Psychiatric issues related to infertility, reproductive technologies, and abortion

Post-Roe v Wade psychiatry: legal, clinical, and ethical challenges in psychiatry under abortion bans

In recent history, the world has witnessed a trend towards liberalization of abortion laws driven by an increasing understanding of the negative personal and public health consequences of criminalizing abortion. By contrast, several countries have recently implemented restrictive reproductive laws, joining the 112 countries where access to abortion care is banned completely or with narrow exceptions. On June 24, 2022, the US Supreme Court ruling in Dobbs v Jackson Women's Health Organization overturned its landmark decisions in Roe v Wade that established abortion until the point of viability of the fetus as a constitutional right. After Roe v Wade having been overturned, it is projected that many women in the USA will be prevented from accessing safe abortion care. Importantly, abortion bans not only impose constraints on patient autonomy, they also restrict physicians' ability to practice evidence-based medicine, which will negatively impact psychiatric care. It is therefore crucial for the practicing psychiatrist to be familiar with this new legal landscape. In this Personal View, we aim to provide a topical overview to help clinicians gain a clear understanding of legal, clinical, and ethical responsibilities, focusing on the USA. We also discuss the reality that psychiatrists might be called upon to determine medical necessity for an abortion on psychiatric grounds, which is new for most US psychiatrists. We predict that psychiatrists will be confronted with very difficult situations in which lawful and ethical conduct might be incongruent, and that abortion bans will result in greater numbers of patients needing psychiatric care from a system that is ill-prepared for additional demands.

Clinical issues in post-abortion care

This article provides an overview of the clinical issues in post-abortion care, including types of abortion procedures, expected post-abortion course, possible complications, and the components of the post-abortion visit. By providing follow-up care to their patients, NPs can increase continuity of care and promote successful contraceptive use.

Is There a Role for the Family and Close Community to Help Reduce the Risk of Postpartum Depression in New Mothers? A Cross-Sectional Study of Turkish Women

OBJECTIVES

Postpartum depression is an important and under-diagnosed problem. The aims of this study were (1) to compare the prevalence of depressive symptomology in Turkish mothers who were 1-3 months postpartum with the prevalence of depressive symptomology in mothers who had not been pregnant for at least 1 year, (2) to identify risk factors associated with depression in both groups, and (3) to examine the effect of postpartum depression on breastfeeding by the mothers.

DESIGN

Cross-sectional study

SETTING

Well-baby clinic

PARTICIPANTS

326 women enrolled in January 2001; 163 were 1-3 months postpartum, and 163 had not been pregnant in the previous year.

RESULTS

The prevalence of depressive symptomology in the postpartum and non-postpartum groups was 17% (28/163) and 24.5% (40/163), respectively; this was not statistically significant (P = 0.102). When we compared mean Beck Depression Inventory (BDI) scores, the difference between the two groups was statistically significant (10.75 +/- 8.06 and 12.63 +/- 8.81, respectively, P = 0.045). Premenstrual tension and a history of depression were risk factors for depressive symptomology in both groups. Three or more births and a history of induced abortion were risk factors for depressive symptomology in the non-postpartum group. In the postpartum group, the effect of depression on breast-feeding was not statistically significant (P = 0.7). The generalisability of the study results to the community is limited.

CONCLUSION

In this study, the prevalence of depressive symptomology in the postpartum and non-postpartum groups did not show a significant difference, but the prevalence of depressive symptomology was high in both groups. Postpartum depression did not have a negative effect on breast-feeding. Lower BDI scores in the postpartum period may be the result of the protective factors of motherhood which is a respected status for women in populations where the preservations of traditions and customs are valued.

Maternal self-esteem after successful treatment for infertility

OBJECTIVE

To [1] investigate self-esteem during pregnancy after previous infertility and [2] establish the relationship among self-esteem, anxiety during pregnancy, and parenting self-efficacy.

DESIGN

Limited prospective study.

SETTING

A regional infertility clinic and antenatal clinic.

PATIENT(S)

Seventy women who had conceived through assisted reproductive technology and 111 women who had conceived naturally.

INTERVENTION(S)

Measures of self-esteem, anxiety, and parenting self-efficacy.

MAIN OUTCOME MEASURE(S)

Self-esteem, anxiety, and parenting self-efficacy.

RESULT(S)

Women who had conceived through IVF treatment did not differ in terms of self-esteem during pregnancy from those who had conceived naturally. All of the women in the present study displayed levels of self-esteem that were within the normal range. Self-esteem increased as pregnancy progressed. Self-esteem was negatively correlated with anxiety during pregnancy. As self-esteem increased, anxiety decreased. Self-esteem at the start of pregnancy (18 weeks) and anxiety in the early stages of parenthood (6 weeks postpartum) predicted parenting self-efficacy.

CONCLUSION(S)

Self-esteem in the early stages of pregnancy, for both women who conceived through IVF and women who conceived naturally, is related to self-reported levels of parenting efficacy. Coaching and mentoring through antenatal clinics in the early stages of pregnancy should be tailored to incorporate advice regarding self-esteem in addition to management of pregnancy and psychological well-being.

Routine follow-up visits after first-trimester induced abortion

Routine follow-up visits after abortion are intended to confirm that the abortion is complete and to diagnose and treat complications. Many clinicians also take advantage of the follow-up visit to provide general reproductive health care: discussing contraceptive plans and providing family planning services; diagnosing sexually transmitted infections; performing a Pap test or discussing abnormal Pap results. We reviewed the evidence related to the routine postabortion follow-up visit. Other than mifepristone medical abortion performed at 50 days of gestation or later and methotrexate medical abortion, we found little evidence that mandatory follow-up visits typically detect conditions that women themselves could not be taught to recognize. In addition, the natural history of the most severe complications after abortion-infection and unrecognized ectopic pregnancy-have time courses inconsistent with the usual timing of the follow-up visit. Costs associated with this visit can be great. These include travel expenses, lost wages, child-care expenses, privacy and emotional burdens for women, and scheduling disruptions and the related opportunity costs caused by "no-shows" for the provider. Follow-up appointments should be scheduled for those women likely to benefit from a physical examination. For the remainder of women, simple instructions and advice about detecting complications, possibly coupled with telephone follow-up, might suffice. Although arguably valuable in their own right, counseling, family planning services, or sexually transmitted infection diagnosis and treatment should not be so inflexibly bundled with postabortion care. Protocols that require in-person follow-up after abortion may not make the best use of a women's time or abilities, or of the medical system.