Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 657–665

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Best Practice & Research ClinicalObstetrics and Gynaecology

journal homepage: www.elsevier .com/locate /bpobgyn

9

Induced abortion and psychological sequelae

Sharon Cameron, Consultant Gynaecologist, Dean *

NHS lothian, Dean Terrace Centre, 18 Dean Terrace, Edinburgh, EH4 1NL, UKRoyal Infirmary of Edinburgh, 51 Little France Crescent, EH16 5SU, UK

Keywords:abortionmental healthpsychological healthpsychiatric illness

* Tel.: þ44 131 343 0912; Fax: þ44 131 332 294E-mail address: Sharon.cameron@ed.ac.uk

1521-6934/$ – see front matter � 2010 Elsevier Ltdoi:10.1016/j.bpobgyn.2010.02.001

The decision to seek an abortion is never easy. Women havedifferent reasons for choosing an abortion and their social,economic and religious background may influence how they cope.Furthermore, once pregnant, the alternatives of childbirth andadoption or keeping the baby may not be psychologically neutral.Research studies in this area have been hampered by methodo-logical problems, but most of the better-quality studies haveshown no increased risk of mental health problems in womenhaving an abortion. A consistent finding has been that of pre-existing mental illness and subsequent mental health problemsafter either abortion or childbirth. Furthermore, studies haveshown that only a minority of women experience any lastingsadness or regret. Risk factors for this include ambivalence aboutthe decision, level of social support and whether or not thepregnancy was originally intended. More robust, definitiveresearch studies are required on mental health after abortion andalternative outcomes such as childbirth.

� 2010 Elsevier Ltd. All rights reserved.

It has been claimed that the decision to terminate an unwanted pregnancy can lead to mental healthproblems for women. However, once a woman is in the situation of having an unwanted pregnancy,there is no magical state of ‘un-pregnancy’ and the alternative courses of action of childbirth andraising a child or adoption may also pose a psychological threat. Childbirth can be a physically andemotionally demanding time for mothers and many studies have demonstrated an increase indepression and anxiety post-partum. In Scotland in 2002, data collected from a subset of generalpractitioner (GP) practices for each face-to-face patient with a GP consultation revealed that 27% ofmothers were diagnosed with depression or anxiety within 12 months of childbirth compared with

1.

d. All rights reserved.

S. Cameron / Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 657–665658

19% in women who had not given birth in the same year.1 Furthermore, there is evidence that if womenare denied an abortion, their children are at an increased risk of mental health problems. A longitudinalstudy that followed up children born in 1961–63 in the former Czechoslovakia (now Czech republic), ofwomen who were denied abortion and forced to continue with the pregnancy, found that compared tomatched controls (children from wanted pregnancies), offspring from unwanted pregnancies were atincreased risk of negative psychosocial development and wellbeing.2 The negative effects on mentalhealth continued into adulthood and, compared to controls, the children of unwanted pregnancieswere more likely as adults to have a psychiatric illness, less job satisfaction and females were morelikely to be single or divorced at age 26–28 years.2

The question whether abortion has a negative effect on mental health of the woman is a recurringone. In 1989, the American Psychological Association (APA) reported the results of a systematic reviewof the published literature at that time. They reported that most methodologically sound studiesindicated that severe negative reactions after legal non-restrictive first trimester abortion were rareand could best be understood in the framework of coping with a normal life stress.3

In more recent times, however, there has been renewed interest in the mental health outcomes ofinduced abortion, exemplified by a headline for an article in the New York Times in 2007 titled ‘Is therea Post abortion Syndrome?4 The term ‘post-abortion syndrome’ is not recognised by any medical orpsychological society, but was coined by Vincent Rue.5 It was used to imply post-traumatic stressdisorder following the stress of abortion, where post-traumatic stress disorder is a severe and ongoingemotional reaction to an extreme psychological trauma.

Given this renewed interest in mental health after abortion and the fact that there had been newrelevant publications since 1989, the APA convened a task force on mental health and abortion in 2007to review the published literature since 1989.6 A further systematic review of published articles overa similar time period (1989 and 2008) was conducted by Charles et al. in 2008.7 The conclusions of bothsystematic reviews by APA and Charles et al. in 2008 were in agreement with the conclusions of theearlier report of the APA, and are outlined below.6,7 Both systematic reviews highlighted the numerousmethodological flaws with research in this area.6,7

Methodological problems with research on mental health and abortion

The systematic reviews of APA and Charles et al. in 2008 of published studies, which examined mentalhealth and abortion, observed recurring methodological problems with the studies in this area.6,7

(i) Comparative groupsFew studies have included appropriate comparative groups such as those women denied an abortion,who give the baby for adoption and women delivering and raising an unwanted child. The generalpopulation of women who deliver a baby are not an appropriate comparison group since women whoplan a pregnancy and deliver a wanted baby may differ in important characteristics from women, suchas level of social support, for whom the pregnancy was clearly unintended.

(ii) Co-occurrence of risk factorsThere is good evidence that factors such as poverty, personality or behaviour (e.g., smoking, alcohol anddrugs) can predispose a woman to unplanned pregnancy and abortion as well predispose to mentalhealth problems.8,9 Few studies assessed or adequately controlled for confounding factors such as theco-occurrence of unwanted pregnancy with adverse circumstances and adverse circumstances withmental health problems.

(iii) SamplingSome studies used volunteer samples that can introduce bias, since women who agree to participate(e.g., in response to a mailed questionnaire) may report different psychological experiences afterabortion to those who do not agree to participate.10 Some studies have also been small in terms ofsample size or have performed secondary analyses of data sets that were not designed to examinerelative risks of mental health after abortion.11,12 Furthermore, in some studies, there was differential

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exclusion of women who had a child but had a subsequent abortion. This introduces selection bias andlimits the generalisability of the findings to the general population.

(iv) Reproductive history and under-reportingA major confounder in studies were history of abortion is self-reported is that of under-reporting due tothe stigma associated with termination of pregnancy.If women who experience most psychological problems following an abortion do not report that theyhad an abortion, this leads to an underestimation of any negative effect of abortion on mental healthand, similarly, this leads to overestimation such women are more likely to report that they had anabortion. Many studies have not specified or clearly reported the gestations that women had abortions,nor the reason for the abortion or whether the pregnancy was originally intended. This is importantbecause abortion at later gestations may be associated with more pain and increased risk of compli-cations with a greater likelihood of being a more distressing experience. A late abortion may also reflectan underlying ambivalence about terminating the pregnancy or the diagnosis of a foetal anomaly inwhat was originally a planned and wanted pregnancy.

(v) Outcome measures and statistical analysisSome studies used poor or unvalidated measures of mental health. In some studies the timing of themeasurement of mental health relative to the time of the abortion was unspecified or varied. It isgenerally accepted that the closer one is to an event, the more accurate ones’ reporting of health oremotion is likely to reflect health/emotion at the time of the event. Many studies focussed only onnegative mental health outcomes and neglected to consider possible positive outcomes. Some studiesreported outcomes that were based upon results of multiple statistical testing and thus may havearisen by chance alone. For many studies the loss to follow-up was considerable. This can affect thevalidity of results, since if most psychologically disturbed women are lost to follow-up, this will lead toan underestimation of any effect of abortion on mental health and vice versa.

Studies indicating a neutral effect of abortion on mental health

One of the studies deemed to be of best quality by both the APA and the systematic review of Charleset al. in 2008 was a prospective, longitudinal, cohort study conducted in England by the Royal College ofGeneral Practitioners and Royal College of Obstetricians and Gynaecologists.13 The study cohortcomprised 13 261 women recruited between 1976 and 1987, who presented to their GP with anunplanned pregnancy, of which 6410 proceeded with an abortion, 6151 did not request an abortion,379 were denied an abortion and 321 who initially requested abortion but then decided to continuewith the pregnancy. At recruitment, socioeconomic data were recorded including history of previouspregnancies and of pre-existing psychiatric illness. Every 6 months until the end of the study, GPsprovided data on new episodes of illness and any further pregnancies. Morbidity on psychoses,depression and anxiety was coded using the World Health Organization codes. There was no significantdifference in the rates of total psychiatric disorder or depression or anxiety between women whounderwent pregnancy termination or childbirth.13 An important finding was that women witha previous history of psychiatric illness were most at risk of psychiatric disorder at the end of thepregnancy regardless of its outcome. Women without a history of mental illness had an apparentlylower relative risk (RR) of psychosis after abortion than childbirth (RR 0.4, 95% confidence interval (CI):0.3–0.7). The authors did note that rates of deliberate self-harm were higher in women refused anabortion (RR 2.9, 95% CI: 1.3–6.3) or having an abortion (RR 1.7, 95% CI: 1.1–2.6) compared to thechildbirth group, but added that this may have been due to possible confounding factors that they wereunable to account for such as co-existing social difficulties associated with the request for terminationand also with self-harm behaviour. This study had the advantages of being large, prospective, withappropriate comparison groups that account for pregnancy intention and with validated outcomemeasures (physician diagnosis). It also had the advantage of comparing across groups at multiple timepoints and controlling for pre-existing mental health.

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Another study that suggested no overall effect of abortion on mental health was that of Russo andZierk, based upon data from the National Longitudinal Survey of Youth (NLSY) from USA.12 This surveyinvolved annual interviews with a stratified sample of the population aged 14–21 years in 1979, withoversampling of black, Hispanic and poor white populations. In this study, out of a cohort of 5295women, interviewed in 1987, those women who reported ever having an abortion (n¼ 773) had nodifferent measures of self-esteem than other women who did not report a history of abortion.12 Thisstudy also reported that having repeated unwanted pregnancies (birth or abortion) was significantlycorrelated with poverty and low education.

Studies from Norway, which followed up women from 10 days to 5 years after a first trimesterabortion (n¼ 80) or miscarriage (n¼ 40), reported no significant differences between the groups inmeasures of anxiety, depression or wellbeing.14–16 While this study inferred similar levels of psycho-logical stress with both miscarriage and abortion; nevertheless, miscarriage is not an appropriatecomparison group for induced abortion as it is not an alternative that can be chosen by women with anunplanned pregnancy.

Studies indicating a negative effect of abortion on mental health

In 2006 a study from New Zealand reported a negative effect of abortion upon the mental health ofyoung women who had an induced abortion.17 This was a longitudinal study that followed up a cohortborn in Christchurch in 1977. The cohort included 630 women who reported their reproductive historybetween 15 and 25 years of age. The researchers reported higher rates of depression, suicidal ideationand illicit drug dependence in those undergoing abortion. While the study did measure validatedoutcomes and was able to account for confounding factors linked to women’s family and childhood,a study flaw was that it relied upon self-reported abortion (thus likely under-reporting) and did notseparate single from multiple abortions. A more recent publication from this same study cohort, whichfollowed 500 women up to age 30 years, reported similar findings of a small increase in mental healthdisorders (e.g., depression, anxiety, suicidal ideation and illicit drug dependence) in those undergoingabortion.18 In the systematic review by Charles et al., the earlier study was deemed to be of ‘fair’ qualityonly since it did not account for pregnancy intentions and compared women having an abortion withwomen who were not pregnant and women who were delivering a child.7 In addition, the study onlycontrolled for pre-existing mental health up to 15 years of age, although the majority of pregnanciesoccurred more than 3 years later. The more recent study was of recent similar design and could becriticised for many of the same reasons.

Using the data set from the NLSY, Cougle et al. examined first pregnancy outcome (abortion orchildbirth) among a sub-sample of 1884 women, and reported that those whose first pregnancy endedin abortion were significantly more likely to exceed the depression score for clinical depression (onaverage 8 years later) than those who gave birth.19 This study has been criticised for inappropriatecomparison groups as there was no accounting for intended-ness of pregnancy and women wereexcluded from the delivery group if they went on to have subsequent abortions. In the systematicreview by Charles et al., this study was rated as being of poor quality.7 In medical record linkage studiesconducted in Finland, higher rates of death of any cause (including violent death, homicide and suicide)within 1 year of the pregnancy were reported for women who had an abortion compared to thosedelivering a baby.20,21 However, subsequent analyses showed that the abortion group actually hadlower rates of death from causes aggravated or related to pregnancy.22,23 In addition, when abortionsconducted for medical (therapeutic) reasons were excluded, there was no difference in deaths of anycause in the abortion group compared to the childbirth group. The most recent study from this group23

was rated as ‘very poor’ quality by the systematic review of Charles et al. as there were inappropriatecomparison groups, no control for pre-existing mental health or other confounders and the studydesign using record linkage being able to provide contextual information only.7

Studies indicating a positive effect of abortion on mental health

Several studies have reported that measures of depression and anxiety are lower after either medicalor surgical abortion compared to just prior to the procedure.24,25 This would suggest that it is the state of

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being pregnant with an unwanted pregnancy itself that is stressful and that this is reduced once thedecision to terminate has been agreed and the procedure has been completed. Findings of these studiesare also consistent with others that have reported that the method of termination during the firsttrimester does not affect emotional adjustment or psychological experiences after the procedure.24,26

In a study of 360 black teenage women in Baltimore, USA, of similar socioeconomic background whowere attending a family planning service for pregnancy testing, those with a positive test who went on tohave an abortion were more likely to have completed education and were better off economically 2 yearslater than those who gave birth.27 Furthermore, teenagers who terminated their pregnancy had nodifferent levels of stress or anxiety than other teenagers at the time of the pregnancy test and were nomore likely to have psychological problems at the 2-year follow-up.27 Another publication based uponthe Christchurch cohort of women in New Zealand, which examined selected social and educationaloutcomes of women who reported an abortion or childbirth prior to age 21 years, reported similarfindings of better subsequent educational achievement and employment in those women who termi-nated the pregnancy.28 This study was a separate publication based on the same sample from NewZealand that had reported a negative association between abortion and mental health.

Abortion and psychological response

Women request abortions for different reasons and at different gestations. Furthermore, womencome from different age groups, cultural, religious and socioeconomic backgrounds, all of which mayaffect the experience of abortion. Studies that have focussed upon the reactions and feelings of womenwho have had an abortion have been used to identify factors that predict individual variation inpsychological response following abortion. Such studies have shown that women at higher risk fornegative emotions several years after an abortion included those with a prior history of mental healthproblems, younger age at the time of the abortion, low perceived social support for their decision andgreater personal conflict about abortion.29–32 The degree to which the pregnancy was intended isimportant with regard to ambivalence of the decision to terminate. In a study of women attendinga hospital clinic requesting a termination that used a validated questionnaire to determine theintended-ness of the pregnancy, majority (80%) of pregnancies were deemed to be clearly unintendedwith 10% deemed fairly unintended.33,34 This would suggest that the majority of women seekinga termination may be certain of their decision and may not require the same level of support as theminority for whom the pregnancy was originally intended and therefore at higher risk of distress orregret. In recognition of the fact that most women do not experience any lasting psychological distress,the Royal College of Obstetricians and Gynaecologists in 2004 recommended that post-abortioncounselling should be available for the ‘small minority’ of women who experience long-term post-abortion distress.35

Personality traits such as low self-esteem and a pessimistic outlook have been reported to beassociated with negative post-abortion experiences.31,36 Many of these same factors also predict howwomen cope with unwanted motherhood or adoption.37–39 Studies have also shown that the perceivedstigma of abortion and keeping the abortion a secret from family and friends were associated withincrease in anxiety and depression.40 The presence of anti-abortion protesters outside an abortionclinic has been shown to increase short-term psychological distress for women seeking an abortion.32

There is some evidence that encouraging women to reappraise an abortion in a more positive or benignway can lead to improved emotional responses. One study that randomised women to one of threecounselling strategies before the abortion, namely creating positive coping mechanisms, or reducingthe extent to which women attributed the pregnancy to their character, or contraceptive advice onlyshowed that women counselled on positive coping strategies were significantly less likely to displaynegative mood after the abortion.41

Report of APA task force on mental health and abortion

The APA conducted a systematic review of English-language, peer-reviewed articles published since1989 relating to mental health and abortion. They examined quantitative data relating to womenundergoing induced abortion with one or more post-abortion measures of mental health.6 The

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systematic review included 50 studies. These studies incorporated a comparison group for the abortiongroup. Twenty-five studies were secondary analyses of public data sets or records, 19 studies wereprimary research studies and six studies were of women having an abortion for foetal anomaly. Thereviewers defined a ‘mental health problem’ as clinically significant disorders such as depression,anxiety disorder and psychosis. The reviewers defined ‘negative psychological experiences’ as regret,sadness and substance misuse. The APA task force set out a series of questions to address regardingabortion and mental health. They stated that the question of whether or not abortion ‘causes’ harm tomental health could not be answered since this would require a randomised controlled trial of abortioncompared to delivery, which was neither ethical nor desirable. They wished to determine how prev-alent mental health problems are after abortion, the relative risk of mental health problems postabortion compared to alternative courses of action and what factors predicted individual variation inpsychological experiences.

The main findings of their report were published in April 2008.6 The authors concluded that, basedupon the best evidence, the relative risk of mental health problems in women undergoing a singleelective first trimester abortion was no greater than women delivering a child. The risk for mentalhealth problems with multiple abortions was judged equivocal with the same risks that predisposewomen to multiple unintended pregnancies possibly also predisposing to mental health problems.

With regard to data pertaining to late abortion for foetal abnormality, six studies with sample sizesranging between 23 and 83 were included.42–47 All of these studies had considerable loss to follow-up.The reviewers concluded that women having an abortion for fetal anomaly are more likely to expe-rience depression and anxiety than those delivering a healthy child, but with a risk similar to womenhaving a late miscarriage. The authors impressed that abortion for foetal anomaly is different fromabortion for an unplanned pregnancy since it often occurs later and in the context of what was orig-inally a planned and wanted pregnancy. One UK study examined depression and anxiety in womenwho proceeded with abortion for a severe foetal cardiac abnormality, women who gave birth to healthychildren and women delivering a child with undiagnosed fetal cardiac abnormalities.46 While anxietyin women post termination was more common than in those who delivered a healthy child, the risk ofdepression and anxiety was greatest in those giving birth to a child with an undiagnosed life-threatening abnormality.

Systematic review by Charles et al

This systematic review covered 21 studies (seven prospective cohort, 11 retrospective cohort andthree cross-sectional studies) that fulfilled the researchers’ inclusion criteria (over 100 subjects, follow-up of over 90 days post abortion) and focussed exclusively on long-term mental health effects ofabortion.7 Studies of women having abortion due to foetal abnormality or studies of women havingmultiple abortions were excluded. This review differed from that of APA in that it rated the studyquality based on methodological factors. Studies were rated as excellent (no studies), very good (fourstudies), fair (eight studies), poor (eight studies) or very poor (one study). None of the 21 studiesincluded was judged as being of excellent quality. The four studies judged to be the most methodo-logically sound were rated as ‘very good’, indicating that they provided good evidence and were at low

Table 1Quality of studies (n¼ 21) included in systematic review by Charles et al 2008, and reported association of abortion and mentalhealth.

Number of studies(N¼ 21)

No associationAbortion andmental health

Mixed findings Negative association abortionand mental health

Excellent (n¼ 0)Very Good (n¼ 4) 4Fair (n¼ 8) 3 3 2Poor (n¼ 8) 1 4 3Very Poor (n¼ 1) 1

Table 2Summary of studies rated as ‘very good’ quality by systematic review of Charles et al 2008.7

Studies Country Design Sample Size Groups Outcomemeasure

Relative Effectof abortion

Gilchrist et al1995(ref 13)

UK Prospectivecohort

13 261 Abortion,Refused abortion,Delivered

PsychosisDepressionAnxietySelf Harm

Neutral

Russo and Zerk1992 (ref 12)

USA Retrospectivecohort

5295 Abortion,Delivered

Self esteem Neutral

Schmiege andRusso 2005(ref 48)

USA Longitudinalsurvey

1247 Abortion,Delivered

Depression Neutral

Steinberg and Russo(ref 49)

USA Longitudinalsurvey

3482 Abortion, Delivered Anxiety Neutral

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risk of bias. One of these very good studies was that of Gilchrist et al. from UK.13 All four very goodstudies reported no association between abortion and subsequent mental health (Tables 1 and 2).

In one ‘very good’ study by Schmiege and Russo, which was a re-analysis of data from the NSLY datafrom USA, the authors concluded that women who had an abortion were no more likely to bedepressed than women having a baby.48 Another study rated as ‘very good’ that controlled for pre-pregnancy anxiety concluded that there was no difference in anxiety between women who had anabortion and those who had a baby.49 The review reported a clear trend for the higher-quality studiesto report findings that were mostly neutral, suggesting few, if any, differences between women whohad abortions and their respective comparison groups in terms of mental health sequelae. By contrast,those studies judged to have the most flawed methodology found negative mental health sequelae ofabortion (Table 1). The systematic review highlighted the importance of appropriate comparisongroups as those women who have an unintended pregnancy may be very different from women whomay be predisposed to mental health problems regardless of the abortion experience.7

In summary, induced abortion is a common event with almost one in three women in the UK andother European countries undergoing this procedure.50 If abortion did have an adverse effect uponmental health then one might expect long-term post-abortion mental disorders to be prevalent. Thebest-quality research from the English-language published literature in countries where abortion islegal indicates that abortion is not associated with any greater risk of adverse mental health problems.Women with risk factors for poor mental health following an abortion include those with pre-existingmental health problems. Long-lasting feelings of sadness, regret and guilt only occur in a minority ofwomen, more often in those with ambivalence about the termination, poor social support, for whomthe pregnancy was originally intended or women who have moral objections to abortion. Identificationof these risk factors in women by health professionals involved in pre-abortion assessment may be ofvalue in directing these women for further post-abortion counselling and support.

Practice points

Women having a single first trimester abortion are not at any higher relative risk of mental healthproblems than if they deliver that pregnancy.A previous history of psychiatric illness has been identified as one of the strongest predictors ofmental health problems after abortion or childbirth.Women who are ambivalent about the decision to have the abortion, or for whom the pregnancywas originally intended, or who lack a supportive partner, or belong to a cultural group thatconsiders abortion to be wrong are at higher risk of negative psychological responses such assadness and anxiety.These same risk factors are also predictive of negative psychological responses followingchildbirth.

Research agenda

Most studies examining mental health outcomes following abortion have suffered from meth-odological problems or failed to account for possible confounding factors.Future studies should contain appropriate comparison groups and should be sufficiently large toinclude critical variables including intended-ness of the pregnancy.

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