for themselves and their families can be psychologically crushed by "the final straw" of imagining yet another person depending on them.

Psychiatric illnesses. Women with psychiatric illnesses, even severe ones, engage in sexual activity and become pregnant approximately as frequently as psychiatrically healthy women.[14] Their illnesses, however, can hamper their judgment, their impulse control, and their general coping skills, placing them at higher risk whatever the outcome of pregnancy.[15]
 
 

Back Myths About Abortion

Casual sex is fostered. Some people fear that the availability of abortion promotes promiscuity and neglect of contraception. However, the available data indicate that women are more careful about sexual behavior and use of contraception after having decided to terminate an unwanted pregnancy than before.[13]

Psychological trauma is inflicted. There is no evidence that abortion, in and of itself, causes psychological trauma.[16] The circumstances that can lead a woman to abort--for example, poverty, sexual abuse, fetal anomalies--can be traumatic. Also, the circumstance of the abortion procedure can be traumatic, especially if it is illegal, secretive, potentially unsafe (eg, safety of abortion setting is threatened by abortion protesters) and physically painful, and entails undue expense and travel.

Parental involvement in an adolescent's decision is essential. Most adolescents do discuss their abortion decisions with their parents; the younger the girl, the more likely that her parents are involved. However, some of the very factors predisposing a young woman to undesired pregnancy--incest, abandonment, and abuse--make some parents inappropriate confidants and decision makers. Young women may be physically abused or exiled from the family home when they inform their parents they are pregnant and wish to terminate it. The laws that declare underage women too immature to decide to terminate a pregnancy could force them to undergo pregnancies and childbirth and meet the demands of motherhood before they are prepared to do so.

Marriage will offer a pregnant teen the structure needed to raise a child. The "shotgun wedding," the marriage of a pregnant adolescent to the man who impregnated her, under threat of bodily harm from a parent, is a sad tradition. Parents and other authorities may assume that marriage will protect a young woman from the adverse consequences of early motherhood. Unfortunately, the reverse is true. Pregnant adolescents who marry are less likely to complete their education, and more likely to be abused and dependent on societal support, than those who remain single.[11]
 
 

Back Psychiatric Facts

Studies performed in environments where abortion is safe, legal, and accessible reveal that the incidence of psychiatric illness following abortion is comparable to that following term delivery.[17] Transient self-limited feelings of sadness and guilt are not uncommon, but for most women, the prominent emotional reaction is one of relief.[2] For some, the decision to have an abortion is experienced as the first time they take charge of their own responsibilities and their own futures. There is no evidence that abortion in itself causes psychiatric illness.

Back Risk Factors for Adverse Outcomes

Preexisting psychiatric illness. As might be expected, women who have psychiatric illnesses before they have abortions are likely to suffer from them afterwards, as well. The same is true for women who go to term.

Paralyzing ambivalence. Some ambivalence about pregnancy is normal, even optimal. It indicates a recognition of the seriousness of parenthood. However, a woman who simply cannot decide between terminating and continuing a pregnancy, or whose conflicting feelings are interfering with her ability to sleep, eat, or carry out her usual life activities, is at risk for psychiatric sequelae whatever her decision. The decision to have an abortion is a weighty one, but one that a healthy woman can make without professional assistance. The health care provider who recognizes that a woman is experiencing extreme stress in struggling with a decision or who knows that the woman has a history of psychiatric problems preceding her pregnancy needs to consider a professional referral.

Duress and coercion. The most important predictors of positive abortion outcome for a woman are an autonomous decision and social support for that decision. The woman who terminates her pregnancy because her husband, lover, parents, or friends would be embarrassed by it, because she is threatened with the loss of financial support for herself or for her children already born, or because she fears abandonment or abuse is at increased risk for adverse psychological sequelae to abortion. The same is true for a woman who undergoes an abortion over the objections of significant others in her life.[18]

Medical or genetic indications for abortion. Not surprisingly, a woman who would otherwise prefer to have a baby, but is advised to terminate her pregnancy because of preexisting medical illness, medical complications, or fetal abnormality, is more likely to become clinically depressed than a woman who did not wish to remain pregnant.[19] Not only does she lose a desired conception, but she also must cope either with the fact that her body cannot provide a safe gestational environment for a developing fetus or that she has produced an abnormal one.

Back Guiding Patients

Decisions about pregnancy termination are necessarily made under time constraints. Nevertheless, it is incumbent on health care professionals to help a woman faced with a problem pregnancy to find the emotional, physical, and chronological space to think through her decision, to garner the resources and support she needs, and to locate the medical resources she requires to carry out whatever decision she makes. A health care provider with religious or philosophical objections to abortion has an ethical obligation to so inform the patient, and to refer her to another setting if she wishes.

 A woman making a decision about a problem pregnancy needs accurate medical information about her own health status, mental and physical, and the risks and benefits of continuing and ending the pregnancy. Counseling, whether from a physician, nurse, social worker, member of the clergy, or other professional, is not necessary for every woman. This is a somewhat controversial issue. On one hand, decisions about pregnancies are extremely important. On the other, people make all other life-and-death decisions without being required to undergo counseling.

 If counseling is sought or provided, its purpose is to help the woman make an informed, autonomous, and supported decision. It should include information about the abortion process, including cost, location, medical personnel, anesthesia, confidentiality, and any choices the patient may or must make. The `counselor' should offer to meet with 1 or 2 friends or relatives of the patient's choice, if she wishes. The patient should be encouraged to review her own background, experience, values, religious beliefs, plans for her future, and available resources (financial, educational, and social) so that she can strengthen the support for whichever course she elects.

A woman should try to formulate a realistic prognostication about her life in 6 months, a year, 5 years, 20 years, after having the abortion or delivering her child. She may want help in dealing with significant others or social agencies, or help in finding a religious leader outside her usual contacts who can help her to clarify her religious beliefs and offer support.

Men, not an afterthought. It is important to determine when a man has strong feelings about potential parenthood so that his feelings are neither ignored nor denigrated. Men involved with a problem pregnancy can feel guilty, ashamed, and angry. When a pregnancy is terminated, they can feel cheated or bereft.[20] Counseling for the "forgotten man," to acknowledge his feelings and help him think through his situation, his relationships, and his plans, can be very valuable.
 
 

Back Conclusion: Coping With Loss

Both health care professionals and patients must appreciate that an abortion is always the loss of a potential life and that feelings of loss are therefore perfectly normal. Primary care physicians can recognize and help the woman having difficulty coping with this loss by familiarizing themselves with the signs and symptoms of psychiatric disorders such as depression and anxiety. While some women may be helped simply by having the opportunity to share their experiences and emotions with an empathetic listener, if a woman has signs and symptoms of a psychiatric disorder, or is increasingly unable to cope, she should be referred to a mental health professional.
 
 

Back About the Author

Dr. Stotland is an associate professor of clinical psychiatry and associate professor of clinical obstetrics and gynecology at the University of Chicago in Illinois.

 Documents regarding disclosure of existing financial relationships between faculty and commercial supporters are available upon request from the Thomas R. Beam Jr., Memorial Institute for Continuing Medical Education. Please contact CME@medscape.com to receive specific conflict of interest declaration information.
 
 

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