The psychological sequelae of therapeutic abortion--denied and completed

Therapeutic termination of pregnancy and women’s mental health: Determinants and consequences

The therapeutic termination of pregnancy (TToP) is an induced abortion following a diagnosis of medical necessity. TToP is applied to avoid the risk of substantial harm to the mother or in cases of fetal unviability. This type of induced abortion is provided after the second semester of gestation if fetal illness or the pregnancy cause physical danger or pathological mental distress to the mother. Socio-cultural and economic determinants could influence the desire for children and family planning in couples, as well as the use of effective contraception and the choice to perform an induced abortion. Also, pre-existing mental health problems could affect the decision between carrying on a problematic pregnancy or having TToP. Furthermore, the TToP is a reproductive event with an important traumatic burden, but also with an intrinsic therapeutic effect and it can produce different psychological and psychopathological effects on women and couples. The aim of this review is to evaluate what demographic, reproductive and psychopathological determinants are involved in the choice of undergoing a TToP in women. Also, we will examine both positive and negative consequences of this procedure on women’s mental health, underlying which factors are related to a worse outcome in order to provide the best clinical support to vulnerable groups.

Reproductive Rights and Women's Mental Health: Essential Information for the Obstetrician-Gynecologist

Reproductive health care is crucial to women's well-being and that of their families. State and federal laws restricting access to contraception and abortion in the United States are proliferating. Often the given rationales for these laws state or imply that access to contraception and abortion promote promiscuity, and/or that abortion is medically dangerous and causes a variety of adverse obstetric, medical, and psychological sequelae. These rationales lack scientific foundation. This article provides the evidence for the safety of abortion, for both women and girls, and encourages readers to advocate against restrictions.

Update on Reproductive Rights and Women's Mental Health

Reproductive rights are essential to the recognition/treatment of women as full-fledged human beings/citizens. Barriers to reproductive rights pose a grave danger to women's well-being. This article explores the origins of these barriers, their nature, and their impact on mental health. The most controversial relationship is between induced abortion and mental health. Barriers, misinformation, and coercion affecting contraceptive, abortion, and pregnancy care are an ongoing danger to women's mental health and the well-being of their families. Mental health professionals are best qualified, and have an obligation, to know the facts, apply them, and provide accurate information to protect women's health.

Antenatal Diagnosis of Renal Tract Anomalies: Has it Increased the Sum of Human Happiness?

When used as a screening procedure, ultrasound examination of the fetal urinary tract seldom leads to beneficial interventions. There is also a cost in terms of parental anxiety and unnecessary investigation and treatment. A formal screening programme would therefore be unjustified. However, screening of women for obstetric purposes will continue to reveal fetal abnormalities, and a strategy for dealing with these is needed. Antenatal treatments remain experimental; for most of the common conditions postnatal treatment has no urgency; and, in cases of minor abnormality detected by ultrasound, the best course may be to do nothing.

Reproductive Rights and Women's Mental Health

Reproductive rights are essential to the recognition/treatment of women as full-fledged human beings/citizens. Barriers to reproductive rights pose a grave danger to women's well-being. This article explores the origins of these barriers, their nature, and their impact on mental health. The most controversial relationship is between induced abortion and mental health. Barriers, misinformation, and coercion affecting contraceptive, abortion, and pregnancy care are an ongoing danger to women's mental health and the well-being of their families. Mental health professionals are best qualified, and have an obligation, to know the facts, apply them, and provide accurate information to protect women's health.

The Adolescent's Right to Confidential Care When Considering Abortion

In this statement, the American Academy of Pediatrics reaffirms its position that the rights of adolescents to confidential care when considering abortion should be protected. Adolescents should be encouraged to involve their parents and other trusted adults in decisions regarding pregnancy termination, and most do so voluntarily. The majority of states require that minors have parental consent for an abortion. However, legislation mandating parental involvement does not achieve the intended benefit of promoting family communication, and it increases the risk of harm to the adolescent by delaying access to appropriate medical care. This statement presents a summary of pertinent current information related to the benefits and risks of legislation requiring mandatory parental involvement in an adolescent's decision to obtain an abortion.

Unintended pregnancy as a predictor of child maltreatment

Whereas child maltreatment research has developed considerable evidence on post-natal risk-factors, pre-natal circumstances have been largely overlooked. The circumstances surrounding a pregnancy may considerably impact the environment in which later parenting behaviors occur. This study examines one of the earliest potentially identifiable risk-factors for child maltreatment: the intentions of a pregnancy. Utilizing both mother and father reports, this study focuses on maltreatment risk, as it relates with both parents' perspectives of the pregnancy's intention. Drawing upon data from the Fragile Families and Child Well Being study, a longitudinal, birth cohort study, survey questions were used that asked parents, at the time of the birth, whether they considered abortion for the child. Unintended pregnancy demonstrates predictive value as one of the earliest identifiable risk-factors for child maltreatment. Regardless of whether the mother or father reported the unintended pregnancy, the relationship with maltreating behavior is largely the same, although for different maltreatment types. Mothers' reports of unintended pregnancy are associated with psychological aggression, and neglect. Fathers' reports of unintended pregnancy are associated with physical aggression. Fathers' perspectives regarding pregnancy intentions matter just as much as mothers,' and accounting for their perspectives could be important in understanding the maltreating behaviors of both parents. Identifiable in the earliest stages of caregiving, unintended pregnancy may be an important risk-factor in predicting and understanding child maltreatment.

Psychiatric aspects of abortion

Objective: To examine the evidence concerning the psychological consequences of abortion, the risk of suicide in pregnancy and the psychological consequences for the mother and the child in cases of refused abortion. Method: An extensive literature search was undertaken and key relevant papers were examined and analysed. Results: Legal abortion has become more widely available throughout the western world and the actual reported incidence of cases of refused abortion is low. The majority of studies indicate that the psychological consequences of abortion itself are in the main mild and transient but there is evidence that women who have strong religious or cultural attitudes negative to abortion do experience high levels of psychological stress following abortion. The risk of suicide is low in pregnancy and suicide is a rare outcome of refused abortion. There is evidence of psychological and social difficulties experienced by mothers of unwanted pregnancies forced to proceed to term and by many offspring of such unwanted pregnancies. Conclusions: Definitive conclusions are difficult to draw from the published studies of refused abortion and many studies are over thirty years old.

Psychiatric aspects of induced abortion

Approximately one third of the women in the United States have an abortion during their lives. In the year 2008, 1.21 million abortions were performed in the United States (Jones and Koolstra, Perspect Sex Reprod Health 43:41-50, 2011). The psychiatric outcomes of abortion are scientifically well established (Adler et al., Science 248:41-43, 1990). Despite assertions to the contrary, there is no evidence that abortion causes psychiatric problems (Dagg, Am J Psychiatry 148:578-585, 1991). Those studies that report psychiatric sequelae suffer from severe methodological defects (Lagakos, N Engl J Med 354:1667-1669, 2006). Methodologically sound studies have demonstrated that there is a very low incidence of frank psychiatric illness after an abortion; women experience a wide variety of feelings over time, including, for some, transient sadness and grieving. However, the circumstances that lead a woman to terminate a pregnancy, including previous and/or ongoing psychiatric illness, are independently stressful and increase the likelihood of psychiatric illness over the already high baseline incidence and prevalence of mood and anxiety disorders among women of childbearing age. For optimal psychological outcomes, women, including adolescents, need to make autonomous and supported decisions about problem pregnancies. Clinicians can help patients facing these decisions and those who are working through feelings about having had abortions in the past.

Induced first-trimester abortion and risk of mental disorder

BACKGROUND

Concern has been expressed about potential harm to women's mental health in association with having an induced abortion, but it remains unclear whether induced abortion is associated with an increased risk of subsequent psychiatric problems.

METHODS

We conducted a population-based cohort study that involved linking information from the Danish Civil Registration system to the Danish Psychiatric Central Register and the Danish National Register of Patients. The information consisted of data for girls and women with no record of mental disorders during the 1995-2007 period who had a first-trimester induced abortion or a first childbirth during that period. We estimated the rates of first-time psychiatric contact (an inpatient admission or outpatient visit) for any type of mental disorder within the 12 months after the abortion or childbirth as compared with the 9-month period preceding the event.

RESULTS

The incidence rates of first psychiatric contact per 1000 person-years among girls and women who had a first abortion were 14.6 (95% confidence interval [CI], 13.7 to 15.6) before abortion and 15.2 (95% CI, 14.4 to 16.1) after abortion. The corresponding rates among girls and women who had a first childbirth were 3.9 (95% CI, 3.7 to 4.2) before delivery and 6.7 (95% CI, 6.4 to 7.0) post partum. The relative risk of a psychiatric contact did not differ significantly after abortion as compared with before abortion (P = 0.19) but did increase after childbirth as compared with before childbirth (P < 0.001).

CONCLUSIONS

The finding that the incidence rate of psychiatric contact was similar before and after a first-trimester abortion does not support the hypothesis that there is an increased risk of mental disorders after a first-trimester induced abortion.

Common mental disorders in late pregnancy in women who wanted or attempted an abortion

BACKGROUND

In countries where legal abortion is restricted, many unwanted pregnancies are carried to term. Attempting an unsuccessful abortion may influence women's mental health. This study investigated the common mental disorders (CMDs) of depression and anxiety in the third trimester of pregnancy in women who wanted or had attempted an abortion in a poor region of Brazil.

METHOD

CMDs were assessed by using the 20-item Self-Reporting Questionnaire (SRQ-20) in all pregnant women aged 18-49 years who were registered with publicly funded primary health care in Recife, Northeast Brazil.

RESULTS

The study achieved a high response rate and 1121 (98.9%) women completed the interview. The prevalence of CMDs for the sample was 43.1% [95% confidence interval (CI) 40.2-46.1], and 63.6% (95% CI 55.4-71.2) among the 13.7% of women who attempted an abortion. The association between CMDs and attempted an abortion [odds ratio (OR) 2.05, 95% CI 1.3-3.1] remained after adjustment for confounders.

CONCLUSIONS

This study found that attempting an abortion in the current pregnancy was associated with CMDs. Good access to family planning programs, including access to contraceptive methods and safe abortion, should help to improve the mental health of women.

Is there an "abortion trauma syndrome"? Critiquing the evidence

The objective of this review is to identify and illustrate methodological issues in studies used to support claims that induced abortion results in an "abortion trauma syndrome" or a psychiatric disorder. After identifying key methodological issues to consider when evaluating such research, we illustrate these issues by critically examining recent empirical studies that are widely cited in legislative and judicial testimony in support of the existence of adverse psychiatric sequelae of induced abortion. Recent studies that have been used to assert a causal connection between abortion and subsequent mental disorders are marked by methodological problems that include, but not limited to: poor sample and comparison group selection; inadequate conceptualization and control of relevant variables; poor quality and lack of clinical significance of outcome measures; inappropriateness of statistical analyses; and errors of interpretation, including misattribution of causal effects. By way of contrast, we review some recent major studies that avoid these methodological errors. The most consistent predictor of mental disorders after abortion remains preexisting disorders, which, in turn, are strongly associated with exposure to sexual abuse and intimate violence. Educating researchers, clinicians, and policymakers how to appropriately assess the methodological quality of research about abortion outcomes is crucial. Further, methodologically sound research is needed to evaluate not only psychological outcomes of abortion, but also the impact of existing legislation and the effects of social attitudes and behaviors on women who have abortions.

Is there a role for psychiatry in late termination of pregnancy?

The aim of the present review was to explore the role of the psychiatrist in late terminations of pregnancy. A literature review was conducted using MEDLINE and psycINFO databases, focussing on articles that explored (i) existing decision-making processes in late terminations; (ii) psychological sequelae of both early and late termination of pregnancy; (iii) the role of psychiatry in both early and late termination of pregnancy; and (iv) the involvement of psychiatry in complex medical decisions. The decision to perform a late termination of pregnancy is complex. Contributing to its complexity is an array of political, legal, societal, and ethical factors. The literature regarding psychological sequelae is frequently confusing and weakened by methodological problems. Methods of assisting in this decision-making process include the involvement of committees and psychiatrists. There are precedents for the involvement of psychiatrists in such a setting. Historically, psychiatrists played a role in screening women who requested an early termination. Psychiatrists are often involved in ethically challenging and complex clinical decisions in the general hospital setting. The involvement of psychiatry in this complex decision-making process has potential advantages and disadvantages. It is timely for psychiatrists to consider their position on their discipline's involvement.

Interface of Women's Mental and Reproductive Health

The interface of women's reproductive and mental health is an evolving area of psychiatric practice, necessitating familiarity with psychobiological factors unique to women. The role of estrogen in particular has profound implications for the etiology and treatment of women's psychiatric illness, and has been reviewed along with the role of other hormones. Additionally, the stress of specific life events such as miscarriage, abortion, and menopause affects female mental health from a biological and psychosocial standpoint with the potential for secondary mood and anxiety disorders. Psychiatric issues during pregnancy and the postpartum period present special diagnostic and treatment challenges to the clinician. Biological and psychosocial treatments of these conditions have been reviewed. Management of psychiatric conditions during pregnancy and the postpartum period should include the obstetrician, pediatrician, and involved family members. Treatment decisions should involve careful assessment of the risks and benefits of any intervention including the risk of no treatment.

Wellbeing and mental growth—long-term effects of legal abortion

The present study aims to increase knowledge about coping with legal abortion by studying women's reasoning, reactions and emotions over a period of 1 year. The study comprises interviews focusing on the experiences and effects of abortion in 58 women, 4 and 12 months after the abortion. The women also answered a questionnaire before the abortion concerning their living conditions, decision-making process and feelings about the pregnancy and the abortion. Majority of the women did not experience any emotional distress post-abortion and almost all the woman reported that they had coped well at the 1-year follow-up, although 12 had had severe emotional distress directly post-abortion. Furthermore, almost all described the abortion as a relief or a form of taking responsibility and more than half reported only positive experiences such as mental growth and maturity of the abortion process. Those without any emotional distress post-abortion stated clearly before the abortion that they did not want to give birth since they prioritised work, studies and/or existing children. The study shows that women generally are able to make the complex decision to have an abortion without suffering any subsequent regret or negative effects, as ascertained at the 1-year follow-up.

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.

The effects of induced abortion on emotional experiences and relationships: a critical review of the literature

This paper reviews post-1990 literature concerning psychological experiences and sexual relationships prior to and following induced abortion. It assesses whether conclusions drawn from earlier reviews are still supported and evaluates the extent to which previous methodological problems have been addressed. Following discovery of pregnancy and prior to abortion, 40-45% of women experience significant levels of anxiety and around 20% experience significant levels of depressive symptoms. Distress reduces following abortion, but up to around 30% of women are still experiencing emotional problems after a month. Women due to have an abortion are more anxious and distressed than other pregnant women or women whose pregnancy is threatened by miscarriage, but in the long term they do no worse psychologically than women who give birth. Self-esteem appears unaffected by the process. Less research has considered impact on the quality of relationships and sexual functioning, but negative effects were reported by up to 20% of women. Conclusions were generally concordant with previous reviews. However, anxiety symptoms are now clearly identified as the most common adverse response. There has been increasing understanding of abortion as a potential trauma, and studies less commonly explore guilt. The quality of studies has improved, although there are still some methodological weaknesses.

Psychological impact on women of miscarriage versus induced abortion: a 2-year follow-up study

OBJECTIVE

To compare the psychological trauma reactions of women who had either a miscarriage or an induced abortion, in the 2 years after the event. Further, to identify important predictors of Impact of Event Scale (IES) scores.

METHOD

A consecutive sample of women who experienced miscarriage (N = 40) or induced abortion (N = 80) were interviewed 3 times: 10 days (T1), 6 months (T2), and 2 years (T3) after the event.

RESULTS

At T1, 47.5% of the women who had a miscarriage were cases (IES score 19 points on 1 or both of the IES subscales), compared with 30% for women who had an induced abortion (p =.60). The corresponding values at T3 were 2.6% and 18.1%, respectively (p =.019). At all measurement time points, the group who had induced abortion scored higher on IES avoidance. Women who had a miscarriage were more likely to experience feelings of loss and grief, whereas women who had induced abortion were more likely to experience feelings of relief, guilt, and shame. At T3, IES intrusion was predicted by feelings of loss and grief at T1, whereas avoidance at T3 was predicted by guilt and shame at T1.

CONCLUSION

The short-term emotional reactions to miscarriage appear to be larger and more powerful than those to induced abortion. In the long term, however, women who had induced abortion reported significantly more avoidance of thoughts and feelings related to the event than women who had a miscarriage.

Abortion and psychiatric practice

The subject of abortion is fraught with politics, emotions, and misinformation. A widespread practice reaching far back in history, abortion is again in the news. Psychiatry sits at the intersection of the religious, ethical, psychological, sociological, medical, and legal facets of the abortion issue. Although the religions that forbid abortion are more prominent in the media, many religions have more liberal approaches. While the basic right to abortion has been upheld by the U.S. Supreme Court, several limitations have been permitted, including parental notification or consent (with the possibility of judicial bypass) for minors, waiting periods, and mandatory provision of certain, sometimes biased, information. Before the Roe v. Wade decision legalizing abortion in 1973, many women were maimed or killed by illegal abortions, and psychiatrists were sometimes asked to certify that abortions were justified on psychiatric grounds. Currently, there are active attempts to convince the public and women considering abortion that abortion frequently has negative psychiatric consequences. This assertion is not borne out by the literature: the vast majority of women tolerate abortion without psychiatric sequelae. The psychiatric outcome of abortion is best when patients are able to make autonomous, supported decisions. Psychiatrists need to know the medical and psychiatric facts about abortion. Psychiatrists can then help patients prevent unwanted pregnancies, make informed decisions consonant with their own values and circumstances when they become pregnant, and find appropriate social and medical resources whatever their decisions may be.

Psychiatric issues related to infertility, reproductive technologies, and abortion

Infertility, treatment with reproductive technologies, and abortion are among the most emotionally weighty and philosophically contentious experiences in most patients' lives. They involve the most intimate body parts and behaviors and the most heartfelt hopes and profound disappointments. They can strain relationships with partners, relatives, and friends. The primary care practitioner who is informed about the psychological impact of these experiences can play an essential role in interpreting medical information; helping patients think through their own values, resources, and options; facilitating communication between members of a couple and with their friends and family; providing emotional support; and identifying and treating psychiatric disorders that sometimes occur before, during, or after these experiences.

State-funded abortions versus deliveries: a comparison of outpatient mental health claims over 4 years

In this record-based study, rates of 1st-time outpatient mental health treatment for 4 years following an abortion or a birth among women receiving medical assistance through the state of California were compared. After controlling for preexisting psychological difficulties, age, months of eligibility, and the number of pregnancies, the rate of care was 17% higher for the abortion group (n = 14,297) in comparison with the birth group (n = 40,122). Within 90 days after the pregnancy, the abortion group had 63% more claims than the birth group, with the percentages equaling 42%, 30%, and 16% for 180 days, 1 year, and 2 years, respectively. Additional comparisons between the abortion and birth groups were conducted on the basis of claims for specific types of disorders and age.

Adolescent pregnancy 1 year later: the effects of abortion vs. motherhood in Northeast Brazil

PURPOSE

To determine social and behavioral consequences of pregnancy and how these differed according to the pregnancy outcome (live birth or abortion) 1 year after the event.

METHODS

This was a prospective study of two groups of young women aged 12-18 years, one attending prenatal services and the other admitted for abortion complications at the same hospital in northeast Brazil. Adolescents who gave birth were subsequently classified as having intended or unintended pregnancies, and those who aborted were divided between those who terminated their pregnancies and those who miscarried. Baseline data were collected between 1995 and 1997 from all teens who met the eligibility criteria. Information was collected through one-on-one interviews using a questionnaire that was structured and precoded. Multiple logistic regression was used to identify characteristics that predicted outcomes at 1 year.

RESULTS

Teens who terminated their pregnancies were the most likely to be in school or working 1 year later. They also showed the greatest increase in self-esteem. The young mothers, however, had the highest self-esteem but perceived the impact of pregnancy on their lives as being more negative than they did initially. Group affiliation was not associated with the quality of partner relationships, which tended to deteriorate over time. The young mothers used contraception at 1 year at higher rates and had experienced fewer subsequent pregnancies than the two abortion groups.

CONCLUSIONS

The experience of adolescent pregnancy for this group of teens produced mixed findings, some more negative than others. Interventions to decrease the adolescent's desire to have a baby will have to be tailored differently from those designed to prevent an unintended pregnancy, but both are needed.

Anxiety in Japanese women after elective abortion

OBJECTIVE

To examine women's anxiety levels after elective abortion.

DESIGN AND SETTING

Women seeking elective abortion at six clinics in Japan were solicited to participate in a questionnaire survey.

PARTICIPANTS

Sixty-six Japanese women requesting abortion participated in this survey.

MAIN OUTCOME MEASURES

State anxiety was measured using Spielberger's State Trait Anxiety Inventory before and after abortion.

RESULTS

Multiple regression analyses using predictor variables with a significant link to postabortion anxiety level showed that among potential predictors, a conservative attitude toward abortion was the most significant predictor of postabortion anxiety after controlling for the level of preabortion anxiety.

CONCLUSION

These findings suggest that a woman's attitude toward abortion and reproductive rights is an important but neglected factor influencing postelective abortion anxiety. Medical and nursing professionals should, therefore, take note of a woman's attitude toward abortion as a part of her mental health care.

Short-term grief after an elective abortion

OBJECTIVE

To identify the short-term grief response after elective abortion.

DESIGN

Descriptive, comparative study.

SETTING

Instruments were administered in a women's health clinic.

PARTICIPANTS

Ninety-three women, 45 who had a history of elective abortion within the past 1 to 14 months and 48 who had never had an abortion. Inclusion criteria included no perinatal losses within the past 5 years; no documented psychiatric history; and ability to read, write, and comprehend English.

MAIN OUTCOME MEASURES

Nature and intensity of short-term grief.

RESULTS

Women with a history of elective abortion experienced grief in terms of loss of control, death anxiety, and dependency. Although there were no statistically significant differences in the intensity of grief in women who had a history of elective abortion and the comparison group, there was an overall trend toward higher grief intensities in the abortion group. Presence of living children, perceived pressure to have the abortion, and the number of abortions appear to affect the intensity of the short-term grief response.

CONCLUSION

Elective abortion has the potential for eliciting a short-term grief response. Research is needed to identify which women are at greatest risk. This grief response should be acknowledged and appropriate interventions undertaken.

Ambivalence--a logical response to legal abortion: a prospective study among women and men

The aim of the study was to elucidate ambivalence in relation to legal abortion by studying emotions, attitudes, motives for abortion and ethical reasoning in a strategic sample of women and men who, 1 year after abortion, expressed both positive and painful feelings in relation to the abortion. The study shows that social perspectives legitimate the decision to have an abortion whilst ethical perspectives complicate the decision. Nearly all women and men described having the abortion as an expression of responsibility. Almost one-half also had parallel feelings of guilt, as they regarded the abortion as a violation of their ethical values. The majority of the sample expressed relief while simultaneously experiencing the termination of the pregnancy as a loss coupled with feelings of grief/emptiness. In spite of the ambivalence, only one woman regretted the abortion. For the vast majority, the impact of the abortion had led to increased maturity and deepened self-knowledge. Thus, ambivalence might be regarded not only as problematic but also as indicating openness to the complexity of the abortion issue. Since incompatible values clash in connection with abortion, experiences of ambivalence become both logical and understandable.

The male partner involved in legal abortion

This study comprises 75 men who have been involved in legal abortion. The men answered a questionnaire concerning living conditions and attitudes about pregnancy and abortion. Most men were found to be in stable relationships with good finances. More than half clearly stated that they wanted the woman to have an abortion while 20 stressed that they submitted themselves to their partner's decision. Only one man wanted the woman to complete the pregnancy. Apart from wanting children within functioning family units, the motivation for abortion revealed that the desire to have children depended on the ability to provide qualitatively good parenting. More than half the men had discussed with their partner what to do in event of pregnancy and half had decided to have an abortion if a pregnancy occurred. More than half expressed ambivalent feelings about the coming abortion, using words such as anxiety, responsibility, guilt, relief and grief. In spite of these contradictory feelings, prevailing expectations concerning lifestyle make abortion an acceptable form of birth control. A deeper understanding of the complexity of legal abortion makes it necessary to accept the role of paradox, which the ambivalence reflects. Obviously, men must constitute a target group in efforts to prevent abortions.

Sequelae of abortion and relinquishment of child custody among women with major psychiatric disorders

A growing number of women with major psychiatric disorders frequently consider the choice of abortion or relinquishment of the custody of children. Psychological reactions to abortion and relinquishment of custody were assessed and contrasted among 119 hospitalized women of M age 40 yr. and psychiatric patients. An original questionnaire was developed to assess emotional symptoms, psychiatric signs, attitudes, and satisfaction with the decision regarding the loss of a fetus or child. As hypothesized, reported sequelae of relinquishments of custody were rated as significantly more severe than sequelae of abortion. Dissatisfaction with choice, negative attitudes, religious affiliation, and involuntary removal of a child from custody were predictive of distress following abortion or relinquishment. The findings show that increased efforts are needed to help women with psychiatric difficulties cope with reproductive planning and losses.

Abortion attitudes as determinants of perceptions regarding male involvement in abortion decisions

Abortion decisions have a potentially meaningful effect on the lives of men. Previous research suggests that both men and women generally believe that men have the right to be involved in such decisions. However, very little research attention has been devoted to identifying individual difference correlates of discrepant levels of endorsement for male involvement in abortion decisions. The extent to which abortion attitudes (on a pro-choice to pro-life continuum), conceptualization of abortion as strictly a female issue, and interest in the issue operate as effective predictors of the appropriate level of male involvement in abortion decisions was examined in a sample of 1,387 college students. Results of a multiple regression analysis revealed that 44% of the variance in male involvement scores was explained by the predictor variables.

Repeat abortion: a comparative study

In a study of 404 women (simple random sample) 20-29 years of age, 201 women (group A) applying for abortion and 203 women (group B) continuing their pregnancies were given a questionnaire and were also interviewed. The aim of the study was to describe women applying for repeat abortion and to compare them with women having their first abortion and with women continuing their pregnancies. Variables measured were socio-economic, psychological and social problems, relationship with the partner, earlier pregnancies, how the present pregnancy was experienced and decision-making. For presentation of the results, the data have been divided into four subgroups: pregnant women applying for their first abortion (A1, n = 137), women applying for repeat abortion (A2, n = 64), women continuing their pregnancies who have never applied for abortion (B1, n = 142), and women continuing their pregnancies who had previously applied for one or more abortions (B2, n = 58). Women who had had previous abortion/abortions had experienced more psychological problems during their lifetime than the other groups studied. They had more contact with the social welfare service and evaluated their relationship with the partner as less harmonious than women having a first abortion, also in comparison with women continuing their pregnancies with no earlier applications for abortion. Women who have had previous abortion/abortions seem to have a need for special attention. This involves not only being provided with efficient and acceptable contraception, but also with social and psychological support based on the experiences of the women.

Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women

OBJECTIVE

We attempted to determine the national rape-related pregnancy rate and provide descriptive characteristics of pregnancies that result from rape.

STUDY DESIGN

A national probability sample of 4008 adult American women took part in a 3-year longitudinal survey that assessed the prevalence and incidence of rape and related physical and mental health outcomes.

RESULTS

The national rape-related pregnancy rate is 5.0% per rape among victims of reproductive age (aged 12 to 45); among adult women an estimated 32,101 pregnancies result from rape each year. Among 34 cases of rape-related pregnancy, the majority occurred among adolescents and resulted from assault by a known, often related perpetrator. Only 11.7% of these victims received immediate medical attention after the assault, and 47.1% received no medical attention related to the rape. A total 32.4% of these victims did not discover they were pregnant until they had already entered the second trimester; 32.2% opted to keep the infant whereas 50% underwent abortion and 5.9% placed the infant for adoption; an additional 11.8% had spontaneous abortion.

CONCLUSIONS

Rape-related pregnancy occurs with significant frequency. It is a cause of many unwanted pregnancies and is closely linked with family and domestic violence. As we address the epidemic of unintended pregnancies in the United States, greater attention and effort should be aimed at preventing and identifying unwanted pregnancies that result from sexual victimization.

The abortion decision: reasons and ambivalence

Self-in-relation theory and pilot data responses to an Abortion Decision Balance Sheet by 20 women attending an abortion-providing clinic challenge previous formulations of the abortion decision. Pilot data suggest that: women may make an abortion decision based primarily on pragmatics, a belief in their right to choose and knowledge of the safety and simplicity of the procedure. A discrepancy may exist for a significant minority of women between their abstract beliefs/knowledge and the personal meaning for them of the pregnancy, abortion and its safety. Important links may exist between maternal attachment and anxiety about the safety of the abortion procedure. Ramifications for counselling and future research are discussed.

Termination of pregnancy and psychiatric morbidity

BACKGROUND

We investigated whether reported psychiatric morbidity was increased after termination of pregnancy compared with other outcomes of an unplanned pregnancy.

METHOD

This was a prospective cohort study of 13,261 women with an unplanned pregnancy. Psychiatric morbidity reported by GPs after the conclusion of the pregnancy was compared in four groups: women who had a termination of pregnancy (6410), women who did not request a termination (6151), women who were refused a termination (379), and women who changed their minds before the termination was performed (321).

RESULTS

Rates of total reported psychiatric disorder were no higher after termination of pregnancy than after childbirth. Women with a previous history of psychiatric illness were most at risk of disorder after the end of their pregnancy, whatever its outcome. Women without a previous history of psychosis had an apparently lower risk of psychosis after termination than postpartum (relative risk RR = 0.4, 95% confidence interval CI = 0.3-0.7), but rates of psychosis leading to hospital admission were similar. In women with no previous history of psychiatric illness, deliberate self-harm (DSH) was more common in those who had a termination (RR 1.7, 95% CI 1.1-2.6), or who were refused a termination (RR 2.9, 95% CI 1.3-6.3).

CONCLUSIONS

The findings on DSH are probably explicable by confounding variables, such as adverse social factors, associated both with the request for termination and with subsequent self-harm. No overall increase in reported psychiatric morbidity was found.

Adolescent sexual activity

Adolescents are becoming sexually active at younger ages. One half of the adolescents in the United States are sexually active. This article reviews adolescent sexual activity, including rates of sexual activity, sexual practices, gay and lesbian youth, and factors affecting the initiation of sexual activity. In addition, adolescent pregnancy, with possible outcomes and effects on teen parents and their offspring, is discussed.

Pregnancy decision making: predictors of early stress and adjustment

Pregnancy decision making was examined among pregnant and nonpregnant women seeking pregnancy testing. The majority of women had decided upon and were certain of a decision to either abort or carry a possible pregnancy before learning the pregnancy-test results. Adjustment to pregnancy decision making was examined longitudinally among the women who tested positive for pregnancy. Pregnant participants were interviewed about their decisions to carry or abort their pregnancies at three times—immediately prior to pregnancy testing, a day after receiving positive test results, and 4 weeks later. Nearly all maintained their original decision over the course of the study. Adjustment was related primarily to which outcome was chosen and, to a lesser degree, to whether a woman was initially decided or not upon the outcome. The time surrounding pregnancy testing was stressful for women who decided to abort their pregnancies. However, negative feelings at the time of pregnancy testing among those who later aborted their pregnancies subsided by the end of the study and did not differ from those who carried their pregnancies.

Post-abortion perceptions: a comparison of self-identified distressed and nondistressed populations

This study investigated the experiences of 25 women who described themselves as responding in an emotionally distressed manner to abortion and a comparison group of 25 women reporting more relieving/neutral responses. Current and initial stress response to the abortion, general mental health, and demographic characteristics were assessed quantitatively, and interviews explored subjective perceptions. The distress group had significantly higher scores on initial stress response and religiosity, were more often currently affiliated with conservative churches, and reported lower degree of social support and confidence in the abortion decision. Qualitatively, 48% of the distress group recalled experiencing feelings of loss immediately post-abortion, in contrast to none in the nondistress group. Both groups identified post-abortion "catalytic" events, such as subsequent childbirth, that affected responses to the abortion over time.