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Legalized Abortion and the Public Health: Report of a Study (1975)

Chapter: 5. The Psychological Effects of Abortion

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Suggested Citation:"5. The Psychological Effects of Abortion." Institute of Medicine. 1975. Legalized Abortion and the Public Health: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/18521.
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Suggested Citation:"5. The Psychological Effects of Abortion." Institute of Medicine. 1975. Legalized Abortion and the Public Health: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/18521.
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Suggested Citation:"5. The Psychological Effects of Abortion." Institute of Medicine. 1975. Legalized Abortion and the Public Health: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/18521.
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Suggested Citation:"5. The Psychological Effects of Abortion." Institute of Medicine. 1975. Legalized Abortion and the Public Health: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/18521.
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Suggested Citation:"5. The Psychological Effects of Abortion." Institute of Medicine. 1975. Legalized Abortion and the Public Health: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/18521.
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Suggested Citation:"5. The Psychological Effects of Abortion." Institute of Medicine. 1975. Legalized Abortion and the Public Health: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/18521.
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Suggested Citation:"5. The Psychological Effects of Abortion." Institute of Medicine. 1975. Legalized Abortion and the Public Health: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/18521.
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Suggested Citation:"5. The Psychological Effects of Abortion." Institute of Medicine. 1975. Legalized Abortion and the Public Health: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/18521.
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Suggested Citation:"5. The Psychological Effects of Abortion." Institute of Medicine. 1975. Legalized Abortion and the Public Health: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/18521.
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Suggested Citation:"5. The Psychological Effects of Abortion." Institute of Medicine. 1975. Legalized Abortion and the Public Health: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/18521.
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Suggested Citation:"5. The Psychological Effects of Abortion." Institute of Medicine. 1975. Legalized Abortion and the Public Health: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/18521.
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Suggested Citation:"5. The Psychological Effects of Abortion." Institute of Medicine. 1975. Legalized Abortion and the Public Health: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/18521.
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Suggested Citation:"5. The Psychological Effects of Abortion." Institute of Medicine. 1975. Legalized Abortion and the Public Health: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/18521.
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Suggested Citation:"5. The Psychological Effects of Abortion." Institute of Medicine. 1975. Legalized Abortion and the Public Health: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/18521.
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Suggested Citation:"5. The Psychological Effects of Abortion." Institute of Medicine. 1975. Legalized Abortion and the Public Health: Report of a Study. Washington, DC: The National Academies Press. doi: 10.17226/18521.
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Chapter 5 THE PSYCHOLOGICAL EFFECTS OF ABORTION There probably is no psychologically painless way to cope with an unwanted pregnancy whether it is voluntarily interrupted or carried to term. While an abortion may elicit feelings of guilt, regret, or loss, such alternatives as entering a forced marriage, bearing an out-of-wedlock child, giving up a child for adoption, or adding an unwanted child to a family may also be accompanied by psychological problems for the woman, the child, and the family. This chapter reviews the available evidence on the psychological consequences of legally induced abortion. The term "psychological" refers in a general way to an individual's emotional or mental condi- tion; the term "psychiatric" relates to mental disturbance or illness. Two questions are asked. First, what is the effect of a legal abortion on the mental health of a woman obtaining an abortion? Second, what are the effects of denying a requested abortion on the woman, on the child then born, and on the larger family? In addition, the research design problems associated with many of the studies cited are discussed in light of their effects on the data generated. Also examined are some of the current studies on the psychological and social factors involved in the decision to delay an abortion until the second trimester, when the medical risks associated with the termination are greater. Much of the research on psychological aspects of abortion is limited, not only because many of the studies are poorly designed and executed, but also because the whole field of mental health research is relatively undeveloped. Due to a lack of data, this chapter does not address the effect of abortion on such subjects as marital relationships, family cohesiveness, or child abuse. Nor does it address the differential impact of legal and illegal abortion on mental health. The only data available on this subject are anecdotal materials, which, as expected, portray an illegal abortion as more traumatic than a legal one. Data are also almost nonexistent on the differential emotional impact associated with various abortion techniques or the trimester in which the abortion is obtained, although psychiatric opinion supports the obstetrical judg- ment that first-trimester abortions are less hazardous than later procedures. 88

89 Definitional and Methodological Problems Most studies on the psychological effect of abortion are clouded by significant problems of definition and method. The uneven quality of the research is evidenced by the lack of consensus on the mental health consequences of abortion, especially for women with no obvious psychiatric disorders prior to the operation. Opinion ranges from the view that abortion is always followed by feelings of regret, loss and depression, to the opposite view that abortion results in feelings of obvious emotional relief.1/ Among the more frequent methodological problems found in many studies on this subject are: . failure to examine the psychological status of the woman before the abortion so as to measure any change caused by the abortion; . poor sampling techniques, and lack of attention to possible inter- viewer bias; . failure to distinguish or identify the differential effects of lega1, illega1, or spontaneous abortion; and . scheduling of follow-up interviews too soon after the abortion to measure long-term psychological effects. An even more serious problem is that many studies do not provide a control group to compare with the women obtaining abortions. Although the absence of such controls may be attributed in part to inadequate research design, it also stems from the difficulty of determining an appropriate comparison group. Is the emotional impact of induced abortion to be compared to the sequelae of term delivery, term delivery followed by adoption, spontaneous abortion, or to the absence of pregnancy? Should women be selected as controls on a random basis or matched on a one-to-one basis in accordance with certain characteristics of women in the abortion group? Each alternative raises issues of research methodology and value judgment that are largely ignored by the studies noted below. With rare exceptions, most inquiries never address the question of the appropriate comparison group to be examined when studying the psychological impact of abortion. The wide range of opinion on the emotional consequences of abortion is also partly explained by the problems of definition that trouble all psychological research. What one evaluator sees as "normal transient depression" following an abortion might be labeled an "adverse reaction" by another. Similarly, "depression" or "guilt" are general terms that do not specify whether such feelings are appropriate, how long they last, or how severe they might be. Inconsistent terminology, therefore, makes a comparison among studies very difficult and also weakens the validity of any single study.

90 Somewhat related to the definition problem is the lack of uniform measurement instruments to gauge the effect of an abortion on the mental health of a woman. Many of the studies classify "seeing a psychiatrist" at some time after the abortion as a negative reaction. Similarly, "being in therapy" either before or after an abortion is presented as evidence of mental illness, although the absence of psychiatric visits is not necessarily considered indicative of mental health. The counseling process can be interpreted alternatively either as an early intervention which is as much preventive as remedia1, or as evidence of mental distress. Furthermore, such criteria as "seeing a psychiatrist", are clearly not standardized and vary among studies. Recording three visits a week for the two months directly following an abortion is clearly not comparable in time or intensity to a few visits several months after the procedure. Yet much of the research fails to define adequately the measurement criteria employed. One additional factor that contributes to the wide variations in con- clusions is that the legal status of abortion has not remained constant during the last 50 years when the bulk of research was conducted. Abor- tion in the United States has only recently begun to gain acceptance by a significant segment of the population. Because psychiatric research often reflects the bias of the investigator and of the culture (whether consciously or subconsciously), many earlier findings conflict with current data generated in an atmosphere increasingly tolerant of legal abortion.* The linkage between the legal and cultural status of abortion and its psychological effects poses a complex problem for researchers hoping to isolate the consequences of abortion. If adverse reactions are clearly present, it is difficult to determine whether they arise more from the abortion itself or from other factors, such as social embarrassment, that relate more to general cultural values or legal norms. The Recent Evidence on Psychiatric Consequences of Abortion This section relies primarily on U.S. data gathered since the late 1960s when the laws governing abortion became less restrictive. Although the studies cited do not represent an exhaustive review, they do con- stitute an illustrative sample of recent work in this field. Data from the JPSA survey will be presented followed by several major studies completed in the last five years. *A Gallup poll conducted in 1972 recorded that over 60 percent of the people interviewed favored the proposition that abortion should be a choice for a woman and her doctor to make. In 1969, only 40 percent of the people interviewed agreed with this same statement.2/

91 Recent data on the psychiatric complication rate of abortion have been compiled by the Joint Program for the Study of Abortion (JPSA), described in more detail in Chapter 3. From July 1, 1970 to June 30, 1971, the 66 participating institutions reported a total of 16 major psychiatric complications from a pool of 72,988 abortions, including two suicides and five depressive reactions associated with major hemorrhage or protracted fever.* The complications recorded in the JPSA data yield a psychiatric complication rate of 0.2 per thousand abortions (without other concurrent surgeries), and 0.4 per thousand abortions for local women obtaining abortions who were later seen for follow-up evalua- tion.**^/ As similarly noted in the several studies below, the JPSA figures indicate that abortion does not carry a significant risk of psychiatric trauma. In a recent study by Levene and Rigney (1970), follow-up question- naires were sent to a consecutive series of 70 patients several months after they obtained therapeutic abortions under the moderately restrictive California abortion law (1968).5/ These women were asked to describe their feelings immediately following abortion and three to five months later. The measurements used were scores on the Depression Rating Scale and the Multiple Affect Adjective Check List, plus a brief statement of each woman%s overall reaction to the procedure. Based on a follow-up sample of 80 percent of the original group, the study compared these ratings with the pre-abortion status recorded in the psychiatric evaluation required of all women requesting abortions at this particular facility. The authors noted that pre-abortion depression was significantly reduced for the great majority of women at time of follow-up as compared with the immediate pre- and post-operative condition. Most of the women recorded positive reactions toward the abortion, although seven of the 56 women contacted claimed that they would not seek abortion again.6/ There were no reports of psychiatric hospitalization from those women reached for follow-up. Although five reported that they had seen a psychiatrist in the interim, two of these had been in therapy prior to becoming pregnant. These data suggest that the emotional impact of abortion is, on balance, positive, although the absence of any control group and the brief interval between abortion and follow-up limit the validity of the conclusions. *0ne of the women committing suicide had a history of psychiatric hospitalization before and after the abortion and it was clear that the abortion itself was not the cause of the suicide. The other suicide was of a young woman who was falsely diagnosed as pregnant and committed suicide before that information could be relayed to her after the surgical procedure.3_/ **As elsewhere in JPSA data, the complication rates for "all cases" represent a minimum estimate, and the rates based on local patients with follow-up a maximum estimate of the true incidence of complications.

92 Margolis et al. (1971) attempted to study 50 women who obtained therapeutic abortions at the University of California/San Francisco hospitals between November 1967 and July 1968.]_/ At the time of initial application for the abortion, a Minnesota Multiphasic Personality Inven- tory (MMPI) profile was obtained from each woman in conjunction with the required psychiatric evaluation. Of the 43 women reached for follow-up, 29 expressed a positive reaction toward abortion, 10 reported neutral feelings and four responded negatively. Thirty-seven of these women said they would repeat the abortion under similar circumstances; two said they would not. An evaluation of 36 pre- and post-abortion MMPI profiles indicated that 15 of the 27 previously abnormal tests became essentially "normal" after the abortion. Like Levene and Rigney, the investigators concluded that abortion does not aggravate mental illness or necessarily have a negative impact. However, this study also is without a control group and relies largely on self reports that use very general terms and measurement scales. Furthermore, not all of the women obtained a simple D&C; nine obtained a saline abortion, one had a hysterotomy, and nine were sterilized. By not distinguishing these subgroups in reporting the follow-up results, the data lose much of their usefulness. Barnes et_ al. (1971) conducted a retrospective study of a group of 114 women who obtained therapeutic abortions at Massachusetts General Hospital between January 1968 and June 1970.8/ Of this group, 99 partici- pated in a follow-up interview. Nine of these 99 women sought some form of psychiatric counseling in the year following the abortion; two women with extensive histories of previous psychiatric hospitalization were readmitted to a mental hospital following the abortion. Those patients aside, the study found that "the patients' experience with therapeutic abortion produced little handicap in most and constructive gains in many".9/ The lack of information on pre-abortion mental health status, however, leaves the study unable to assess scientifically the actual effect of the termination. That is, there must first be baseline data against which to measure any subsequent changes. Niswander and Patterson studied a group of women obtaining abortions between 1963 and 1965 at the hospital affiliated with the State University of New York at Buffalo.*10/ From an original pool of 170 women, 116 eventually returned a follow-up questionnaire. About 66 percent of these women reported that they "felt better" immediately following the abortion— a figure that rose to 83 percent eight months or more post-operatively; 80 percent said they were "better off emotionally" at time of follow-up. The authors reported that when confronted directly with the question was "therapeutic abortion the best answer for you?" only six of the 116 patients failed to respond in the affirmative.ll/ Although "minor doubts" *This study, and the Patt study that follows are included as examples of research conducted in the middle 1960s when attitudes towards abortion were beginning to be less restrictive.

93 were fairly common, the study noted that these feelings were always accompanied by the expressed belief that, under the circumstances, the decision to abort had been a good decision. Patt et al. (1969) obtained follow-up data on 35 of 48 women who obtained abortions for psychiatric reasons from 1964-1968 at Michael Reese Hospital in Chicago.12/ The data collected came from direct interviews with the women or their psychiatrists and from hospital records. The study concluded that for 20 women, the short-term impact of abortion was very favorable; the remaining 15 exhibited some negative reactions, including depression, for a period of two to six months following the abortion. The long-term effects recorded were considerably more favorable; more than three-fourths of the women studied reported improved "life functioning" several years after the abortion, although five women regarded themselves as "harmed", and four felt unchanged. The study concluded quite simply that "with rare excep- tions, abortion was genuinely therapeutic."13/ Both of these studies contain various methodological shortcomings, most of which have been mentioned in connection with other studies reviewed, e.g. absence of accurate pre-abortion data or a control group, and lack of standardized follow-up measures. Yet the data from all these studies show a general agreement: While abortion may elicit feelings of guilt, regret or loss in some women, these reactions tend to be temporary and appear to be outweighed by positive life changes and feelings of relief. Moreover, these studies indicate that although abortion may indeed be followed by some minor negative feelings, major psychiatric trauma is essentially non-existent. From their review of the recent literature, Osofsky, Osofsky, and Rajan (1973) concluded: For most women, abortion has had few, if any [negative] psychological sequelae [consequences]. In the limited number of cases where feelings of guilt or depression have been present, they have tended to be mild and transient in nature. On the whole, the experience has led to further emotional maturation and resolution of conflict. In the rare instances where psychiatric disturbances have been noted post-abortion, they have appeared related to existent psychopathology rather than to the procedure.14/ Early Research on the Psychiatric Consequences of Legal Abortion Research before the middle 1960s on the psychiatric consequences of abortion was conducted in a different social and legal context than currently exists. The restrictions placed on the availability of abortion were compounded by the stresses on the woman seeking a legal abortion—social stigma, uncertainty as to whether the abortion could be obtained, ethical doubts, insensitivity and even contempt from

94 hospital staff,* and the play-acting sometimes necessary to obtain psychiatric approval for the abortion. The prevalent psychoanalytic theory of woman defined her traditional maternal role as instinctive, and concluded that any attempt to thwart this role would cause psychiatric problems. Accordingly, abortion was often viewed as a violation of woman's natural character as "giver, nurturer, and protector of life."IV The law supported this attitude by restricting the availability of abortion to medical or psychiatric necessity. Reflecting this general situation, the psychiatric research from the period placed the whole abortion issue in the realm of mental illness, primarily because psychiatry was charged with determining the mental health indications for and consequences of abortion. A review of the early literature was conducted by Simon and Senturia (1966) in an effort to establish not only what had been done in the field, but also to examine the validity of the research designs and the associated conclusions.16_/ In their analysis of the 25 principal studies conducted between 1934 and 1965 they concluded that the research methods were grossly inadequate. They note how sobering it is to observe the ease with which reports can be embedded in the literature, quoted, and requoted many times without consideration for the data in the original paper. Deeply held personal convictions frequently seem to outweigh the importance of data, especially when conclusions are drawn.17/ Simon and Senturia also conclude from their review, however, that "there is some agreement that women with diagnosed psychiatric illness prior to abortion continue to have difficulty following abort ion. "1JJ/ That is, women who have a history of instability prior to the pregnancy are more likely to manifest psychiatric problems after an abortion than women with no prior psychiatric history, regardless of the procedure used.lj)/ By the same token, for these women abortion cannot be viewed as a solution for psychiatric disturbance, and may perhaps exacerbate the condition. Simon and Senturia do not offer any further conclusions on the psychological consequences of abortion from their review of these early studies, since the quality of the data reported in these studies limits further analysis. Most important, however, is that even if these early studies had, in fact, outlined the emotional impact of abortion con- clusively, the recently changed status and availability of legal abortion in this country would probably make these earlier findings out of date and somewhat irrelevant. *Although many of these conditions persist, it can be assumed that they were more acute prior to the widespread legalization of abortion.

95 Psychological Consequences of Abortion and Birth The psychiatric consequences of abortion also need to be viewed in comparison to alternative outcomes of unwanted pregnancy. For example, what are the relative emotional impacts of "post-partum blues" (depression, following childbirth, that is considered normal rather than pathological 2QJ) and "post-abortion blues?" In 1970, Fleck reported that there are some 4,000 documented post- partum psychoses requiring hospitalization in the U.S. per year, about one to two per 1,000 deliveries.2JL/ If these rates are compared to the estimated post-abortion psychosis rates compiled by the JPSA study cited earlier (between 0.2 and 0.4 per 1,000 abortions), one might conclude that abortion is substantially less traumatic than childbirth. However, without more complete information on the pre-abortion/delivery status of these women, the two data sets can only be presented for preliminary con- sideration. Definitive conclusions, either about the comparative status of the two complication rates, or about the role of abortion and childbirth in precipitating mental illness, must await further research. But there is no evidence here that abortion is significantly more hazardous psychologically than is term delivery. A recent study attempted to relate the psychiatric sequelae of abortion to other pregnancy related events. As such, the study is one of the few that has tried to establish a control group in a study of abortion. Between October 1970 and February 1972, At lianasiou et al. studied three matched groups of women, one group planning term deliveries, one obtaining suction curettage abortion and the third obtaining second-trimester saline abortions.22/ Findings were based on detailed interviews and administration of several standardized questionnaires during pregnancy and about one year after the abortion or delivery. Of the original sample of 373 women, three matched samples totaling 114 women were eventually included in the follow-up evaluation. The only statistically significant difference among the three groups occurred on the paranoia scale of the Minnesota Multiphasic Personality Inventory (MMPI); term birth patients apparently had more extreme scores than either first- or second-trimester abortion patients. Athanasiou states that "if any conclusion were to be drawn ..., it would be that early abortion by suction curettage was possibly more therapeutic [with respect to this indicator] than carrying a pregnancy to term."23/ Although the follow-up information was clearly incomplete, these data continue to support the findings of other recent studies that abortion is not a damaging procedure leading to or aggravating mental illness. Indeed, Kummer has suggested that the whole concept of post- abortion psychiatric illness is a myth.2V

96 The Consequences of Denied Abortion A parallel issue to the psychiatric consequences of legal abortion is whether denying abortion to a woman requesting such a procedure has adverse effects. For the pregnant woman denied abortion, the stresses are clearly different than for a woman who obtains an abortion. Beyond any private distress or depression, the pregnancy is obvious to all with whom she comes in contact, her education or career may be interrupted for at least some time, and responsibility for the child may last for decades unless adoption is elected. Studies of women to whom legal abortions were denied are complicated by the observation that a large percentage of such women eventually manage to obtain an abortion—legally or illegally—after initial refusal. Thus, the residual group who continue their pregnancy are a specific subset of the original group and are not necessarily representative of all women who are denied abortions. Although not nearly enough is known about the decisions and prob- lems that face women with unwanted pregnancies, or how they cope with the children who were unwanted at the time that the abortion was sought, some recent research has begun to examine these issues. Illsley and Hall (1972) surveyed published reports and concluded that "although many women who are refused abortions do adjust to their situation and grow to love the child, about half would still have preferred an abortion, a large minority suffer considerable distress, and a small minority [eventually] develop severe disturbance."^/ The problem of unwanted pregnancy is important; estimates from the 1970 National Fertility Survey indicate that 15 percent of all recent births to married couples were "never wanted" and that the percentages unwanted were much greater among couples who had already had three children or who were in the near-poor and poor populations.26/ The effects on the child born of an unwanted pregnancy are even more difficult to evaluate than the effects on the mother. The litera- ture is sparse on the relationship of "unwantedness" or "wantedness" to specific, objective criteria of physica1, menta1, or social health.27/ Evidence that planned pregnancies more frequently produce psycho- logically healthy children is mostly inferential. What little is known about discernible differences between matched samples of "wanted" and "unwanted" children from birth through early childhood comes from two studies that compared children born after their mothers were denied abortions to children who were ostensibly "wanted." One such study was conducted in Sweden by Forssmann and Thuwe (1966). This 20-year follow-up study of 120 children born to Swedish women who were denied abortion showed that, in comparison with a matched group of children born at the same time, the "unwanted children" were registered more often with psychiatric services, had engaged in more antisocial and criminal be- havior and had received more public assistance. Also, many more of the un- wanted than control children had not had the advantage of a secure family life during childhood. Out-of-wedlock birth and/or death or divorce of

97 parents during early childhood were more frequent among the unwanted children, many of whom were reared under difficult social circumstances. Unfortunately, this study is flawed by major social and economic differences between the two groups of children being compared and between their mothers, thereby making the comparative observations less sound.28/ Additional data are available from Prague on a follow-up study of the first seven to nine years of life of approximately 200 children born during 1961-1963 to women denied abortion both on initial request and on subsequent appeal. These children were compared with about 200 control children who were born to women who did not seek abortion and who were carefully matched to the subject group by grade in schoo1, sex, birth order, number of siblings, mother's marital status, and father's occupation. Although the initial differences noted between the Czech experimental and control children are not dramatic, they do suggest that the "unwanted" boys in particular, now entering adolescence, suffer a greater incidence of illness, have poorer grades in schoo1, have more difficulty with peer group relationships and are at seemingly greater risk for future deliquency.29/ Continuing observations will be needed to assess the validity of these predictions. Psychological Aspects of First- and Second-Trimester Abortions Increasing interest in why some women obtain abortions in the second trimester rather than the first has stimulated new research on the psy- chologica1, sociological, and cultural factors involved in the decision to seek abortion.3_0/ Recent work of Kaltreider (1973) examined the psy- chological factors involved in the delay of the decision to seek abortion until the second trimester when the more risky saline method must be used. Kaltreider noted that a first-trimester group of ten women moved swiftly into the process leading to abortion, while the eight women obtaining second-trimester abortions—similar to the first group in age, race and marital status—underwent a period of denial of suspected pregnancy, procrastination, and general emotional confusion. The latter group was more ambivalent about the termination of their pregnancies and, prior to conception, seemed to have less effective abilities for coping with stress. After abortion, the second-trimester group spoke of the termination in such terms as "labor", "delivery" and "childbirth" and also referred to the "baby" or "child" rather than "the fetus" or "the pregnancy"—terms that the first-trimester group used. The mid- trimester group also appeared to undergo more of a mourning period after the abortion than the women obtaining D&Cs. Whether such post-abortion phenomena are a simple function of experiencing a saline rather than a curettage abortion or evidence of psychological differences between the two groups of women prior to the abortion is not clear. The evi- dence is consistent, however, with the view that the longer the period of gestation, the more the fetus will be viewed as a "baby", and the more likely that an abortion will be accompained by a grief or loss reaction.31/

98 In a study with a similar purpose, Kerenyi et al. interviewed random samples of 200 women obtaining D&Cs and 200 women obtaining saline abortions in a New York City hospital from late 1971 to the middle of 1972. Kerenyi found that the second-trimester women were on the average 3.4 years younger than the D&C group, less educated, more frequently single, less often employed, and were more likely to be students. The women obtaining saline abortions were also more frequently pregnant for the first time (65 percent versus 44 percent), and thus less experienced at detecting and coping with pregnancy. While both groups expressed similar emotional reactions to the discovery of being pregnant, the women obtaining second- trimester abortions were slower to master their feelings and proceed to action. Like Kaltreider, Kerenyi notes that in addition to ambivalence, denial of the pregnancy also seemed to contribute to the delay in seeking early abortion. Even though a large majority of both groups of women had regular menses, twice as many of the women obtaining DS.Cs as salines consulted a physician after missing only one period.3j/ In addition to the problems described by Kaltreider and Kerenyi, delays in obtaining an abortion may also be related to ethical or religious conflicts. Social barriers may also play a role in the postponement. For example, if access to medical care is limited by age, ignorance, or poverty, abortion may be delayed into the second trimester while the woman attempts to master the necessary steps to obtain it. To the extent that pregnancy tests are difficult to arrange, information on abortion is limited, medical facilities are inaccessible, or pregnancy counseling is unavail- able, some women will require the later procedure through no ambivalence or reluctance of their own. To date, though, no research has sorted out the extent to which such factors in the health care system influence the delay in obtaining an abortion. Further research on the social and psychological dimensions of second- trimester abortion is needed. Because the medical risks associated with later abortion are greater, an improved understanding of the processes leading to later abortion could contribute to a reduction in the number of women obtaining such procedures and, therefore, to a lowering of the mortality and morbidity risks associated with abortion. Summary Certain trends emerge from a review of the scientific literature on the mental health effects of abortion. Emotional stress and pain are involved in the decision to obtain an abortion, and there are strong emotions that surround the entire procedure. However, the mild de- pression or guilt feelings experienced by some women after an abortion appear to be only temporary, although for women with a previous psychiatric history, abortion may be more upsetting and stressful.

99 There are many methodological problems in abortion research, more serious in the studies conducted prior to the mid-1960s than in later studies. In the early studies, the design shortcomings, in combination with a legal and social climate hostile to objective discussion of the subject, probably account for a wide variety of findings that range from abortion having no negative psychological consequence to its being an emotionally damaging experience. The more recent studies generally agree that the feelings of guilt, regret, or loss elicited by a legal abortion in some women are gener- ally temporary and appear to be outweighed by positive life changes and feelings of relief. The effects of denied abortion are also not completely documented, although two studies indicate that the children subsequently born to women who have been denied abortion exhibit more social-psychological problems than the "wanted" children. The impact of denied abortion on the woman and her family is even less defined, and is not addressed in this chapter. The last two studies presented discuss certain psychological aspects of first- as against second-trimester abortion. Research defining the psychological differences between women obtaining second- rather than first- trimester abortions, coupled with research on the social and economic barriers to earlier abortions, may suggest ways to encourage women seeking abortion to do so in the first trimester, thereby avoiding the higher mortality and morbidity associated with later abortion.

100 REFERENCES 1. R. Illsley and M. H. Hall. "Psycho-social Aspects of Abortion: A Review of Issues and Needed Research," Aberdeen, Scotland, August 1973. (Mimeographed); and Emily Moore-Cavar. International Inventory of Information on Induced Abortion. New York: International Insti- tute for the Study of Reproduction, Columbia University, 1974. 2. Richard Pomeroy and Lynn C. Landman. "Public Opinion Trends: Elective Abortion and Birth Control Services to Teenagers," Family Planning Perspectives 4: 53, October 1972. 3. Christopher Tietze and Sarah Lewit. "Joint Program for the Study of Abortion (JPSA): Early Medical Complications of Legal Abortion," Studies in Family Planning 3: 109, June, 1972; and personal communication with Christopher Tietze, September 13, 1974. 4. Ibid., p. 107. 5. Howard Levene and Francis Rigney. "Law, Preventive Psychiatry, and Therapeutic Abortion," The Journal of Nervous and Mental Disease 151: 51-59, 1970. 6. Ibid., p. 58. 7. Alan Margolis et_ al•. "Therapeutic Abortion Follow-up Study," American Journal of Obstetrics and Gynecology 110: 243-247, May 15, 1971. 8. Ann B. Barnes et_ al•. "Therapeutic Abortion: Medical and Social Sequels," Annals of Internal Medicine 75: 881-886, December 1971. 9. Ibid., p. 885. 10. Kenneth Niswander and Robert Patterson. "Psychologic Reaction to Therapeutic Abortion," Obstetrics and Gynecology 29: 702-706, May 1967. 11. Ibid., p. 703. 12. Stephen L. Patt, et_ al•. "Follow-up of Therapeutic Abortion," Archives of General Psychiatry 20: 408-414, April 1969. 13. Ibid., p. 410. 14. Joy D. Osofsky, Howard J. Osofsky, and Renga Rajan. "Psychological Effects of Abortion: With Emphasis Upon Immediate Reactions and Followup," in Howard J. Osofsky and Joy D. Osofsky eds., The Abortion Experience. Hagerstown, Maryland: Harper and Row, 1973, p. 203.

101 15. Carl H. Jonas, "More Victims Than One," Way 23: 40, July-August 1967, cited in Daniel Callahan. Abortion: Law, Choice and Morality. New York: MacMillan Publishing Co., Inc., 1970, p. 71. 16. Nathan M. Simon and Audrey G. Senturia. "Psychiatric Sequelae of Abortion," Archives of General Psychiatry 15: 378-389, October 1966. 17. Ibid., p. 387. 18. Ibid. 19. Committee on the Working of the Abortion Act. Report of the Committee. Vol. 1, London: Her Majesty's Stationery Office, 1974. 20. C. V. Ford. "Emotional Responses to Abortion," Contemporary Obstetrics/Gynecology 1: 15-18, 1972. 21. S. Fleck. "Some Psychiatric Aspects of Abortion," Journal of Nervous and Mental Disease 151: 44, 1970. 22. Robert Athanasiou et_ al. "Psychiatric Sequelae to Term Birth and Induced Early and Late Abortion: A Longitudinal Study," Family Planning Perspectives 5: 227-231, Fall 1973. 23. Ibid., p. 230. 24. Jerome M. Kummer. "Post-Abortion Psychiatric Illness - A Myth?" American Journal of Psychiatry 119: 980-983, April 1963. 25. Illsley and Hal1, p. 46. 26. C. F. Westoff and R. Parke, Jr., eds. Demographic and Social Aspects of Population Growth. Washington, D.C.: The Commission on Population Growth and the American Future, Research Reports 1, 1972.. 27. E. W. Pohlman. The Psychology of Birth Planning. Cambridge, Massa- chusetts: Schenkman, 1969. 28. Hans Forssman and Inga Thuwe. "One Hundred and Twenty Children Born After Application for Therapeutic Abortion Refused," Acta Psychiatrica Scandinavia 42: 70-87, 1966. 29. Z. Dytrych, Z. Matejcek, V. Schuller, Henry P. David, and Herbert L. Friedman. "Children Born to Women Denied Abortion: Initial Findings of a Matched Control Study in Prague, Czechoslovakia." Paper presented at the International Roundtable on Psychosocial Research in Abortion and Fertility Behavior organized for the annual meeting of the Population Association of America, New York City, Apri1, 1974. Also reported in Family Planning Digest 3: 10, November 1974.

102 30. For example, see M. Bracken and S. Kasl. "Delay in Seeking Induced Abortion: A Review and Theoretical Analysis," American Journal of Obstetrics and Gynecology 121: 1008-1019, April 1, 1975. 31. Nancy B. Kaltreider. "Psychological Factors in Mid-Trimester Abortion," Psychiatry in Medicine 4: 132-133, Spring 1973. 32. Thomas D. Kerenyi, Ellen L. Glascock, and Marjorie L. Horowitz. "Reasons for Delayed Abortion: Results of Four Hundred Interviews," American Journal of Obstetrics and Gynecology 117: 299-304, October 1, 1973.

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